Effect of emicizumab-neutralizing antibodies on activated partial thromboplastin time-based clotting time test results in patients treated with emicizumab

Background

Emicizumab is a bispecific humanized monoclonal antibody that shortens the activated partial thromboplastin time (aPTT), making aPTT-based tests unreliable.

Objectives

To evaluate the efficacy of a mixture of 2 anti-idiotype monoclonal antibodies (anti-emi) in neutralizing emicizumab in samples from persons with hemophilia A treated with emicizumab.

Methods

Fifty samples from persons with hemophilia A treated with emicizumab were analyzed for aPTT and factor VIII procoagulant activity; FVIII inhibitor titer was measured using Nijmegen-Bethesda assay in 50 plasma samples of additional patients (positive for FVIII inhibitor) treated with emicizumab. FVIII procoagulant activity and inhibitor titer were measured using 1-stage (Actin FS, Siemens) and chromogenic assays with bovine regents (Factor VIII Chromogenic Assay, Siemens). Emicizumab concentration was measured by modified a 1-stage assay calibrated with a drug-specific calibrator (r2 Diagnostics Inc). All the tests were performed on Sysmex CS-2400 (Sysmex) before and after the addition of anti-emi (Chugai Pharmaceutical).

Results

Emicizumab concentrations measured after neutralization were <1.6 μg/mL in all samples. FVIII levels were >480 IU/dL with an aPTT of <30.8 seconds in all samples before neutralization and were <1 IU/dL with an aPTT of >70 seconds after adding anti-emi. FVIII inhibitor resulted in a false negative result in 44 of 50 samples measured with the 1-stage assay before neutralization. A good correlation (r = 0.98) was found between inhibitor titer measured using the chromogenic (insensitive to emicizumab) and 1-stage assays after neutralization.

Conclusion

The anti-emi antibodies were shown to completely neutralize emicizumab, making samples pretreated with anti-emi analyzable with the 1-stage assay.

Analytical Performance of Different Laboratory Methods for Measuring Susoctocog-Alfa

Recombinant porcine factor VIII (rpFVIII) is indicated for treating bleeding episodes in acquired haemophilia A, but there are few data regarding laboratory methods to adequately monitor treatment. This study involving three Italian laboratories aimed to evaluate the analytical performance of different assays for measuring rpFVIII. Five spiked rpFVIII samples (0.5–1.5 IU/mL) were analysed on three days, in triplicate, with eleven combinations of reagents (Werfen, Boston, MA, USA: SynthasIL and SynthaFax for one-stage assay, Chromogenix Coamatic FVIII for chromogenic assay), FVIII depleted plasmas (with or without von Willebrand factor—VWF) and calibrators (HemosIL human calibrator plasma, porcine calibrator diluted in FVIII deficient plasma with or without VWF). The assays were performed on ACL TOP analysers (Werfen, Boston, MA, USA). Intra- and inter-assay and inter-laboratory Coefficient of Variation (CV%) were calculated together with percentage of recovery (% recovery) on the expected value. The results showed that the reagent combinations reaching satisfactory analytical performance are: SynthasIL/human calibrator/deficient plasma+VWF (total recovery 99.4%, inter-laboratory CV 4.04%), SynthasIL/porcine calibrator/deficient plasma+VWF (total recovery 111%, inter-laboratory CV 2.75%) and Chromogenic/ porcine calibrator/deficient plasma+VWF (total recovery 96.6%, inter-laboratory CV 8.32%). This study highlights that the use of porcine standard (when available) and FVIII deficient plasma with VWF should be recommended.

Does conjugation strategy matter? Cetuximab-conjugated gold nanocages for targeting triple-negative breast cancer cells

The efficient targeting of cancer cells depends on the success of obtaining the active targeting of overexpressed receptors. A very accurate design of nanoconjugates should be done via the selection of the conjugation strategy to achieve effective targeted nanoconjugates. Here, we present a detailed study of cetuximab-conjugated nonspherical gold nanocages for the active targeting of triple-negative breast cancer cells, including MDA-MB-231 and MDA-MB-468. A few different general strategies were selected for monoclonal antibody conjugation to the nanoparticle surface. By varying the bioconjugation conditions, including antibody orientation or the presence of a polymeric spacer or recombinant protein biolinker, we demonstrate the importance of a rational design of nanoconjugates. A quantitative study of gold content via ICP-AES allowed us to compare the effectiveness of cellular uptake as a function of the conjugation strategy and confirmed the active nature of nanoparticle internalization in cancer cells via epidermal growth factor receptor recognition, corroborating the importance of the rational design of nanomaterials for nanomedicine.

