Vaccination for seasonal influenza in patients with cancer: recommendations of the Italian Society of Medical Oncology (AIOM).

BACKGROUND: Influenza virus causes annual epidemics in the winter-spring season with significant morbidity in the general population and important mortality in high-risk groups, including cancer patients. Opinions on the suitability of patients with malignancies not undergoing active treatment and in different phases of antineoplastic therapy, to receive influenza vaccination, vary considerably among oncologists, sometimes even within one center. METHODS: We reviewed available data, including recommendations by national health authorities, on impact of influenza in patients with cancer and their capacity to mount protective immunological responses to vaccination, thus allowing, on behalf of Italian Association of Medical Oncology, to make suitable recommendations for the prevention and treatment of seasonal influenza. RESULTS AND DISCUSSION: Patients with cancer often have disease- or treatment-related immunosuppression, and as a consequence, they may have a suboptimal serologic response to influenza vaccination. The protective effect of the different preparations of influenza vaccines in patients with cancer has not been widely investigated, especially in adult patients harboring solid tumors. The optimal timing for administration of influenza vaccines in patients receiving chemotherapy is also not clearly defined. However, since vaccination is the most effective method, along with antiviral drugs in selected patients, for preventing influenza infection, it has to be recommended for cancer patients. Implementing vaccination of close contacts of oncology patients would be an additional tool for enhancing protection in fragile patient populations.

Investigation of an imported case of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection in Florence, Italy, May to June 2013.

On 31 May 2013, the first case of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection in Italy was laboratory confirmed in a previously healthy adult man, who developed pneumonia with moderate respiratory distress after returning from a holiday in Jordan. Two secondary cases were identified through contact tracing, among family members and colleagues who had not previously travelled abroad. Both secondary cases developed mild illness. All three patients recovered fully.

Ventricular tachycardias above the initially programmed tachycardia detection interval in patients with implantable cardioverter-defibrillators: incidence, prediction and significance.

OBJECTIVES: This retrospective study was performed to provide data on ventricular tachycardias (VT) with a cycle length longer than the initially programmed tachycardia detection interval (TDI) in patients with implantable cardioverter defibrillators (ICDs). BACKGROUND: It has been clinical practice to program a safety margin of 30 to 60 ms between the slowest spontaneous or inducible VT and the TDI. METHODS: Baseline characteristics of 659 consecutive patients with ICDs were prospectively; follow-up information was retrospectively collected. RESULTS: During a mean follow-up of 31+/-23 months, 377 patients (57.2%) had at least one recurrent VT or ventricular fibrillation; 47 patients (7.1%) suffered 61 VTs above the TDI. The risk of a VT above the TDI ranged between 2.7% and 3.5% per year during the first four years after ICD implantation. The difference between the cycle length of the slowest VT before ICD implantation, spontaneous or induced, and the first VT above TDI was 108+/-58 ms. Fifty-four VTs (88.5%) above the TDI were associated with significant clinical symptoms (angina or palpitation 63.9%, heart failure 6.6% and syncope 8.2%). Six patients (9.8%) had to be resuscitated. Kaplan-Meyer analysis identified New York Heart Association class II or III (p = 0.021), ejection fraction < 0.40 (p = 0.027), spontaneous (p<0.001) or inducible (p<0.001) monomorphic VTs and the use of class III antiarrhythmic drugs (amiodarone, p<0.001; sotalol, p = 0.004) as risk predictors of VTs above the TDI. The risk of recurrent VTs above TDI was 11.8%, 12.5% and 26.6% during the first, second and third year after first VT above TDI, respectively. CONCLUSIONS: The risk of VTs above the TDI is significantly increased in some patients, and many VTs above TDI cause significant clinical symptoms. A larger safety margin between spontaneous or inducible VTs and the TDI seems to be necessary in selected patients. This is in conflict with an increased risk of inadequate episodes and demands highly specific and sensitive detection algorithms in these patients.

Syncope in patients with an implantable cardioverter-defibrillator: incidence, prediction and implications for driving restrictions.

