Patients with antiphosholipid syndrome and thrombotic recurrences: A real world observation (the Piedmont cohort study)

BACKGROUND

Patients with antiphospholipid syndrome (APS) often have thrombotic recurrences, sometimes despite appropriate ongoing anticoagulant treatment. Identifying APS vascular patients at high risk for thrombotic recurrences is still an unsolved issue.

OBJECTIVES

To report the real-life experience of thrombotic recurrences in APS patients included in the Piedmont observational cohort study, and evaluate clinical and laboratory risk factors for thrombotic recurrences.

PATIENTS

A multi-centre observational study was performed by enrolling 177 patients with vascular APS (primary APS in 99 subjects (56%)); the median follow-up was five years (range 1-26 years).

RESULTS

The observed thrombotic recurrence rate was about 7.5/100 patient years in the first five years after the first thrombotic event. While the first recurrence often occurred (45%) in patients who were not on oral anticoagulant therapy (OAT), the second recurrence mainly occurred despite ongoing OAT (80%). However, due to the real-life observational nature of this study, treatment was based on the treating physician's judgement, and no structured therapeutic protocol was applied. Moreover, compliance with OAT was not available. No differences in antiphospholipid antibodies (aPL) profile were observed between patients with or without thrombotic recurrences, but a high risk aPL profile (Miyakis type 1 and 2a) was present in 96% of our patients, 26% of whom had triple positivity. Diabetes (p < 0.01, OR 10), inherited thrombophilia (p < 0.0078, OR 4) and OAT withdrawal were independent risk factors for recurrences.

CONCLUSIONS

With the limit of a real-life observational cohort study, the thrombotic recurrence rate in APS was as high as 7.5/100 patient years in the first five years after the first thrombotic event. OAT discontinuation, diabetes and inherited thrombophilia, when associated with a high-risk aPL profile, are risk factors for thrombotic recurrences.

Thrombotic recurrences and bleeding events in APS vascular patients: a review from the literature and a comparison with the APS Piedmont Cohort

In APS vascular patients, thrombotic recurrences are more frequent than in non-APS thrombotic patients. To better define this clinical setting, a systematic review of the literature after 1999 was performed: 8 cohort studies (including the recent APS Piedmont Cohort) and 6 intervention studies were selected and evaluated. Thrombotic recurrences, bleeding events, therapeutic strategies, antiphospholipid (aPL) profile, inherited and acquired risk factors (when present) were calculated and compared. Emerging risk factors for thrombotic recurrences include withdrawal of oral anticoagulant therapy (OAT), high intensity OAT (INR range 3-4), aPL profile (triple positivity, Miyakis types 1 and 2a profiles) and association with inherited or acquired pro-thrombotic risk factors. Moreover, there are evidences that high risk (mainly for aPL profile) APS vascular patients have a high recurrence rate in spite of correct OAT treatment. Clinical trials in this clinical setting are needed.

Anti-cardiolipin and anti-β2-glycoprotein I antibodies: normal reference ranges in northwestern Italy

Laboratory tests for anticardiolipin antibodies (aCL) and anti-β2glycoprotein I antibodies (a-β2GPI) face problems common to many autoantibody assays: the lack of a reference standard and the need for each laboratory to assess assay-specific cut-off values. The aims of the study were to evaluate the reference range upper limits (99th percentile) used for aCL and a-β2GPI in the northwest of Italy and to investigate the analytical performances of these assays with the newly obtained reference ranges. We assayed aCL and a-β2GPI in 104 serum samples from patients without a history of thrombosis, pregnancy morbidity, tumours, infections and/or autoimmune diseases (30 males and 74 non-pregnant females). We tested all the commercial assays available in our regions (i.e. Orgentec Diagnostika, Aesku Diagnostics and Inova Diagnostics ELISA; CliA Zenit-RA and EliA Phadia Laboratory Systems). A further 30 serum samples, including 10 from healthy subjects, 10 from antiphospholipid syndrome (APS) patients and 10 from septic patients were assessed to investigate the analytical performance of the obtained cut-off limits. Reference range upper limits obtained with the commercial kits differ among assays and from the values reported by the manufacturer. Moreover, normal reference ranges calculated for IgG and IgM aCL differed from the arbitrary selected laboratory classification values suggested in the guidelines of 40 GPL and MPL.

