Biallelic EPCAM deletions induce tissue-specific DNA repair deficiency and cancer predisposition

We report a case of Mismatch Repair Deficiency (MMRD) caused by germline homozygous EPCAM deletion leading to tissue-specific loss of MSH2. Through the use of patient-derived cells and organoid technologies, we performed stepwise in vitro differentiation of colonic and brain organoids from reprogrammed EPCAMdel iPSC derived from patient fibroblasts. Differentiation of iPSC to epithelial-colonic organoids exhibited continuous increased EPCAM expression and hypermethylation of the MSH2 promoter. This was associated with loss of MSH2 expression, increased mutational burden, MMRD signatures and MS-indel accumulation, the hallmarks of MMRD. In contrast, maturation into brain organoids and examination of blood and fibroblasts failed to show similar processes, preserving MMR proficiency. The combined use of iPSC, organoid technologies and functional genomics analyses highlights the potential of cutting-edge cellular and molecular analysis techniques to define processes controlling tumorigenesis and uncovers a new paradigm of tissue-specific MMRD, which affects the clinical management of these patients.

Somatic health according to people with severe mental disease

OBJECTIVES

Patients with schizophrenia have a 15- to 20-year shorter life expectancy compared with the general population. The aim of this study was to explore these patients' perception of their physical health.

METHODS

A patient reported outcomes measure (PROM) has been developed by patients with severe mental disease. This survey had to better capture undetected, under-rated and non-prioritized physical domains by traditional routine clinical scales that are important for people who live with mental health disease. These patients have tested the applicability of this PROM with peers with severe mental disease in medical, social and community-based centers from Hauts-de-France.

RESULTS

Two and a half years have been required to develop this PROM, to test its applicability to patients with severe mental disease and to analyze the results. The study process has been slowed by the sanitary context induced by the COVID-19 pandemic. Thirty-two questionnaires have been collected by the participants. Despite this low number of data, participants have been satisfied by the results and their experience. The results show that people with severe mental disease consider physical health as a major concern, notably pain and somatic diseases. External factors (such as accessibility to health care and medication) and internal factors (such as self-esteem, cognitive and negative symptoms, sleep, alimentation, and substance use) have been identified as barriers for physical health.

CONCLUSIONS

These results support the development of PROMs highlighting personal experience of people with severe mental disease. The data obtained thanks to these measures will allow to build programs to help them to cope with barriers for physical health.

Five waves of COVID-19 pandemic in Italy: results of a national survey evaluating the impact on activities related to arrhythmias, pacing, and electrophysiology promoted by AIAC (Italian Association of Arrhythmology and Cardiac Pacing)

BACKGROUND

The subsequent waves of the COVID-19 pandemic in Italy had a major impact on cardiac care.

METHODS

A survey to evaluate the dynamic changes in arrhythmia care during the first five waves of COVID-19 in Italy (first: March-May 2020; second: October 2020-January 2021; third: February-May 2021; fourth: June-October 2021; fifth: November 2021-February 2022) was launched.

RESULTS

A total of 127 physicians from arrhythmia centers (34% of Italian centers) took part in the survey. As compared to 2019, a reduction in 40% of elective pacemaker (PM), defibrillators (ICD), and cardiac resynchronization devices (CRT) implantations, with a 70% reduction for ablations, was reported during the first wave, with a progressive and gradual return to pre-pandemic volumes, generally during the third-fourth waves, slower for ablations. For emergency procedures (PM, ICD, CRT, and ablations), recovery from the initial 10% decline occurred in most cases during the second wave, with some variability. However, acute care for atrial fibrillation, electrical cardioversions, and evaluations for syncope showed a prolonged reduction of activity. The number of patients with devices which started remote monitoring increased by 40% during the first wave, but then the adoption of remote monitoring declined.

CONCLUSIONS

The dramatic and profound derangement in arrhythmia management that characterized the first wave of the COVID-19 pandemic was followed by a progressive return to the volume of activities of the pre-pandemic periods, even if with different temporal dynamics and some heterogeneity. Remote monitoring was largely implemented during the first wave, but full implementation is needed.

Implantable defibrillator-detected heart failure status predicts ventricular tachyarrhythmias

Background

The occurrence of ventricular tachyarrhythmias is associated with increased mortality and hospitalizations for heart failure in implantable cardioverter defibrillator (ICD) patients. Nonetheless, the temporal relationship between heart failure worsening and ventricular tachyarrhythmias has been scarcely explored so far.

Purpose

We hypothesized that in patients with heart failure and reduced ejection fraction with ICDs, physiological sensor-based heart failure status, as reflected in the HeartLogic index, would predict appropriate device therapies for ventricular tachyarrhythmias (shocks and antitachycardia pacing).

Methods and results

568 patients implanted with ICDs (n=410, 72%) or cardiac resynchronization therapy-defibrillators (CRT-D, n=158, 28%) endowed with the HeartLogic algorithm were included in this prospective observational multicenter analysis. Over a follow-up of 25 [25th-75th percentile: 15–35] months, 122 (21%) patients received an appropriate device therapy (shock, n=74, 13%), while the HeartLogic index crossed the threshold value 1200 times (0.71 alerts/patient-year) in 370 subjects (65%). The occurrence of at least one HeartLogic alert was significantly associated with both appropriate shocks (HR: 2.44, 95% CI: 1.49–3.97, p=0.003) and any ICD therapies (HR: 1.95, 95% CI: 1.37–2.85, p=0.003). Using a time-dependent Cox model, the weekly IN-alert state was the strongest predictor of ICD shocks (HR: 2.94, 95% CI: 1.73–5.01, p<0.001), after correction for age, secondary prevention, and use of CRT. As compared to clinically stable subjects with no therapies, patients experiencing shocks had significantly higher baseline values of the HeartLogic index, third heart sound amplitude, and respiratory rate. Beginning about one month prior to the arrhythmic event, we noticed further increase of the combined index and the third heart sound amplitude, a decrease of thoracic impedance, and higher resting heart rate (Figure 1).

Conclusions

The HeartLogic index is an independent predictor of appropriate defibrillator therapies. The combined index and its individual physiological components change well before the arrhythmic event, suggesting the existence of a window of opportunity to prevent shocks.

Funding Acknowledgement

Type of funding sources: None.

