Real-World Effectiveness and Safety of SDZ ETN, an Etanercept Biosimilar, in Patients with Rheumatic Diseases: Final Results from Multi-Country COMPACT Study

INTRODUCTION

COMPACT, a non-interventional study, evaluated the persistence, effectiveness, safety and patient-reported outcomes (PROs) in patients with rheumatoid arthritis (RA), axial-spondyloarthritis (axSpA) or psoriatic arthritis (PsA) treated with SDZ ETN (etanercept [ETN] biosimilar) in Europe and Canada.

METHODS

Patients (aged ≥ 18 years) who have been treated with SDZ ETN were categorised on the basis of prior treatment status (groups A-D): patients in clinical remission or with low disease activity under treatment with reference ETN or biosimilar ETN and switched to SDZ ETN; patients who received non-ETN targeted therapies and switched to SDZ ETN; biologic-naïve patients who started SDZ ETN after conventional therapy failure; or disease-modifying anti-rheumatic drug (DMARD)-naïve patients with RA considered suitable for treatment initiation with a biologic and started on treatment with SDZ ETN. The primary endpoint was drug persistence, defined as time from study enrolment until discontinuation of SDZ ETN treatment.

RESULTS

Of the 1466 patients recruited, 844 (57.6%) had RA, 334 (22.8%) had axSpA and 288 (19.6%) had PsA. Patients had an ongoing SDZ ETN treatment at the time of enrolment for an observed average of 138 days (range 1-841); 22.7% of patients discontinued SDZ ETN through 12 months of study observation. Overall, all the patients receiving SDZ ETN showed good treatment persistence at 12 months with discontinuation rates of 15.2%, 25.7% and 27.8% in groups A, B and C, respectively. Across all patient groups, no major differences were observed in the disease activity and PRO scores between baseline and month 12. Injection-site reactions were low across the treatment groups.

CONCLUSION

These results support the effectiveness and safety of SDZ ETN treatment in patients with RA, axSpA or PsA in real-life conditions. The treatment persistence rates observed were consistent with previously published reports of patients treated with reference or other biosimilar ETN. No new safety signals were identified.

GP2017-HCF, a high concentration formulation, demonstrates similar pharmacokinetics, immunogenicity and safety to GP2017, an approved adalimumab biosimilar

BACKGROUND

GP2017 is an adalimumab biosimilar. The objective of this study is to compare the pharmacokinetics (PK) of GP2017 in its approved formulation and GP2017-high concentration formulation (HCF) in a randomized, double-blind, two-arm PK bridging study.

RESEARCH DESIGN AND METHODS

Healthy male subjects received a single 40 mg subcutaneous injection of either GP2017-HCF (n = 162) or GP2017 (n = 168). PK, safety, and immunogenicity were assessed over 72 days post-injection.

RESULTS

The 90% confidence intervals [CIs] of geometric mean ratios between GP2017-HCF and GP2017 for Cmax, AUC0-inf, AUC0-360 and AUC0-last were within the pre-defined margin of 0.80 to 1.25; thus, PK comparability between GP2017-HCF and GP2017 was demonstrated. Subgroup analysis of PK comparability by anti-drug antibody (ADA) subpopulation showed that the 90% CIs of geometric mean ratios between GP2017-HCF and GP2017 for Cmax, AUC0-inf, AUC0-360 and AUC0-last were within the margin of 0.80 to 1.25 in ADA-positive and ADA-negative subjects. The proportions of subjects with positive ADA responses and with neutralizing antibodies were comparable between the GP2017-HCF and GP2017 groups. GP2017-HCF and GP2017 were well tolerated, and there were no reports of deaths or other serious adverse events.

CONCLUSION

Results show PK comparability between GP2017-HCF and GP2017 and comparable safety and tolerability.

POS0640 REAL-WORLD EFFECTIVENESS AND SAFETY OF GP2015 IN PATIENTS WITH RHEUMATIC DISEASES: FINAL RESULTS OF THE COMPACT STUDY

Background

COMPACT is a non-interventional study evaluating the effectiveness and safety in patients (pts) with rheumatoid arthritis (RA), axial-spondyloarthritis (axSpA) or psoriatic arthritis (PsA) treated with GP2015 (an etanercept [ETN] biosimilar) in real-world conditions.

Objectives

We present the effectiveness and safety data from the final analysis of the COMPACT study for all patient groups.