Cell death following BNCT: a theoretical approach based on Monte Carlo simulations

In parallel to boron measurements and animal studies, investigations on radiation-induced cell death are also in progress in Pavia, with the aim of better characterisation of the effects of a BNCT treatment down to the cellular level. Such studies are being carried out not only experimentally but also theoretically, based on a mechanistic model and a Monte Carlo code. Such model assumes that: (1) only clustered DNA strand breaks can lead to chromosome aberrations; (2) only chromosome fragments within a certain threshold distance can undergo misrejoining; (3) the so-called "lethal aberrations" (dicentrics, rings and large deletions) lead to cell death. After applying the model to normal cells exposed to monochromatic fields of different radiation types, the irradiation section of the code was purposely extended to mimic the cell exposure to a mixed radiation field produced by the (10)B(n,α) (7)Li reaction, which gives rise to alpha particles and Li ions of short range and high biological effectiveness, and by the (14)N(n,p)(14)C reaction, which produces 0.58 MeV protons. Very good agreement between model predictions and literature data was found for human and animal cells exposed to X- or gamma-rays, protons and alpha particles, thus allowing to validate the model for cell death induced by monochromatic radiation fields. The model predictions showed good agreement also with experimental data obtained by our group exposing DHD cells to thermal neutrons in the TRIGA Mark II reactor of the University of Pavia; this allowed to validate the model also for a BNCT exposure scenario, providing a useful predictive tool to bridge the gap between irradiation and cell death.

1H and 10B NMR and MRI investigation of boron- and gadolinium-boron compounds in boron neutron capture therapy

(10)B molecular compounds suitable for Boron Neutron Capture Therapy (BNCT) are tagged with a Gd(III) paramagnetic ion. The newly synthesized molecule, Gd-BPA, is investigated as contrast agent in Magnetic Resonance Imaging (MRI) with the final aim of mapping the boron distribution in tissues. Preliminary Nuclear Magnetic Resonance (NMR) measurements, which include (1)H and (10)B relaxometry in animal tissues, proton relaxivity of the paramagnetic Gd-BPA molecule in water and its absorption in tumoral living cells, are reported.

In vitro and in vivo studies of boron neutron capture therapy: boron uptake/washout and cell death

Boron neutron capture therapy (BNCT) is a binary radiotherapy based on thermal-neutron irradiation of cells enriched with (10)B, which produces α particles and (7)Li ions of short range and high biological effectiveness. The selective uptake of boron by tumor cells is a crucial issue for BNCT, and studies of boron uptake and washout associated with cell survival studies can be of great help in developing clinical applications. In this work, boron uptake and washout were characterized both in vitro for the DHDK12TRb (DHD) rat colon carcinoma cell line and in vivo using rats bearing liver metastases from DHD cells. Despite a remarkable uptake, a large boron release was observed after removal of the boron-enriched medium from in vitro cell cultures. However, analysis of boron washout after rat liver perfusion in vivo did not show a significant boron release, suggesting that organ perfusion does not limit the therapeutic effectiveness of the treatment. The survival of boron-loaded cells exposed to thermal neutrons was also assessed; the results indicated that the removal of extracellular boron does not limit treatment effectiveness if adequate amounts of boron are delivered and if the cells are kept at low temperature. Cell survival was also investigated theoretically using a mechanistic model/Monte Carlo code originally developed for radiation-induced chromosome aberrations and extended here to cell death; good agreement between simulation outcomes and experimental data was obtained.

Selective uptake of p-boronophenylalanine by osteosarcoma cells for boron neutron capture therapy

Osteosarcoma is the most common non-hematologic primary cancer type that develops in bone. Current osteosarcoma treatments combine multiagent chemotherapy with extensive surgical resection, which in some cases makes necessary the amputation of the entire limb. Nevertheless its infiltrative growth leads to a high incidence of local and distant recurrences that reduce the percentage of cured patients to less than 60%. These poor data required to set up a new therapeutic approach aimed to restrict the surgical removal meanwhile performing a radical treatment. Boron neutron capture therapy (BNCT), a particular radiotherapy based on the nuclear capture and fission reactions by atoms of (10)B, when irradiated with thermal neutrons, could be a valid alternative or integrative option in case of osteosarcoma management, thanks to its peculiarity in selectively destroying neoplastic cells without damaging normal tissues. Aim of the present work is to investigate the feasibility of employing BNCT to treat the limb osteosarcoma. Boronophenylalanine (BPA) is used to carry (10)B inside the neoplastic cells. As a first step the endocellular BPA uptake is tested in vitro on the UMR-106 osteosarcoma cell line. The results show an adequate accumulation capability. For the in vivo experiments, an animal tumor model is developed in Sprague-Dawley rats by means of an intrafemoral injection of UMR-106 cells at the condyle site. The absolute amounts of boron loading and the tumor to normal tissue (10)B ratio are evaluated 2 h after the i.v. administration of BPA. The boron uptake by the neoplastic tissue is almost twice the normal one. However, higher values of boron concentration in tumor are requested before upholding BNCT as a valid therapeutic option in the treatment of osteosarcoma.

