Modeling chronic oil pollution from ships

Stochastic simulations of virtual oil spills from ships were performed for the Adriatic Sea over 2017-2020, applying the European Marine Observation and Data Network vessel densities as a proxy for starting locations of operational spillage. The MEDSLIK-II oil spill model was run using high-resolution currents provided by the Copernicus Marine Service and the European Centre for Medium-Range Weather Forecasts winds. Chronic exposure to operational oil spills was reported in terms of hazard indices for five vessel groups: pleasure and passenger ships, cargo and service vessels, the fishing fleet, tankers, and other ships. The northernmost Adriatic expectedly showed the highest hazard values, including the areas of Trieste and Venice, where cargo and service ships were the dominant polluters. The Croatian coastal waters were more chronically polluted than the Italian coastal waters; the predominant contribution was from coastwise pleasure and passenger ships.

Feasibility, safety and long term outcomes of complex left main bifurcation treatment using the nano inverted t stenting: a multicentre registry

Background

The role of double stenting techniques in distal bifurcation left main (LM) disease has gaining interest over the latest years.

Purpose

We present the 3-year multicentre registry outcomes of dual stenting using ultra-thin strut stents and the Nano Inverted-T (NIT) technique in complex unprotected true LM bifurcation disease.

Methods

We analysed the procedural and medical data of consecutive patients enrolled between 1st January 2014 and 1st December 2019 in a multicentre registry for complex LM bifurcation disease treated with the double stenting technique called NIT due contraindications and/or refusal to surgical treatment. Target lesion failure (TLF) was defined as the composite of cardiovascular death, target-vessel MI (TVMI) and clinically driven target lesion revascularization (TLR).

Results

Among two hundred-ninety-five patients (138 males, mean age 70.3±12.8 years), post-operative success was achieved in 100% of cases. Contrast volume, procedural time, and radiation exposure were 139.2±23.4 ml, 15.3±4.9 min, and 1080±1034 cGy/m2 (Figure), respectively. At a mean follow-up of 39.5±0.6 months TLF rate was 6.1% (n=18) while TLR and cardiovascular mortality rates were 3.0 (n=9) and 2.6% (n=8), respectively. Clinically driven angiographic follow-up was available in 26.4% of patients at a mean time from the procedure of 7.5±0.4 months. Clinically restenosis rate was 3.3%.

Conclusions

Revascularization of complex LM bifurcation disease using the NIT double stenting technique resulted feasible and safe with a low incidence of TLF, excellent survival rate and no stent thrombosis. Figure 1.The NIT technique is based on the use of ultra-thin strut (≤80 micron) stents and double stenting starting with side branch stenting frst. The side branch stent is precisely positioned with one possibly only strut protruding into the main vessel which is balloon crushed before the implantation of the main branch stenting. The Proximal optimization technique (POT)–snuggle kissing–POT sequence is mandatory to ensure the coverage of the side branch ostium by both side branch and main branch stents. Snuggle kissing was performed placing the LCX balloon with the proximal marker at the middle rather than at the proximal marker of the LM-LAD balloon, in order to minimize the elliptical deformation of the LM stent.

Funding Acknowledgement

Type of funding sources: None. Figure 1

A multicenter total therapy strategy for de novo adult Philadelphia chromosome positive acute lymphoblastic leukemia patients: final results of the GIMEMA LAL1509 protocol

The GIMEMA LAL1509 protocol, designed for adult (≥18-60 years) de novo Philadelphia chromosome positive (Ph+) acute lymphoblastic leukemia (ALL) patients, was based on dasatinib plus steroids induction - with central nervous system prophylaxis - followed by dasatinib alone in patients in complete molecular response or by chemotherapy and/or allogeneic transplant in patients not reaching complete molecular response. Sixty patients (median age 41.9 years) were enrolled: 33 were p190+, 18 p210+ and nine p190/p210+. At the end of induction (day +85), 58 patients (97%) achieved complete hematologic remission. No deaths in induction were recorded. Eleven patients (18.3%) obtained complete molecular response. Among the incomplete molecular responders (n=47), 22 underwent an allogeneic transplant. Seventeen hematologic relapses occurred (median 7 months; range, 3-40.1): 13 during consolidation and four post-transplant. ABL1 mutations (five T315I, three V299L, one E281K and one G254E) were found in ten of 13 relapsed cases. With a median follow-up of 57.4 months (range, 4.2-75.6), overall survival and disease-free survival were 56.3% and 47.2%. A better disease-free survival was observed in patients who obtained a molecular response at day +85 compared to cases who did not. The presence of additional copy number aberrations - IKZF1 plus CDKN2A/B and/or PAX5 deletions - was the most important unfavorable prognostic factor on overall and disease-free survival (P=0.005 and P=0.0008). This study shows that in adult Ph+ ALL long-term survivals can be achieved with a total-therapy strategy based on a chemotherapyfree induction and, in complete molecular responders, also without further systemic chemotherapy. Finally, the screening of additional copy number aberrations should be included in the diagnostic work-up (clinicatrial gov. Identifier: EudraCT 2010-019119-39).

Use of MitraClip system for severe mitral regurgitation in cardiogenic shock: results from a multicentre observational Italian experience (the MITRA-SHOCK study)

Background/Introduction

Cardiogenic shock (CS) is a medical emergency and a frequent cause of death. CS can be complicated by mitral regurgitation (MR). The presence of at least moderate MR in the setting of shock was associated with about three-times higher odds of 1-year mortality. In the setting of refractory CS, percutaneous mitral valve repair (PMVR) can be a potential therapeutic option.

