Split Hand-Foot and Deafness in a Patient with 7q21.13-q21.3 Deletion Not Including the DLX5/6 Genes

Split Hand-Foot Malformation (SHFM) is a congenital limb defect characterized by a median cleft of the hands and/or feet due to the absence/hypoplasia of the central rays. It may occur as part of a syndromic condition or as an isolated malformation. The most common of the six genetic loci identified for this condition is correlated to SHFM1 and maps in the 7q21q22 region. SHFM1 is characterized by autosomal dominant transmission, incomplete penetrance and variable expressivity. Associated features often include hearing loss, intellectual disability/developmental delay and craniofacial abnormalities. Disruption of the DLX5/DLX6 genes, mapping within the SHFM1 locus, is now known to be responsible for the phenotype. Through SNP array, we analyzed a patient affected by SHFM1 associated with deafness and an abnormality of the inner ear (incomplete partition type I); we identified a deletion in 7q21, not involving the DLX5/6 genes, but including exons 15 and 17 of DYNC1I1, known to act as exonic enhancers (eExons) of the DLX5/6 genes. We further demonstrated the role of DYNC1I1 eExons in regulating DLX5/6 expression by means of showing a reduced expression of the DLX5/6 genes through RT-PCR in a patient-derived lymphoblastoid cell line. Furthermore, our data and a review of published cases do not support the hypothesis that DLX5/6 are imprinted in humans. This work is an example of how the disruption of regulatory elements can be responsible for congenital malformations.

A regional-based newborn hearing screening program: the Emilia-Romagna model after ten years of legislation

Background

Hearing loss, occurring in 1-3/1,000 newborns in the well-babies population, is one of the most common congenital diseases, and hearing screening at birth still represents the only means for its early detection. Since 2011 the Emilia Romagna Regional Health Agency has recommended Newborn Hearing Screening for all babies at its birth points and for newborns moving to the region. The aims of this study are to analyze the results of this regional-based Newborn Hearing Screening program and to discuss the impact of the legislative endorsement on the organization.

Material and methods

This is an observational retrospective chart study. The recordings of well-babies and babies at Neonatal Intensive Care Units were collected during the period from January 1st 2015 to December 31st 2020. The following data were included: Newborn Hearing Screening coverage, percentage of refer at otoacoustic emissions, prevalence and entity of hearing loss, unilateral/bilateral rate, presence of audiological risk factors.

Results

More than 99% of a total of 198,396 newborns underwent the Newborn Hearing Screening test during the period January 1st 2015 to December 31st 2020, with a coverage ranging between 99.6% and 99.9%. Overall, the percentage of confirmed hearing loss cases was about 17-30 % of refer cases, 745 children received a diagnosis of hearing loss (prevalence 3.7/1,000). Considering profound hearing loss cases, these represent 13% of bilateral hearing loss.

Conclusion

A regional-based Newborn Hearing Screening program is valuable and cost-effective. In our experience, the centralization of the data system and of the data control is crucial in order to implement its efficiency and effectiveness. Healthcare policies, tracking systems and public awareness are decisive for a successful programme implementation.

Monitoring of Auditory Function in Newborns of Women Infected by SARS-CoV-2 during Pregnancy

BACKGROUND

Gestational SARS-CoV-2 infection can impact maternal and neonatal health. The virus has also been reported to cause newborn sensorineural hearing loss, but its consequences for the auditory system are not fully understood.

OBJECTIVE

The aim of this study was to evaluate the impact of maternal SARS-CoV-2 infection during pregnancy on newborn' hearing function during the first year of life.

METHODS

An observational study was conducted from 1 November 2020 to 30 November 2021 at University Modena Hospital. All newborns whose mother had been infected by SARS-CoV-2 during pregnancy were enrolled and underwent audiological evaluation at birth and at 1 year of age.

RESULTS

A total of 119 neonates were born from mothers infected by SARS-CoV-2 during pregnancy. At birth, five newborns (4.2%) presented an increased threshold of ABR (Auditory Brainstem Evoked Response), but the results were confirmed only in 1.6% of cases, when repeated 1 month later, while the ABR thresholds in all other children returned to normal limits. At the 1-year follow-up, no cases of moderate or severe hearing loss were observed, while concomitant disorders of the middle ear were frequently observed.

