Survivin in adrenocortical tumors - pathophysiological implications and therapeutic potential

Treatment options for adrenocortical carcinoma (ACC) are very limited. In other solid tumors, small vaccination trials targeting the anti-apoptotic molecule survivin suggested immunological and clinical benefit in selected patients. Therefore, we investigated whether survivin might be a suitable target for immunotherapy in ACC. Survivin mRNA and protein expression was assessed in adrenal tissue specimens [by real-time-PCR in 29 ACC, 24 adrenocortical adenomas (ACA) and 12 normal adrenal glands; by immunohistochemistry in 167 ACCs, 15 ACA, and 5 normal adrenal glands]. Expression was correlated with clinical outcome using Kaplan-Meier and Cox regression analyses. The anti-apoptotic role of survivin was investigated in the SW13 ACC cell line using survivin siRNA. The presence of spontaneous survivin specific T-cells in peripheral blood was assessed by FACS dextramere staining in 29 ACC patients in comparison to healthy controls. Survivin mRNA in ACC was significantly overexpressed when compared with ACA or normal adrenal glands. Immunohistochemistry confirmed survivin protein expression in 97% of the ACCs. In 83% of samples, staining was moderate or high and clinical outcome in this subgroup showed a trend towards poorer prognosis [hazard ratio for death 2.28 (95% CI 0.99-5.28); p=0.053]. Survivin knockdown in SW-13 cell significantly increased the rate of apoptosis. Finally, spontaneous survivin-reactive T cells were detectable in 3 of 29 ACC patients. In conclusion, our data suggest that survivin could play an important role in the anti-apoptotic mechanisms in ACC and provide first hints that targeting survivin might be an interesting new therapeutic approach in this rare disease.

New techniques for high-temperature melting measurements in volatile refractory materials via laser surface heating

An original technique for the measurement of high-temperature phase transitions was implemented based on a laser-heating method, enabling chemically unstable, refractory materials to be melted under controlled conditions. This technique includes two independent but correlated methods: In the first, fast multichannel pyrometry is employed to measure thermograms and spectral emissivity; in the second, a low-power probe laser beam is used for the detection of reflectivity changes induced by phase transitions on the sample surface. The experiments are carried out under medium ( approximately 10(2) kPa) or high ( approximately 10(2) MPa) inert-gas pressures in order to kinetically suppress evaporation in volatile or chemically instable samples. Two models for the simulation of the laser-heating pulses are as well introduced. Some results are presented about the successful application of this technique to the study of the melting behavior of oxides such as UO(2+x), ZrO(2), and their mixed oxides. The method can be extended to a broad class of refractory materials.

Mucoadhesive Tablets for Buccal Administration Containing Sodium Nimesulide

The possibility of improving the flux of nimesulide across the buccal mucosa using the drug in the form of a sodium salt was investigated in our study. The salt form may increase to flux across buccal membrane, starting from a suspension; its lower permeation coefficient is compensated by a higher concentration gradient. The salt was inserted into a mucoadhesive tablet for buccal administration. The tablets were designed to prevent the loss of the drug into the saliva by means of a protective layer and placed on the area not in contact with the mucosa. Ten volunteers were used. The in vitro release from mucoadhesive tablets was examined through a porcine buccal mucosa, using a standard Franz cell, modified for present purposes. The advantages of a higher concentration gradient for the flux, related to a higher solubility of the salt, and to a sufficiently high permeation coefficient of the drug, despite the ionized form, could not be completely exploited, because the composition of the formulation destroys the chemical form of the drug.

Adrenal morpho-functional alterations in patients with acromegaly

Acromegaly is associated with a greater morbidity and higher incidence of tumors, possibly due to the permissive role of elevated GH and IGF-I levels. In the general population, adrenal masses are frequently discovered (prevalence 1-5%) at computed tomography (CT). We evaluated the prevalence of adrenal lesions in patients with acromegaly. We studied 94 acromegalic patients, 54 females (mean age 55.0+/-16.0 yr) and 40 males (mean age 50+/-14 yr) referred to 5 Endocrinology Units between 2001-2003; 49 had active disease and 45 had been treated with surgery and/or were controlled with medical therapy. Abdominal CT showed adrenal lesions in 27 patients; 9 of them had unilateral masses (10%) with benign features (diameter 0.5-3 cm) and 18 had hyperplasia (14 monolateral and 4 bilateral), with no significant differences between patients with active vs controlled disease, and with no correlation between prevalence of masses and duration of disease, GH and IGF-I levels. Hormone study (urinary free cortisol, catecholamines/metanephrines, upright plasma renin activity and aldosterone, morning plasma ACTH and low-dose dexamethasone suppression test) disclosed no major endocrine alterations. During a 1-yr follow-up, the adrenal masses increased in size in 3 cases and 1 patient also developed subclinical Cushing's syndrome. Adrenal lesions seem more frequent in acromegaly than in the general population, but no single factor (GH/IGF-I levels or disease duration) predicts them. The masses appear to be benign and nonhypersecreting, but a longer follow-up is recommended to disclose any changes in their morphofunctional state.