P-563 The effect of embryo culture time on concordance rates between invasive and non-invasive preimplantation genetic testing for aneuploidies (niPGT-A) in spent culture media (SCM) analysis

Study question

To evaluate different embryo culture times (day5 versus day6) to understand the ideal time-frame for the performance of concordance analysis between invasive and non-invasive PGT-A(niPGT-A)

Summary answer

Different levels of ploidy concordance rates were observed between day5 and day6 groups: 72,6% versus 84,8%, respectively

What is known already

The recent data supports that a non-invasive approach for evaluating embryo ploidy status may be an alternative to standard invasive methods. Embryo cell-free DNA(cfDNA) released into culture media during in-vitro embryo development represents the potential source for this analysis. The release of cfDNA from embryos is expected to be directly proportional to embryo culture time and late-stage released cfDNA may be more representative of the embryo. Therefore, it is important to estimate the most effective time frame of the culture that will provide the most conclusive data from spent-culture-media(SCM) without adversely affecting the development of the embryo

Study design, size, duration

A total of 334 SCM from blastocyst stage embryos have been included in this study. The SCM samples were divided in 2 subgroups according to the embryo culture time as day5 (n = 154) and day6 (n = 180). The cfDNA of SCM samples were amplified by whole genome amplification(WGA) and analyzed by next generation sequencing(NGS) in parallel to day5 or day6 trophectodermal(TE) biopsied samples of their corresponding embryos. Ploidy status and concordance were compared between two groups

Participants/materials, setting, methods

Day3 embryos were washed and transferred in 20µl fresh culture media until the biopsy. SCM samples were collected in PCR tubes and stored at -20 °C while embryos were biopsied for standard PGT-A analysis. Both SCM and corresponding TE biopsy samples were amplified by Sureplex(Vitrolife). Then TE and SCM samples were analyzed by next-generation sequencing(NGS) using MiSeq® System (Illumina). Data analysis has been done by Bluefuse Multi Software 4.5(Illumina) for all SCM and TE samples

Main results and the role of chance

A successful DNA amplification rate (>30ng/µl) was obtained in both day5 and day6 groups with 95,5% (147/154) and 99,4% (179/180) respectively. The DNA concentration after WGA was ranging between 30.1-122.5ng/µl and 38.5-123.2ng/µl in day5 and day6 groups respectively. Not conclusive (NC) results including a noisy NGS profile and chaotic chromosome aneuploidies (>5 chromosomes) were excluded in both groups. Therefore, 64,6% (95/147) of SCM samples in day5 group and 81,0% (145/179) of SCM samples in day6 group were conclusive for NGS analysis. The ploidy concordance rate between SCM and TE samples (euploid vs euploid, aneuploid vs aneuploid) was 72,6% (69/95) in day5 and 84,8% (123/145) in day6 group. In day5 group, the false-negative rate was 10.5% (10/95), and false-positive rate was 16.8% (16/95) while in day6 group the false-negative rate was 6,8% (10/145), and false-positive rate was 8,2% (12/145). Sensitivity and specificity were calculated as 83,6% and 52,9% in day5 group, and 90,9% and 65,7 in day6 group respectively

Limitations, reasons for caution

We have high number of samples in our study, but larger prospective studies may change the significance of ploidy concordance. One of the important issues in SCM analysis is the maternal DNA contamination risk which cannot be revealed always. Therefore the use of molecular markers would increase the reliability

Wider implications of the findings

A non-invasive approach for aneuploidy screening may be an alternative to standard PGT-A procedure with invasive embryo biopsy but the evaluation of ideal culture time is crucial for the performance of niPGT-A method. Our study demonstrates that the late collection time of SCM provides significantly better ploidy concordance rates

Trial registration number

Not applicable

The subcutaneous ICD replacement in the clinical practice: preliminary observations from the multicentre RHYTHM DETECT

Funding Acknowledgements

Type of funding sources: None.

Background

Experience with the subcutaneous implantable cardioverter-defibrillator (S-ICD) is expanding rapidly. However, few data on generator replacement exist.

Purpose

The aim of this analysis was to describe the procedural characteristics of the pulse generator replacement in the current Italian practice and to provide a preliminary insight in the possible acute complications associated with first elective S-ICD generator replacements.

Methods

We analyzed 106 consecutive patients enrolled in the Rhythm Detect registry who underwent elective replacement of the S-ICD generator from September 2019 to July 2021. Procedures were accomplished according to the local clinical practice. A chest X-ray was performed, and the PRAETORIAN score was assessed and compared with the one measured after the first implantation.

Results

All replacements were performed in electrophysiology laboratories, 50% in day-hospital regimen, by 1 or 2 expert operators. Procedures were performed using local (87%) or general anaesthesia (13%). The median procedure duration was 40 (30-45) min. The previous S-ICD generator was in a subcutaneous pocket in 58 (55%) patients, and in an intermuscular pocket in the remaining patients. The PRAETORIAN score of the previous system was low (<90) in 93% of patients and intermediate in 7% of patients. In all patients with the device in an intermuscular pocket, the PRAETORIAN score was <90. During the replacement procedure, 22 S-ICD (3 with PRAETORIAN ≥90 before replacement) were removed from the initial subcutaneous position and placed in an intermuscular pocket. After replacement all patients with intermuscular devices had a score <90, and the overall proportion of patients with low-risk PRAETORIAN score raised to 97%. Defibrillation testing was performed only in 10% of patients, while testing was performed in 77% of patients at the first implantation procedure. No procedure-related complications occurred.

Conclusions

S-ICD replacements seem easy to perform with no peri-procedural complications. The adoption of an intermuscular pocket is associated with optimal positioning according to the PREATORIAN score, and seems preferred also in many cases of generators previously placed subcutaneously. In the Italian clinical practice conversion testing is rarely performed at device replacement.

Device-detected sleep-disordered breathing predicts implantable defibrillator therapy in patients with heart failure

Funding Acknowledgements

Type of funding sources: None.

Background

Sleep-disordered breathing is highly prevalent in heart failure (HF) and it has been suggested as a risk factor for malignant ventricular arrhythmias. The Respiratory Disturbance Index (RDI) algorithm computed by select implantable cardioverter defibrillators (ICDs) can identify severe sleep apnea (SA).

Purpose

In the present analysis we evaluated the association between ICD-detected SA and the incidence of appropriate ICD therapy in patients with HF.

Methods

We enrolled 411 HF patients (age 69±10years, 77% male, ejection fraction 32±8%), implanted with an ICD endowed with an algorithm (ApneaScan, Boston Scientific) that calculates the RDI each night. In this analysis the weekly mean RDI value was considered. The endpoint was the first appropriate ICD shock. The median follow-up was 26 months [25th–75th percentile: 16-35].

Results

During follow-up, one or more ICD shocks were documented in 58 (14%) patients.

Patients with shocks were younger (66±13years versus 70±10years, p=0.038), and more frequently implanted for secondary prevention (21% versus 10%, p=0.026). The maximum RDI value calculated during the entire follow-up period did not differ between patients with and without shocks (55±15episodes/h versus 54±14episodes/h, p=0.539). However, the ICD-detected RDI showed a considerable variability during follow-up. The overall median of the weekly RDI was 33episodes/h [25th–75th percentile: 24-45]. Using a time-dependent Cox regression model, the continuously measured weekly mean RDI≥45episodes/h was independently associated with shock occurrence (HR:4.63, 95%CI:2.54-8.43, p<0.001), after correction for baseline confounders (age, secondary prevention).

Conclusions

In HF patients, patients were more likely to receive appropriate ICD shocks during periods of time when they exhibited more sleep-disordered breathing.