Neutron autoradiography imaging of selective boron uptake in human metastatic tumours

The ability to selectively hit the tumour cells is an essential characteristic of an anti-tumour therapy. In boron neutron capture therapy (BNCT) this characteristic is based on the selective uptake of (10)B in the tumour cells with respect to normal tissues. An important step in the BNCT planning is the measurement of the boron concentration in the tissue samples, both tumour and healthy. When the tumour is spread through the healthy tissue, as in the case of metastases, the knowledge of the different kinds of tissues in the sample being analysed is crucial. If the percentage of tumour and normal tissues cannot be evaluated, the obtained concentration is a mean value depending on the composition of the different samples being measured. In this case an imaging method that could give information both on the morphology and on the spatial distribution of boron concentration in the sample would be a fundamental support. In this paper, the results of the boron uptake analysis in the tumour and in the healthy samples taken from human livers after boron phenylalanine (BPA) infusion are shown; boron imaging was performed using neutron autoradiography.

ZAP-70 expression, as detected by immunohistochemistry on bone marrow biopsies from early-phase CLL patients, is a strong adverse prognostic factor

Zeta-associated protein-70 (ZAP-70), mostly assessed by flow-cytometry (FC), recently emerged as reliable prognostic factor in chronic lymphocytic leukaemia (CLL) at presentation. We evaluated ZAP-70 expression in 156 CLL patients by immunohistochemistry (IHC) on formalin-fixed bone marrow (BM) biopsies at diagnosis. At presentation, 117 patients (75%) were with Binet stage A, 27 (17%) stage B and 12 (8%) stage C. Median follow-up was 61 months (range 6-242). ZAP-70 was expressed in neoplastic lymphocytes of 69 patients (44%). Concordance between ZAP-70 by IHC and ZAP-70 by FC, immunoglobulin heavy chain variable genes (IGHV) mutational status and CD38 expression was found in 41/46 (89%), 41/49 (80%) and in 60/88 (68%) tested cases, respectively. ZAP-70 expression significantly correlated with advanced Binet stage (B-C), diffuse BM infiltration, increased lactate dehydrogenase (LDH) and beta2-microglobulin serum levels and lymphocyte doubling time <12 months. ZAP-70 positivity was significantly related to poorer time to progression (median 16 months vs 158 of ZAP-70-negative cases) (P<0.0001) and overall survival (median 106 months vs not reached) (P=0.0002); this correlation was confirmed at multivariate analysis. ZAP-70 expression correlated with poorer outcome also when evaluated only in the 117 stage A patients. In conclusion, immunohistological detection of ZAP-70 on formalin-fixed BM biopsies at diagnosis appears a useful methodological approach to identify patients with poor prognosis in CLL.

Survivin silencing sensitizes imatinib-resistant CML cells to the cytotoxic effect of hydroxyurea

13119

Background: Imatinib Mesylate (IM), a semi-specific inhibitor of the BCR-ABL tyrosine kinase, is currently the treatment of choice for Chronic Myeloid Leukemia (CML). However, about one third of CML patients treated with IM develop resistance to the drug because of reactivation of BCR-ABL kinase activity. This phenomenon is usually ascribed to the amplification of the BCR-ABL gene or to the selection of leukemic clones harboring point mutations that abrogate IM binding. To identify novel anti-apoptotic signaling pathways employed by BCR-ABL and devise strategies capable of killing IM-resistant CML cells, we investigated the interplay between BCR-ABL and the Inhibitor of Apoptosis Protein Survivin. Methods: Murine hematopoietic cells (32D) transduced with p210 BCR-ABL and human cell lines either positive (K562, KCL22, KYO1 and LAMA84) or negative (HL60) for the BCR-ABL oncoprotein, were analyzed for Survivin expression by western blot before and after IM treatment. Three different pathways (MAPK, PI3K and JAK2/STA3) potentially involved in BCR-ABL-mediated induction of Survivin were studied using inhibitors specific for each signaling cascade. The effect of Survivin on the proliferation and viability of IM-sensitive and IM-resistant CML cells was investigated after silencing Survivin expression with small interfering RNAs. Results: BCR-ABL tyrosine kinase activity induced an over-expression of Survivin in both human and murine hematopoietic cell lines. This over-expression was both at the transcriptional and the translational level and required the JAK2/STAT3 pathway. Survivin silencing by siRNA increased IM cytotoxicity in IM-sensitive cells but failed to restore IM efficacy in IM-resistant cells. However, Survivin silencing sensitized CML cells to the cytotoxic effect of hydroxyurea and enhanced the efficacy of this compound on three different murine cell lines are insensitive to IM because of point mutations in the BCR-ABL kinase domain (Ba/F3p210Y253F, Ba/F3p210D276G and Ba/F3p210T315I). Conclusions: Reduction of Survivin expression improves the efficacy of IM and increases the sensitivity of IM-resistant CML cells to hydroxyurea. Survivin may represent an attractive therapeutic target for both IM-sensitive and IM-resistant CML patients.