OBJECTIVES: This retrospective study was undertaken to provide information on occurrence, risk prediction and prevention of syncope in patients with an implantable cardioverter-defibrillator (ICD). BACKGROUND: ICDs effectively terminate ventricular tachycardia and fibrillation (VT/VF). Incapacitating symptoms, such as syncope, may still occur. METHODS: We performed a retrospective analysis of data from 421 patients (clinical history, outpatient chart reviews and episode data) with mean (+/-SD) follow-up of 26 +/- 18 months. RESULTS: Of 421 patients, 229 (54.4%) had recurrent VT/VF, and 62 (14.7%) had syncope. The actuarial survival rate free of VT/VF was 58%, 45% and 37% and that for survival free of syncope was 90%, 85% and 81% at 12, 24 and 36 months after implantation, respectively. Once VT/VF had occurred, 76%, 68% and 62% of patients remained free of syncope during the following 12, 24 and 36 months, and 68%, 64% and 56% remained free of second syncope 12, 24 and 36 months after first syncope, respectively. In cases of syncope, the mean cycle length (CL) of VT was 251 +/- 56 ms. A low baseline left ventricular ejection fraction (LVEF), induction of fast VT (CL <300 ms) during programmed ventricular stimulation and chronic atrial fibrillation (AF) were associated with an increased risk of syncope. If the LVEF was >40%, fast VT had not been induced, and patients had no chronic AF; 96%, 92% and 92% of patients remained free of syncope after 12, 24 and 36 months, respectively. Once patients had a VT recurrence, syncope during the first VT and a high VT rate were the strongest risk predictors of future syncope. CONCLUSIONS: Identification of patients with an ICD with a low and high risk of syncope seems to be feasible and might help as a guide to driving restrictions in such patients.

Influence of host species on the evolution of the nonstructural (NS) gene of influenza A viruses.

The matrix (M) and nonstructural (NS) genes of influenza A viruses each encode two overlapping proteins. In the M gene, evolution of one protein affects that of the other. To determine whether or not this evolutionary influence operating between the two M proteins also occurs in the NS gene, we sequenced the NS genes of 36 influenza A viruses isolated from a broad spectrum of animal species (wild and domestic birds, horses, pigs, humans, and sea mammals) and analyzed them phylogenetically, together with other previously published sequences. These analyses enabled us to conclude the following host species-related points that are not found in the other influenza A virus genes and their gene products. (1) The evolution of the two overlapping proteins encoded by the NS gene are lineage-dependent, unlike the M gene where evolutionary constraints on the Ml protein affect the evolution of the M2 protein (Ito et al.. J. Virol. 65 (1991) 5491 5498). (2) The gull-specific lineage contained nonH13 gull viruses and the non-gull avian lineage contained H13 gull viruses, indicating that the gull-specific lineage does not link to the H13 HA subtype in the NS gene unlike findings with other genes. (3) The branching topology of the recent equine lineage (H7N7 viruses isolated after 1973 and H3N8) indicates recent introduction of the NS, M, and PB2 genes into horses from avian sources by genetic reassortment.

Percutaneous transluminal angioplasty versus surgery for subclavian artery occlusive disease.

Twenty-one patients who underwent percutaneous transluminal angioplasty (PTA) for proximal stenosis of the subclavian artery were compared with 15 patients who underwent carotid subclavian reconstruction. This represents the first attempt to directly compare the two procedures. All patients had routine Doppler examination during follow-up. Mean follow-up was 30 +/- 24 months after PTA and 40 +/- 25 months after surgery. The incidences of procedural complications were similar (PTA one complication, surgery two complications). Although better early results were achieved in patients who underwent PTA (actuarial patency: PTA 91 percent, surgery 87 percent), after dilatation, we observed a continuous deterioration of the hemodynamic status of the artery, which led to a high rate of late restenosis (actuarial patency: PTA 54 percent, surgery 87 percent). There were no significant changes postoperatively. The specific role of each procedure is analyzed in view of the new acknowledgment of the clinical importance of proximal subclavian artery disease.

First recovery of A/equine/Fontainebleau/1/79 influenza viruses in Italy.