Methods

Pts aged ≥18 years on treatment with GP2015 were enrolled. Baseline visit corresponded with date of study inclusion and not with date of GP2015 treatment start. Pts were categorised based on prior treatment status: pts on clinical remission or low disease activity under treatment with reference ETN or biosimilar ETN (initial ETN: [iETN]) and switched to GP2015 (Group A) or pts who received non-ETN targeted therapies and switched to GP2015 (Group B) or biologic-naïve pts who started GP2015 after conventional therapy failure (Group C) or DMARD-naïve pts with recent diagnosis of RA considered suitable for treatment initiation with a biologic and started on treatment with GP2015 (Group D). Effectiveness assessments included Disease Activity Score 28-joint count Erythrocyte Sedimentation Rate (DAS28-ESR) or Ankylosing Spondylitis Disease Activity Score (ASDAS) until Month 12 after enrolment (baseline) in the study.

Results

Of the 1466 pts enrolled, 572 were switched from iETN (Group A), 171 were switched from other targeted therapies (Group B), 713 were biologic-naïve (Group C), and 10 were RA DMARD-naïve (Group D). Comorbidities were more frequent in pts with RA (68.7%,) followed by pts with PsA (59.4%) and axSpA (52.1%). After 12 months of treatment with GP2015, pts with RA or PsA achieved comparable DAS28-ESR scores irrespective of whether they switched from iETN, or from other targeted therapies or were biologic-naïve. At Month 12, the mean ASDAS scores were comparable between the treatment groups in pts with axSpA (Table 1). Across all pt groups, no major differences were observed in the disease activity scores between baseline and Month 12 that may be explained by the ongoing GP2015 treatment at the time of enrolment for an observed average of 138 days. Overall, the proportion of patients with at least one adverse event (AE) and serious AE (SAE) was 47.6% and 7.7% in pts who were switched from iETN, 56.7% and 9.9% in pts switched from other targeted therapies, 56% and 8.7% in biologic-naïve pts, and 60% and 0% in DMARD-naïve pts. Rate of injection site reaction was low across the groups (Figure 1).

Table 1.

Effectiveness outcomes in patients treated with GP2015

Effectiveness outcomesGroup AGroup BGroup CGroup DOverall (A-D)RADAS28-ESR, n, mean (SD)N=295N=88N=451N=10N=844Baselinen=259n=70n=392n=8n=7292.5 (1.1)3.6 (1.3)3.3 (1.5)3.8 (1.2)3.0 (1.4)Month 12n=135n=47n=238n=2n=4222.5 (1.3)2.7 (1.0)2.8 (1.4)4.3 (2.5)2.7 (1.3)PsAN=117N=36N=135N=0N=288Baselinen=80n=30n=116-n=2262.1 (1.0)2.9 (1.6)2.9 (1.6)2.6 (1.5)Month 12n=32n=13n=60-n=1052.6 (1.9)2.6 (1.6)2.3 (1.4)2.4 (1.5)AxSpAASDAS, n, mean (SD)N=160N=47N=127N=0N=334Baselinen=77n=18n=59-n=1541.6 (0.6)1.8 (0.8)2.3 (0.9)1.9 (0.8)Month 12n=39n=8n=23-n=701.8 (0.9)1.9 (0.6)1.9 (1.0)1.8 (0.9)

N, total number of patients in the treatment group; n, number of patients with available data at each time point, SD, standard deviation

Figure 1.

Overall safety outcomes in patients treated with GP2015

Figure 1 represents the adverse events reported during GP2015 treatment.

N, total number of patients in the treatment; n, number of patients in each treatment group

Conclusion

The results show comparable disease activity scores between pts who were switched from iETN, pts switched from other targeted therapies and biologic-naïve pts after 12 months of treatment with GP2015. No impact on the effectiveness of ETN was observed in pts with RA, axSpA or PsA who switched to GP2015. No new safety signals were reported.

Disclosure of Interests

Marc Schmalzing Speakers bureau: Novartis, AbbVie, Chugai/Roche, Janssen-Cilag, Lilly, Consultant of: AstraZeneca, Chugai/Roche, Hexal/Sandoz, Gilead, AbbVie, Janssen-Cilag, Boehringer/Ingelheim, Grant/research support from: Chugai/Roche, Boehringer/Ingelheim, Celgene, Medac, Herbert Kellner: None declared, Ayman Askari: None declared, Javier de Toro Santos: None declared, JULIO CESAR VAZQUEZ PEREZ-COLEMAN Speakers bureau: Sandoz, Abbvie, Sanofi, Fresenius, Rosario Foti Speakers bureau: Abbivie, Gilead, Lilly, Pfizer, UCB, Roche, Novartis, Pfizer, UCB, Sławomir Jeka: None declared, Boulos Haraoui Consultant of: Abbvie, Amgen, Fresenius Kabi, Lilly and Pfizer, Grant/research support from: Abbvie, Amgen, Fresenius Kabi, Lilly and Pfizer, Yannick Allanore Consultant of: Sandoz Hexal, Mylan, Astra-Zeneca, Masiur Rahman Employee of: Sandoz Hexal AG, Fabricio Furlan Employee of: Sandoz Hexal AG, Sohaib HACHAICHI Employee of: Sandoz Hexal AG, Tom Sheeran Speakers bureau: Pfizer, UCB, Roche, Consultant of: Novartis, Pfizer, Grant/research support from: Novartis, UCB, Roche

