Association between plasma monocyte chemoattractant protein-1 concentration and cardiovascular disease mortality in middle-aged diabetic and nondiabetic individuals

OBJECTIVE

Monocyte chemoattractant protein-1 (MCP-1/CCL2) is a chemokine involved into the pathogenesis of atherosclerosis and has prognostic value in the acute and chronic phases in patients with acute coronary syndromes.

RESEARCH DESIGN AND METHODS

MCP-1/CCL2 concentration was measured in plasma fractions of 363 middle-aged overweight/obese individuals (aged 61 +/- 12 years, BMI 30.1 +/- 6.6 kg/m(2), 15% with type 2 diabetes, and 12% with impaired glucose tolerance) of a population survey carried out in 1990-1991 in Lombardy, Italy (Cremona Study), and cardiovascular disease (CVD) mortality was assessed in 2006 through Regional Health Registry files.

RESULTS

At baseline MCP-1/CCL2 was increased in individuals with type 2 diabetes (P < 0.05) and showed significant correlations with biochemical risk markers of atherosclerosis. After 15 years, among the 363 subjects, there were 82 deaths due to CVD. In univariate analysis age, sex, fasting glucose and insulin, fibrinogen, glucose tolerance status, smoking habit, and MCP-1/CCL2 were associated with CVD mortality. Age, sex, fasting serum glucose, MCP-1/CCL2, and smoking habit maintained an independent association with CVD mortality in multiple regression analysis. In a subgroup of 113 subjects in whom data for C-reactive protein (CRP) were available, its level was not predictive of CVD mortality.

CONCLUSIONS

In middle-aged overweight/obese individuals MCP-1/CCL2 was independently associated with CVD mortality. Further studies will be necessary to establish its role as a surrogate biomarker and as a potential therapeutic target.

Comparison of VerifyNow-P2Y12 test and Flow Cytometry for monitoring individual platelet response to clopidogrel. What is the cut-off value for identifying patients who are low responders to clopidogrel therapy?

Background

Dual anti-platelet therapy with aspirin and a thienopyridine (DAT) is used to prevent stent thrombosis after percutaneous coronary intervention (PCI). Low response to clopidogrel therapy (LR) occurs, but laboratory tests have a controversial role in the identification of this condition.

Methods

We studied LR in patients with stable angina undergoing elective PCI, all on DAT for at least 7 days, by comparing: 1) Flow cytometry (FC) to measure platelet membrane expression of P-selectin (CD62P) and PAC-1 binding following double stimulation with ADP and collagen type I either in the presence of prostaglandin (PG) E₁; 2) VerifyNow-P2Y₁₂ test, in which results are reported as absolute P2Y₁₂-Reaction-Units (PRU) or % of inhibition (% inhibition).

Results

Thirty controls and 52 patients were analyzed. The median percentage of platelets exhibiting CD62P expression and PAC-1 binding by FC evaluation after stimulation in the presence of PG E₁ was 25.4% (IQR: 21.4–33.1%) and 3.5% (1.7–9.4%), respectively. Only 6 patients receiving DAT (11.5%) had both values above the 1^st quartile of controls, and were defined as LR. Evaluation of the same patients with the VerifyNow-P2Y₁₂ test revealed that the area under the receiver-operating-characteristic (ROC) curve was 0.94 (95% CI: 0.84–0.98, p < 0.0001) for % inhibition and 0.85 (0.72–0.93, p < 0.005) for PRU. Cut-off values of ≤ 15% inhibition or > 213 PRU gave the maximum accuracy for the detection of patients defined as having LR by FC.

Conclusion

In conclusion our findings show that a cut-off value of ≤ 15% inhibition or > 213 PRU in the VerifyNow-P2Y₁₂ test may provide the best accuracy for the identification of patients with LR.

Chronic kidney disease classification stratifies mortality risk after elective stent graft repair of the thoracic aorta

OBJECTIVE

Risk factors for perioperative and late mortality after thoracic endovascular aortic repair (TEVAR) remain ill-defined. In this study, we examined the prognostic significance of chronic kidney disease (CKD), a well-known predictor of death after thoracic aorta open repair, employing a stratification based on CKD stages derived from glomerular filtration rate (GFR) values.

METHODS

A prospective database was evaluated for 179 consecutive patients electively submitted to TEVAR between 1999 and 2007. Preoperative GFR was estimated by using the Cockcroft-Gault equation. Patient groups were stratified into four quartiles by baseline serum creatinine (SC) and GFR values, with quartile I being the lowest, and quartile IV the highest, and into the five CKD stages in reverse order (I GFR >or= 90 ml/min/1.73 m(2); II 60-89; III 30-59; IV 15-29; V < 15). Prognostic significance of preoperative GFR values and CKD stages were investigated by means of univariate and multivariate analyses, and the Kaplan-Meier log-rank method.