In Italy epizootics of equine influenza often occur, but no virus isolation has been reported since 1971. This paper describes the antigenic and biochemical characterization of two equine influenza viruses isolated in Italy from 1985 to 1989. The virus isolates were shown to differ antigenically from earlier strains of the same subtype, A/equine/Miami/1/63 (H3N8). Monoclonal antibody analysis showed that the haemagglutinins of these strains were serologically indistinguishable from A/equine/Fontainebleau/1/79, a variant of A/equine/Miami, never isolated in Italy before. One of the two virus isolates was obtained from a horse immunized with a bivalent inactivated influenza vaccine, not containing A/equine/Fontainebleau/79 antigens. The vaccine failure underlines the importance of antigenic relatedness between currently circulating viruses and vaccine strains. Therefore, to improve the protection afforded by equine immunization, the vaccine composition should be decided according to the results of a virological surveillance activity, systematically conducted among horses.

Iopamidol 150 in intra-arterial digital angiography of the peripheral vasculature: a comparative study.

The results of a comparative double-blind clinical trial involving peripheral intra-arterial DSA performed with low iodine iopamidol concentrations (150 and 200 mg. I/ml.) are reported. Forty-six patients were examined for vital signs, local (heat and pain sensations) and systemic reactions and monitored throughout the procedure. No untoward effect was observed apart from mild local reactions, which on the other hand did not produce any movement artifacts. Image quality was good to optimal in 98% of the cases. In no case were higher concentrations of contrast medium (cm) needed. No significant differences between the two concentrations of cm used were observed with respect to either contrast ability or tolerability.

A new ePTFE stretch graft for aorto-iliac reconstructions. Surgical evaluation and one year follow-up with magnetic resonance imaging.

Since its introduction at the beginning of the 60s Dacron has proved to be a reliable and durable substitute for aortic reconstructions. It is however susceptible to late thrombosis, infection and aneurysmal dilatation in a significant number of cases. ePTFE vascular prosthesis, introduced in 1972, have proved to perform well for peripheral reconstructions and was used in aortoiliac position since 1980. In 1991 a new type of ePTFE rendered longitudinally extensible (Gore-Tex Stretch) was introduced into clinical practice. The aim of this study is to evaluate surgical performance, short term patency and interaction with periprosthetic tissues of Gore-Tex Stretch straight and bifurcated prosthesis. Between October 1991 and December 1993, 59 patients underwent aortic reconstruction at our Institution either for infrarenal aortic aneurysm (19 patients, 16 males, 3 females, mean age 68.8 +/- 8.5 years) or for aortoiliac occlusive disease (40 patients, 36 males, 4 females, mean age 60.5 +/- 7.2 years). Forty-eight bifurcated and eleven straight grafts were implanted using Gore-Tex sutures. Preoperative workup included Ultrasonography, Magnetic Resonance Imaging (MRI) in patients with aneurysms and Intra Arterial Digital Subtraction Arteriography (DSA) in patients with occlusive disease. Intraoperative parameters were recorded. Postoperative follow-up included ultrasonographic evaluation at 1st and 7th day, 15th postoperative week and at 3 monthly intervals; Intra Venous DSA before dismission and MRI at the 1st and 15th postoperative week. Intraoperatively the grafts proved to be soft and flexible with good handling and suturing characteristics. Perioperative bleeding was 480 +/- 299 ml for occlusive disease cases and 633 +/- 314 for aneurysm cases. No operative mortality was recorded.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical treatment and prognostic variables of hepatocellular carcinoma in 122 cirrhotics.

A 10-year experience in surgical treatment of HCC in 122 cirrhotic patients has been reviewed in order to evaluate: perioperative mortality and morbidity, survival rates and prognostic variables by multiple-logistic analysis. Mortality rate declined from 7% in period 1983-88 to 2% in period 1989-92. Operative complications also decreased from 46% to 30%. The 3-year and 5-year overall survival rates were 42.6% and 23.3%. The 3-year and 5-year survival of patients who died only for HCC was 51.1% and 34.2% and the disease-free survival 30.6% and 19.1%. The good results of overall survival were vanished by the high rate of recurrence (19.1%). Multiple logistic regression analysis for the probability of mortality was significant for satellite nodules (RR 2.437), microvascular infiltration (RR 2.432), tumor size (RR 1.147); the model for the probability of recurrence was significant for microvascular infiltration (RR 2.290), satellite nodules (RR 2.280), lesions number (RR 2.216) and tumor size (RR 1.247).

[Coarctation and hypoplasia of the abdominal aorta]. / Coartazione ed ipoplasia dell'aorta addominale.