Purpose

The aim of the study was to evaluate the efficacy of percutaneous approach of severe MR in patients with CS assessing short-term clinical outcomes.

Methods

In this study we retrospectively included patients with CS and concomitant severe MR treated with Mitraclip system. We enrolled 28 patients from 5 Italian centers between 2012 and 2019. MitraClip implantation was performed according to each hospital standard care. CS was defined utilizing the Diagnostic Criteria of Cardiogenic Shock used in the SHOCK trial. Procedural success was defined as the presence of moderate or less MR after MitraClip implantation.

Results

All patients presented at least severe MR. All treated patients were at high surgical risk (STS mortality score 36.4±11.7%). Procedural success was obtained in 24 patients (86%). A mean of 1.71±0.76 clips per patients were implanted. In-hospital complications occurred in 13 patients (46%): 7 minor bleedings (25% of patients), 7 major bleedings (25%), 8 acute kidney injuries (28%). In-hospital mortality was 25% and the reported causes of death were cardiovascular in all patients. At Cox multivariate analysis procedural success was a strong predictor of in-hospital survival (HR 0.11, CI 95% 0.02–0.67, p=0.017).

Conclusions

PMVR with Mitraclip system in patients with CS and concomitant MR demonstrated high procedural success and acceptable safety. It can be considered a bailout option in this setting of patients with high short-term mortality. Larger prospective studies are needed.

In-hospital mortality predictors

Funding Acknowledgement

Type of funding source: None

Gene expression, proteome and calcium signaling alterations in immortalized hippocampal astrocytes from an Alzheimer's disease mouse model

Evidence is rapidly growing regarding a role of astroglial cells in the pathogenesis of Alzheimer’s disease (AD), and the hippocampus is one of the important brain regions affected in AD. While primary astroglial cultures, both from wild-type mice and from rodent models of AD, have been useful for studying astrocyte-specific alterations, the limited cell number and short primary culture lifetime have limited the use of primary hippocampal astrocytes. To overcome these limitations, we have now established immortalized astroglial cell lines from the hippocampus of 3xTg-AD and wild-type control mice (3Tg-iAstro and WT-iAstro, respectively). Both 3Tg-iAstro and WT-iAstro maintain an astroglial phenotype and markers (glutamine synthetase, aldehyde dehydrogenase 1 family member L1 and aquaporin-4) but display proliferative potential until at least passage 25. Furthermore, these cell lines maintain the potassium inward rectifying (Kir) current and present transcriptional and proteomic profiles compatible with primary astrocytes. Importantly, differences between the 3Tg-iAstro and WT-iAstro cell lines in terms of calcium signaling and in terms of transcriptional changes can be re-conducted to the changes previously reported in primary astroglial cells. To illustrate the versatility of this model we performed shotgun mass spectrometry proteomic analysis and found that proteins related to RNA binding and ribosome are differentially expressed in 3Tg-iAstro vs WT-iAstro. In summary, we present here immortalized hippocampal astrocytes from WT and 3xTg-AD mice that might be a useful model to speed up research on the role of astrocytes in AD.

Blood flow distribution in a polymyxin coated fibrous bed for endotoxin removal. Effect of a new blood path design

The analysis of flow distribution in cartridges designed for hemoperfusion is extremely important. Taking advantage of a new imaging technique, based on the analysis of a helical scanner-generated imaging sequence, we studied the blood flow distribution in a series of cartridges for extracorporeal removal of endotoxin. Cartridges with improved design were compared to cartridges with a standard design. The improved design consists in a different structure of the holes of the distributor of the flow within the adsorbent unit. Cartridges were studied in vitro with human blood from voluntary donors at blood flows of 100 and 250 ml/min. The progression of density in specific regions of interest (ROI) was analyzed to detect the distribution of the dye injected in the blood circuit. The study demonstrates that both at 100 ml/min and at 250 ml/min of blood flow, the progression of flow appears more homogeneous in the devices with improved design. In detail, the flow distribution measured by the incremental density values detected in the ROIs of the proximal corners (close to the arterial port) and in the ROIs of the central region of the device (close to the inner wall of the case) displays a significant difference between the standard and the improved device. The ROIs studied in the standard devices display a slower increase in density and significantly lower absolute values expressed in Hounsfield units. The experimental method utilized to analyze flow distribution seems to represent an important means to study the performance and design of this type of device.

Integration of Blood Volume, Blood Pressure, Heart Rate and Bioimpedance Monitoring for the Achievement of Optimal Dry Body Weight during Chronic Hemodialysis

Background

Achieving optimal dry body weight in hemodialysis is challenging. Clinical assessment alone is inadequate, and methods such as bioimpedance monitoring may be impractical for every patient treatment. Continuous blood volume monitoring, blood pressure and heart rate variability inform clinical decision-making, but integrated use of multiple methodologies to achieve dry weight and understand patient factors has not yet been described.

Methods

Nineteen chronic hemodialysis patients underwent thrice-weekly treatments for two weeks. Baseline hydration status and target weight were determined by bioimpedance. During subsequent treatments, ultrafiltration was adjusted and relative blood volume, blood pressure and pulse were recorded non-invasively Bioimpedance was repeated to assess hydration. Response of variables to progressive change in weight was assessed and selected patients underwent additional autonomic function testing.