RESULTS

A primary technical success was achieved in 166 of 179 patients (92.7%), and an initial clinical success in 158 (88.3%). Thirty-day mortality was 5% (nine cases). Paraplegia or paraparesis were observed in 11 (6.1%) patients, and completely resolved in six cases after cerebrospinal fluid drainage. Preoperative GFR quartiles and CKD stages were significant predictors of 30-day mortality (P = .004 and P < .0001 respectively), whereas SC quartiles did not affect the outcome (P = .12). In particular, GFR quartile I (<60 ml/min/1.73 m(2)) was associated with a ten-fold greater risk of perioperative death compared with the other three quartiles (Odds Ratio 11.4, 95% Confidence Interval 2.3-57.0, P = .003). Midterm survival was 88.8% (159 of 179) at a mean follow-up of 35.6 +/- 23.7 months. Actuarial survival at 60 months was 57.8%, 81.1%, 92.3%, and 100% for GFR quartiles I to IV respectively (P < .0001), and 0.0%, 66.7%, 59.2%, 88.6%, and 100% (P < .0001) for CKD stage V to I respectively. At univariate analyses, age (P = .019), preoperative SC quartiles (P = .001), GFR quartiles (P = .0002), and CKD stages (P < .0001) were all predictive of mid-term mortality. At multivariate Cox proportional hazards regression analysis, only CKD stages remained independently associated with the outcome (P = .008).

CONCLUSIONS

GFR is an accurate prognostic predictor in patients submitted to TEVAR. Also, perioperative and midterm mortality directly correlate with the severity of CKD stages, allowing a risk stratification model to be employed both for risk-adjusted preoperative evaluation, and to establish accurate matching criteria for comparative studies.

Far and near visual acuity with multifocal intraocular lenses in an optomechanical eye model with imaging capability

PURPOSE

To compare the quantitative and qualitative visual performances of different multifocal intraocular lenses (IOLs) in an experimental model of the human eye.

SETTING

University Hospital San Raffaele, Milan, Italy.

METHODS

Five multifocal IOLs and 1 monofocal IOL were implanted in an optomechanical eye model with imaging capability. The comparative optical characterization of the imaging performance included aberrometry, simulated visual acuity testing at variable contrast for far and near distance, glare tests, and image records of optotype charts.

RESULTS

The maximum recorded far visual acuity for the monofocal IOL was between 20/12.5 and 20/16; the multifocal IOLs decreased visual acuity by 1 to 2 lines. The difference tended to increase at reduced contrast. Full-contrast near visual acuity with multifocal IOLs ranged between 20/63 and 20/25; the near distance performance of the monofocal IOL without an additional correcting lens was worse by 1 to 3 lines of acuity with large pupils but was comparable with small pupils. Multifocal IOLs of different designs showed marked differences as a function of contrast, which tended to balance between far and near behaviors.

CONCLUSIONS

Multifocal IOLs of different optical designs were well characterized and distinguished by simulated contrast acuity testing in an experimental eye model, allowing quantitative comparison. Their overall visual performance, averaged over contrast and distance, was not superior to the performance of a monofocal IOL without an additional correcting lens.

Results of Endografting of the Aortic Arch in Different Landing Zones

INTRODUCTION

Endovascular approach to the aortic arch is an appealing solution for selected patients. Aim of this study is to compare the technical and clinical success recorded in the different anatomical settings of endografting for aortic arch disease.

METHODS

Between June 1999 and October 2006, among 178 patients treated at our Institution for thoracic aorta disease with a stent-graft, the aortic arch was involved in 64 cases. According to the classification proposed by Ishimaru, aortic "zone 0" was involved in 14 cases, "zone 1" in 12 cases and "zone 2" in 38 cases. A hybrid surgical procedure of supraortic debranching and revascularization was performed in 37 cases to obtain an adequate proximal aortic landing zone.

RESULTS

"Zone 0" (14 cases). Proximal neck length: 44+/-6mm. Initial clinical success 78.6%: 2 deaths (stroke), 1 type Ia endoleak. At a mean follow-up of 16.4+/-11 months the midterm clinical success was 85.7%. "Zone 1" (12 cases). Proximal neck length: 28+/-5mm. Initial clinical success 66.7%: 0 deaths, 4 type Ia endoleaks. At a mean follow-up of 16.9+/-17.2 months the midterm clinical success was 75.0%. "Zone 2" (38 cases) Proximal neck length: 30+/-5mm. Initial clinical success 84.2%: 2 deaths (1 cardiac arrest, 1 multiorgan embolization), 3 type Ia endoleaks, 1 case of open conversion. Two cases of delayed transitory paraparesis/paraplegia were observed. At a mean follow-up of 28.0+/-17.2 months the midterm clinical success was 89.5%.