Tubulointerstitial lesions in lupus nephritis: International multicentre study in a large cohort of patients with repeat biopsy

BACKGROUND

The glomerulocentric International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification is the gold standard for the evaluation of lupus nephritis, while tubulointerstitial (TIN) parameters are often under-recognized in pathological reports.

METHODS

Renal biopsies from 142 patients who underwent repeat biopsy (RB) were evaluated for the following histological parameters: (i) inflammatory interstitial infiltrates; (ii) interstitial fibrosis; (iii) tubulitis; and (iv) tubular atrophy. The inter-relationships between the four TIN variables were explored by multivariate analysis. A linear mixed model was used to investigate the potential impact of TIN variables on eGFR and proteinuria at the two biopsy occasions.

RESULTS

The study showed that moderate-severe lesions were not so frequent at the reference biopsy, but more extensively represented upon RB. A strong association was found between the two inflammatory indices and between those related to chronic damage, while the relationship with the ISN/RPS classification was present at RB. If class IV-G was the most related with TIN (especially at RB), the existence of primary TIN in class II patients was also confirmed. Finally, our results support the hypothesis that tubulitis is an independent predictive factor for eGFR.

CONCLUSIONS

We recommend that the standard histological evaluation of SLE nephritis also includes TIN features.

[Phosphate binders in renal patients: a point estimate from rationale, through evidences to the real world setting]

Phosphate binders represent a common intervention in renal patients affected by chronic kidney disease and mineral bone disorder (CKD-MBD). Although counteracting P overload through binders adoption is argued by a physiology-driven approach, the efficacy of this intervention on hard endpoints remains poorly evident. The inconsistencies between rationale and methodological weakness, concerning the clinical relevance of P binding in chronic kidney disease, will be herein discussed with special focus on the need of a multi-factorial treatment against CKD-MBD, which is currently more achievable due to the variety of P binders and the rapid evolution of nutritional therapy, dialysis techniques and nursing science.

The value of repeat biopsy in the management of lupus nephritis: an international multicentre study in a large cohort of patients

BACKGROUND

The International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification represents the gold standard for the histological evaluation of Systemic Lupus Erythematosus (SLE) nephritis. A repeat biopsy (RB) might be an important tool to provide information on long-term renal outcomes and optimal therapy. Aims of this study were to evaluate the use of the ISN/RPS classification and the role of RB in routine clinical practice.

METHODS

A total number of 142 patients with SLE nephritis and with adequate reference and RB samples were included in this multicentre retrospective study. A meticulous histological examination was centrally performed on first and RB and compared with clinical variables and follow-up data.

RESULTS

Morphological features of the ISN/RPS classification: at first and RB, significant differences were observed between segmental classes (III, IV-S) and Class IV-G in mesangial proliferation, wire loops and tuft necrosis. Clinical features and ISN/RPS classification: the correlation between serum creatinine, proteinuria, blood pressure levels and histological classes at first and RB demonstrated more severe renal disease in Class IV-G, both at first and RB. Agreement between ISN/RPS classification at first and RB: 40.8% of patients changed the histological class. Fifty per cent of Class II (mild mesangial form) were reclassified as Class IV-G at RB, whereas 18.9% of Class IV-G were reclassified as Class II. The transition among segmental (III/IV-S) and mesangial forms (II/IV-G) was extremely rare. The comparison between the clinical parameters at the final follow-up and the ISN/RPS classification confirmed that the trend of serum creatinine and proteinuria between the different classes was better described at the RB (higher in Class IV-G) than on the first biopsy.

CONCLUSIONS

The histopathological data suggest that morphological differences between segmental and global forms do exist, possibly due to different pathogenetic mechanisms. An RB strategy could provide additional information on long-term renal outcomes. A strategy of protocol biopsies could be useful in perspective future trials to better understand the therapeutic response and the natural history of this disease.