Results

Four distinct hemodynamic patterns emerged. Profile A: 4 patients demonstrated overhydration at baseline. With decreasing target, pulse and blood pressure remained stable while blood volume and bioimpedance demonstrated achievement of dry weight. Profile B: 8 patients demonstrated overhydration at baseline. With decreasing target, blood pressure remained stable while pulse increased. Profile C: 5 patients were overhydrated, but as weight decreased, blood pressure became unstable and heart rate failed to compensate. Further testing confirmed autonomic dysfunction. Profile D: 2 patients were dehydrated, and with increasing target demonstrated stable pulse and pressure, while blood volume and bioimpedance revealed achievement of dry weight.

Conclusions

Integrating existing non-invasive, continuous monitoring during hemodialysis enabled achievement of dry weight and identified distinct profiles of the patients, some with autonomic dysfunction. This strategy may contribute to achieving optimum dry weight while improving cardiovascular tolerability of hemodialysis.

Genetic risk of prediabetes and diabetes development in chronic myeloid leukemia patients treated with nilotinib

Impaired fasting glucose and type 2 diabetes represent adverse events in patients with chronic myeloid leukemia (CML) treated with the second generation tyrosine kinase inhibitor nilotinib. An unweighted genetic risk score (uGRS) for the prediction of insulin resistance, consisting of 10 multiple single-nucleotide polymorphisms, has been proposed. We evaluated uGRS predictivity in 61 CML patients treated with nilotinib. Patients were genotyped for IRS1, GRB14, ARL15, PPARG, PEPD, ANKRD55/MAP3K1, PDGFC, LYPLAL1, RSPO3, and FAM13A1 genes. The uGRS was based on the sum of the risk alleles within the set of selected single-nucleotide polymorphisms. Molecular response (MR)^3.0 and MR^4.0 were achieved in 90% and 79% of patients, respectively. Before treatment, none of the patients had abnormal blood glucose. During treatment and subsequent follow-up at 80.2 months (range: 1-298), seven patients (11.5%) had developed diabetes that required oral treatment, a median of 14 months (range: 3-98) after starting nilotinib treatment. Twelve patients (19.7%) had developed prediabetes. Prediabetes/diabetes-free survival was significantly higher in patients with a uGRS <10 than in those with higher scores (100% vs. 22.8 ± 12.4%, p <0.001). Each increment of one unit in the uGRS caused a 42% increase in the prediabetes/diabetes risk (hazard ratio = 1.42, confidence interval: 1.04-1.94, p = 0.026). The presence of more than 10 allelic variants associated with insulin secretion, processing, sensitivity, and clearance is predictive of prediabetes/diabetes development in CML patients treated with nilotinib. In clinical practice, uGRS could help tailor the best tyrosine kinase inhibitor therapy.

Clinical relevance of hypogammaglobulinemia, clinical and biologic variables on the infection risk and outcome of patients with stage A chronic lymphocytic leukemia

The prognostic effect of hypogammaglobulinemia (HGG), clinical and biologic characteristics on the infection risk and outcome has been retrospectively analyzed in 899 patients with stage A chronic lymphocytic leukemia (CLL). Low levels of IgG were recorded in 19.9% of patients at presentation, low levels of IgM and/or IgA in 10.4% and an additional 20% of patients developed HGG during the course of the disease. Before the start of any treatment, 160 (12.9%) patients experienced at least one grade ≥3 infection requiring a systemic anti-infective treatment and/or hospitalization. While IgG levels at diagnosis were not associated with an increased risk of grade ≥3 infection or with an adverse outcome, a significantly increased rate of grade ≥3 infections was recorded in patients with unmutated IGHV (p=0.011) and unfavorable FISH aberrations (p=0.009). Late onset HGG, more frequently recorded in patients with Rai stage I-II (p=0.001) and unmutated IGHV (p=0.001), was also associated with a higher rate of severe infections (p=0.002). These data indicate that, stage A patients with clinical and biologic characteristics of a more aggressive disease develop more frequently late onset HGG, grade ≥3 infections and require a closer clinical monitoring.

A sequential approach with imatinib, chemotherapy and transplant for adult Ph+ acute lymphoblastic leukemia: final results of the GIMEMA LAL 0904 study

In the GIMEMA LAL 0904 protocol, adult Philadelphia positive acute lymphoblastic leukemia patients were treated with chemotherapy for induction and consolidation, followed by maintenance with imatinib. The protocol was subsequently amended and imatinib was incorporated in the induction and post-remission phase together with chemotherapy. Due to the toxicity of this combined approach, the protocol was further amended to a sequential scheme based on imatinib plus steroids as induction, followed by consolidation with chemotherapy plus imatinib and, when applicable, by a hematopoietic stem cell transplant. Fifty-one patients (median age 45.9 years) were enrolled in the final sequential protocol. At the end of induction (day +50), 96% of evaluable patients (n=49) achieved a complete hematologic remission; after consolidation, all were in complete hematologic remission. No deaths in induction were recorded. Overall survival and disease-free survival at 60 months are 48.8% and 45.8%, respectively. At day +50 (end of imatinib induction), a more than 1.3 log-reduction of BCR-ABL1 levels was associated with a significantly longer disease-free survival (55.6%, 95%CI: 39.0-79.3 vs. 20%, 95%CI: 5.8-69.1; P=0.03), overall survival (59.1%, 95%CI: 42.3-82.6 vs. 20%, 95%CI: 5.8-69.1; P=0.02) and lower incidence of relapse (20.5%, 95%CI: 7.2-38.6 vs. 60.0%, 95%CI: 21.6-84.3; P=0.01). Mean BCR-ABL1 levels remained significantly higher in patients who subsequently relapsed. Finally, BCR-ABL1^p190 patients showed a significantly faster molecular response than BCR-ABL1^p210 patients (P=0.023). Though the study was not powered to evaluate the role of allogeneic stem cell transplant, allografting positively impacted on both overall and disease-free survival. In conclusion, a sequential approach with imatinib alone in induction, consolidated by chemotherapy plus imatinib followed by a stem cell transplant is a feasible, well-tolerated and effective strategy for adult Philadelphia positive acute lymphoblastic leukemia, leading to the best long-term survival rates so far reported. (clinicaltrials.gov identifier: 00458848).