Controversy on the First Ionization Potential of PuO2 (Nearly) Settled by New Experimental Evidence

The first ionization potential of the PuO2 molecule was for a long time considered to be 4-5 eV higher than that of UO2. This feature could hardly be explained by the most advanced "ab initio" calculations, which, on the other hand, provide satisfactory results for other actinide oxides. From recent experiments, performed with different techniques, a lower ionization potential of approximately 7 eV was measured, in better agreement with the theoretical predictions. Our recent experiments, where thermally produced ions were measured, make it possible to formulate an accurate relation between the ionization potential of PuO2 and that of PuO: I0(PuO2) = I0(PuO) + 0.42 +/- 0.005 eV. The present uncertainty of I0(PuO) leads to the final assessment, 6.2 < or = I0(PuO2) < or = 6.6 eV, whereby the upper limit is more in line with the aforementioned recent measurements. Considering the still existing uncertainties, one can conclude that these results remove major doubts on the validity of the current theoretical predictions. However, the very small ionization cross section of PuO2 by low-energy electron collisions, which led to the previous spurious assessment of the ion appearance potential, has still an unexplained cause.

Analysis of somatostatin receptors 2 and 5 polymorphisms in patients with acromegaly

OBJECTIVE

The aim of the study was to investigate the possible correlation of single nucleotide polymorphisms in somatostatin receptor (SSTR)2 and SSTR5 genes with the responsiveness to somatostatin analogs in a cohort of acromegalic patients.

STUDY DESIGN

Three single nucleotide polymorphisms (a-83 g, c-57 g, and t80c) of SSTR2 and three (t-461c, c325t, and c1004t) of SSTR5 were analyzed in 66 acromegalic patients with different responsiveness to somatostatin analogs and 66 healthy controls.

RESULTS

Allele frequencies in patients and controls were similar. No association between SSTR2 genotypes and GH and IGF-I levels was found. When considering SSTR5 variants, patients homozygous or heterozygous for the substitution c1004 (P+) showed basal IGF-I levels significantly lower than patients homozygous for 1004t (P-). Moreover, serum GH levels were lower in patients with P+/T- haplotype (having c1004 allele and no t-461 allele) than in those with P-/T+. No correlation between SSTR2 and SSTR5 genotypes, responsiveness to somatostatin therapy, and mRNA expression in the removed adenomas (n = 10) was found.

CONCLUSIONS

These data suggest a role for SSTR5 t-461c and c1004t alleles in influencing GH and IGF-I levels in patients with acromegaly, whereas SSTR2 and SSTR5 variants seem to have a minor role in determining the responsiveness to somatostatin analogs.

Evaluation of cardiac structure by echoreflectivity analysis in acromegaly: effects of treatment

OBJECTIVES

Cardiac echoreflectivity is a noninvasive tool for evaluating cardiac fibrosis. The present paper aimed to study the modifications of cardiac echoreflectivity in a group of acromegalic patients before and after therapy, and to assess possible correlations with serum levels of procollagen III (PIIINP), a peripheral index of collagen synthesis.

DESIGN AND METHODS

Cardiac echoreflectivity (as assessed by analyzing 2-D echocardiograms digitized off-line onto a personal computer) and PIIINP levels were evaluated in 16 acromegalic patients of new diagnosis not affected by arterial hypertension (10 males, six females, age+/-s.d.: 38+/-10 years), and in a group of 16 sex- and age-matched healthy subjects. All the patients were re-evaluated after surgical and/or medical therapy for acromegaly. The echo patterns were analyzed by software that supplies the derived collagen volume fraction (dCVF), an index of fibrosis.