No significant financial relationships to disclose.

[Pseudosarcomatous lesions: report of two cases]

Of unknown etiology, mainly located on the upper limbs, the nodular fasciitis nowadays is considered as a reactive inflammatory lesion more than a neoplastic one. With very few symptoms, it can be diagnosed through histology and the extent of the excision is related to the report of the pathological examination.

Neoformation of boldenone and related steroids in faeces of veal calves

Conflicting findings regarding the boldenone content of bovine faeces suggest it may be synthesized de novo in emitted faeces. We tested this hypothesis by analysing uncontaminated urine, fresh and various forms of dried faeces from 10 calves (not given boldenone) by liquid chromatography/tandem mass spectrometry for 17alpha- and 17beta-boldenone (alpha and beta BOL); 1,4-androstadiene-3,17-dione (ADD); 4-androstene-3,17-dione (AED), testosterone (T) and epitestosterone (ET). Urine contained no alpha BOL, beta BOL or ADD. The analysed substances were variably present in the rectal faeces, and at generally higher levels in faeces scraped from skin or stall floor. In pooled rectal faeces naturally dried for 13 days, alpha BOL, ADD, AED and ET levels were extremely high (much higher than accounted for by increases due to drying), and beta BOL and T were absent. It is concluded that de novo synthesis of alpha BOL and metabolites occurs naturally in bovine faeces and only uncontaminated urine should be analysed for illegal boldenone.

High resolution mini-gammacamera and 99mTc [HMPAO] - leukocytes for diagnosis of infection and radioguided surgery in diabetic foot

Discovery of osteitis may be delayed because of late appearance of X-ray signs in patients with diabetic foot. Scintigraphy with labelled leukocytes is able to detect flogosis but often misses bone involvement, due to inadequate resolution of Anger camera, the commonest detector used in nuclear medicine. Radioguided surgery and biopsy with high resolution scintigraphy (HRS) started to be studied since 2000: although this method had never been tested for planning and guiding diabetic foot surgery, in our opinion it can help early diagnosis and surgical treatment of diabetic foot. Five patients with diabetic foot and suspected infection were studied with standard 99mTc [HMPAO]-leukocyte scan. In the same patients 2 mm spatial resolution HRS was performed 24 hours after administration of labelled WBC, using our inch2 field-of-view portable mini-gammacamera. Operations were done just after the 24h scan and were guided with the portable high resolution device in the four patients who showed positive scan. Scintigraphy with Anger camera and HRS were positive in four patients. HRS showed a bar-shaped radioactivity corresponding to small phalanges, close to the main inter-digital hot spot. The presence of osteitis on phalanges that had been shown by HRS was confirmed at surgery, that was successfully driven with the high resolution mini-camera. In conclusion HRS is able to diagnose early osteitis of diabetic foot and to guide diabetic foot surgery.

Should Female Patients Undergoing Parathyroid-Sparing Total Thyroidectomy Receive Routine Prophylaxis for Transient Hypocalcemia?