CONCLUSIONS

Total debranching of the arch for "zone 0" aneurysms allowed to obtain a longer proximal aortic landing zone with lower incidence of endoleak, however a higher risk of cerebrovascular accident was observed. The relatively high incidence of adverse events in "zone 1" could be associated to a shorter proximal neck, therefore this landing zone is reserved for patients unfit for sternotomy. In case of endoleak, discovered after a satisfactorily positioned endograft in the arch, the rate of spontaneous resolution within the first 6 months is high.

PHOTODYNAMIC THERAPY WITH VERTEPORFIN FOR CHOROIDAL NEOVASCULARIZATION ASSOCIATED WITH RETINAL PIGMENT EPITHELIAL DETACHMENT IN AGE-RELATED MACULAR DEGENERATION

PURPOSE

To assess the effectiveness of photodynamic therapy (PDT) with verteporfin for choroidal neovascularization (CNV) associated with retinal pigment epithelium detachment (PED) in age-related macular degeneration.

METHODS

Thirty eyes of 26 patients with CNV and PED were treated with PDT. The eyes were divided in two groups based on CNV location in relation to PED; group 1 included 13 eyes with CNV within PED, and group 2 included 17 eyes with CNV at the edge of PED. The median follow-up was 16 months.

RESULTS

Patients received a mean +/- SD of 2.83 +/- 1.26 treatments (range, 1-6 treatments). In the whole cohort, the mean preoperative visual acuity changed from 20/144 (0.86 +/- 0.42 logarithm of minimal angle of resolution [logMAR]) to 20/182 (0.96 +/- 0.51 logMAR; P = 0.39) at month 18. Five eyes (16%) gained a mean of 1.5 Snellen lines from baseline. Twelve eyes (40%) lost a mean of 1.7 Snellen lines of visual acuity. Vision in 13 eyes (44%) remained stable. In group 1, the mean visual acuity at month 12 was 20/303 (1.18 +/- 0.51 logMAR) and significantly (P = 0.015) worse than that, 20/110 (0.74 +/- 0.42 logMAR), in group 2.

CONCLUSION

PDT can improve or stabilize visual function in 60% of eyes with vascularized PED. CNV at the edge of PED appears to respond more favorably to PDT. Appropriate patient selection and prompt treatment are essential to obtain the best outcomes after verteporfin therapy.

Lipoprotein(a), fibrinogen and vascular mortality in an elderly northern Italian population

BACKGROUND AND OBJECTIVES

High lipoprotein a [Lp(a)] and fibrinogen levels are suggested risk factors for coronary heart disease (CHD) and stroke morbidity and mortality. Experimental data strongly suggest that the mechanisms of atherothrombosis include an interaction between fibrinogen and Lp(a), but little clinical evidence of a synergism between these two parameters has been reported.

DESIGN AND METHODS

Within the frame of a prospective population study conducted in the area of Cremona (Lombardy, Italy), 343 women and 216 men aged > or =65 years were evaluated for clinical and biochemical cardiovascular risk factors. Lp(a) levels > or =30 mg/dL were observed in 22.7% and 23.9% of men and women, respectively. Fibrinogen levels were higher in women (p<0.0001). After a median follow-up of 6.3 years 107 deaths were recorded, of which 33 were due to CHD or ischemic stroke.

RESULTS

The combined incidence rate of CHD and stroke mortality increased from 10.8 (per 1000 person-years) for subjects with either Lp(a) > or =30 mg/dL or fibrinogen within the 5th quintile of the gender-specific distribution to 38.4 for subjects with both Lp(a) > or =30 mg/dL and fibrinogen within the 5th quintile. Age (p<0.0001), insulin (p<0.0002) and the combination of high Lp(a) and fibrinogen (hazard ratio=3.11, p=0.014), but not fibrinogen or Lp(a) levels in isolation, were independent predictors of CHD and stroke mortality. In a subgroup of 447 subjects in whom C-reactive protein (CRP) was measured, CRP levels were not predictive of combined CHD and stroke mortality.

INTERPRETATIONS AND CONCLUSIONS

Based on these results obtained in a relatively small population of elderly subjects, the association of high Lp(a) and fibrinogen levels appears to carry an increased risk of pooled CHD and stroke mortality.