RESULTS

At baseline, acromegalic patients showed significantly higher dCVF values and PIIINP levels than healthy controls (3.1+/-0.5% vs 1.6+/-0.3%, P<0.01 and 8.7+/-2.2 vs 3.1+/-1.1 ng/ml, P<0.05, respectively, by unpaired Student's t-test). After therapy, dCVF and PIIINP levels normalized in the six controlled patients (that is, GH of <2.5 microg/l and IGF-I within normal range) (dCVF from 2.8+/-0.4% to 1.4+/-0.2%, P<0.001; PIIINP from 8+/-2.7 to 3.3+/-1.9 ng/ml, P<0.05), while no significant changes were found in noncontrolled patients (dCVF from 3.3+/-0.6% to 2.9+/-1.2% and PIIINP from 9.1+/-1.9 to 7.9+/-3.5 ng/ml, P=NS). A positive correlation between dCVF and PIIINP (r=0.75, P<0.001) and between IGF-I and both dCVF and PIIINP (r=0.65 and 0.61 respectively, P<0.05) was found in acromegalic patients.

CONCLUSIONS

Cardiac echoreflectivity, which may be a reflection of heart collagen content, is increased in patients with active acromegaly and correlates with PIIINP concentrations. After cure or adequate control of the disease, both parameters revert to normal. Echoreflectivity analysis could be a useful adjuvant parameter in the assessment of the activity of acromegalic disease.

Degradation of components in drug formulations: a comparison between HPLC and DSC methods

Information about the stability of drug components and drug formulations is needed to predict the shelf-life of the final products. The studies on the interaction between the drug and the excipients may be carried out by means of accelerated stability tests followed by analytical determination of the active principle (HPLC and other methods) and by means of the differential scanning calorimetry (DSC). This research has been focused to the acetyl salicylic acid (ASA) physical-chemical characterisation by using DSC method in order to evaluate its compatibility with some of the most used excipients. It was possible to show, with the DSC method, the incompatibility of magnesium stearate with ASA; the HPLC data confirm the reduction of ASA concentration in the presence of magnesium stearate. With the other excipients the characteristic endotherms of the drug were always present and no or little degradation was observed with the accelerated stability tests. Therefore, the results with the DSC method are comparable and in good agreement with the results obtained with other methods.

Therapy for the syndromes of GH excess

This short review summarizes the results of treatments now available in Italy for the management of GH and IGF-I excess due to primary pituitary somatotroph adenoma, which accounts for over 99% of cases of acromegaly. Goals of treatment of acromegaly should now include, in addition to the reduction of tumor bulk and symptomatic relief, the lowering of GH circulating concentrations to below a critical level (2.5 microg/l, "safe" GH), the normalization of serum IGF-I concentrations according to age, improvement (or at least not worsening) of co-morbidities (diabetes mellitus, hypertension, cardiomyopathy, sleep-apnea), the decrease of the risk of premature mortality. Surgery, radiation (fractionated conventional radiotherapy and radiosurgery) and medical treatments with dopamine agonists and somatostatin analogs are the available options that are discussed in detail. The treatment of acromegaly must be tailored to the needs of the individual patient. Age, tumor size and invasiveness, GH concentrations, the patient's general medical conditions, presence and severity of co-morbidities, availability of local resources such as an expert neurosurgeon or gamma-knife radiosurgery, and of course the informed wishes of the patient are all factors that must be taken into account. For most patients the treatment will be multimodal. However, despite criteria and guidelines based on continuously emerging information about the management of acromegaly, patient outcomes are still less than desirable, with 10 to 20% of patients with uncontrolled disease, despite the use of all available therapies. This underscores the need for the quick introduction in clinical practice of the new therapies.

In vitro permeation through porcine buccal mucosa of caffeic acid phenetyl ester (CAPE) from a topical mucoadhesive gel containing propolis

Recent studies have shown that propolis has on the oral cavity appreciable antibacterial, antifungal and antiviral actions, as well as anti-inflammatory, anaesthetic and cytostatic properties. In light of these studies, an assessment of the diffusion and permeation of caffeic acid phenetyl ester (CAPE) through porcine buccal mucosa was considered useful as a possible application in the stomatological field. To do so, a mucoadhesive topical gel was prepared to apply to the buccal mucosa. The gel was formulated in such a way as to improve the solubility of the propolis, conducting to an increase of the flux. The mucosal permeation of CAPE from the formulation was evaluated using Franz cells, with porcine buccal mucosa as septum between the formulation (donor compartment) and the receptor phase chamber. The diffusion through the membrane was determined by evaluating the amount of CAPE present in the receiving solution, the flux and the permeation coefficient (at the steady state) in the different formulations at set intervals. Qualitative and quantitative determinations were done by HPLC analysis. From the results, CAPE allowed a high permeability coefficient in comparison to the coefficient of other molecules, as expected from its physical-chemical structure. Moreover, the developed gel improved the CAPE flux approximately 35 times more with respect to an ethanol solution formulated at the same gel concentration. The developed gel was also tested in order to evaluate the mucoadhesive behaviour and comfort in vivo on 10 volunteers in a period of 8 h. The in vivo evaluation of mucoadhesive gel revealed adequate comfort and non-irritancy during the period of study and it was well accepted by the volunteers.