[Metabolomic profiles of exhaled breath condensate of 39 nickel exposed workers]

Nickel compounds have proven lung carcinogenic effects and their processing involve a large amount of population. The aim of this study was to investigate the metabolomic profiles of Exhaled Breath Condensate (EBC) of a group of nickel exposed workers. Nickel in blood, urine and EBC of 39 workers (electroplaters) and 50 controls was measured. The 10 most nickel exposed workers were chosen for the analysis of EBC metabolomic profiles, matched to controls by gender and smoke habits. All the samples were analyzed using the HPLC-MS/MS system (High-Performance Liquid Chromatography/Mass Spectrometry). The profiles of the spectra obtained by the mass spectrometer (Orbitrap) analysis were processed using the MZmine 2.4 software. Nickel concentrations in EBC of the exposed workers were significantly higher compared to controls (1.39 microg/L; 0.039 microg/L, p = 0.017). The observation of the metabolomic profiles pointed out a significantly different response pattern between the exposed and the controls. This result was further studied by a subsequent processing with the XCMS program: an overexpression of 3 hypothetical substances in controls compared to exposed was detected. Although these data must be considered as preliminary, it has been observed that the mass-to-charge ratio of one of these substances may respond to the Phenylacethylglutamine (PAG) one, whose role in the control of cellular cycle is controversial and uncertain. Even if further studies to confirm these results are necessary, the analysis of the metabolomic profiles in the biological matrices is supposed to provide useful information both in the clinical and in the prevention fields.

Alterations of atrial electrophysiology induced by electrolyte variations: combined computational and P-wave analysis

AIMS

Haemodialysis (HD) therapy represents a unique model to test in vivo, in humans, the effects of changes in plasma ionic concentrations. Episodes of paroxysmal atrial fibrillation (AF) often occur during the treatment. We investigated the effects of HD-induced electrolyte variations on atrial electrophysiology by analysing ECG P-wave duration (PWd), which reflects atrial conduction velocity (CV), and simulated atrial action potential (AP).

METHODS AND RESULTS

In 20 end-stage renal disease patients PWd (signal-averaged ECG), heart rate (HR), blood pressure, Na(+), K(+), Ca(2+), and Mg(2+) plasma concentrations were measured before and after HD session. The Courtemanche computational model of human atrial myocyte was used to simulate the atrial AP. AP upstroke duration (AP(ud)), AP duration and atrial cell effective refractory period (ERP) were computed. Extracellular electrolyte concentrations and HR were imposed to the average values measured in vivo. HD decreased K(+) (from 4.9 +/- 0.5 to 3.9 +/- 0.4 mmol/L, P < 0.001) and Mg(2+) (0.92 +/- 0.08 to 0.86 +/- 0.05 mmol/L, P < 0.05), and increased Na(+) (139.8 +/- 3.4 to 141.6 +/- 3.1 mmol/L, P < 0.05) and Ca(2+) (1.18 +/- 0.09 to 1.30 +/- 0.07 mmol/L, P < 0.001) plasma concentrations. PWd systematically increased in all the patients after HD (131 +/- 11 to 140 +/- 12 ms, P < 0.001), indicating an intra-atrial conduction slowing. PWd increments were inversely correlated with K(+) variations (R = 0.73, P < 0.01). Model-based analysis indicated an AP(ud) increase (from 2.58 to 2.94 ms) after HD, coherent with experimental observations on PWd, and a reduction of ERP by 12 ms.

CONCLUSION

Changes of plasma ionic concentrations may lead to modifications of atrial electrophysiology that can favour AF onset, namely a decrease of atrial CV and a decrease of atrial ERP.

Renal hilus paraganglioma: a case report and brief review

Paraganglioma is a rare tumour that originates from any paraganglia. Among extra-adrenal paraganglioma, renal hilus is a rare location. The authors report a case of a 43-year-old female who was admitted for evaluation of a renal mass detected incidentally by ultrasound imaging. Suspecting malignancy, the patient underwent radical nephrectomy. Upon macroscopic examination, the lesion was located into the renal hilus. Histological study revealed a neoplasm constituted of nests of monomorphic cuboidal cells with basophilic granular cytoplasm and round to oval nuclei. Necrosis was absent. The proliferative index (Mib-1) was very low (< 5%). Immunohistochemical examination revealed reactivity for neuron specific enolase (NSE), chromogranin A and synaptophysin. The final diagnosis was renal hilus paraganglioma. The paper shows the difficulty in diagnostic approaches to paraganglioma in this atypical site.