Early lenalidomide treatment for low and intermediate-1 International Prognostic Scoring System risk myelodysplastic syndromes with del(5q) before transfusion dependence

Lenalidomide is approved for the treatment of transfusion-dependent (TD) del(5q) myelodysplastic syndromes (MDS). However, few data are available in patients with transfusion-independent (TI) del(5q) MDS. In the first, observational, part of this 2-part study, we assessed the impact of transfusion dependence on overall survival (OS) and non-leukemic death in untreated del(5q) MDS patients who were TD (n = 136), TI with hemoglobin (Hb) ≥10 mg/dL (n = 88), or TI with Hb <10 mg/dL (n = 96). In the second, interventional, part we assessed the quality-of-life (QoL) benefits and clinical efficacy of lenalidomide (10 mg/day) in 12 patients with TI del(5q) MDS and Hb <10 mg/dL. In the untreated population, OS was significantly longer in TI than in TD patients (TI [Hb ≥10 g/dL], 108 months; TI [Hb <10 g/dL], 77 months; TD, 44 months). Transfusion dependence also negatively impacted non-leukemic death rates. In the interventional part of the study, baseline Hb levels were found to correlate significantly with physical (R = 0.666, P = 0.035) and fatigue (R = 0.604, P = 0.049) QoL scores. Median physical QoL scores improved significantly after 12 weeks' treatment with lenalidomide (+12.5; P = 0.020). Evaluable TI patients experienced early increases in Hb levels, and all attained an erythroid response. Our findings suggest that TI patients with moderate anemia may benefit from early treatment with lenalidomide.

Efficacy of biosimilar granulocyte colony-stimulating factor versus originator granulocyte colony-stimulating factor in peripheral blood stem cell mobilization in de novo multiple myeloma patients

BACKGROUND AIMS

Filgrastim and lenograstim are the standard granulocyte colony-stimulating factor (G-CSF) agents for peripheral blood stem cell mobilization (PBSC) in patients who undergo autologous stem cell transplantation.

METHODS

To assess whether biosimilars are effective, we conducted a single-center, prospective study that included 40 consecutive de novo multiple myeloma patients who received cyclophosphamide 4 g/m(2) per day plus biosimilar filgrastim G-CSF to mobilize PBSC. These patients were compared with a group of 37 patients matched for age, diagnosis, previous chemotherapy and mobilization who had been treated with originator G-CSF. The mean number of CD34+ cells/μL in the peripheral blood was 199.6 ± 207.4 in the biosimilar and 192.8 ± 154.7 in the originator group (P = 0.87). The median number of CD34+ cells/kg recipient collected was 11.5 ± 5.8 and 12.3 ± 5.3 in the biosimilar and originator groups, respectively (P = 0.51). The mobilization failure rate was 2.5% and 2.7% in the biosimilar filgrastim and originator filgrastim cohorts (P = NS), respectively.

RESULTS

Twenty-nine patients in the biosimilar group and 28 patients in the originator group underwent autologous transplantation. There were no statistically significant differences between the biosimilar and originator G-CSF cohorts in terms of hematopoietic recovery parameters and transplant-related toxicities.

CONCLUSIONS

The efficacy of biosimilar G-CSF appears to be equivalent to the reference G-CSF.

Tolerability and efficacy of busulfan and fludarabine as allogeneic pretransplant conditioning therapy in acute myeloid leukemia: comparison with busulfan and cyclophosphamide regimen

BACKGROUND

The aim of this study was to compare safety and efficacy of the association of busulfan with cyclophosphamide (BuCy2) versus busulfan and fludarabine (BuFlu) as a conditioning regimen in allogeneic hematopoietic progenitor cell transplantation (allo-HPCT) in patients with acute myeloid leukemia (AML).

PATIENTS AND METHODS

A total of 65 consecutive patients who received an allo-HPCT from Human Leucocyte Antigen-matched sibling donors were analyzed. The conditioning was BuCy2 in 48 patients and BuFlu in 17 patients.

RESULTS

There were no significant differences between the 2 cohorts in hematological engraftment, incidence of extrahematological toxicities, and acute graft versus host disease (GVHD). The incidence of chronic GVHD was 34% in the BuCy2 group versus 57% in the BuFlu group (P = .03). Transplant-related mortality was 17% (8 patients) in the BuCy2 group versus 0 in the BuFlu arm. Disease-related mortality was similar in the whole study population; in high-risk AML patients it was 11% in the BuCy2 group and 19% in the BuFlu group (P = .015). The probability of disease-free and event-free survival at 2 years was, respectively, 70% and 60% in the BuCy2 group and 59% and 58% in the BuFlu group (P = .06 and P = not significant [ns]). The probability of overall survival at 2 years was 71% in the BuCy2 group and 63% in the BuFlu group (P = ns), and in the high-risk group it was 83% and 67% in the BuCy2 and BuFlu group, respectively (P = ns).