Remotely-driven management of diuretic therapy in heart failure patients with a multiparametric ICD algorithm

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boston Scientific

Background

HeartLogic algorithm combines data from multiple sensors to predict future heart failure (HF) decompensation in patients with an implantable defibrillator (ICD) . An optimal strategy to manage algorithm alerts is not yet known, although decongestive treatment with diuretics is the most frequent alert-triggered action reported so far.

Purpose

We describe the implementation of HeartLogic for remote monitoring of HF patients, and we evaluate the approach to diuretic dosing and timing of the intervention in patients with device alerts.

Methods

The study was conducted in eight Italian high-volume arrhythmia centers. The algorithm was activated in 229 ICD patients during a median follow-up was 17 months [25th–75th percentile: 11-24] between December 2017 and July 2020. Remote data reviews and patient phone contacts were undertaken at the time of HeartLogic alerts, to assess the patient’s status and to prevent HF worsening. The study protocol did not mandate any specific intervention algorithm, and physicians were free to remotely implement clinical actions, to schedule extra in-office visits when deemed necessary for additional investigations or for interventions, or to adopt an active monitoring approach. We analyzed alert-triggered augmented HF treatments, consisting of isolated increases in diuretics dosage.

Results

We reported 242 alerts (0.8 alerts/patient-year) in 123 patients, 137 (56%) alerts triggered clinical actions to treat HF. Overall, timely diuretic changes were associated with a shorter "in-alert" state duration in comparison with late changes, i.e. 28 days [25th-75th percentile: 20-43] versus 62 days [25th-75th percentile: 44-118], p<0.001. By contrast, major and minor diuretic augmentations resulted in comparable durations, i.e. 47 days [25th-75th percentile: 30-58] versus 38 days [25th-75th percentile: 23-79], p=0.954. Of the 56 decongestive treatment adjustments, 47 resolved the alert condition, while in the remaining 9 cases, further treatments were required (augmented HF therapy during hospitalization or unscheduled intravenous decongestive therapy in outpatients). The need of hospitalization for further treatments to resolve the alert condition was associated with higher HeartLogic index values on the day of the diuretics increase (odds ratio: 1.11, 95%CI: 1.02-1.20, p=0.013) and with late interventions (odds ratio: 5.11, 95%CI: 1.09-24.48, p=0.041). No complications were reported after drug adjustments.

Conclusions

Decongestive treatment adjustments triggered by HeartLogic alerts, even when such adjustments were completely dependent on the physicians’ clinical expertise and were not standardized. The early use of decongestive treatment and the use of high doses of diuretics seem to be associated with more favorable outcomes.

P–582 High level of concordance between invasive and non-invasive preimplantation genetic testing for aneuploidies (niPGT-A) at day5 and day6–7

Study question

To explore ploidy concordance between invasive and non-invasive PGTA (niPGT-A) at different embryo culture time.

Summary answer

High level (>84%) of concordance rate for ploidy and sex, sensitivity (>88%), and specificity (76%) were obtained for both day6/7 samples and day5 samples.

What is known already

The analysis of embryo cell free DNA (cfDNA) that are released into culture media during in vitro embryo development has the potential to evaluate embryo ploidy status. However, obtaining sufficient quality and quantity of cfDNA is essential to achieve interpretable results for niPGT-A. More culture time is expected to be directly proportional to the release of more cfDNA. But embryo culture time is limited due to in-vitro embryo survival potential. Therefore, it is important to estimate the duration of the culture that will provide the maximum cfDNA that can be obtained without adversely affecting the development of the embryo.

Study design, size, duration

A total of 105 spent culture media (SCM) from day5-day7 blastocyst stage embryos have been included in this cohort study. The cfDNA of SCM samples were amplified and analyzed for niPGT-A by NGS analysis. The SCM samples were divided into 2 subgroups according the embryo culture hours (Day5 and Day6/7 group). The DNA concentration, informativity and euploidy results have then been compared with their corresponding embryos after trophectoderm biopsy (TE) and PGT-A analysis by NGS

Participants/materials, setting, methods

Embryos cultured until Day3 washed and cultured again in 20µl fresh culture media until embryo biopsy on Day5, 6, or 7. After biopsy SCM samples were immediately collected in PCR tubes and conserved at –20 °C until whole genome amplification by MALBAC® (Yicon Genomics). The TE and SCM samples were analyzed by next-generation sequencing (NGS) using Illumina MiSeq® System. NGS data analysis has been done by Bluefuse Multi Software 4.5 (Illumina) for SCM and TE samples

Main results and the role of chance

Only the SCM samples which have an embryo with a conclusive result were included in this cohort (n = 105). Overall 97.1% (102/105) of SCM samples gave a successful DNA amplification with a concentration ranging 32.4–128.5ng/µl. Non-informative (NI) results including a chaotic profile (>5 chromosome aneuploidies) were observed in 17 samples, so 83.3%(85/102) of SCM samples were informative for NGS data analysis. Ploidy concordance rate with the corresponding TE biopsies (euploid vs euploid, aneuploid vs aneuploid) was 84.7% (72/85). Sensitivity and specificity were 92,8% and 76,7%, respectively with no significant difference for all parameters for day 6/7 samples compared with day 5 samples. The false-negative rate was 3.5% (3/85), and false-positive rate was 11.7% (10/85).

Limitations, reasons for caution

The sample size is relatively small. Larger prospective studies are needed. As this is a single-center study, the impact of the variations in embryo culture conditions can be underestimated. Maternal DNA contamination risk cannot be revealed in SCM, therefore the use of molecular markers would increase the reliability.

Wider implications of the findings: Non-invasive analysis of embryo cfDNA analyzed in spent culture media demonstrates high concordance with TE biopsy results in both early and late culture time. A non-invasive approach for aneuploidy screening offers important advantages such as avoiding invasive embryo biopsy and decreased cost, potentially increasing accessibility for a wider patient population.

Trial registration number

Not applicable

A multiparametric ICD algorithm for heart failure risk stratification and management: an analysis in clinical practice

Funding Acknowledgements

Type of funding sources: None.

Introduction

The HeartLogic algorithm combines multiple implantable cardioverter defibrillator (ICD) sensors to identify patients at risk of heart failure (HF) events.

Purpose

We sought to evaluate the risk stratification ability of this algorithm in clinical practice. We also analyzed the alert management strategies adopted in the study group and their association with the occurrence of HF events.

Methods

The HeartLogic feature was activated in 366 ICD and cardiac resynchronization therapy ICD patients at 22 centers. The HeartLogic algorithm automatically calculates a daily HF index and identifies periods IN or OUT of an alert state on the basis of a configurable threshold (in this analysis set to 16).