CONCLUSIONS

Maternal SARS-CoV-2 infection, regardless of the trimester in which it was contracted, appears not to induce moderate or severe hearing loss in infants. It is important to clarify the possible effect of the virus on late-onset hearing loss and future research is needed.

P53 SURGICAL CUTDOWN VERSUS PERCUTANEOUS ACCESS IN TRANSFEMORAL TAVI: A RETROSPECTIVE SINGLE–CENTER EXPERIENCE

Background

The transfemoral (TF) approach is the most common route in TAVI, but it is still associated with risk of bleeding and vascular complications. Nowadays, it is not evident a clear superiority of percutaneous (PC) versus surgical cutdown (SC) approach. The aim of our retrospective study is to compare the outcomes of the two different types of accesses.

Methods

From January 2018 to December 2021, 377 patients underwent TF–TAVI. The mean age was of 81,17 ± 8,62 years, with a percentage of female of 55,6%. The mean STS score was of 4,37 ± 2,28. The mean LVEF was of 57,22 ± 9,93%. Forty patients underwent a previous cardiac surgery. Seventeen valve–in–valve procedures were performed. The baseline clinical and echocardiographic data and operative features were prospectively collected. The primary endpoint was 30–day bleeding and vascular complications defined according to VARC–2 criteria. Secondary endpoints were clinical outcomes and in–hospital mortality. The PC group included 246 patients, while the SC group 128 patients.

Results

The baseline characteristics in the two groups were not statistically different, except for male sex (40,9% vs 52,3% p = 0.04) and NYHA Class III–IV (55,8% vs 25,7% p = 0.00) in PC and SC group, respectively (Table 1 and Table 2).

Conclusions

The rates of major vascular complications and major bleeding did not differ statistically between the two groups. The SC approach is associated with a significant lower rate of minor vascular complications, but a higher in–hospital mortality. The choice of the access should probably be based on the operator‘s experience and patient‘s vascular anatomy.

P37 DIAGNOSIS AND TREATMENT OF HUMORAL REJECTION IN HEART–TRANSPLANT PATIENTS: SINGLE CENTER EXPERIENCE

Introduction

Heart Transplantation remains the gold standard treatment for Advanced Heart Failure patients. Antibody–mediated humoral rejection (AMR) is one of the main causes of medium and long–term morbility and mortality. Success, therefore, is strictly connected to the possibility of modulating immune response in the recipient through innovative diagnostic approaches of immunosuppression–therapy tailoring.

Method

Since 2019, San Camillo Hospital’s Heart Transplant Center in Rome has adopted a new integrated protocol for early diagnosis and treatment for humoral rejection which consists of clinical, instrumental and laboratory monitoring through Solid Phase Flow Cytometric Techniques in order to identify Donor Specific Anti–HLA antibodies (DSA) both fixing and not fixing complement (cytotoxicity).

Results

113 transplant patients were studied, resulted negative in prospective crossmatch at the time of surgery. Post–transplant DSA production has been monitored according to ISHLT guidelines in 1, 3, 6, 12 months’–time and, afterwards, once a year or after evidence of clinical symptoms or echocardiographic signs of graft disfunction associated always with biopsy. During the monitored period, 32 patients showed post–transplant DSA: 2 pz (6%) Class I, 16 (50%) Class II, DSA and the last 14 patients (44%) both Class I and II DSA. The capability of fixing complement (cytotoxicity) was evaluated in 19 patients. In 13 cases (68%) DSAs resulted positive for the specific test used (LSA–C1Q). In the aforementioned subgroup AMR incidence was of 23%; no AMR cases were found in the DSA C1q negative group. 3 patients showed clinical–functional deterioration and echocardiographic and bioptical alterations. Usage of apheretic treatment and re–modulation of immunosoppression therapy (FK, MMF or Everolimus) resulted in important reduction in DSAs amount, clinical recovery and echocardiocraphic signs of improvement.

Conclusions

The adopted protocol for monitoring and diagnosis of humoral rejection resulted in early identification of patients at higher risk of early graft failure. This leads to specific diagnostic and therapeutic strategies to improve long–term outcome.