Persistent renal hypertrophy and faster decline of glomerular filtration rate precede the development of microalbuminuria in type 1 diabetes

Soon after the onset of type 1 diabetes, renal hypertrophy and hyperfiltration become manifest, particularly among patients who will subsequently develop diabetic nephropathy. Whether these early renal dysfunctions are involved in the pathogenesis of diabetic nephropathy is currently unclear. We evaluated, during the same day, kidney volume and glomerular filtration rate (GFR) in 146 patients with type 1 diabetes and normal renal function. All the individuals were then monitored for a mean of 9.5 +/- 4.4 years for the development of microalbuminuria. Kidney volume and GFR were reevaluated in a subset of 68 patients 4 years after baseline. During follow-up, microalbuminuria developed in 27 of 146 diabetic patients. At baseline, kidney volume (312.8 +/- 52.6 vs. 281.4 +/- 46.1 vs. 236.8 +/- 41.6 ml/1.73 m(2), P < 0.05) but not GFR was increased in patients predisposed to microalbuminuria. Risk of progression was higher in patients with increased kidney volume (P = 0.0058). Patients predisposed to microalbuminuria showed a stable increase in kidney volume (P = 0.003), along with a faster decline of GFR (P = 0.01). Persistent renal hypertrophy and faster decline of GFR precede the development of microalbuminuria in type 1 diabetes. These findings support the hypothesis that renal hypertrophy precedes hyperfiltration during the development of diabetic nephropathy.

A randomized clinical trial of trimetazidine, a partial free fatty acid oxidation inhibitor, in patients with heart failure

OBJECTIVES

This study sought to assess whether the long-term addition of trimetazidine to conventional treatment could improve functional class, exercise tolerance, and left ventricular function in patients with heart failure (HF).

BACKGROUND

Previous small studies have shown that trimetazidine may be beneficial in terms of left ventricular function preservation and control of symptoms in patients with post-ischemic HF.

METHODS

Fifty-five patients with HF were randomly allocated in an open-label fashion to either conventional therapy plus trimetazidine (20 mg three times daily) (28 patients) or conventional therapy alone (27 patients). Mean follow-up was 13 +/- 3 months. At study entry and at follow-up, all patients underwent exercise testing and two-dimensional echocardiography. Among the others, New York Heart Association (NYHA) functional class and ejection fraction (EF) were evaluated.

RESULTS

In the trimetazidine group, NYHA functional class significantly improved compared with the conventional therapy group (p < 0.0001). Treatment with trimetazidine significantly decreased left ventricular end-systolic volume (from 98 +/- 36 ml to 81 +/- 27 ml, p = 0.04) and increased EF from 36 +/- 7% to 43 +/- 10% (p = 0.002). On the contrary, in the conventional therapy group, both left ventricular end-diastolic and -systolic volumes increased from 142 +/- 43 ml to 156 +/- 63 ml, p = 0.2, and from 86 +/- 34 ml to 104 +/- 52 ml, p = 0.1, respectively; accordingly, EF significantly decreased from 38 +/- 7% to 34 +/- 7% (p = 0.02).

CONCLUSIONS

In conclusion, long-term trimetazidine improves functional class and left ventricular function in patients with HF. This benefit contrasts with the natural history of the disease, as shown by the decrease of EF in patients on standard HF therapy alone.

The anti-ischemic effect of trimetazidine in patients with postprandial myocardial ischemia is unrelated to meal composition

BACKGROUND

Previous studies provide evidence for a significant reduction of coronary flow reserve after ingestion of meals of different compositions. A possible role of hyperinsulinemia and increased free fatty acid levels, which are deleterious during acute myocardial ischemia and reperfusion, has been hypothesized. We assessed in patients with stable coronary disease the effects of high-fat meals (HFMs) and high-carbohydrate meals (HCMs) on ischemic threshold and stress left ventricular function on placebo and after partial fatty acid inhibition by trimetazidine (TMZ).

METHODS

Ten patients (9 men, age 68 +/- 7 years) were allocated to placebo and TMZ (40 mg TID), both administered in the 24 hours preceding testing, according to a randomized double-blind study design. All patients underwent stress (treadmill exercise testing according to the Bruce protocol) echocardiography after fasting (8 hours) and after an HFM and HCM (2 hours) either on placebo or on TMZ. Time to 1-mm ST-segment depression (time to 1 mm) and stress wall motion score index (WMSI) were evaluated.