Results

The HeartLogic index crossed the threshold value 273 times (0.76 alerts/patient-year) in 150 patients over a median follow-up of 11 months [25-75 percentile: 6-16]. Overall, the time IN the alert state was 11% of the total observation period. Patients experienced 36 HF hospitalizations and 8 patients died of HF (rate: 0.12 events/patient-year) during the observation period. Thirty-five events were associated with the IN alert state (0.92 events/patient-year versus 0.03 events/patient-year in the OUT of alert state). The hazard ratio in the IN/OUT of alert state comparison was (HR: 24.53, 95% CI: 8.55-70.38, p < 0.001), after adjustment for baseline clinical confounders. Alerts followed by clinical actions were associated with a lower rate of HF events (HR: 0.37, 95% CI: 0.14-0.99, p = 0.047). No differences in event rates were observed between in-office and remote alert management. By contrast, verification of HF symptoms during post-alert examination was associated with a higher risk of HF events (HR: 5.23, 95% CI: 1.98-13.83, p < 0.001).

Conclusions

This multiparametric ICD algorithm identifies patients during periods of significantly increased risk of HF events. The rate of HF events seemed lower when clinical actions were undertaken in response to alerts. Extra in-office visits did not seem to be required in order to effectively manage HeartLogic alerts, while post-alert verification of symptoms seemed useful in order to better stratify patients at risk of HF events.

Safety of omitting defibrillation efficacy testing with subcutaneous defibrillators: a propensity matched case-control study

Funding Acknowledgements

Type of funding sources: None.

Background

Defibrillation efficacy testing (DT) is recommended at implantation of subcutaneous implantable cardioverter–defibrillators (S-ICD). However, prior works found that adherence to this recommendation is declining in clinical practice.

Purpose

To compare survival from all-cause death and first ineffective shock (primary endpoint) and the composite of all-cause death, ineffective shock, inappropriate shock and device-related complication (secondary endpoint) between patients who underwent DT and those with omitted DT.

Methods

We analyzed 1652 consecutive patients who underwent S-ICD implantation in 60 Italian centers from 2013 to 2019.

Results

DT was not performed in 325 (20%) patients (no-DT patients). As compared with the DT group, these patients were older (51 ± 16 vs. 48 ± 15 years; p < 0.01) and had lower ejection fraction (37 ± 16% vs. 46 ± 16%; p < 0.01). The 325 no-DT patients were propensity matched with 325 patients of the DT group. During a median follow up of 19 months, 27 (4.2%) patients died for any-cause. During follow-up, 34 (5.2%) patients received appropriate shocks to treat discrete episodes of VT/VF. The first shock was effective in 30 out of 34 patients (88%), whereas a second shock was required to terminate VT/VF in 3 patients and a third shock in the last one. The primary endpoint occurred in 31 (4.8%) patients, and the risk was not significantly increased in the no-DT cohort (HR = 1.26, 95%CI:0.62-2.55, p = 0.522). Inappropriate shocks were reported in 36 (5.5%) patients and device-related complications in 25 (3.8%) patients during follow-up. Survival from the composite secondary endpoint was comparable between groups (HR = 0.86, 95%CI:0.57-1.32, p = 0.500).

Conclusions

Our data confirmed that DT is frequently omitted in current clinical practice, especially in older patients with worse systolic function. A strategy that omits DT did not appear to compromise the effectiveness of the S-ICD and no additional risk seems associated with DT omission at a mid-term follow-up. These data suggest that routine DT at S-ICD implant might not be necessary. Randomized trials are needed to confirm this finding.

P538Single- and Multi-Site Pacing Strategies for Optimal Cardiac Resynchronization Therapy: Impact on Device Longevity and Therapy Cost

Funding Acknowledgements

No funding

Introduction

Multiple left ventricular pacing strategies have been suggested for improving response to cardiac resynchronization therapy (CRT). However, these programming strategies can be obtained by accepting configurations with high pacing threshold and accelerated battery drain. We assessed the feasibility of predefined pacing programming protocols and we evaluated their impact on device longevity and their cost-impact.

Methods

We estimated battery longevity in 167 CRT-D (RESONATE, Boston Scientific) patients based on measured pacing parameters and according to multiple programming strategies: single-site pacing associated with lowest threshold, non-apical location, longest interventricular delay, pacing from two electrodes. To determine the economic impact of each programming strategy, we applied the results of a published model-based cost analysis to a 15-year time-horizon.

Results

Selecting the electrode with the lowest threshold resulted in a median device longevity of 11.5 years. Non-apical pacing and interventricular delay maximization were feasible in most patients (99% non-apical pacing, 65% RV-to-LV interval >80ms), and were obtained at the price of a few months of battery life. Device longevity of >10 years was preserved in 87% of cases of non-apical pacing and in 77% on pacing at the longest interventricular delay. The mean reduction in battery life when the second electrode was activated was 1.5 years. Single-site pacing strategies increased the therapy cost by 4-6%, and multi-site pacing by 12-13%, in comparison with the best-case scenario.

Conclusions

Modern CRT-D systems ensure effective pacing and allow multiple optimization strategies for maximizing service life or for enhancing effectiveness. Single- or multi-site pacing strategies can be implemented without compromising device service life and at an acceptable increase in therapy cost.

Abstract Figure. Image1

P521Conversion test during Subcutaneous Implantable Cardioverter-Defibrillator Implantation in clinical practice: in-hospital and mid-term outcome

Funding Acknowledgements

No funding

OnBehalf

RHYTHM DETECT Registry

Background

With subcutaneous implantable cardioverter–defibrillators (S-ICD), conversion test (CT) is still recommended at implantation. However, prior works found that adherence to this recommendation is declining in clinical practice.

Purpose

To describe current practice regarding CT at S-ICD implantation, and also measure in-hospital outcome of patients who underwent CT and mid-term outcome of patients without CT.

Methods

We analyzed 1652 consecutive patients (49 ± 15 years old, 80% male, 51% with ischemic or non-ischemic dilated cardiomyopathy, 45% with ejection fraction ≤35%) who underwent S-ICD implantation in 60 Italian centers from 2013 to 2019.

Results

CT data were missing in 27 patients. CT was performed in 1300 patients. Successful conversion with ≤65J was obtained in 97.4% of patients. Shock at 80J was not effective in 12 (0.9%) patients. In 10 of these patients the CT was successful after device repositioning, while in 2 patients it was decided to implant a transvenous ICD. Two (0.15%) episodes of electromechanical dissociation (1 fatal) were reported as consequence of CT. CT was not performed in 325 patients (for clinical reasons in 182 patients, for facility preference in 71, ventricular fibrillation not inducible in 72 patients). As compared to the CT group, these patients were older (51 ± 16 vs. 48 ± 15 years; p < 0.01) and had lower ejection fraction (37 ± 16% vs. 46 ± 16%; p < 0.01). 243 non-CT patients had at least 6 months follow-up (median 15 months). In this group, 12 (4.9%) patients had appropriate shocks to treat VT/VF (all successfully terminated with the first shock), and 9 (3.7%) patients had inappropriate shocks.

Conclusions

This analysis showed that CT is frequently omitted in current clinical practice, especially in older patients with worse systolic function. Shocks at CT are very frequently effective and system revision after CT is rarely required. CT is also safe, although serious adverse events cannot be excluded. A strategy that omits CT did not appear to compromise the effectiveness of the S-ICD, but larger populations and longer follow-up are needed to confirm this finding.