Effects of two different somatostatin analogs on glucose tolerance in acromegaly

Impaired glucose tolerance is present in many acromegalic patients and treatment with somatostatin analogs has variable effects on glycemic control. The aim of this study was to compare the effects of 2 somatostatin analogs on glucose metabolism, lanreotide slow release (L-SR) and octreotide long acting release (O-LAR), in 10 patients with acromegaly (2 of whom with overt Type 2 diabetes mellitus). Glucose and insulin levels in fasting conditions and in response to OGTT, evaluated as AUC, insulin resistance (IR) evaluated by homeostatic model assessment (HOMA-IR), glycosylated hemoglobin (HbA1c), GH, IGF-I, were assessed during L-SR and O-LAR treatment. Mean fasting glucose, glucose response to OGTT and HbA1c levels in 8 non-diabetic patients did not significantly change after L-SR therapy while they all increased after O-LAR treatment (p<0.05 vs baseline and L-SR). Mean HOMA-IR values calculated in acromegalic patients before medical therapy were higher than in normal subjects (p<0.005) and showed a significant decrease during both treatments (p<0.05). In the 2 diabetic acromegalic patients a worsening in glucose metabolism was observed during O-LAR treatment but not during L-SR. GH and IGF-I levels significantly decreased with both drugs and normalized respectively in 38% and 12% with L-SR, 50% and 25% with O-LAR. In conclusion, both drugs decreased IR in acromegalic patients; O-LAR seems to be more detrimental to glucose metabolism than L-SR, despite being more effective in reducing GH and IGF-I levels.

Development of a mucoadhesive dosage form for vaginal administration

The antimycotic imidazole derivative clotrimazole is employed locally for the treatment of genitourinary tract mycotic infections and is formulated as creams, foams, tablets, gels, irrigations, or pessaries. In this study, a new dosage form was developed by including bioadhesive polymers (polycarbophyl, hydroxypropylmethylcellulose, and hyaluronic sodium salt) into pessaries made of semisynthetic solid triglycerides. These polymers hold the delivery systems in the vaginal tract for a few days without any toxic effects or important physiological modifications, prolonging the permanence of the drug on the vaginal mucosa. Technological controls (compatibility with differential scanning calorimetry [DSC] studies, particle size analysis, and liquefaction time test) and biopharmaceutics studies for the evaluation of the release of the drug from the dosage form and of the bioadhesive properties were carried out. Moreover, a new test for the evaluation of the permanence of the drug in a simulated application site was developed from a modification of the Satnikar and Fantelli method for the evaluation of the liquefaction time of rectal suppositories. This test simulates the physiological vaginal condition and verifies the efficiency of the polymers in prolonging the permanence of the dosage form in the location where it is applied. The technological controls demonstrated that the presence of the polymers did not have an influence on the characteristics of the pessaries. On the other hand, there was an improvement in adhesivity of the pessaries in the in vitro adhesion test and prolonging of the liquefaction time in the liquefaction time test in the presence of mucoadhesive polymers, which increased with increasing polymer concentration. The presence of the mucoadhesive had a large influence on the permanence of the drug in the simulated application site because it modified the distribution of the drug along the simulated application site. In conclusion, the developed new formulations showed good technological and adhesion properties and the capacity of hold the dosage form in the target site. Among the employed bioadhesive polymers, the best behavior in the performed test was by polycarbophyl at its maximum concentration.