In this study we report one case of abdominal aortic coarctation of unknown etiology, probably congenital or connatal, and two cases of aortoiliac occlusion in young non-diabetic patients, with an intrinsically small aortoiliac tree. These syndromes usually appear in young age; the principal clinical features are arterial insufficiency involving the lower extremities, often well tolerated, and hypertension. The differential diagnosis is with primitive atherosclerotic or inflammatory pathology. Echography and Doppler-echography can be helpful in the diagnosis, but intra arterial digital angiography is mandatory in confirming it. Medical therapy is usually unsuccessful, especially in controlling blood pressure, therefore surgery still remains the treatment of choice, together with PTA that can be applicable in selected cases.

[Abdominal abscesses: their treatment and the study of prognostic factors]. / Ascessi addominali: trattamento e studio dei fattori prognostici.

The aim of this study is to define outcome predictors that might influence the prognosis and the mortality rate either of percutaneous drainage (DP) or open surgical drainage (DC) for abdominal abscesses. Seventy-one patients with 81 intra-abdominal abscesses were prospectively studied. They were 40 males and 31 females. Mean age was 47 +/- 15 years. Thirty-six (50.7%) patients had a simple abscess, while 35 (49.2%) had a complex abscess. Abscesses occurred most commonly in the sub-hepatic area, pelvic and para-colic space. Thirty-two (45%) patients had a percutaneous drainage, while 39 (54.9%) underwent an operative drainage management. Criteria for treatment selection were not randomized. However the two groups were statistically similar in respect to clinical features, cirrhosis, nutritional status, APACHE II scores), genesis and characteristics (simple, complex) of the abscesses. The treatment was considered successful when not requiring further drainage and the patient survived. Abdominal abscesses were cured in 53 (74.6) patients. In 13 cases (18.3%) a further drainage was necessary to obtain a complex resolution. Post drainage complications were significantly higher in the surgical drainage group (38.4% vs 12%, p < 0.05) because of the high incidence of wound infections. The overall mortality rate was 7%. Using an univariate analysis model, the only significant variable related to unsuccessful outcome in both the percutaneous and surgical group was abscess complexity (p < 0.005). Elderly (p < 0.005), malnutrition (p < 0.03), presence of cancer (p < 0.05), a high APACHE II score (p < 0.005) and the presence of a complex abscess (p < 0.02) were significantly identified as determinants of death.

[Conservative treatment of postoperative pancreatic fistula. Role of interventional radiology]. / Trattamento conservativo della fistola pancreatica postoperatoria. Ruolo della radiologia interventistica.

OBJECTIVE: To assess the role of interventional radiology in the conservative treatment of postoperative pancreatic fistula. CASE REPORT: A case of a high flow mixed entero-bilio-pancreatic fistula caused by dehiscence of pancreatic-jejunal anastomosis after duodenocephalopancreasectomy for endocrine neoplasm of the head of the pancreas, SETTING: General Surgery Division and Diagnostic Radiology. CONCLUSIONS: Conservative treatment represents at the time being, due to the current possibilities in assisting critical patients and in controlling pancreatic secretory activity, the first choice in pancreatic fistula treatment. The effectiveness of this treatment depends on the severity of inflammatory disease of the pancreas. Clinical (Ranson, Glasgow, APACHE II) and radiological (Balthazar, Vernacchia) parameter evaluation is a critical step in therapeutic choice. Surgery should be used in patients with severe pancreatitis. Conservative treatment represents the first choice in stable and critical patients with mild pancreatitis.

[The surgical treatment of inflammatory aneurysms of the abdominal aorta. The usefulness of nuclear magnetic resonance (MR) in the preoperative diagnosis]. / Trattamento chirurgico degli aneurismi infiammatori dell'aorta addominale. Utilità della risonanza magnetica nucleare (RM) nella diagnostica preoperatoria.

Inflammatory abdominal aortic aneurysms (IAAA) represent a peculiar variant compared with the common atherosclerotic origin of aortic aneurysms. Between January 1988 and March 1992, 111 aneurysmectomies were performed at our institution: 98 elective and 13 emergency procedures. In 10 cases (all males, mean age 68.5) an IAAA was found. 8/10 of those patients operated upon electively were studied preoperatively with MRI. All the IAAA but one were correctly identified preoperatively. Identification of IAAA with MRI in these cases improved the surgical approach. In conclusion, patients with IAAA can be operated upon safely especially if a preoperative diagnosis is present. MRI greatly improves our ability to characterize non invasively IAAA.