P526Are 40 joules enough for successfully defibrillate with subcutaneous implantable cardioverter-defirbrillator?

Funding Acknowledgements

NO FUNDING

OnBehalf

Rhythm Detect Registry

Background

The subcutaneous ICD (S-ICD) is an effective alternative to the traditional transvenous option. Due to its extracardiac design the S-ICD requires a higher shock output than the traditional ICD. Nonetheless, preliminary data suggest that acute defibrillation test may be successful even at energies lower than the usually tested value of 65J, and that optimization of implantation technique may increase the defibrillation safety margin among S-ICD recipients.

Purpose

To evaluate the efficacy of conversion test performed at 40J, and to investigate the association between shock efficacy, clinical characteristics and device position.

Methods

VF was induced and subsequently, conversion test was performed by delivering a 40J shock. Success was defined as termination of VF by the first shock. S-ICD system positioning was evaluated with the PRAETORIAN score using bidirectional chest X-rays. Cranial-caudal S-ICD placement was defined as superior if the entire generator was contained in the cardiac silhouette, inferior if partially or completely outside.

Results

233 consecutive patients (83% male, 49 ± 14 years, BMI 26 ± 4kg/m2, ejection fraction 46 ± 17%, 112 (48%) ischemic/non-ischemic dilated cardiomyopathy) were enrolled and underwent S-ICD implantation with conversion test at 40J. The generator was positioned in an intermuscular pocket in 228 patients (98%). The PRAETORIAN score was <90 (low risk of conversion failure) in 218 (94%) patients. Cranial-caudal generator placement was superior in 188 (81%) patients. Overall, VF termination occurred in 191 (82%) patients with 40J. The BMI was similar in patients with successful and unsuccessful termination (26 ± 4kg/m2 versus 27 ± 6kg/m2, p = 0.195). The efficacy was comparable in patients with dilated cardiomyopathy (86%) versus other conditions (79%, p = 0.153). PRAETORIAN score was not associated with shock efficacy at 40J (82% with score <90 versus 87% with score ≥90, p = 1.000), while a trend toward higher efficacy was seen with superior generator placement (84% versus 73%, p = 0.093).

Conclusions

We observed high S-ICD defibrillation success rate at 40J, suggesting that the safety margin is frequently higher than the usually accepted 15J. We found no difference in efficacy according to the cardiac disease and no association between test failure and body habitus. The intermuscular positioning of the generator resulted in low values of the PRAETORIAN score that however did not appear associated with test efficacy.

855Performance of a multisensor icd algorithm in heart failure patient management

Funding Acknowledgements

No funding

Background

The HeartLogic index combines data from multiple implantable cardioverter-defibrillator (ICD)-based sensors and has proved to be a sensitive and timely predictor of impending heart failure (HF) decompensation.

Purpose

To describe a multicenter experience of remote HF management of patients who received a HeartLogic-enabled ICD or cardiac resynchronization therapy ICD (CRT-D).

Methods

The HeartLogic feature was activated in 104 patients (76 male, 71 ± 10 years, left ventricular ejection fraction 29 ± 7%). In accordance with a standardized follow-up protocol, remote data reviews and patient phone contacts were performed monthly and at the time of HeartLogic alerts (when the index crossed the nominal threshold value of 16), to assess the patient decompensation status. In-office visits were performed every 6 months or when deemed necessary.

Results

During a median follow-up of 13[11-18] months, 100 HeartLogic alerts were reported (0.82 alerts/pt-year) in 53 patients. 60 HeartLogic alerts were judged clinically meaningful (i.e. associated with worsening of HF or resulted in active clinical actions). Specifically, multiple associated conditions were reported: 45 (75%) symptoms or signs of clinical deterioration of HF, 13 (22%) discontinuations or reductions of prescribed HF therapy, 11 (18%) declines in CRT percentage (with or without new onset atrial fibrillation), 8 (13%) recurrences of previous HF events. For 48 out of 60 alerts the clinician was not previously aware of the condition. Of these, 43 alerts triggered multiple clinical actions. Alert-triggered actions were: 30 (70%) diuretic dosage increases, 15 (35%) other drug adjustments, 6 (14%) HF hospitalizations, 3 (7%) device reprogramming/revisions, 1 (2%) cardioversion, 1 (2%) patient education on therapy adherence. Out of 40 non-clinically meaningful alerts (0.33 alerts/pt-year), 8 (20%) were associated with non-HF therapy changes or interventions, 3 (8%) with pulmonary events, 29 (72%) remained unexplained. The overall number of HF hospitalizations was 16 (rate 0.13 hospitalizations/pt-year). Five HF hospitalizations were not preceded by HeartLogic alert (0.04 hospitalizations/pt-year).

Conclusions

The HeartLogic index provided clinically meaningful information and allowed to remotely identify relevant HF related clinical conditions, with a low rate of unexplained detections and undetected HF events. In this experience, remote monitoring using HeartLogic alerts allowed to drive HF care and take effective clinical actions.

Combined flow-based imaging assessment of optimal cardiac resynchronization therapy pacing vector: a case report

Background

There are still many pendent issues about the effective evaluation of cardiac resynchronization therapy impact on functional mitral regurgitation. In order to reduce the intrinsic difficulties of quantification of functional mitral regurgitation itself, an automatic quantification of real-time three-dimensional full-volume color Doppler transthoracic echocardiography was proposed as a new, rapid, and accurate method for the assessment of functional mitral regurgitation severity. Recent studies suggested that images of left ventricle flow by echo-particle imaging velocimetry could be a useful marker of synchrony. Echo-particle imaging velocimetry has shown that regional anomalies of synchrony/synergy of the left ventricle are related to the alteration, reduction, or suppression of the physiological intracavitary pressure gradients.

Case summary

We describe a case in which the two technologies are used in combination during acute echocardiographic optimization of left pacing vector in a 63-year-old man, Caucasian, who showed worsening heart failure symptoms a few days after an implant, and the effect of the device’s optimization at 6-month follow-up.

Discussion

The degree of realignment of hemodynamic forces, with quantitative analysis of the orientation of blood flow momentum (φ), can represent improvement of fluid dynamics synchrony of the left ventricle, and explain, with a new deterministic parameter, the effects of cardiac resynchronization therapy on functional mitral regurgitation. Real-time three-dimensional color flow Doppler quantification is feasible and accurate for measurement of mitral inflow, left ventricular outflow stroke volumes, and functional mitral regurgitation severity.

Conclusion

This clinical case offers an innovative and accurate approach for acute echocardiographic optimization of left pacing vector. It shows clinical utility of combined three-dimensional full-volume color Doppler transthoracic echocardiography/echo-particle imaging velocimetry assessment to increase response to cardiac resynchronization therapy, in terms of reduction of functional mitral regurgitation, improving fluid dynamics synchrony of the left ventricle.