Hypocalcemia following parathyroid-sparing total thyroidectomy is frequent and can prolong hospital stay. We undertook this study to identify preoperative predictors of postoperative hypocalcemia useful in the postoperative management of these patients. We examined patients undergoing total thyroidectomy for benign disease with preservation of at least three parathyroids from January 2000 to January 2001. Low serum calcium was considered below 8.0 mg/dL. Age, gender, preoperative serum calcium, thyroid stimulating hormone (TSH), T3, T4, albumin, cholesterol, and tryglicerides were compared in patients with normal and low serum calcium level on the second postoperative day and on discharge day by using χ2 test and a model of logistic regression. Data were reported using their frequency distribution among the two groups of patients. Eighty patients, 60 females (F) and 20 males (M), underwent parathyroid-sparing total thyroidectomy. On second postoperative day, hypocalcemia occurred in 42 patients, and 56 per cent were symptomatic. Only female gender (88% F vs 12% M) ( P < 0.05) and TSH <0.27 mUI/mL (38% vs 18%) ( P < 0.05) predicted hypocalcemia. Similarly, female gender predicted hypocalcemia in a logistic regression analysis ( P < 0.05). On the day of discharge, 22 patients had low serum calcium levels, and 50 per cent were symptomatic. At this time, only TSH value <0.27 mlU/mL significantly predicted hypocalcemia (48% vs 17%) ( P < 0.05). This was confirmed in a logistic regression analysis ( P < 0.05). All but one patient (98%) eventually returned to normal serum calium levels. Despite preservation of parathyroids, transient symptomatic hypocalcemia is common after total thyroidectomy. Female gender and low TSH serum level predicted hypocalcemia. Therefore, female patients undergoing total thyroidectomy with preoperative low TSH levels should receive calcium prophylaxis to decrease morbidity, shorten hospital stay, and decrease costs.

Should female patients undergoing parathyroid-sparing total thyroidectomy receive routine prophylaxis for transient hypocalcemia?

Hypocalcemia following parathyroid-sparing total thyroidectomy is frequent and can prolong hospital stay. We undertook this study to identify preoperative predictors of postoperative hypocalcemia useful in the postoperative management of these patients. We examined patients undergoing total thyroidectomy for benign disease with preservation of at least three parathyroids from January 2000 to January 2001. Low serum calcium was considered below 8.0 mg/dL. Age, gender, preoperative serum calcium, thyroid stimulating hormone (TSH), T3, T4, albumin, cholesterol, and tryglicerides were compared in patients with normal and low serum calcium level on the second postoperative day and on discharge day by using chi2 test and a model of logistic regression. Data were reported using their frequency distribution among the two groups of patients. Eighty patients, 60 females (F) and 20 males (M), underwent parathyroid-sparing total thyroidectomy. On second postoperative day, hypocalcemia occurred in 42 patients, and 56 per cent were symptomatic. Only female gender (88% F vs 12% M) (P < 0.05) and TSH <0.27 mUI/mL (38% vs 18%) (P < 0.05) predicted hypocalcemia. Similarly, female gender predicted hypocalcemia in a logistic regression analysis (P < 0.05). On the day of discharge, 22 patients had low serum calcium levels, and 50 per cent were symptomatic. At this time, only TSH value < 0.27 mlU/mL significantly predicted hypocalcemia (48% vs 17%) (P < 0.05). This was confirmed in a logistic regression analysis (P < 0.05). All but one patient (98%) eventually returned to normal serum calium levels. Despite preservation of parathyroids, transient symptomatic hypocalcemia is common after total thyroidectomy. Female gender and low TSH serum level predicted hypocalcemia. Therefore, female patients undergoing total thyroidectomy with preoperative low TSH levels should receive calcium prophylaxis to decrease morbidity, shorten hospital stay, and decrease costs.

[Diagnosis and therapy of severe acute colitis, still an open issue. Our experience]

From a review of a series of 12 cases of whom 52 operated and of the literature, the Authors discuss about aetiology, pathogenesis and diagnosis of severe colitis. Clinical and laboratory findings, CT and plain films of the abdomen and at last colonoscopy should be evaluated very carefully for certainty diagnosis of a severe acute colitis or toxic megacolon. They suggest a multidisciplinary approach as fundamental for medical management, for indications and correct timing of surgical procedures and to decrease postoperative morbility and mortality. Total colectomy with ileostomy is recommended in emergency surgical treatment of this colonic acute diseases, whereas for urgency operation, performed not later than 48-72 hour of adequate medical treatment, colectomy is suggested with ileorectal or ileoanal anastomosis and ileostomy.

Surgical controversies in the treatment of recurrent achalasia of the esophagus

BACKGROUND/AIMS

Surgery remains the first choice for achalasia of the esophagus with good results in 90% of cases.

METHODOLOGY

We studied the cause of failure for surgical treatment and the results of a second operation in 20 patients that were followed up for at least three years.

RESULTS

The results were good in 70% of the cases.

CONCLUSIONS

To improve this procedure, according to the authors, it is essential for a careful presurgery evaluation, an early reoperation in case of failure and a careful surgical technique in order to avoid periesophageal sclerosis.