[Myeloid sarcoma in uterine leiomyoma]

In this case report we present a 44-year-old woman with a 2-weekhistory of vaginal bleeding. Gynaecological examination revealed the presence of a polypoid neoformation in the endometrial cavity with a maximum diameter of 4 cm. Histological analysis showed a classic leiomyoma infiltrated by a second monomorphic, highly undifferentiated neoplasia. Immunohistochemical analysis revealed a negative reaction for cytokeratin, CD10, inhibin, CD99, CD20, CD3, TdT and CD34, and positivity for CD45, MPO, CD68 and CD117. A diagnosis of myeloid sarcoma in myometrial leiomyoma was made. The following days the patient showed the onset of an acute myeloid leukaemia M5a. Forty days after diagnosis the patient died for complications related to immunodeficiency caused by therapy. Especially when a common antibody panel reveals negativity for epithelial, mesenchymal and lymphoid markers, this case underlines the importance of considering myeloid sarcoma in differential diagnosis of undifferentiated tumours arising in an extramedullary site in order to avoid errors and permit optimal therapeutic management.

Mast cell--pituitary interaction: modulation by serine phospholipids

The influence of mast cell activation on the secretion of prolactin has been studied in rats receiving lysophosphatidylserine, a natural occurring phospholipid with secretagogue activity in these cells. After the i.v. injection of lysophosphatidylserine (10 mg/kg) a plasma prolactin peak correlates with an increased blood histamine level. Following the secretory event, which is inhibited by the H1 anti-histamine tripelenamine, plasma prolactin level drops below the basal line. Repeated lysophosphatidylserine administrations induce mast cell desensitisation, thus reducing also the pituitary response. Under these conditions a decrease in prolactin basal level is still observed, although the pituitary stores of this hormone are preserved. Control tests in vitro with lysophosphatidylserine, show that the diacyl lysophosphatidylserine derivative amplifies the inhibitory effect of dopamine on prolactin secretion from isolated pituitaries. The data suggests that lysophosphatidylserine induces prolactin secretion through mast cell activation. After this event, the reacylation of this phospholipid into lysophosphatidylserine in the pituitary membrane may enhance the inhibitory control by dopamine.

Bone mineral density and bone metabolism in Duchenne muscular dystrophy

Very few studies on bone mineral density and bone metabolism in Duchenne muscular dystrophy (DMD) have been reported. DMD is a severe, progressive muscular disease resulting in death at a young age. No specific therapies are available, but corticosteroids induce improvement and slower progression of the disease. However, long-term steroid therapy is a serious risk factor for osteoporosis. This study was aimed at evaluating bone mineral density and calciotropic hormones in a group of children affected by DMD, with or without steroid therapy. Bone mineral density was measured by DXA scan on lumbar spine and total body. Evaluation of calcium, phosphorus, bone turnover markers and calciotropic hormones was performed. Thirty-two children affected by DMD were studied: twenty-two on long-term prednisone therapy, ten not taking corticosteroids. Bone mineral density was lower than normal for age in all patients, and even lower in the group of steroid-treated children. Trunk and lower limb bone mineral densities were more reduced than upper limb mineral density, especially in the steroid-treated subjects. A marked reduction in spine bone mineral density, hypocalciuria, low 25-hydroxyvitamin D levels, and increased bone turnover markers were observed, and even these especially in the steroid-treated group. In conclusion, decreased bone mineral density and derangement of calcium metabolism were present in DMD patients, and were worsening during corticosteroid therapy. It is thus recommended that bone and mineral metabolism be carefully evaluated in patients with DMD, so that appropriate measures could be taken, especially now that chronic corticosteroid therapy is frequently given.

Effects of 12-month GH treatment on bone metabolism and bone mineral density in adults with adult-onset GH deficiency