Electronic supplementary material

The online version of this article (10.1186/s13256-019-2048-1) contains supplementary material, which is available to authorized users.

Thyroid Hormone and Thyrotropin Regulate Intracellular Free Calcium Concentrations in Human Polymorphonuclear Leukocytes: In Vivo and in vitro Studies

Intracellular free calcium concentrations ([Ca++]1) were studied in polymorphonuclear leukocytes (PMNs) from 13 athyreotic patients who had been previously treated by total thyroidectomy and radioiodine therapy for differentiated thyroid carcinoma, and from age- and sex-matched euthyroid healthy controls. Patients were studied twice, when hypothyroid (visit 1) and after restoration of euthyroidism by L-T4 TSH-suppressive therapy (visit 2). PMNs from patients at visit 1 had significantly lower resting [Ca++]1 levels compared to both visit 2 and controls. Values at visit 2 did not differ from those of the controls. Stimulus-induced [Ca++]1 rise was also significantly blunted at visit 1 and normalized at visit 2, possibly through a differential contribution of distinct intracellular Ca++ stores, as suggested by the response pattern to the chemotactic agent, N-formyl-Met-Leu-Phe (fMLP), to the selective SERCA pump inhibitor, thapsigargine, and to the mitochondrial uncoupler, carbonyl cyanide p-trifluoromethoxyphenyl-hydrazone (FCCP). In vitro treatment of PMNs from healthy subjects with high TSH concentrations impaired intracellular Ca++ store function. Both resting [Ca++]1 levels and fMLP-induced [Ca++]1 rise increased in the presence either of low-concentration TSH or of T4, but effects of TSH and T4 were not additive. T3, rT3, and TRIAC had no effect. In conclusion, this study provides evidence for a direct relationship between thyroid status and [Ca[Ca++]1 homeostasis in human PMNs, mainly related to direct actions of TSH and T4 on these cells.

Schistocytic anaemia, severe thrombocytopenia, and renal dysfunction: thrombotic microangiopathy due to severe acquired ADAMTS-13 deficiency

We present the case of a woman (age: 64 years) with acute thrombotic microangiopathy due to severe acquired ADAMTS-13 (von Willebrand factor-cleaving protease) deficiency. She was successfully treated with plasma exchange therapy and glucocorticosteroids. She relapsed seven months later, and splenectomy led to lasting remission.

Pathomechanisms of thrombotic thrombocytopenic purpura, especially the role of ADAMTS-13, are discussed and therapeutic measures outlined.

TP53 mutations are early events in chronic lymphocytic leukemia disease progression and precede evolution to complex karyotypes

TP53 abnormalities lead to resistance to purine analogues and are found in over 40% of patients with refractory chronic lymphocytic leukemia (CLL). At diagnosis, no more than 5% of patients carry the 17p deletion, most cases harbour mutations within the other TP53 allele. The incidence of a TP53 mutation as the only alteration is approximately 5%, but this depends on the sensitivity of the technique. Recently, having a complex karyotype has been considered a strong adverse prognostic factor. However, there are no longitudinal studies simultaneously examining the presence of the 17p deletion, TP53 mutations and karyotype abnormalities. We conducted a retrospective longitudinal study of 31 relapsed/refractory CLL patients. Two to six blood samples per patient were analyzed, with a median follow-up of 8 years. In this report, we assessed the sequence of events of TP53 clonal evolution and correlated the presence of TP53 abnormalities to genetic instability during progression and treatment. Next-generation sequencing allowed the early detection of TP53 mutated clones and was able to be performed on a routine basis, demonstrating an excellent correlation between the Illumina and Ion Torrent technologies. We concluded that TP53 mutations are early events and precede clonal evolution to complex karyotypes. We strongly recommend the early and iterated detection of TP53 mutations in progressive cases.

Telangiectases in Venous Insufficiency: Point of Reflux and Treatment Strategy

Objective:

To verify the role of sources of non-saphenous reflux in the appearance of reticular varices and telangiectases in areas other than the lateral venous system of Albanese.

Setting:

Institute of General Surgery and Surgical Specialisations, Interdepartmental Centre of Research, Treatment and Phlebolymphological Rehabilitation, University of Siena.

Patients and methods:

The study was carried out on 106 women aged 18–65 years who were affected by chronic venous insufficiency (CVI) at the Cla-s Ep Asl stage, according to the CEAP classification. The patients had telangiectases (200 telangiectactic areas) and reticular varices of the lower limbs of type II and III of the classification of Weiss, with competent saphenous trunks and a normal deep venous system. Sclerotherapy was therefore performed, after clinical and duplex ultrasound examination. The records of 185 telangiectactic area treated 3 years earlier were reviewed.

Results:

In all cases reticular varices was found together with the telangiectases. In 73.5% (147/200 areas) one or more incompetent perforating veins was found (average diameter 1.6 mm) and in 83.6% (123/147 areas) it was possible to establish that the main source of reflux was in the base of the telangiectasia. Complete elimination of microvarices was achieved in 88% of cases (176/200 areas; average sessions: 3.5). The complications were haemosiderin pigmentation (1.5%, 3/200 areas) and matting (1%, 2/200 areas). In 24 areas resistant to the therapy it was not possible to demonstrate the presence of reflux, while in 24.5% of cases (49/200 areas, average surface 15.4 cm2) two sessions of sclerotherapy were sufficient eventually to obtain (about 4 weeks later) the disappearance of the micro-varices. Follow-up after 3 years revealed the appearance of new telangiectases in 58.9% of cases (109/185 check-ups). Of these 95.4% (104/109) arose in areas other than those treated and therefore only 4.6% (5/109) recurred in the area where the sclerosing treatment had been carried out.

Conclusion:

In CVI all telangiectases are accompanied by reticular varices, even when not visible on clinical examination; in most cases the sources of reflux are distinguishable as incompetent perforating veins and are situated beneath telangiectactic efflorescences.

Expanding the Living Donor Pool "Second Act": Laparoscopic Donor Nephrectomy and ABO-Incompatible Kidney Transplantation Improve Donor Recruitment

BACKGROUND

To safely expand our living donor pool, we recently decided to work on 3 areas: analysis of causes of exclusion of potential donors, the results of which we recently published, introduction of laparoscopic donor nephrectomy (LDN), and ABO-incompatible (ABOi) transplantation. We sought to determine the impact of the new strategy on living donor recruitment and transplantation during over a 10-year period at a single institution.

METHODS

From January 2005 to September 2014, we evaluated 131 living donors. Of these, 80 (61%) were genetically related, 51 (39%) unrelated, 119 (91%) ABO compatible (ABOc), 12 ABOi (9%). The analysis was divided into 2 eras: era 1, 2005-2010 (n = 53) included the use of open lumbotomy and acceptance of ABOc only; and era 2, 2011-2014 (n = 78), which saw the introduction of LDN and ABOi transplantation.