RESULTS

An HFM did not affect exercise variables compared with fasting, whereas an HCM resulted in a reduction of the ischemic threshold (time to 1 mm from 402 +/- 141 to 292 +/- 123 seconds, P = .025). Compared with placebo, TMZ improved time to 1 mm after fasting, HFM, and HCM (432 +/- 153 vs 402 +/- 141, 439 +/- 118 vs 380 +/- 107, 377 +/- 123 vs 292 +/- 123, F(1,9) = 26.91, P = .0006). Compared with placebo, on TMZ, stress WMSI decreased from 1.55 +/- 0.25 to 1.29 +/- 0.14 after fasting, from 1.57 +/- 0.10 to 1.39 +/- 0.28 after HFM, and from 1.64 +/- 0.21 to 1.39 +/- 0.21 after HCM (F(1,9) = 37.04, P = .0002). Interestingly, stress WMSI on TMZ was never different from rest WMSI on placebo.

CONCLUSIONS

In patients with coronary disease, exercise testing after an HCM results in more severe myocardial ischemia compared with that after an HFM. The observed beneficial effects of the partial fatty acid inhibitor TMZ seem to be unrelated to meal composition and are possibly caused by the better glucose use induced by the drug.

Long-lasting CCR5 internalization by antibodies in a subset of long-term nonprogressors: a possible protective effect against disease progression

Exposure to HIV-1 does not necessarily result in infection and progression toward disease, thus suggesting that the control of viral infection may be achieved. Antibodies to CCR5 have been detected in HIV-exposed but uninfected subjects (ESNs); thus, these antibodies could be involved in HIV protection. To assess whether anti-CCR5 antibodies may also contribute to slow HIV disease progression, we searched for anti-CCR5 antibodies in 497 subjects, including 85 long-term nonprogressors (LTNPs), 70 progressors, 135 HIV(+) patients treated with highly active antiretroviral therapy (HAART), and 207 seronegative donors. We found anti-CCR5 antibodies in a fraction of the LTNPs(23.5%) but not in the other populations studied (P < .001). These antibodies recognized a conformational epitope within the first extramembrane loop of CCR5, and they induced a stable and long-lasting downregulation of CCR5 on the surface of T lymphocytes, which inhibited HIV entry. In addition, CD4(+) lymphocytes from LTNPs having anti-CCR5 antibodies are resistance to R5 strains of HIV-1. Follow-up studies showed that the loss of anti-CCR5 antibodies occurred in some subjects, and this loss was significantly associated with a progression toward disease, whereas subjects who retained anti-CCR5 Abs maintained their LTNP status. Induction of anti-CCR5 Abs could be relevant to vaccine design and therapeutics.

Effects of metabolic modulation by trimetazidine on left ventricular function and phosphocreatine/adenosine triphosphate ratio in patients with heart failure

AIMS

The addition of trimetazidine to standard treatment has been shown to improve left ventricular (LV) function in patients with heart failure. The aim of this study is to non-invasively assess, by means of in vivo 31P-magnetic resonance spectroscopy (31P-MRS), the effects of trimetazidine on LV cardiac phosphocreatine and adenosine triphosphate (PCr/ATP) ratio in patients with heart failure.

METHODS AND RESULTS

Twelve heart failure patients were randomized in a double-blind, cross-over study to placebo or trimetazidine (20 mg t.i.d.) for two periods of 90 days. At the end of each period, all patients underwent exercise testing, 2D echocardiography, and MRS. New York Heart Association (NYHA) class, ejection fraction (EF), maximal rate-pressure product, and metabolic equivalent system (METS) were evaluated. Relative concentrations of PCr and ATP were determined by cardiac 31P-MRS. On trimetazidine, NYHA class decreased from 3.04+/-0.26 to 2.45+/-0.52 (P = 0.005), whereas EF (34+/-10 vs. 39+/-10%, P = 0.03) and METS (from 7.44+/-1.84 to 8.78+/-2.72, P = 0.03) increased. The mean cardiac PCr/ATP ratio was 1.35+/-0.33 with placebo, but was increased by 33% to 1.80+/-0.50 (P = 0.03) with trimetazidine.

CONCLUSION

Trimetazidine improves functional class and LV function in patients with heart failure. These effects are associated to the observed trimetazidine-induced increase in the PCr/ATP ratio, indicating preservation of the myocardial high-energy phosphate levels.

Back pain after photodynamic therapy with verteporfin

PURPOSE

To report the incidence of back pain after photodynamic therapy, which suggests methods for prevention that are related to its pathogenesis.

DESIGN

Retrospective case series.

METHODS

We retrospectively observed 548 patients who had undergone photodynamic therapy with verteporfin.