Design and evaluation of buccal adhesive hydrocortisone acetate (HCA) tablets

Many studies have shown that topical buccal therapy with steroid anti-inflammatory drugs is useful in controlling ulcerative and inflammatory mucosal diseases. This local treatment is based on the concept that a high activity of steroids can be produced at the site of administration and, at the same time, the degree of systemic side effects can be minimized or avoided. In this study we developed a new formulation consisting of a mucoadhesive tablet formulation for buccal administration of hydrocortisone acetate (HCA). Three types of tablet were developed containing three mucoadhesive components: hydroxypropylmethyl cellulose (Methocel K4M), carboxyvinyl polymer (Carbopol 974P), and polycarbophyl (Noveon AA1); the first polymer is a cellulose derivative, the others are both polyacrylic acid derivatives. For each of those, three tablet batches were produced changing the quantity of the mucoadhesive component (10, 20, and 30%), resulting in 9 different formulations. The compatibility of HCA with all excipients using Differential Scanning Calorimetry (DSC) was assessed. Tablets were manufactured by wet granulation followed by compression. Technological controls on granulates (Hausner index, Carr index, granulometry and Karl-Fischer percentage humidity) and tablets (thickness, diameter, friability, hardness, uniformity of content, weigh uniformity and dissolution kinetic) were carried out. Mucoadhesion properties, ex vivo permeability through porcine buccal mucosa, in vivo behavior and compliance were evaluated. Technological controls have demonstrated that the increase in the (percentage) of mucoadhesive causes an increase in granulometry followed by a reduction in the granulate flowability, however all the tablets have given satisfactory technological results and conformed to the 3rd Ed. European Pharmacopoeia specifications. Mucoadhesion, ex vivo permeability and in vivo behavior results notably differed among tablets, depending on the quality and quantity of the mucoadhesive component. An overall comparison of results showed the tablets containing Carbopol 20% resulted to be the best formulation among those developed.

Comparative bioavailability of two formulations containing atenolol and chlortalidone associated in a 4:1 fixed combination

Atenolol (CAS 29122-68-7) and chlortalidone (CAS 77-36-1) are marketed associated in a 4:1 strength ratio (100/25 and 50/12.5 mg) for the treatment of hypertension. According to EU guidelines, the bioequivalence of one dosage strength can also cover additional strengths when the pharmacokinetics of a given drug is linearly related with the dose. The kinetics of atenolol is linearly correlated with the dose and chlortalidone has linear kinetics with doses < or = 100 mg. Thus this trial carried out on the 100/25 mg strength also covers the 50/12.5 mg strength. The trial was carried out on 18 healthy volunteers (9 males and 9 females) according to a single dose, two-period, two-treatment, two-sequence study design with washout. Timed atenolol plasma concentrations and chlortalidone blood concentrations were used to assess primary pharmacokinetic parameters Cmax, tmax and AUC extrapolated to infinity by a non-compartmental model. The bioavailability of the two formulations was compared through the 90% confidence intervals (C.I.) of Cmax and AUC in accordance with operating guidelines. C.I. of chlortalidone were fully comprised in the 0.80-1.25 range. In the case of atenolol, which displayed a higher data dispersion, C.I. were comprised in the enlarged 0.70-1.43 range. Time to peak, tmax, did not show any statistically significant difference between the test and reference product with respect to both analytes. Pharmacodynamic measurements of the decrease in systolic blood pressure led to fully overlapping results with test and reference. The authors conclude that the test formulation should be considered bioequivalent with the reference with chlortalidone and in the borderline of bioequivalence with atenolol. As no safety problems were involved and pharmacodynamics led to overlapping results as between test and reference, the bioequivalence conclusion could be extended also to atenolol.

Buccoadhesive tablets for the slow delivery of cetylpyridinium chloride: design and in vitro/in vivo analysis

A buccoadhesive slow-release system constituted by a monolayer tablet was developed for the administration of cetylpyridinium chloride (CPC). Tablet composition was based on a mixture of a bioadhesive polymer with conventional excipients. Three different polymers (Methocel K4M, Noveon AA1, Carbopol 974P) in three different concentrations (10%, 20%, 30%) were used. The release profile and the adhesion properties of nine formulations were evaluated in vitro. Based on these results three formulations containing 10% w/w of the tested polymers were chosen to assess, with preliminary in vivo studies, the compliance and the residence time in the month of the systems. Tablets containing Noveon AA1 showed the best performances.

[Spontaneous rupture of the spleen during the development of chronic pancreatitis. One case]

Spontaneous rupture of the spleen is a relatively rare occurrence during the course of chronic pancreatitis. The physiopathology remains imprecise and mechanical factors are associated with pancreatic enzyme diffusion and vascular changes in explaining its aetiology. The diagnosis is difficult since it often mimics an acute exacerbation of pancreatitis or even actual acute pancreatitis when the existence of the pancreatic condition is not previously known. Abdominal echotomography or peritoneal puncture-lavage and, now, CAT scanning are the key factors in reaching the diagnosis.