RESULTS

Forty-five (34%) potential candidates successfully donated, 67 (51%) were excluded, and 19 (15%) were actively undergoing evaluation. Overall, 53 potential donors were evaluated in era 1 (8.8 donors/year), 78 in era 2 (19.5 donors/year). There were fewer excluded donors in era 2 vs era 1 (62% era 1 vs 44% era 2), and living donor kidney transplantation (LDKT) significantly increased in era 2 vs era 1 (3.3/year era 1 vs 7.1/year era 2). The establishment of an ABOi LDKT program led to a 15% increase of evaluations in era 2 (12/78 donors).

CONCLUSIONS

LDN along with ABOi LDKT allowed for an improvement in recruitment of living donors and corresponding LDKT.

Hemodynamic overload and intra-abdominal adiposity in obese children: Relationships with cardiovascular structure and function

BACKGROUND AND AIMS

Childhood obesity promotes adverse changes in cardiovascular structure and function. This study evaluated whether these changes are related to intra-abdominal adiposity and associated cardiometabolic risk or to body-size induced hemodynamic overload.

METHODS AND RESULTS

55 obese children/adolescents and 35 healthy-weight controls underwent carotid, cardiac and abdominal ultrasound to assess carotid artery intima-media thickness (IMT), diameter, distension and stiffness, left ventricular (LV) dimension, mass and function and extent of intra-abdominal adiposity. As compared to controls with healthy BMI, obese children had higher systolic blood pressure (BP), stroke volume and lower total peripheral resistance (P < 0.001-0.0001), higher plasma triglycerides, glycated hemoglobin, insulin and HOMA-IR index (P = 0.01-<0.0001), higher carotid IMT, diameter and distension (P < 0.005-0.0005), higher LV diameter, wall thickness and mass (P < 0.001-0.0001), and impaired LV diastolic function assessed by myocardial longitudinal performance (P < 0.005). In entire population, independent determinants of carotid diameter, LV diameter, wall thickness and mass were fat-free mass (or stroke volume, respectively) and BP. Carotid distension was determined by carotid diameter and BP, and carotid IMT by carotid diameter, BP, HDL-cholesterol and glycated hemoglobin. LV diastolic performance was inversely related to preperitoneal fat thickness and plasma insulin levels.

CONCLUSIONS

Obese youths present signs of impaired lipid and glucose metabolism, hyperdynamic circulation and cardiovascular changes. Increase in LV dimensions and mass and in carotid diameter and distension seems to reflect adaptation to body-size induced increase in hemodynamic load, changes in LV diastolic performance a negative impact of intra-abdominal adiposity and associated metabolic risk, and increase in IMT both adaptive remodeling and metabolic risk.

Monoamine oxidase A polymorphism moderates stability of attention problems and susceptibility to life stress during adolescence

Attention problems affect a substantial number of children and adolescents and are predictive of academic underachievement and lower global adaptive functioning. Considerable variability has been observed with regard to the individual development of attention problems over time. In particular, the period of adolescence is characterized by substantial maturation of executive functioning including attentional processing, with the influence of genetic and environmental factors on individual trajectories not yet well understood. In the present investigation, we evaluated whether the monoamine oxidase A functional promoter polymorphism, MAOA-LPR, plays a role in determining continuity of parent-rated attention problems during adolescence. At the same time, a potential effect of severe life events (SLEs) was taken into account. A multi-group path analysis was used in a sample of 234 adolescents (149 males, 85 females) who took part in an epidemiological cohort study at the ages of 11 and 15 years. Attention problems during early adolescence were found to be a strong predictor of attention problems in middle adolescence. However, in carriers of the MAOA-LPR low-activity variant (MAOA-L), stability was found to be significantly higher than in carriers of the high-activity variant (MAOA-H). Additionally, only in MAOA-L carriers did SLEs during adolescence significantly impact on attention problems at the age of 15 years, implying a possible gene × environment interaction. To conclude, we found evidence that attention problems during adolescence in carriers of the MAOA-L allele are particularly stable and malleable to life stressors. The present results underline the usefulness of applying a more dynamic GxE perspective.

Elderly kidney transplant recipient with intermittent fever: a case report of leishmaniasis with acute kidney injury during liposomal amphotericin B therapy

We present a case report of visceral leishmaniasis in an elderly kidney transplant recipient (age, 73 years) with high intermittent fever in the 2 months before admission. Symptoms started 16 years after transplant. The patient received appropriate treatment with liposomal amphotericin and experienced transient increases in serum creatinine levels. Progression to dialysis was avoided with short duration of therapy (5 consecutive days, plus 1 more dose 1 week apart, a schedule alternative to 15-21 days [supported by the literature]) and a temporary reduction in tacrolimus exposure. After 4 months, recurrence of symptoms without other explanation required a second bone marrow aspirate; it revealed the persistence of amastigote forms. Visceral leishmaniasis is a potentially life-threatening infection; to the best of our knowledge, this is the oldest transplanted patient with a case of leishmaniasis described in the literature.

Efficacy and safety of dabigatran in a "real-life" population at high thromboembolic and hemorrhagic risk: data from MonaldiCare registry

OBJECTIVE

Dabigatran is a novel target specific oral anticoagulant for stroke prevention in non valvular atrial fibrillation. Little is still known about its real-world effectiveness and safety in the italian population. Aim of our study was to evaluate the efficacy and safety of dabigatran in a large single-center cohort of "real-life" italian population with non-valvular AF and to compare the results with those obtained from the RE-LY trial and the Medicare study.

PATIENTS AND METHODS

We studied a prospective cohort of 2108 patients (1119 male; mean age 69.4 ± 9.4 years) who started the oral anticoagulant treatment with dabigatran 110 mg twice-daily (DAB 110; N = 1075; 51%) or 150 mg twice-daily (DAB 150; N = 1033; 49%). Follow-up data were obtained trough outpatients visits each 3-6 months for assessing the clinical status, adherence to treatment, occurrence of side effects and major cardiovascular complications.

RESULTS

In DAB 150 group the mean age was 64.9 ± 8.8 years, 56.8% of patients was male. CHA2DS2Vasc Score was ≥ 3 in 94.3% and HAS-BLED was ≥ 3 in 59.7%. In DAB 110 group (N = 1075) the mean age was 73.9 ± 7.5 years; 49.5% of patients was male. CHA2DS2Vasc Score was ≥ 3 in 73.4% and HAS-BLED was ≥ 3 in 87.4% of DAB 110 patients. One patient taking Dabigatran 110 mg bid had ischemic stroke without significantly neurological sequelae. In both groups, no patient experienced hemorrhagic stroke during the follow-up period. 147 patients (6.9%) of MonaldiCare population reported adverse effects from treatment with dabigatran, of whom 121 patients (5.7%) discontinued therapy. We reported one case of subarachnoid hemorrhage (0.05%) in a patient with high thrombo-embolic and high hemorrhagic risk score who was taking dabigatran 150 mg bid and one case (0.05%) of bladder bleeding in a patient who was taking dabigatran 110 mg bid. No major gastrointestinal bleeding was observed in the MonaldiCare population.