Serum bone-Gla protein (BGP), bone alkaline phosphatase (B-AP), and C-terminal cross-linked telopeptide of type I collagen (ICTP) levels were evaluated in 18 adults with acquired GH deficiency (GHD, 14 males and 4 females, age range: 25-59 yr) before, at 3, 6, 9 and 12 months of rec-GH treatment (0.125 IU/kg/week for the first month, followed by 0.25 IU/kg/week for 11 months) and 6 months after the withdrawal of therapy. Total body bone mineral density (BMD, g/cm2) was measured with dual energy X-ray absorptiometry (Hologic QDR 1000/W) before, at 12 months of GH treatment and 6 months after its withdrawal. Before treatment, BGP (mean+/-SE: 5.1+/-0.4 ng/ml), B-AP (59.4+/-6.5 IU/l), ICTP (3.1+/-0.3 ng/ml) levels of patients were similar to in healthy controls (BGP: 5.4+/-0.1 ng/ml; B-AP: 58.2+/-2.0 IU/l; ICTP: 4.1+/-0.3 ng/ml). GH treatment caused a significant increase of BGP, B-AP, ICTP levels, the maximal stimulation of bone resorption, occurring after 3 months of GH treatment, while the maximal effect on bone formation being evident later (at 6th month). A slight decline in BGP, B-AP, T-AP and ICTP levels occurred at 9-12 months of therapy, although the values remained significantly higher than in basal conditions and with respect to healthy controls. Before treatment, mean total body BMD of patients (1.110+/-0.027 g/cm2, range: 0.944-1.350 g/cm2) was not significantly different (z-score: +0.47+/-0.31, NS) from that observed in healthy controls (1.065+/-0.008 g/cm2, range: 1.008-1.121 g/cm2). GH therapy was associated with a significant reduction of mean total body BMD values (6th month: -1.8+/-0.5%, p<0.01; 12th month: -2.1+/-1.0%, p<0.05 vs baseline), particularly evident in the first six months of treatment. Six months after the withdrawal of GH therapy, BGP (5.9+/-0.5 ng/ml), B-AP (57.3+/-7.0 IU/l) and ICTP (3.2+/-0.1 ng/ml) levels returned similar to those recorded before treatment, while total BMD increased (+1.5+/-0.7, p<0.05), remaining however slightly lower than in basal conditions (-0.6+/-1.2, NS). In conclusion, our study shows that: a) acquired GHD in adulthood is associated with both normal bone formation/resorption indexes and normal total body BMD; b) GH therapy causes a significant rise of bone formation/resorption markers (earlier and greater for bone resorption); c) one-year GH therapy is associated with a reduction of total body BMD values, particularly evident in the first 6 months of treatment; d) the effects of GH therapy on bone turnover are transient, being completely reverted six months after the withdrawal of GH therapy; e) the increase of total body BMD (up to baseline values) after GH withdrawal might be explained as consequence of persisting effects of previous GH stimulation on bone remodeling.

Leukotriene D4-induced activation of smooth-muscle cells from human bronchi is partly Ca2+-independent

Cysteine-containing leukotrienes (cysteinyl-LTs) are potent bronchoconstrictors and play a key role in asthma. We found that histamine and LTD4 markedly constrict strips of human bronchi (HB) with similar efficacy. However, in human airway smooth-muscle (HASM) cells, LTD4, at variance with histamine, elicited only a small, transient change in intracellular calcium ion concentration. HASM cells express both Ca2+-dependent and -independent isoforms of protein kinase C (PKC) (i.e., PKC-alpha and PKC-alpha ). Western blot analysis showed that PKC-alpha is activated by histamine and, to a lesser extent, by LTD4, whereas only LTD4 translocates PKC-alpha. This translocation was specifically inhibited by the LTD4 antagonist pobilukast. Phorbol-dibutyrate ester (PDBu) (a PKC activator) contracted HB strips to the same extent in the presence as in the absence of extra- and intracellular Ca2+. In the absence of Ca2+, LTD4 contracted HB strips to the same extent as did PDBu, suggesting the involvement of a Ca2+-independent PKC in LTD4-mediated signal transduction. PDBu-induced desensitization and the PKC inhibitor H7 abolished the slow and sustained LTD4-triggered contraction of HB strips in the absence of Ca2+, although H7 did not greatly affect the response in the presence of the ion. Thus, in human airways, we identified a novel LTD4 transduction mechanism linked to bronchial smooth-muscle contraction, which is partly independent of Ca2+ and involves the activation of PKC-alpha.

Efficacy and safety of alendronate for the treatment of osteoporosis in diffuse connective tissue diseases in children: a prospective multicenter study

OBJECTIVE

Osteopenia/osteoporosis is being increasingly reported as a complication of many chronic diseases, even in children. In this preliminary study, we evaluated the effect of an oral bisphosphonate (alendronate) on bone mass in children with diffuse connective tissue diseases.

METHODS

Thirty-eight children with low bone mass were treated with alendronate for 1 year; 38 children who had the same primary disorders as the study patients but in a less severe form served as untreated control patients. We were also able to evaluate changes in bone mass (before and after alendronate) in 16 of the treated patients whose bone mineral density (BMD) had been routinely measured before the present study was initiated.