RESULTS

Of 548 patients at the first treatment, 14 patients (2.6%) experienced pain during the infusion. Eleven patients were being treated for age-related macular degeneration; their mean age was 81 years, which significantly differed from the mean age of the overall age-related macular degeneration group (P = .003). The pain was mild in eight patients, moderate in four patients, and severe in two patients, with dyspnea and precordial pain. Five of the 14 patients had further courses of photodynamic therapy. After being treated prophylactically 60 minutes before photodynamic therapy, only one patient reported further mild pain.

CONCLUSIONS

The biologic mechanisms of back pain may involve a high level of circulating thromboxanes that are induced by the liposomal composition of verteporfin. Prevention may include hydration, nonsteroidal anti-inflammatory drugs, and halving the infusion rate.

Surgical ablation of atrial fibrillation with a novel bipolar radiofrequency device

OBJECTIVE

When used for epicardial ablation, unipolar devices do not predictably yield transmural scars. Bipolar radiofrequency proved highly effective on the animal model, but clinical experience is still initial. We describe acute electrophysiologic findings and follow-up results of epicardial ablation with a novel bipolar radiofrequency device.

METHODS

A bipolar ablator was used to perform a simplified left atrial lesion set in 90 consecutive patients with atrial fibrillation undergoing open heart surgery. Pacing thresholds were assessed during surgery to validate 24 pulmonary vein encircling lines (12 patients). Follow-up was 100% complete.

RESULTS

In 67 of 90 patients (84%), mitral valve disease was the main indication to surgery. Atrial fibrillation was continuous in 74 patients (82%) and intermittent in 16 patients (18%). Pacing threshold assessment showed a complete conduction block in 22 of 24 pulmonary vein couples (92%) after a single ablation and in all patients after doubling of the encircling lines. No complications related to the ablation procedure were recorded. The sinus rhythm restoration rate was 79% at 3 months, 87% at 6 months, and 89% (17/18 patients) at 1 year. Postablation organized arrhythmias consisted in right atrial flutter in 2 patients (2%) and left atrial flutter in 6 patients (7%).

CONCLUSIONS

Epicardial ablation with bipolar radiofrequency grants acute transmurality. A simplified lesion set proved highly effective in eliminating atrial fibrillation at 1-year follow-up. Our data suggest that addition of a lesion to the mitral annulus is advisable to prevent left atrial flutter.

Cytokine levels in sputum of cystic fibrosis patients before and after antibiotic therapy

It is not known whether cytokine levels in sputum may be used as outcome measures after parenteral antibiotic therapy in cystic fibrosis (CF) patients. Here, we assessed the effects of antibiotic therapy on cytokine levels in sputum and serum obtained from young CF patients. Thirty-two CF patients (14 females; mean age, 18.6 years; range, 11.4-35.7 years), consecutively admitted at the CF Center of Milan for parenteral antibiotic therapy during pulmonary exacerbation, were enrolled in the study. Before and after 21 days (range, 5-41) of intravenous antibiotic treatment, all patients underwent routine laboratory determinations (including white blood cell (WBC) count and C-reactive protein (CRP)), a chest X-ray, pulmonary function tests (forced expiratory volume in 1 sec (FEV1) and forced vital capacity (FVC) as % predicted), and sputum cultures. Interleukin (IL)-6, IL-8, IL-10, and tumor necrosis factor (TNF)-alpha levels in serum and sputum samples were determined by means of immunometric assays. After therapy, FEV1 and FVC significantly improved (median increase of 7.5% and 8.5% predicted, respectively), while CRP and WBC count were significantly decreased (median values from 14 to 5.5 mg/dl and from 8,350 to 7,400 n/mm3, respectively). While levels of IL-6 and IL-10 in sputum were generally undetectable, IL-8 and TNF-alpha were always measurable, and IL-8 levels significantly decreased after antibiotic treatment (median values from 7,165 to 5,415 pg/ml). Following antibiotic therapy, IL-8 and TNF-alpha levels in sputum were inversely related with both FEV(1) and FVC. In conclusion, TNF-alpha and IL-8 levels in sputum of young CF patients with pulmonary exacerbation were always detectable and may be useful, noninvasive outcome measures to assess response to therapy in CF patients.

Islet isolation for allotransplantation: variables associated with successful islet yield and graft function

AIMS/HYPOTHESIS

Efficient islet isolation is an important prerequisite for successful clinical islet transplantation. Although progressively improved, islet yield and quality are, however, unpredictable and variable and require standardisation.

METHODS

Since 1989 we have processed 437 pancreases using the automated method. The donor characteristics, pancreas procurement, and digestion and purification procedures including a wide enzyme characterisation of these pancreases were analysed and correlated with islet yield and transplant outcome.