P46 THREE–DIMENSIONAL ECHOCARDIOGRAPHY EVALUATION OF MITRAL VALVE ANATOMY AFTER PERCUTANEOUS EDGE TO EDGE REPAIR

Background

Transcatheter edge–to–edge repair (TEER) is a safe strategy for high–risk patients with significant mitral regurgitation (MR). We aimed to characterize by three–dimensional echocardiography (3D–E) acute reshaping of mitral valve apparatus, with specific reference to the underlying MR mechanism (functional (FMR)and degenerative (DMR))

Methods

We prospectively enrolled 15 patients(November 2020 to September 2021),(median age 81 y.o, range 79–84, 50% male, 1 urgent procedure) with severe mitral valve regurgitation who underwent intra–procedural 3D–E before and after device deployment. Using a dedicated semiautomatic software, we obtain parametric quantification of mitral valve anatomy to describe acute changes in FMR and DMR.

Results

Eight patients (53%) were affected by FMR of whom one case was performed as bridge to heart transplantation candidacy. In the remaining 7 DMR cases, P2 prolapse was present in 5 (71%), commissural flail and A2 flail in 2 cases. Procedural success (MR < 2) was achieved in 14 cases (93%). 30–day survival was 100% in elective cases. A second clip was necessary in 8 patients (53%). After TEER, the FMR group experienced an immediate annular reshaping, with reduction of antero–posterior diameter (p 0.05), next to a recovery of physiological saddle–shape, defined by lower non–planar angle (p = 0.001) and higher annulus height (p ≤ 0.001). The DMR group showed a trend of decrease of maximum annular velocity, addressing a stabilizing effect of the device.The deployment of a second clip has no significant effect of the annular reshaping in both groups.

Conclusions

TEER causes multiple effects on mitral valve geometry which variesaccording to MR mechanism. Three–D parametric quantification of MV anatomy identifiedspecific parameters of acute annular remodeling. FMR exhibited pronounced modification. This “annuloplasty–like” effect may play a role in the late freedom from MR.

Paget's Disease in Gynecomastia: Immunohistochemical Study of a Case

A case of Paget's disease and gynecomastia in a 70-year-old man is reported. Paget's disease was connected to an intraductal carcinoma, and the immunohistochemical study revealed similar positivity for cytokeratin A, carcinoembryonic antigen and epithelial membrane antigen in Paget cells and intraductal neoplastic cells whereas Paget cells resulted negative for cytokeratin B and C. The study using monoclonal anti-cytokeratin A (35 βH11), B (34 βE12) and C (34 βB4) could represent a good tool, supporting the theory of a ductal origin of Paget cells. A review of the literature has shown the rarity of Paget's disease in the male breast and revealed only two previous reports with an associated gynecomastia, in 2 patients with Klinefelter's syndrome and infiltrating breast carcinoma.

Sequential pediatric bilateral cochlear implantation: The effect of time interval between implants

OBJECTIVE

To examine speech intelligibility in children subjected to sequential bilateral cochlear implants (CI) surgery and to assess the influence of the inter-stage interval duration.

INTRODUCTION

Binaural hearing recovery can have additional benefits, especially in speech and language development in patients with congenital profound sensorineural hearing loss; so recently there has been an increase in the number of children receiving bilateral CI.

METHODS

Twenty-seven children who underwent sequential bilateral cochlear implant (SBCI) with a short (1-3 yrs), medium (4-6 yrs) and long (7-12 yrs) range interval between both implantations, respectively, were evaluated. All patients underwent periodic speech perception test in quiet and noise after second implant activation in three conditions: with the first or second implant alone and with both implants. Results were examined according to the inter-stage interval.

RESULTS

Speech intelligibility in noise was significantly better under bilateral conditions than either ear alone, in all three groups. Small improvements were seen in quiet, especially in the third group (6-12 yrs).

CONCLUSION

Benefits of second implant in the early-implanted children and after a short inter-implant delay are more evident. However our study support that, even after a long period of deafness and despite a prolonged inter-stage interval, sequential bilateral cochlear implantation should be considered.