CONCLUSIONS

MonaldiCare registry showed a safety profile of both dosages of dabigatran regarding major of fatal bleeding in a "real life" single center italian population at high thromboembolic and hemorrhagic risk. The majority of MonaldiCare patients tolerated dabigatran treatment without significant side effects. The efficacy of dabigatran was demonstrated by very low prevalence of ictus/TIA, also when patients underwent electrical AF cardioversion independently of the transesophageal examination.

Mood and coping in clinically isolated syndrome and multiple sclerosis

OBJECTIVE

Few studies have examined behavioural changes in the early phase of multiple sclerosis (MS). The aim of the study is to investigate mood alterations and to explore coping strategies regarding patients with clinically isolated syndrome (CIS) and relapsing-remitting MS (RRMS).

MATERIALS AND METHODS

The communication of diagnosis was made by one neurologist using a standardized approach. Depression, anxiety and coping questionnaires were filled in within 1 month from the diagnosis and at 3, 6, 12, 18 and 24 months subsequently.

RESULTS

Thirty-nine patients were examined (11 CIS, 28 RRMS), also 39 healthy controls. At entry, patients showed a lower degree of hostile behaviour and a higher level of depression than the controls. At follow-up, a reduction in depression, anxiety and a better coping adjustment was observed. A higher reliance on 'Accepting responsibilities' coping score was seen in patients with higher levels of depression and anxiety. No significant differences were revealed by group comparisons between CIS and RRMS.

CONCLUSIONS

This study highlights transient mood alterations and an improving of adaptive coping over a period of time in patients with CIS and RRMS. Similar emotional reactions and coping in clinical subgroups suggest that these factors are independent from the type of information provided during the communication of the diagnosis.

C-type natriuretic peptide plasma levels are reduced in obese adolescents

The high prevalence of obesity in children may increase the magnitude of lifetime risk of cardiovascular disease (CD). At present, explicit data for recommending biomarkers as routine pre-clinical markers of CD in children are lacking. C-type natriuretic peptide (CNP) is assuming increasing importance in CD; in adults with heart failure, its plasma levels are related to clinical and functional disease severity. We have previously reported five different reference intervals for blood CNP as a function of age in healthy children; however, data on plasma CNP levels in obese children are still lacking. Aim of this study was to assess CNP levels in obese adolescents and verify whether they differ from healthy subjects. Plasma CNP was measured in 29 obese adolescents (age: 11.8 ± 0.4 years; BMI: 29.8 ± 0.82) by radioimmunoassay and compared with the reference values of healthy subjects. BNP was also measured. Both plasma CNP and BNP levels were significantly lower in the obese adolescents compared to the appropriate reference values (CNP: 3.4 ± 0.2 vs 13.6 ± 2.3 pg/ml, p<0.0001; BNP: 18.8 ± 2.6 vs 36.9 ± 5.5 pg/ml, p=0.003). There was no significant difference between CNP values in males and females. As reported in adults, we observed lower plasma CNP and BNP levels in obese children, suggesting a defective natriuretic peptide system in these patients. An altered regulation of production, clearance and function of natriuretic peptides, already operating in obese adolescents, may possibly contribute to the future development of CD. Thus, the availability of drugs promoting the action of natriuretic peptides may represent an attractive therapeutic option to prevent CD.

Choice and standardization of test protocols in cytotoxicology: A multicentre approach

A major problem that interferes with the introduction of in vitro tests for toxicological risk assessment is that of defining reliable standardized protocols. This issue was approached in the present study with an interlaboratory comparison of three cytotoxicity assays detecting chemical toxicity as impairment of cell viability in confluent cultures, reduction of colony forming ability, and inhibition of cell proliferation over 3 days of treatment. The study was performed using V79 cells, which are unable to activate indirectly-acting xenobiotics, and six chemicals with different mechanisms of action: two antioxidants (butylated hydroxyanisole and butylated hydroxytoluene), an inhibitor of protein synthesis (cycloheximide), an alkylating agent requiring metabolic activation (cyclophosphamide), an uncoupler of oxidative phosphorylation (dinitrophenol), and a genotoxic metal salt (potassium dichromate). The three tests produced the same rank of relative toxic potency for the tested chemicals, based on LC(50) values. The cell viability test appeared to be the most suited for the screening of unknown chemicals, given its simplicity and better reproducibility.

Fatigue and its relationships with cognitive functioning and depression in paediatric multiple sclerosis

BACKGROUND

There is limited information on fatigue and its clinical and psychosocial correlates in children and adolescents with multiple sclerosis (MS).

OBJECTIVE

To assess the relationships between fatigue, cognitive functioning and depression in paediatric MS.

METHODS

The study cohort consisted of patients with MS recruited for an Italian collaborative study on cognitive and psychosocial functioning in paediatric MS. The present assessment included evaluation of fatigue on the Pediatric Quality of Life Inventory-Multidimensional Fatigue Scale, cognitive functioning on an extensive neuropsychological battery and depression on the Children's Depression Inventory (CDI). A psychiatric interview through the Kiddie-SADS-Present and Lifetime Version was also administered.

RESULTS

In total, 57 patients with relapsing-remitting MS were compared with 70 healthy controls. Percentages of fatigued patients ranged from 9% to 14% according to self-reports, and from 23% to 39% according to parent reports. Fatigue was significantly related with higher scores on the CDI (p < 0.03). Higher levels of self-reported cognitive fatigue were associated with impaired performance on a problem-solving test, whereas higher levels of parent-reported cognitive fatigue were associated with impairment on tests of verbal learning, processing speed, complex attention and verbal comprehension.

CONCLUSIONS

Our data show that fatigue can affect a sizeable proportion of paediatric MS patients, and confirm the association between fatigue and depressive symptoms in MS. They also highlight the difficulties of fatigue assessment in the paediatric population and provide a few clues to further research in the field.

Phytotreatment of sludges (Phragmites australis) for their reuse in the environment

The aim of this study is the evaluation of the agronomic characteristics acquired by a phytotreated sludge coming from a wastewater treatment plant (WWTP) located in Tuscany (central Italy). The chemical characterization showed values which are within the Italian legislation limits for mixed composts. From an agronomic point of view, the sludge did not present a level of phytotoxicity, as shown by the germination index (GI% = 77). Furthermore, pathogen compounds are inexistent (Escherichia coli < 1,000 CFU/g). Different substrates (obtained by mixing the sludge with sandy agronomic soil - 0.5% w/w, 1% w/w, 2.5% w/w and 5% w/w) were prepared in order to evaluate the best mixture performance in terms of water retention capacity and plant growth. No significant differences were observed for all sludge mixtures. Different plants were tested in plots (Lepidium sativum, Cucumis sativus and Avena sativa). The best plant adaptation, measured as dry biomass production, was observed for Avena sativa. The results obtained underlined that the phytotreatment of sludge can bring about the transformation of sewage sludges into organic products that are reusable in agriculture, if previously mixed with other appropriate materials and taking into account their heavy metal content.