RESULTS

BMD increased by a mean +/- SD of 14.9 +/- 9.8% (P < 0.002 versus baseline) in the treated patients (reaching the normal range in 13 patients), while the BMD was 2.6 +/- 5% (not significant versus baseline) in the control group (15 had a decrease). Most interestingly, there was a large increase in BMD (15.3 +/-9.9%) after alendronate therapy in the 16 children who had their BMD followed up in the year before the study, during which time they had shown little increase in BMD (1.03 +/- 6.3%), and often a decrease. Considering their condition, increases in the height of all patients was satisfactory. No new fractures were observed after alendronate therapy was initiated.

CONCLUSION

Bisphosphonates can be considered essential components of the treatment of secondary osteoporosis, not only in adults, but also in pediatric patients. Alendronate has a positive effect on secondary osteopenia/osteoporosis in children with connective tissue diseases.

Bone mass change during methotrexate treatment in patients with juvenile rheumatoid arthritis

Thirty-two children affected by juvenile rheumatoid arthritis (JRA) were studied with serial measurements of bone mass for an average of 18 months, to evaluate the effects of long-term methotrexate (MTX) treatment on bone. Bone mineral density (BMD) was measured on lumbar spine and total body. During MTX therapy some increase in BMD was observed, though this was smaller than in a control group of healthy children. Axial (spine and trunk) and appendicular (upper and lower limbs) BMD showed similar increases. BMD, either as an absolute value or as a percent variation from baseline, did not correlate with either MTX dose or length of therapy. In children treated also with corticosteroids, these drugs negatively influenced bone mass increase. The main determinant of absolute spine BMD value appeared to be weight, while height and lean mass seemed to be the determinants of total body BMD. Pubertal stage and disease activity significantly influenced the yearly change in BMD. In conclusion, our data suggest that long-term, low-dose therapy with MTX does not induce osteopenia in children with JRA.

[Solitary cyst of the liver]

The rareness of the illness and the infrequency of infectious complications have led the authors to report a case which has come to their attention. After a brief exam of the etiopathogenesis and pathologic anatomy of these hepatic forms of cyst and the following considerations on their clinical aspects, which range from complete lack of symptoms to the compression of nearby organs (gall ducts, stomach, kidney) due to an increase in their volume, to occurrence of complications (rupture, haemorrhage, suppuration), the authors evaluate the therapeutic problem. Emptying and internal drainage being nowadays discarded and everyone agree on the necessity of excising the whole cystic wall with the minimum loss of hepatic parenchyma, the most indicated operation is total cystectomy. As such an operation is not always feasible because of the adherences of the cyst to the hepatic parenchyma; partial cystectomy can be practiced, leaving in situ part of the cystic wall. If the cyst is complicated by rupture, haemorrhage or suppuration, typical or atypical hepatic resection is recommended. The reported case concerns a patient in good general conditions, bearer of a large left hepatic lobe cyst, complicated by suppuration, with normal liver function, who has been submitted to ablation of the third hepatic segment according to the Ton That Tung transparenchymal technique. Finally the authors point out the possibility of a new conservative therapeutic approach, practiced in a few centres, consisting in echo or CT guided percutaneous needle suction and sclerosis of the cyst with 95% pure alcohol.

Effects of recombinant growth hormone (GH) treatment on bone mineral density and body composition in adults with childhood onset growth hormone deficiency

Lumbar spine, whole proximal femur and total body bone mineral density (BMD, g/cm2) and the regional soft tissue composition were measured with dual energy X-ray absorptiometry (Hologic QDR 1000/W) in eight adults with childhood onset GHD, before and after 6 months of recombinant GH treatment (0.5 IU/kg/week). Data obtained from patients were compared with those recorded in an age and sex matched control group. Before treatment, lumbar (L2-L4) spine BMD (mean +/- SD: 0.811 +/- 0.159 g/cm2), whole proximal femur BMD (0.739 +/- 0.094 g/cm2) and total body BMD (0.946 +/- 0.087 g/cm2) of patients were significantly (p < 0.001, 0.01 and 0.001, respectively) lower than those recorded in an age- and sex-matched control group (1.077 +/- 0.155 g/cm2, 0.968 +/- 0.166 g/cm2 and 1.168 +/- 0.058 g/cm2, respectively), although three patients showed BMD values at the lower limit of the normal range. Mean lumbar spine BMD, whole proximal femur BMD and total body BMD did not significantly change alter 6 months' GH treatment (-1.4 +/- 3.7%, +2.7 +/- 3.7% and -1.1 +/- 5.0% vs basal values, respectively). On the other hand, trochanteric subregion showed a significant 4.8 +/- 5.3% increase (vs basal, p < 0.05), while other hip subregions did not show significant changes. GH therapy caused marked effects on body composition; in fact, a significant decrease (p < 0.01) of trunk fat (-25.2 +/- 15.0%) and a marked increase (p < 0.01) of limbs lean mass (+10.0 +/- 5.3%), resulting in a significant (p < 0.02) reduction (-16.5 +/- 13.5%) of the axial to peripheral fat ratio (APFR), were clearly evident after six months of therapy. In conclusion, our study shows that six months of GH treatment do not exert relevant effects on the BMD of adults with childhood onset GHD. On the contrary, the effects of GH therapy on body composition are more marked, being clearly appreciable after six months of treatment.