LEVEL OF EVIDENCE

Level 4.

Cerebrospinal Fluid Leak in Cochlear Implantation: Enlarged Cochlear versus Enlarged Vestibular Aqueduct (Common Cavity Excluded)

Objective. To share our experience of cerebrospinal fluid gusher in cochlear implantation in patients with enlarged cochlear or vestibular aqueduct. Study Design. Case series with comparison and a review of the literature. Methods. A retrospective study was performed. Demographic and radiological results of patients with enlarged cochlear aqueduct or enlarged vestibular aqueduct in 278 consecutive cochlear implant recipients, including children and adults, were evaluated between January 2000 and December 2015. Results. Six patients with enlarged cochlear aqueduct and eight patients with enlarged vestibular aqueduct were identified. Cerebrospinal fluid gusher occurs in five subjects with enlarged cochlear aqueduct and in only one case of enlarged vestibular aqueduct. Conclusion. Based on these findings, enlarged cochlear aqueduct may be the best risk predictor of cerebrospinal fluid gusher at cochleostomy during cochlear implant surgery despite enlarged vestibular aqueduct.

Posterior wall as atypical localization of left atrial myxoma : Diagnosis and management

Atrial myxomas are the most common benign cardiac neoplasms. Although the majority occur in the left atrium (LA) and are attached to the interatrial septum (75-80 % of cases), they can arise from any part of the LA and the cardiac chambers. We report the case of a 65-year-old woman who presented with features of worsening dyspnea and persistent headache. During transthoracic echocardiography, a suspected cardiac myxoma was found arising from the posterior wall of the LA.

Untargeted screening of secondary metabolites in fungal cultures and samples from mouldy indoor environments by time-of-flight mass spectrometry

Nowadays, complaints about poor indoor air quality have become common. The variety of indoor air health problems include chronic fatigue, allergy, skin and eye irritation, and can be caused by several factors including fungi and their metabolites present in a building. The objective of this study was to establish a method for untargeted analysis of secondary fungal metabolites in indoor environments. As a detection technique, time-of-flight mass spectrometry was chosen, as it provided mass accuracy and higher sensitivity in full scan acquisition mode compared to tandem mass spectrometers. The method was first applied to fungal cultures, namely Penicillium brevicompactum and Chaetomium murorum, which were isolated from mouldy houses and grown on building materials under laboratory conditions for 7-21 days. Following the proposed strategy based on accurate mass measurement and post-acquisition data processing using principal component analysis, roquefortine C, brevianamide A and mycophenolic acid were identified in Penicillium sp., while chaetoglobosin A was found to be produced by Chaetomium sp. Subsequently, samples from mouldy inhabited buildings were analysed using the developed method. The actual presence of meleagrin was demonstrated in mouldy indoor environment. Applying the method to air and dust samples collected in these mouldy buildings, no metabolites were detected possibly due to generally low concentrations in these types of samples.

[Treatment of sudden sensorineural hearing loss (SSHL) with HELP-apheresis: our experience]

In a specific group of patients affected by sudden sensorineural hearing loss (SSHL) with high plasma levels of LDL-cholesterol and/or fibrinogen, HELP-apheresis treatment makes a difference in hearing recovery and is a further option available in SSHL therapy.

[A pilot study on adolescents of both sexes. Correlation between phenotype, athletic performances and family history to type 2 diabetes]

The authors have studied the influence of family history of type 2 diabetes on the physical phenotype of 47 health adolescents. In both sexes groups with positive family history (FH+) had the highest values of stature and body weight (P<0.05 for males, not significant for females), waist circumference (P<0.05 for males, not significant for females), and wrist circumference (P=0.05 for males, not significant for females). Considering athletic performance, FH+ males showed a significant higher performance in power exercises than FH- males; no significant differences were found between FH+ and FH- female groups. The study confirms that family history of type 2 diabetes can induce in both sexes precocious phenotype and athletic performances linked-related variations; larger studies are necessary to confirm these data and to verify preventive interventions promoting significant life-style changes.