CONCLUSION

BuFlu is well tolerated and is less toxic than BuCy2 and our results did not suggest that in high-risk AML, BuCy2 should be the favorite regimen in terms of efficacy.

Patent foramen ovale-mania: an unusual case of misdiagnosis

Patent foramen ovale (PFO) is rapidly becoming in Europe, more than in the USA, a matter of over-diagnosis and over-treatment. A migrainous 34-year-old female with episodic hypostenia and even paralysis of the left arm was referred to a peripheral hospital for a complete neurological work-up. Being the Doppler ultrasound of carotid and vertebral arteries negative and angio-magnetic resonance imaging (MRI) positive for multiple white-matter lesions. A transthoracic echocardiography revealed a possible shunt through a patent foramen ovale with a right-to-left shunt and a mild buldging of interatrial septum, but the patient did not tolerate a further attempt of transesophageal echocardiography to confirm the diagnosis. Coagulation screening essay demonstrated a moderate hyperhomocisteinemia. In the hypothesis of embolic PFO mediated by a moderate prothrombotic state caused by hyperhomocisteinemia, the patient was referred to our attention for an attempt of PFO closure but on intracardiac echocardiography normal fossa ovalis without any shunt was revealed. One year later, during the follow-up, the patient became severely symptomatic for left arm hypostenia and parhestesia, both at rest and during efforts. Thus, the patient was submitted to a thoracic and upper limbs angio-MRI in order to exclude disease of the main arteries causing functional impotence. The MRI demonstrated thoracic outlet syndrome of both arms, more severe in the left arm with functional occlusion of the subclavian vein with abduction of the arm and possible cloth image at the subclavian vein next to the joint. The patient was referred to the thoracic surgeon for surgical repair.

Quality of life in elderly patients with acute myeloid leukemia: patients may be more accurate than physicians

BACKGROUND

The aim of this study was to evaluate changes in quality of life scores and their association with therapy and survival in unselected elderly patients with acute myeloid leukemia.

DESIGN AND METHODS

From February 2003 to February 2007, 113 patients aged more than 60 years with de novo acute myeloid leukemia were enrolled in a prospective observational study. Two different quality of life instruments were employed: the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire - C30 (EORTC QLQ-C30) and a health-related quality of life questionnaire for patients with hematologic diseases (QOL-E).

RESULTS

Forty-eight patients (42.4%) received intensive chemotherapy and 65 (57.6%) were given palliative treatments. Age greater than 70 years (P=0.007) and concomitant diseases (P=0.019) had a significant impact on treatment allocation. At diagnosis, general quality of life was affected [median QOL-E standardized score 54, interquartile range 46-70; median EORTC global score 50, interquartile range 41-66]. Most patients were given a good ECOG Performance Status (< 2), which did not correlate with the patients' perception of quality of life. At multivariate analysis, palliative approaches (P=0.016), age more than 70 years (P=0.013) and concomitant diseases (P=0.035) each had an independent negative impact on survival. In a multivariate model corrected for age, concomitant diseases and treatment option, survival was independently predicted by QOL-E functional (P=0.002) and EORTC QLQ-C30 physical function (P=0.030) scores.

CONCLUSIONS

Quality of life could have an important role in elderly acute myeloid leukemia patients at diagnosis as a prognostic factor for survival and a potential factor for treatment decisions.

Darbepoetin alfa for the treatment of anemia associated with myelodysplastic syndromes: efficacy and quality of life

To evaluate efficacy, safety, changes in biological features, and quality of life (QoL) in low-risk anemic patients with MDS treated with darbepoetin alfa (DPO), 41 patients received DPO 150 microg weekly for 24 weeks. The dose was increased to 300 microg weekly in non-responsive patients. During treatment, 10/17 (59%) transfusion-dependent (TD) and 13/23 (56%) transfusion-free (TF) patients responded. In TF patients, Hb increased from 9.2 +/- 0.9 g/dL to 10.3 +/- 1.4 g/dL by 24 weeks (p = 0.004). The mean response duration was 22 weeks (95% CI: 19.7-24.0) in TF patients compared with 15.1 weeks (95% CI: 13.3-17.5) in TD patients. Response to treatment was associated with increases in QoL. Decreases in the percentage of apoptotic progenitor cells (p = 0.007) and CD34+ cells (p = 0.005) were observed. These results confirm previous studies demonstrating the safety and efficacy of DPO in anemic patients with MDS. Biological changes and improvement in QoL were associated with response. Adequate dosing is to be determined.

Changes in RPS14 expression levels during lenalidomide treatment in Low- and Intermediate-1-risk myelodysplastic syndromes with chromosome 5q deletion

BACKGROUND

Haploinsufficiency of the ribosomal protein S14 RPS14 gene, located in the common deleted region of chromosome 5q, is a potential causal factor of 5q- syndrome. Lenalidomide elicits high response rates and morphological improvements in myelodysplastic syndrome (MDS) patients with chromosome 5q deletion [del(5q)].

METHODS

To further evaluate the role of RPS14, its transcription was tested in bone marrow cells from 17 patients with International Prognostic Scoring System defined Low- or Intermediate-1-risk MDS with del(5q) as a single or additional cytogenetic abnormality receiving treatment with lenalidomide.