RESULTS

By univariate analysis, islet yield was significantly associated with donor age (r=0.16; p=0.0009), BMI (r=0.19; p=0.0004), good pancreas condition (p=0.0031) and weight (r=0.15; p=0.0056), total collagenase activity (r=0.22; p=0.0001), adjusted collagenase activity/mg (r=0.18; p=0.0002), collagenase activity/solution volume (r=0.18; p=0.0002) and neutral protease activity/solution volume (r=0.14; p=0.0029). A statistically significant contribution to the variability of islet yield in a multivariate analysis performed on donor variables was found for donor BMI (p=0.0008). In a multivariate analysis performed on pancreas variables a contribution was found for pancreas weight (p=0.0064), and for a multivariate analysis performed on digestion variables we found a contribution for digestion time (p=0.0048) and total collagenase activity (p=0.0001). Twenty-four patients with type 1 diabetes received single islet preparations from single donors. In these patients, multivariate analyses showed that the reduction in insulin requirement was significantly associated with morphological aspects of islets (p=0.0010) and that 1-month C-peptide values were associated with islet purity (p=0.0071).

CONCLUSIONS/INTERPRETATION

These data provide baseline donor, digestion and purification selection criteria for islet isolation using the automated method and indicate that the morphological aspect may be a clinically relevant measure of islets on which the decision for transplant can be based.

Predictive value of anti-cell and anti-human immunodeficiency virus (HIV) humoral responses in HIV-1-exposed seronegative cohorts of European and Asian origin

Unconventional immune responses have been demonstrated in individuals who, despite repeated exposure to human immunodeficiency virus (HIV) infection, remain seronegative. As environmental exposure to pathogens and genetic background may modulate immune responses differentially, one Italian and two Asian populations of HIV-1-exposed seronegative individuals were studied. In serum samples from each group, IgG to CCR5, IgG to CD4 and IgA to gp41 were measured, which were previously described as markers of unconventional immunity in HIV-exposed seronegative Caucasians. Given the importance of conformational epitopes in virus-cell interactions, IgG to CD4-gp120 complex was also measured. It was found that markers of HIV exposure were present in all populations studied. HIV-specific humoral responses (IgA to gp41 and IgG to CD4-gp120 complex) were extremely significant predictors of HIV exposure (P<0.0001 in both cases), whereas the predictive values of anti-cell antibodies (anti-CCR5 and anti-CD4) varied between populations. Evidence is provided for the correlation of these differences with route of exposure to HIV and level of natural antibodies to cross-reactive microbial antigens. In conclusion, exposed seronegative individuals of ethnically different origins display similar signs of HIV-dependent unconventional immunity. A specific relevance must be attributed to different innate and acquired factors.

Prognostic significance of JC virus DNA levels in cerebrospinal fluid of patients with HIV-associated progressive multifocal leukoencephalopathy

BACKGROUND

Progressive multifocal leukoencephalopathy (PML) remains a frequent and life-threatening complication of human immunodeficiency virus (HIV) infection in the era of highly active antiretroviral therapy (HAART). Although one-half of patients with this disease will survive, the outcome is unpredictable at diagnosis, and prognostic markers are needed.

METHODS

JC virus (JCV) DNA levels were measured in cerebrospinal fluid (CSF) samples obtained from 61 HIV-infected patients with PML, including 38 patients who were treated with HAART and 23 patients who did not receive HAART, with use of real-time polymerase chain reaction. The diagnostic reliability of the assay was evaluated by comparing CSF findings with histopathological findings in patients with PML or other HIV-related diseases of the central nervous system. The prognostic value was assessed by comparing JCV DNA levels with survival and other patient variables.

RESULTS

The assay had a diagnostic sensitivity of 76% and specificity of 100%. In the first CSF sample obtained after onset of PML symptoms, JCV DNA values ranged from undetectable to 7.71 log copies/mL (median, 3.64 log copies/mL). JCV DNA levels >3.64 log copies/mL correlated significantly with shorter survival and lower CD4+ cell counts in patients not receiving HAART. However, neither relationship was found in patients who were treated with HAART. The analysis of sequential CSF samples obtained from 24 patients demonstrated a marked decrease in JCV DNA levels over time in HAART-treated patients showing PML stabilization, but not in untreated or HAART-treated patients with progressively fatal disease.

CONCLUSIONS

Measurement of JCV DNA levels in CSF samples may be a useful virological marker for management of PML in patients receiving HAART.