Effects on bone mineral density of 12-month goserelin treatment in over 40-year-old women with uterine myomas

We evaluated the effects on bone mineral density (BMD) of a 12-month treatment with goserelin depot, a gonadotropin-releasing hormone agonist, in a group of women with symptomatic uterine myomas requiring hysterectomy. Sixteen women, mean age 45.6 +/- 5.0, reporting menorrhagia associated with uterine myomas, candidates for hysterectomy, were scheduled to be treated with goserelin depot for 12 months. BMD was measured at the vertebral (L2-L4) and proximal femur level (femoral neck and trochanter) at the start of therapy and 6, 12, and 18 months later using dual energy X-ray absorptiometry (Hologic QDR 1000/W). The patients were followed for a minimum of 6 months after the end of treatment. Thirteen of the 16 women enrolled completed the treatment and three suspended it after 5, 6, and 7 months, respectively, because of side effects (hot flashes, insomnia, depression). Of the 13 women who completed the treatment, three underwent hysterectomy because of myoma regrowth and the recurrence of symptoms 3-18 months later; four reached the menopause 5-16 months later, and six were all menstruating normally with a follow-up varying from 6 to 18 months. After 12 months of therapy we observed a bone loss at vertebral, femoral neck, and trochanter of 4.4% (P < 0.05 versus baseline; P = not significant versus 6 months), 7.5% (P < 0.01 versus baseline, P < 0.01 versus 6 months), and 7.6% (P < 0.001 versus baseline, P < 0.05 versus 6 months), respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Sexually dimorphic effects of aging on rat somatotropes and lactotropes

During the aging process modified functions of hypothalamic factors may cause sexually dimorphic changes in pituitary somatotropes and lactotropes. To test this hypothesis, pituitary tissue from young adult (4 months) and old (20-22 months) male and female rats was labeled immunocytochemically for growth hormone (GH) and prolactin (PRL). The total amount of immunoreactive material as well as the total area and number of immunoreactive structures were evaluated. With increasing age the intracellular GH content was moderately increased in male and decreased in female rats. An age-dependent PRL increase, due both to increased cell number and intracellular hormone content, was present only in female rats. The amount of GH- and PRL-immunoreactive material, distributed into classes of increasing density, differed both between sex and age groups. Our results indicate that the aging process of the somatotrope and lactotrope cell populations in rats appears to be different in the two sexes.

Age-dependent changes in the mechanisms controlling prolactin secretion and phosphatidylinositol turnover in male rats: effect of phosphatidylserine

The present study was undertaken in order to better characterize the functional state of anterior pituitary gland in young and old rats by using prolactin secretion and incorporation of radioactive phosphate into phosphatidylinositol (PI) as markers. The in vitro incorporation of radiolabeled phosphate into anterior pituitary PI was significantly (p less than 0.01) greater in young (3-5 months) than in aged (24-25 months) male Sprague-Dawley rats. No significant difference was found in the incorporation by pituitary tissue of 32P into phosphatidylcholine (PC) and phosphatidylethanolamine (PE). Also, the extent of prolactin secretion from isolated pituitary was significantly greater in young than in aged rats, while the prolactin pituitary content was significantly higher in aged animals. In vitro dopamine (DA) decreased the incorporation of 32P into PI, both in young and old pituitary glands, and inhibited prolactin secretion into the incubation medium. Brain cortex-phosphatidylserine (BC-PS), a pharmacologically active purified phospholipid, capable of stimulating the dopaminergic system in the hypothalamus and of decreasing prolactin secretion both in humans and rats in vitro and in vivo, inhibited the incorporation of labeled phosphate into PI of pituitary glands from either young or old rats, but did not alter the prolactin secretion from the glands incubated in vitro. Baseline prolactin plasma levels did not differ significantly between young and old rats either when blood was collected from the trunk after decapitation or underwent sampling from chronically cannulated rats.(ABSTRACT TRUNCATED AT 250 WORDS)