RESULTS

After 12 wk of lenalidomide treatment, erythroid responses were observed in all cases with an increase in hemoglobin levels of 2.7 +/- 2.5 g/dL (up to a mean 11.8 +/- 1.9 g/dL; P = 0.001). Before treatment, RPS14 expression levels were under-expressed in 15 patients with respect to normal controls. After 12 wk of lenalidomide treatment, all patients had an erythroid response. There was a significant increase in median RPS14 expression from baseline 0.01 (IQR 0.05-0.31) to 12 wk 204.71-fold (2.86-446.32; P < 0.0001).

CONCLUSIONS

These observations in the patient setting support the importance of RPS14 in the pathogenesis of MDS with del(5q).

Iron chelation therapy associated with improvement of hematopoiesis in transfusion-dependent patients

BACKGROUND

It is well known that iron overload may cause multiple organ failure. In chronically transfused patients, optimal iron chelation therapy is associated with reduced morbidity and mortality. Furthermore, chelation therapy has been associated with erythroid responses.

STUDY DESIGN AND METHODS

Among chronically transfused adults affected by myeloproliferative neoplasms and treated with iron chelators, two case reports are described.

CASE REPORT

A male adult patient with myelodysplastic syndrome (MDS) and a female adult with aplastic anemia (AA), both transfusion-dependent, were treated with deferasirox, an oral iron chelator.

RESULTS

A significant reduction in transfusion requirement was observed and was dependent on chelation therapy. The patient affected by AA also experienced a significant increase in hemoglobin levels. Minimal doses of deferasirox maintained the erythroid responses. Many mechanisms of action of the drug on erythropoiesis have been postulated. The early erythroid response seems to be independent of the removal of iron from deposits, per se, since the reduction of ferritin levels (a surrogate marker of iron deposits) below threshold levels occurs as a later event.

CONCLUSION

Although there are few reports on erythroid responses in patients undergoing iron chelation therapy, they may give new insights in the pathogenesis of MDS and other myeloproliferative neoplasms. AA may benefit in terms of erythroid response. The findings in these cases underline the clinical importance of treating patients with iron overload. A survival benefit of chelation in patients with myeloproliferative neoplasms is still to be confirmed.

Safety and long-term results of patent foramen ovale transcatheter closure in patients with thrombophilia

AIM

Trials on transcatheter closure of patent foramen ovale (PFO) in different settings attempted to exclude patients with thrombophilia for the risk of device thrombosis. Authors sought to retrospectively evaluate safety and results of transcatheter PFO closure in patients with confirmed coagulation abnormalities.

METHODS

Between December 2006 and December 2008, 30 out of 98 consecutive patients (mean age 40+/-10.9 years, 23 females) referred to Rovigo General Hospital for transcatheter closure had coagulation abnormalities including mutations of factor V Leiden, factors X, VIII, protein C, S, MHFTR factors, and antiphospholipid and anticardiolipin antibodies, hyperhomocisteinimia. All patients underwent preoperative transesophageal echo and brain magnetic resonance imaging, and intra-cardiac echo-guided transcatheter PFO closure.

RESULTS

Success rate was 100%; there was no difference in occlusion and complications rates between patients with and without thrombophilia: in particular no device thrombosis or recurrent cerebral ischemia or stroke were observed during the follow-up. Patients with thrombophilia had a higher incidence of atrial septal aneurysm, migraine with aura and deep venous thrombosis in the previous medical history compared to patients without.

CONCLUSIONS

Despite its small sample, this study suggests that patients with coagulation abnormalities should not be excluded from the trial; they have potentially a higher risk of stroke through a PFO compared to other patients, and transcatheter closure is as safe and effective as in general population with almost no additional therapy rather than aspirin.

Seroprevalence of Antibodies to Neospora caninum in Urban and Rural Dogs in north-west Italy

Sera were collected from 490 dogs from north-west Italy. One hundred and eighty-eight dogs were urban, while 302 dogs were rural. Among the latter, 190 were shepherd dogs and 112 were cattle farm dogs. Sera were tested for the presence of antibodies against Neospora caninum using the Neospora agglutination test. Seroprevalence at 1/40, 1/80, 1/160 dilution titres was significantly higher in rural (36.4%, 19.5%, 9.9% respectively) than in urban dogs (20.2%, 10.6%, 4.8% respectively). Seroprevalence did not differ significantly in males and females. In shepherd dogs, prevalence increased according to dogs' age, thus suggesting a post-natal exposure by horizontal transmission. The observed higher seroprevalence in rural dogs suggests the importance of lifestyle and alimentary habits (i.e. aborted foetuses, placentas and small mammals) in the acquisition of N. caninum infection. Our results confirm that dogs are exposed to N. caninum and play an important role in the epidemiology of N. caninum.

ERK1/2 phosphorylation is an independent predictor of complete remission in newly diagnosed adult acute lymphoblastic leukemia

Extracellular signal-regulated kinase-1/2 (ERK1/2) is frequently found constitutively activated (p-ERK1/2) in hematopoietic diseases, suggesting a role in leukemogenesis. The aim of this study was to assess the expression and clinical role of p-ERK1/2 in adult acute lymphoblastic leukemia (ALL). In 131 primary samples from adult de novo ALL patients enrolled in the Gruppo Italiano per le Malattie Ematologiche dell'Adulto (GIMEMA) Leucemia Acute Linfoide (LAL) 2000 protocol and evaluated by flow cytometry, constitutive ERK1/2 activation was found in 34.5% of cases; these results were significantly associated with higher white blood cell (WBC) values (P=.013). In a multivariate analysis, p-ERK1/2 expression was an independent predictor of complete remission achievement (P=.027). Effective approaches toward MEK inhibition need to be explored in order to evaluate whether this may represent a new therapeutic strategy for adult ALL patients.