Nitric-oxide mediated effects of transdermal capsaicin patches on the ischemic threshold in patients with stable coronary disease

BACKGROUND

Capsaicin has been shown to exert direct vasodilating effects through increased calcitonin gene-related peptide (CGRP) release. However, no data exist on its effect following systemic administration in humans.

METHODS

Twelve male patients with stable coronary disease and a persistently positive exercise were selected for study. According to a double blind, placebo-controlled, cross-over study, patients were randomized to placebo or 3 g oleic capsaicin-containing patches, on 2 different days and with a 2-day interval between treatments. Patients performed treadmill exercise testing according to the Bruce protocol. Time to 1 mm ST segment depression and to peak exercise, maximal ST segment depression, and the number of ECG leads showing diagnostic changes were also measured. Blood samples for nitric oxide (NO) and CGRP were drawn at baseline, 2, 6, and 24 hours after exercise.

RESULTS

On placebo, all patients had a positive ECG during exercise test. Only 1 patient experienced angina, on both treatments. With capsaicin, 1 patient had a negative exercise, while 8 patients significantly increased time to 1 mm ST depression from 328 +/- 167 to 401 +/- 174 seconds (P = 0.01). Of the remaining patients, 1 did not show any changes and 2 showed a worse ischemic threshold when on capsaicin. CGRP levels were not significantly different between placebo and capsaicin treatment. Conversely, when on capsaicin, NO significantly increased at 6 hours.

CONCLUSIONS

Transdermal capsaicin may improve ischemic threshold in patients with stable coronary disease, probably through arteriolar vasodilation. Increased capsaicin-induced NO availability could represent the principal mechanism of action.

Coseasonal sublingual immunotherapy reduces the development of asthma in children with allergic rhinoconjunctivitis

BACKGROUND

We wondered whether short-term coseasonal sublingual immunotherapy (SLIT) can reduce the development of asthma in children with hay fever in an open randomized study.

OBJECTIVE

We sought to determine whether SLIT is as effective as subcutaneous immunotherapy in reducing hay fever symptoms and the development of asthma in children with hay fever.

METHODS

One hundred thirteen children aged 5 to 14 years (mean age, 7.7 years) with hay fever limited to grass pollen and no other clinically important allergies were randomized in an open study involving 6 Italian pediatric allergy centers to receive specific SLIT for 3 years or standard symptomatic therapy. All of the subjects had hay fever symptoms, but at the time of study entry, none reported seasonal asthma with more than 3 episodes per season. Symptomatic treatment was limited to cetirizine, loratadine, nasal budesonide, and salbutamol on demand. The hay fever and asthma symptoms were quantified clinically.

RESULTS

The actively treated children used less medication in the second and third years of therapy, and their symptom scores tended to be lower. From the second year of immunotherapy, subjective evaluation of overall allergy symptoms was favorable in the actively treated children. Development of asthma after 3 years was 3.8 times more frequent (95% confidence limits, 1.5-10.0) in the control subjects.

CONCLUSIONS

Three years of coseasonal SLIT improves seasonal allergic rhinitis symptoms and reduces the development of seasonal asthma in children with hay fever.

Integrated assessment of traffic impact in an Alpine region

This paper reports the results of an integrated assessment of traffic impact on a tourist-popular high altitude region which includes mountain passes and road tunnels. A modeling system for air quality assessment and management has been established and revised. The system has been used to evaluate the impact of traffic due to the re-opening of the Mont Blanc tunnel: the increase in NO(x) concentrations ranges from 50% at the bottom of the upper valley to 150% near to tunnel entrance.

Donor and Isolation Variables Associated with Human Islet Monocyte Chemoattractant Protein-1 Release

Human islets have chemotactic activity toward macrophages mediated by the secretion of monocyte chemoattractant protein-1 (CCL2/MCP-1) that negatively affect clinical outcome in islet after kidney recipients. The aim of the present work was to identify the donor features and the variables involved in the procedures of islet isolation associated with islet CCL2/MCP-1 release in vitro. We used a retrospective approach studying the outcome in 170 islet isolations. The univariate analysis demonstrated that CCL2/MCP-1 release was significantly associated with the surgical team in charge for organ harvesting, the proteins for dilution solution, the type of gradient, the type of enzyme, and the donor noradrenalin treatment. The multivariate analysis confirmed that the surgical team (P = 0.001) and the enzyme (P = 0.001) were independently associated with in vitro CCL2/MCP-1 islet release (r(2) = 17%). Strategies aimed to optimize the procedures of organ harvesting and islet isolation may reduce the pro-inflammatory properties of the preparation and therefore may improve islet engraftment.