[Endobronchial ultrasonography: a novel technique for investigation of the mediastinum]

Mediastin pathology includes primary lesion and lymph node invasion. The exploration of this anatomical region remains difficult and even hazardous, particularly to obtain histological biopsies. No invasive diagnostic exploration (thorax tomodensitometry and positron emission tomography) allows a histological precision, so mediastinoscopy remains the gold standard in the mediastinum investigation. However, it is not deprived of risk. Recently, guided biopsies and real-time transbronchial needle aspiration by endobronchial ultrasonography (EBUS) have been shown to increase the diagnostic yield over conventional bronchoscopic techniques. Therefore, EBUS is a suitable alternative to mediastinoscopy in the diagnosis of pulmonary or extra-thoracic malignancy, in the staging of mediastinal lymphadenopathy, and in the evaluation of mediastinal response after induction therapy. In the present paper, we present this new diagnostic approach and clarify the current indications of EBUS.

Donor lymphocyte infusions for refractory pure red cell aplasia relapsing after both autologous and nonmyeloablative allogeneic peripheral stem cell transplantation

Pure red cell aplasia (PRCA) is characterized by a selective marrow aplasia of the erythroid compartment. Immunosuppressive therapy achieves good results in about 25% of cases, but relapses are frequent. Autologous or allogeneic haematopoietic stem cell transplantation (HSCT) may be valuable in selected patients. Here, we report details of a 29-year-old woman treated successfully by donor lymphocyte infusions (DLIs) following allogeneic HSCT for acquired refractory relapsed PRCA. The nonmyeloablative conditioning regimen consisted of cyclophosphamide 60 mg/kg/day for 2 days and fludarabine 30 mg/m(2) daily for 4 days. Haematopoiesis was still completely 'recipient' 1 month after allo-HSCT, but progressed to full donor engraftment after three doses of 'escalating' DLI. The possible role of a graft-versus-autoimmunity effect induced by allogeneic HSCT followed by DLI infusions in the treatment of the disease is discussed.

Intense immunosuppressive therapy followed by autologous peripheral blood selected progenitor cell reinfusion for severe autoimmune disease

Autologous stem cell transplantation (HSCT) has been shown to be effective in curing a large spectrum of autoimmune disorders. Case reports are being collected in the EBMT/EULAR Autoimmune Disease Stem Cell Project registry, which reports transplant-related mortality (TRM) of 6%. In order to reduce TRM and preserve the anti-autoimmune effect we evaluated a more immunoablative as opposed to myeloablative conditioning regimen for the autotransplant of severe immunomediated diseases. We enrolled patients affected by systemic lupus erythematosus (SLE: 3 patients), by autoimmune thrombocytopenic purpura (AITP: one patient), by thrombotic thrombocytopenic purpura (TTP: one patient), by pure red cell aplasia (PRCA: one patient), and by a severe cryoglobulinemia (one patient). All patients were mobilized with cyclophosphamide (Cy) 4 g/m2 + G-csf. Conditioning regimen consisted of Cy 50 mg/kg/day (days -6 and -5); anti-T-globulin (ATG) 10 mg/kg/day and 6-methylprednisolone (PDN) 1 g/day (days -4, -3, and -2). Immunomagnetically selected CD34+ cells were re-infused on day 0. In three patients neutrophil count fell below 0.5 x 10(9)/l, while a PLT count below 20 x 10(9)/l was registered in two patients. Extrahematological toxicity was very low. Four patients (2 SLE, 1 TTP, 1 cryoglobulinemia) are in complete corticosteroid-free remission with a median follow up of 335 days. The third SLE patient improved considerably; however, he still needs low-dose corticosteroid maintenance. The AITP and PRCA patients achieved a CR but soon relapsed; nevertheless, the procedure restored a steroid-sensitive status. The use of this immunoablative conditioning regimen in auto-HSCT transplant was shown to be effective in controlling disease progression and could be a valuable strategy in reducing TRM.