Management of fluid overload in congestive heart failure: learning from a case report

A case of refractory fluid overload due to congestive heart failure and consequent renal insufficiency is reported. The case was approached multidisciplinarily, at the beginning with conservative and pharmacological therapy, subsequently with extracorporeal fluid removal in which a specific attention was payed to the maintenance of circulating blood volume and achievement of dry weight, and finally with chronic peritoneal dialysis as a maintenance therapy. The case seems to summarize the pathway of many patients seen initially in intensive care and cardiology departments and subsequently in nephrological wards.

Artificial in vivo biofiltration: slow continuous intravenous plasmafiltration (SCIP) and artificial organ support

An intravenous plasmafiltration (SCIP) catheter has been developed and is proposed for clinical investigation into the alleviation of acute fluid overload by SCUF of the extracted plasma. The system utilizes a unique backflushing technique, high intravenous shear flow rates and biocompatible polymers to minimize protein and platelet aggregation along the filter surfaces. The absence of platelets from the extracted plasma promotes the longevity of ultrafiltration cartridges, thus theoretically minimizing attendant labor associated with continuous renal replacement therapies. Clinical studies are currently being planned for the near future. Plasma SCUF is envisioned as a predecessor technology to future applications in therapeutic apheresis, tissue engineering, therapeutic sorbent technologies. Further, with improved longevity profiles, intravenous SCUF or dialysis and implantable or wearable artificial organs based upon artificial in vivo biofiltration are possible.

Survival of elderly patients with acute myeloid leukemia

BACKGROUND AND OBJECTIVES

The prognosis of elderly patients with acute myelogenous leukemia (AML) is usually dismal, while the true survival of older patients not included in clinical trials is not known. We retrospectively evaluated the impact on survival of an aggressive versus a non-aggressive approach in 1005 patients aged >60 years registered in the database of the GIMEMA cooperative group.

DESIGN AND METHODS

Group A patients (n=621) received aggressive treatment, while group B patients (n=384) underwent non-aggressive therapy. The groups were different for risk factor distribution: the patients in group B had a higher median age, worse performance status (PS) and a higher proportion of previous myelodysplastic disease.

RESULTS

The overall median survival was 7 and 5 months in groups A and B, respectively (p min of 0.0001). At multivariate analysis the following factors were associated with a significantly shorter survival: age >71 years (RR=1.27; 95% CI=1.07-1.50), PS=2-4 (RR=1.44; 95% CI=1.24-1.68), white cell count > 10,000 mL (RR=1.37; 95% CI=1.06-1.75), and heart dysfunction requiring treatment (RR=1.26; 95% CI=1.05-1.50). No difference in survival was associated with aggressive or non-aggressive treatment (RR=1.1; 95% CI=0.94-1.32). Patients aged min of 70 years, with no heart disease, but a white cell count > 10,000/mL showed a significantly better survival when treated aggressively (median survival 7 vs 3 months, p = 0.011).

INTERPRETATION AND CONCLUSIONS

Despite an obvious selection of patients with a worse prognosis in group B, the difference in survival between the two groups was marginal. Multivariate analysis failed to demonstrate a significant survival benefit in aggressively treated patients. All these considerations indicate that elderly patients with AML are overall unlikely to benefit from aggressive treatment, so that this should be offered only to selected patients.

Blood flow distribution in a polymyxin coated fibrous bed for endotoxin removal. Effect of a new blood path design

The analysis of flow distribution in cartridges designed for hemoperfusion is extremely important. Taking advantage of a new imaging technique, based on the analysis of a helical scanner-generated imaging sequence, we studied the blood flow distribution in a series of cartridges for extracorporeal removal of endotoxin. Cartridges with improved design were compared to cartridges with a standard design. The improved design consists in a different structure of the holes of the distributor of the flow within the adsorbent unit. Cartridges were studied in vitro with human blood from voluntary donors at blood flows of 100 and 250 ml/min. The progression of density in specific regions of interest (ROI) was analyzed to detect the distribution of the dye injected in the blood circuit. The study demonstrates that both at 100 ml/min and at 250 ml/min of blood flow, the progression of flow appears more homogeneous in the devices with improved design. In detail, the flow distribution measured by the incremental density values detected in the ROIs of the proximal comers (close to the arterial port) and in the ROIs of the central region of the device (close to the inner wall of the case) displays a significant difference between the standard and the improved device. The ROIs studied in the standard devices display a slower increase in density and significantly lower absolute values expressed in Hounsfield units. The experimental method utilized to analyze flow distribution seems to represent an important means to study the performance and design of this type of device.

[Color-Doppler ultrasonography and hypertension. Functional assessment of the renal region]