[Treatment of obliterating arteriopathies of the lower limbs using angioplasty. Comparison of 2 techniques of recanalization: Nd-YAG laser and radiofrequency thermal probe]. / Trattamento delle arteriopatie obliteranti degli arti inferiori mediante angioplastica assistita. Confronto fra due tecnologie di ricanalizzazione: Laser Nd-YAG e thermoprobe a radiofrequenza.

The Authors report their experience about 20 cases of femoro-popliteal revascularization: in 15 cases a Nd-YAG Laser was used; in 5 cases a unity which employs radiofrequency energy to heat the tip (Thermoprobe) was utilized. We obtained an immediate recanalization in 19 out of 20 superficial femoral arteries with two early thrombosis. In 12 patients of the first group a significant increase of the ankle-brachial index (45%) was seen; it remained unchanged during the follow-up. We had successful revascularization in all the 5 patients of the second group (Thermoplaster). In selected cases, when the lesion is shorter than 10 cm, not completely calcified, and there is a valid run-off, Laser angioplasty could be a valid alternative to surgery or medical therapy.

[Failed dissolution of a gallstone by methyl tert-butyl ether: importance of predicting gallstone chemical composition]. / Mancata dissoluzione di un calcolo colecistico con metil-tert-butil-etere: l'importanza di predire la composizione chimica del calcolo.

In December 1986 we attempted direct chemical litholysis using methyl-tertiary-butyl-ether (MTBE) in a sixty-year-old man with severe ischemic heart disease who had suffered frequent episodes of biliary colic due to a radiolucent gallstone. MTBE was infused for a total of 17 hrs over a period of 5 days; however the gallstone diameter remained unchanged. The patient was subsequently cholecystomized and chemical analysis revealed that the gallstone was a pigment stone. The need for accurate prediction of gallstone composition before beginning an invasive, such as MTBE infusion, is emphasized.

[Incidental findings in cardiology. Diagnosing today what can cause illness tomorrow]. / Zufallsbefunde in der Kardiologie. Heute diagnostizieren, was morgen krank macht.

Among the anatomical and functional findings in cardiology, congenitally corrected transposition of the major vessels (ventricular inversion), bicuspid aortic valve and prolapse of the mitral valve with simultaneous mitral insufficiency have at least a potential for causing future problems. In such cases, regular cardiological checks or a further diagnostic work-up is to be recommended. The assessment of cardiac sounds can usually be correctly interpreted on the basis of the history, physical examination and auscultation. Among the electrocardiological findings, complete left bundle-branch block and prolongation of the QT segment, mandate clarification of a structural heart condition. Furthermore, in the event of ventricular extrasystoles, right-ventricular cardiomyopathy needs to be excluded. Such isolated conduction disorders as left-anterior fascicular block or right bundle-branch block are of no prognostic significance.

Induction of antibodies and T cell responses by a recombinant influenza virus carrying an HIV-1 TatΔ51-59 protein in mice.

Recombinant influenza viruses hold promise as vectors for vaccines to prevent transmission of mucosal pathogens. In this study, we generated a recombinant WSN/TatΔ(51-59) virus in which Tat protein lacking residues 51 to 59 of the basic domain was inserted into the N-terminus of the hemagglutinin (HA) of A/WSN/33 virus. The TatΔ(51-59) insertion into the viral HA caused a 2-log reduction in viral titers in cell culture, compared with the parental A/WSN/33 virus, and severely affected virus replication in vivo. Nevertheless, Tat-specific antibodies and T cell responses were elicited upon a single intranasal immunization of BALB/c mice with WSN/TatΔ(51-59) virus. Moreover, Tat-specific immune responses were also detected following vaccine administration via the vaginal route. These data provide further evidence that moderately large HIV antigens can be delivered by chimeric HA constructs and elicit specific immune responses, thus increasing the options for the potential use of recombinant influenza viruses, and their derivatives, for prophylactic and therapeutic vaccines.