Crohn's disease complicated by relapsed extranodal Hodgkin's lymphoma: prolonged complete remission after unmanipulated PBPC autotransplant

Crohn's disease and ulcerative colitis are inflammatory bowel diseases (IBD), which are thought to result from an inappropriate immunologic (autoimmune) response to luminal antibodies. Allogeneic stem cell transplantation (SCT) performed for coincidental diseases is able to cure both leukaemia and Crohn's disease. Autologous SCT is currently performed worldwide for severe autoimmune diseases (SADs) because of its reduced transplant-related mortality (TRM). We report the case of a 30-year-old male patient with a 10-year history of severe Crohn's disease, who developed Hodgkin's disease and received an unmanipulated peripheral blood autologous transplant. Three years after the transplant the patient is in complete treatment-free remission of both diseases.

Effects of calcium and vitamin supplementation on colon cell proliferation in colorectal cancer

Calcium and antioxidant vitamins, such as A, C, and E, have been shown to reduce colorectal epithelial proliferation and thereby to act as possible chemoprotective agents in colorectal cancer. We investigated the effects of an intervention with calcium and vitamins on cell proliferation in the colonic mucosa of patients operated on for colorectal cancer. Patients with resected colorectal cancer Dukes' stage B-C were randomized to receive daily 30,000 IU of axerophthol palmitate (vitamin A) plus 1 g ascorbic acid (vitamin C) plus 70 mg of dl-alpha-tocopherol acetate (vitamin E) and 2 g natural calcium daily or indistinguishable placebo for 6 months. At the time of surgery and after 6 and 12 months of treatment, cell kinetics of normal colonic mucosa were assessed by using proliferating cell nuclear antigen (PCNA). Ninety patients were enrolled and 77 were assessable: 34 in the treatment group and 43 in the placebo group. A significant reduction of mean total PCNA labeling index (PCNALI) was evident in both groups after 6 months (vitamins/calcium, from 16.11 +/- 2.43 to 10.71 +/- 2.81; placebo, from 17.30 +/- 2.63 to 12.53 +/- 3.40). The difference in the percentage of reduction of mean PCNALI between baseline and after 6 months was not statistically significant in the treatment and placebo groups: 34% and 28%, respectively. A second control, 6 months after discontinuation of vitamin and calcium supplementation, showed a further decrease of mean total PCNALI in both groups, but this was not statistically significant. Our randomized trial showed that calcium and vitamin supplementation does not reduce cell kinetics of colon epithelium. Furthermore, this study suggests the need for extreme caution in the interpretation and publication of studies on chemoprotectants in colon cancer without a control group.

Successful treatment of resistant thrombotic thrombocytopenic purpura/hemolytic uremic syndrome with autologous peripheral blood stem and progenitor (CD34+) cell transplantation

The first-line treatment of thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS syndrome) induces a response and survival rate of approximately 85%, even if a considerable number of patients relapse; nevertheless, a number of these patients are resistant to conventional management. Immunoablation followed by stem cell transplantation has been shown to be capable of inducing remissions in a large spectrum of experimental autoimmune disorders. We report here the case of a 20-year-old male patient with the TTP-HUS syndrome who was resistant to conventional treatment and was transplanted with autologous immunoselected CD34+ PBPC after conditioning with cyclosphosphamide, anti-T lymphocyte globulin and prednisone. Seven months after transplant the patient is alive and well, without any further treatment being given.

Autologous peripheral blood stem and progenitor (CD34+) cell transplantation for systemic lupus erythematosus complicated by Evans syndrome

Immunoablation followed by allogeneic stem cell (SC) transplantation has been shown to be capable of curing a large spectrum of experimental autoimmune disorders, hereditary and/or induced. Superimposable results, albeit with some exceptions, have been obtained in human patients affected by coincidental autoimmune and blood diseases. However, both because of encouragine experimental results and of the procedure's greater safety, autologous SC are being increasingly utilized worldwide. Case reports are being collected in the registry of the European Group for Blood and Marrow Transplantation (EBMT)/European League against Rheumatism (EULAR) Autoimmune Disease Stem Cell Project. Among the severe autoimmune diseases (SADs), which are the target of autologous transplantation, severe refractory systemic lupus erythematosus (SLE) is a condition which may benefit from this procedure. We report here the case of a 19 year old female patient with a six year history of SLE with secondary antiphospholipid syndrome (APS), who later developed refractory Evans syndrome. She was transplanted with autologous mobilized CD34+ SC and progenitor cells after conditioning with cyclosphosphamide, anti-T lymphocyte globulin and prednisone. Eight months after transplant, the patient is alive and well, with normal blood counts and persistent low-titre direct antiglobulin (DAT, Coombs) and anti-nuclear antibody (ANA) tests. Anti-double stranded DNA antibody (Anti-dsDNA), lupus anticoagulant tests and anti-cardiolipin antibody (ACA) test are negative.