Color-Doppler US can be used for the morphofunctional assessment of most arterial districts. In hypertension, color-Doppler US can be used to study the renal arteries for both the diagnosis of renovascular hypertension and better physiopathologic assessment of renal arterial blood flow in essential hypertension. To this purpose, we studied renal flow characteristics with the resistive index in both basal conditions and after pharmacologic stimulation with angiotensin-converting enzyme inhibitors. The resistive index was seen to rise in parallel with hypertension severity, as measured by mean arterial pressure; the change was statistically significant (p < 0.05). Values rose step by step from 57.4 (+/- 4.96) in the right renal artery and from 56.6 (+/- 4.18) in the left one in controls, up to 62.2 (+/- 6.6) in the right and 62.3 (+/- 7) in the left renal arteries of severe hypertensives. After pharmacologic stimulation in controls and in mild hypertensives, resistive index values rose significantly (+2.32 +/- 2.1 and +3.5 +/- 5.2, respectively), while in more advanced stages of the disease this index remained unvaried from a statistical point of view (+0.5 +/- 1.7 in moderate and -0.2 +/- 2.1 in severe hypertensives). These data can be explained by reduced capability of renal blood flow autoregulation, as a consequence of a defined vascular damage. In the follow-up of more severe stages of the disease, although pharmacologic treatment had been optimized and mean arterial pressure values reduced (109.08 vs. 118.25 mmHg), even after a prolonged therapeutic wash-out, an abnormal RI response persisted in controls (-1.79 +/- 2.62 vs. -0.94 +/- 1.64), due to persistent arteriolar damage. To date, it is still to be defined if our studies can be applied not only to populations but also to single patients.

Phenotypic and genotypic switch in Philadelphia-positive, BCR-positive blast crisis of chronic myeloid leukemia

We report a case of Ph1-positive, bcr-positive chronic myeloid leukemia blast crisis (CML-BC) which at presentation showed a mixed myeloid/B-lymphoid immunophenotype along with TdT positivity and, at the molecular level, an oligoclonal rearrangement of the immunoglobulin heavy chain (IgH) gene region. After obtaining a successful remission, at the time of relapse the patient underwent a phenotypic and genotypic switch from mixed to myeloid phenotype, characterized by the loss of the lymphoid markers and TdT expression and by a germline configuration of the IgH gene region. The same bcr rearrangement was, however, found in both phases of the disease, supporting the suggestion of a true phenotypic and genotypic conversion. This report confirms that the neoplastic event in CML may take place at an early multipotent stem-cell level, prior to a well-defined phenotypic and genotypic lineage expression. Moreover, it is suggested that different factors (chemotherapy? growth factors?) may have either eradicated the bcr+/IgH+ clone and promoted the growth of bcr+/IgH- leukemic cells or, alternatively, supported the lymphoid differentiation program and induced a myeloid lineage shift.

[Research on the psychological view of maternity in women in the puerperium]

The aim of our research was to observe the ways in which the hospital and the social environment react towards delivery and birth and how pregnant women experience this event from the psychological point of view. A questionnaire was submitted to 58 puerperas at their third-fifth day. From the analysis of the results we can observe that the hospital structure tends to treat this experience as a mechanical and routinary event; this particularly jouful moment which should be a time of celebration is often undervalued. As a matter of fact the hospital does not create an atmosphere of joy which should accompany any event connected with birth and which should be transmitted to the child offering him a sense of confidence from the very first moment of his life. Women are generally the victims of a culture of terror, originated by an ideology of "institutionalism" which tends to regard the process of birth as a medical phenomenon and not as a natural one, and so they prefer to hand over all responsibility to the specialist, instead of taking charge of it themselves. We have also noticed that women very rarely undertake psycho-physical training before the delivery; the reasons may be the culture of terror or also because the training techniques are considered inadequate for the psychological aspects. We have observed that most of all, women are frightened by the delivery itself and of giving birth to a deformed child. Women lack an experience of psychological growth which would help them to reach an emotional maturity. This is necessary to help the child to develop his infinite potential and abilities which he already possesses from the moment he is born and which will help him to face whole heartedly the fascinating albeit painful adventure that is life.

Natural killer cell activity and T subpopulations in thalassemia major

Natural killer (NK) cell activity against K562 cell targets and the distribution of T cell subpopulations were investigated in the peripheral blood of 25 patients affected by beta thalassemia major, 18 clinically healthy heterozygotes, and 25 age-matched normal subjects. It was found that thalassemia major patients display augmented levels of NK activity [specific lysis 41.9 +/- (se) 4.5%], while thalassemic carriers behave as normal controls [specific lysis 34.6 +/- (se) 3.5%]. The increase of NK function was neither related to the splenectomy nor to the siderosis, but rather to the age and the amount of blood units that the patients had received. An imbalance of circulating T subsets with the helper/suppressor cell ratio significantly diminished (p less than 0.001) was also detected in homozygotes but not in carriers. The finding that NK function is enhanced in homozygous beta thalassemia might be of clinical interest in assessing the risk of development of malignancies in these patients.

"In vitro" colony growth of blood T-lymphocytes from B-cell chronic lymphocytic leukemia

T-lymphocyte colony formation in agar culture was investigated in 20 untreated B-cell Chronic Lymphocytic Leukemia (CLL) patients in stage O. As compared to the controls, colony growth was very poor when unseparated peripheral-blood lymphocytes from CLL-patients were seeded. The number of colonies was greatly higher when T-cell enriched fractions from CLL were plated; however, they failed to reach the normal range even in this experimental condition. The role of adherent cells in the colony growth was also investigated. Depletion of these cells resulted in impaired colony generation either in normals or in CLL-patients, which was subsequently restored by the addition of the same adherent cells. In the patients investigated in this study, an imbalance of T-subsets was found with increase of OKT8-positive cells (T-suppressors). When the number of colonies and the percentage of OKT8-positive cells were plotted, an inverse correlation was found. Conversely, a linear relationship was detected between the percentage of OKT4-positive cells (T-helpers) and the values of colonies. On the basis of the present experiments, it is suggested that the defective colony growth of T-cell fractions in B-cell CLL may be related to the low number of OKT4-positive cells plated, which are known to be mainly responsible for the colony generation in agar culture.