Phorbol 12-myristate 13-acetate induces prolactin secretion from rat anterior pituitary gland by the activation of protein kinase-C

The purpose of this study was to characterize the action of phorbol 12-myristate 13-acetate (PMA), a tumor-promoting agent, on rat anterior pituitary gland, focusing the attention on prolactin secretion. PMA elicited a significant increase in prolactin secretion without affecting phosphatidylinositol turnover, considered as an early post-receptor event controlling PRL secretion. However incubation of anterior pituitary glands with PMA caused a loss of protein kinase-C activity in cytoplasm concomitant with an increased enzyme activity in the membrane. The action of PMA on prolactin secretion seems to be mainly dependent from the redistribution and activation of protein kinase-C. In fact, the phorbol ester did not affect pituitary cAMP and cGMP metabolism either in basal conditions or after theophylline.

[Iatrogenic common bile duct calculosis. Results of choledochorrhaphy with non-absorbable suture material]

The use of non-absorbable suture material during the surgery of the choledochus can be a cause of choledocholithiasis. An interesting case of a female patient who underwent author's observation for recurrent cholangitis with partial pathological obstruction of the common bile duct after cholecystectomy (1948) and choledochotomy for choledocholithiasis (1977) is reported.

[Non-neoplastic gastro-jejuno-colic fistula. Presentation of 3 cases]

3 cases of non-neoplastic gastrojejunocolic fistula are reported. These were treated by mass resection of the fistulous route with the stomach, small intestine and colon segments involved, followed by immediate restoral of intestinal continuity. After examining the aetiopathogenetic aspects of this disease and reporting the various therapeutic proposals, careful preoperative study is considered vital to clarify the cause of the fistula (hypervagotomy, gastrinoma, hyperparathyroidism). On this basis, surgery is then adapted to avert the danger of recurrence.

[Primary suture of the common bile duct]

The Author reviews 102 cases of primary choledochotomy treated during a 14 years period of biliary surgery; he examines immediate and follow-up results. The excellent results are ascribed parthy for the exactues of indication, parthy to transduodenal sphincteroplasty that had been combined with aforesaid operation in 76% of cases.

[Hemorrhagic duodenal ulcer]

The authors report their experience in the treatment of hemorrhagic duodenal ulcers in 19 patients (17 men, 2 women) between 1972 and 1977. They compare the results obtained with the two methods adopted, namely gastric resection and local hemostasis of the ulcer followed by troncular or selective vagotomy, or selective proximal vagotomy and pyloroplasty. The results so analyzed speak definitely in favor of the latter procedures as opposed to gastrectomy.

[Nuclear insulin assay after a starch and maltose load in chronic diseases of the pancreas: a preliminary note (author's transl)]

In a group of 48 patients with chronic pancreatitis the authors investigated the variations of blood insulin content after stimulation with starch and maltose, and compared these changes with the correspondind glycemia values. The two curves, practically matching in normal subjects, tend to diverge considerably in patients with chronic pancreatitis. According to the authors, since the assessment of exocrine pancreas function by common laboratory methods is none too satisfactory, this method may yield better appreciation of extant damage to the pancreas.

[Our experience in the treatment of perforated duodenal ulcer]

The Authors considers 49 cases of perforated duodenal ulcers in free peritoneum, observed in 6 years from 1972 to 1977. They are quite exclusively males (9 : 1), aged from 22 to 80 years, observed from over 4 to 72 hours from effective perforation. After the bare necessities of their hydroelectrolitics balancing, 20 cases came to a simple suture, 29 to an ulcer excision, vagotomy and pyloric plastics. No post operative complications were noted in the two groups: mortality has been of 2 patients in the first group and of no one in the second; pathological ulcerous relaps have been of 47% in the first group and 0 in the second one, with from over 15 months to 6 years controls. By clinical, radiological and andoscopical examinations the AA, concludes that the best therapy treatment in perforated duodenal ulcers--except very particular cases--consists at the same time in the treatment of ulcerous pathology and its complications, with vagotomy completed by piloric plastics sec. Judd, and ulcer's excision.

[Echinococcosis of the pancreas. Description of a case]

After a brief survey of the world literature on echinococcus cysts in the pancreas, a case is described. The peculiar clinical picture as well as treatment are underlined.