Low-dose long-term oral idarubicin in maintenance treatment of elderly acute myeloid leukemia

BACKGROUND AND OBJECTIVE

Low-dose long-term oral IDA may play a role in maintainance treatment of elderly patients with AML; in fact, continuous exposure to IDA and IDAol could be efficacious in the disease control possibly inducing cell-differentiation and/or apoptosis.

METHODS

We enrolled 25 previous responder patients in standard induction therapy to receive maintenance oral IDA 5 mg daily on days 1-14 at 2-week intervals for at least 6 months. We also evaluated the cell-cycle and apoptosis in leukemic cells from patients after IDA administration and, as a control, from HL60 lines exposed to IDA and IDAol in vitro.

RESULTS

Long-term long-dose IDA was well-tolerated. Neutrophil and platelet count never below under 1 x 10(9)/L and 50 x 10(9)/L respectively in CR patients, and no infectious complications were encountered. Non-hematological toxicity was also acceptable: easily controlled nausea and vomiting, non-recorded diarrhea or mucositis were reported. The convenience of oral administration contributed to excellent compliance. DNA analysis performed in vivo after IDA and IDAol exposure showed an increase of G2/M cell frequencies and evidence of sub-G1 peak.

INTERPRETATION AND CONCLUSIONS

In conclusion, long-term low doses of oral IDA would appear valuable as a maintenance regimen for elderly patients. Our results seem to confirm the preliminary hypothesis that IDA + IDAol induce an increase of apoptosis in leukemic cells.

Needle liver biopsy in thalassaemia: analyses of diagnostic accuracy and safety in 1184 consecutive biopsies

We report the reliability and safety of percutaneous liver biopsy in the evaluation of hepatic iron loading and histology in patients with homozygous beta-thalassaemia prior to and in serial biopsies following allogeneic bone marrow transplantation for this disorder. 501 thalassaemic patients aged 11 +/- 4.5 years (range 1-32 years) underwent 1184 consecutive percutaneous liver biopsies without ultrasound guidance. Overall, 81% of biopsies were evaluable for histological examination and grading of iron. The adequacy of liver biopsy specimens increased with patient age: evaluable specimens were obtained in 73% of patients < 5 years of age and in 86% of samples in patients aged > 15 years. The degree of iron overload and fibrosis in each biopsy was reported separately by at least two pathologists who did not know the clinical status of each patient. In 103 biopsies, iron grade by light microscopy corresponded to an iron concentration varying between a mean of 32.46 +/- 14 mumol/g dry weight liver tissue for iron stores graded by light microscopy as absent to 417.6 +/- 150 mumol/g dry weight liver tissue for stores graded as severe. The fibrosis score of multiple samples of liver obtained at autopsy within 100 d of the percutaneous biopsy in 41 patients who died following BMT correlated perfectly with that of the first sample in > 60% biopsies; in most of the discordant cases fibrosis had been underestimated in the percutaneous biopsy. Liver biopsy demonstrated evidence of chronic hepatitis in 30% of patients with normal transaminase and in 57% of patients with transaminase within twice the normal range. Liver biopsy was complicated in six patients (0.5%) by haemoperitoneum, periocholecystic haematoma, kidney haematoma, or bile peritonitis; no complication was fatal. These data demonstrate that percutaneous liver biopsy provides reliable information regarding liver iron and histology in homozygous beta-thalassaemia with an extremely low risk of complications.

Angiotropic large-cell lymphoma with predominant kidney involvement. A case report

The authors report a case of non Hodgkin lymphoma which, given its particular course and histomorphological features, can be classified as angiotropic large-cell lymphoma (i.e. proliferating angioendotheliomatosis). The most important characteristic is that the kidney was the target organ in this case, an observation rarely reported in the literature.