POS0608 SWITCHING OF TREATMENT FROM REFERENCE ETANERCEPT TO SANDOZ ETANERCEPT BIOSIMILAR IN PATIENTS WITH RHEUMATIC DISEASES: AN INTERIM ANALYSIS OF REAL-WORLD DATA FROM THE COMPACT STUDY

Background:

Sandoz etanercept (SDZ ETN) is a biosimilar of etanercept (ETN). COMPACT is an ongoing, non-interventional study, evaluating the effectiveness, safety, and quality of life with SDZ ETN treatment in patients (pts) with rheumatoid arthritis (RA), axial-spondyloarthritis (axSpA) or psoriatic arthritis (PsA) in real-world conditions.

Objectives:

We have reported an interim analysis, with the effectiveness and safety data focusing on pts who were in clinical remission or low disease activity under treatment with reference ETN or biosimilar ETN other than SDZ ETN (initial ETN; iETN) and switched to SDZ ETN.

Methods:

Pts aged ≥18 years for whom treatment with SDZ ETN were initiated are being enrolled. Pts were categorized under four treatment groups based on prior treatment status: Group A,

pts on clinical remission or low disease activity under treatment with iETN and switched to SDZ ETN; Group B, pts who received targeted therapies and switched to SDZ ETN; Group C, biologic naïve considered uncontrolled with conventional therapy; Group D, DMARD naïve with recent diagnosis of RA considered suitable for treatment initiation with a biologic and started on treatment with SDZ ETN. Effectiveness assessments included Disease Activity Score 28-joint count Erythrocyte Sedimentation Rate (DAS28-ESR) or Ankylosing Spondylitis Disease Activity Score (ASDAS) until Week 24 after enrollment (baseline; BL) in the study. Functional disability was measured by the Health Assessment Questionnaire Disability Index (HAQ-DI). The effectiveness and safety results are reported for the pts who switched from iETN (Group A).

Results:

Of the 1437 pts recruited (analysis cut-off date: 16 Oct, 2020), 567 pts were switched from iETN, 163 were switched from other targeted therapies, 697 were biologic-naïve, and 10 were RA DMARD-naïve. Among pts who switched from iETN, 51.5% had RA, followed by axSpA (28.0%) and PsA (20.5%). Comorbidities were more frequent in pts with RA (70.2%) followed by PsA (58.6%) and axSpA (49.7%); musculoskeletal and connective tissue disorders were reported in 31.8% and 15.7% of pts with RA and axSpA, respectively. At BL, whilst receiving iETN, the mean (SD) DAS28-ESR scores were 2.5 (1.1) and 2.1 (1.1) in pts with RA and PsA, respectively (figure 1). The mean change from BL in DAS28-ESR score at Week 24 after switch to SDZ ETN was -0.1 (1.1) and 0 (1.0) in pts with RA and PsA, respectively. In pts with axSpA, the mean (SD) ASDAS score was 1.5 (0.7) at BL; mean change from BL in ASDAS score at Week 24 was 0.1 (0.5). At BL, the mean (SD) HAQ-DI scores were 0.8 (0.7), 0.5 (0.7) and 0.5 (0.6) in pts with RA, PsA and axSpA, respectively. Overall, the proportion of patients with at least one adverse event (AE) was 37.3%, 33.6% and 25.8% in pts with RA, PsA and axSpA, respectively. Serious AEs were reported in 6.5%, 1.7% and 3.1% of pts with RA, PsA, and axSpA, respectively. Injections site reactions were reported in 2.7%, 0.9% and 1.3% of pts with RA, PsA and axSpA, respectively.

Figure 1.

Disease activity in patients who switched from iETN to SDZ ETN

Conclusion:

The interim analysis results shows that switch from iETN to SDZ ETN does not impact the effectiveness of ETN in pts with RA, axSpA or PsA, without any new safety signals.

Disclosure of Interests:

Marc Schmalzing Speakers bureau: Novartis, AbbVie, Chugai/Roche, Janssen-Cilag, Lilly, Consultant of: AstraZeneca, Chugai/Roche, Hexal/Sandoz, Gilead, AbbVie, Janssen-Cilag, Boehringer/Ingelheim, Grant/research support from: Travel grants: Chugai/Roche, Boehringer/Ingelheim, Celgene, Medac, Ayman Askari: None declared, Tom Sheeran Speakers bureau: Pfizer, UCB, Roche, Consultant of: Novartis, Pfizer, Grant/research support from: Novartis, UCB, Roche, David Walsh: None declared, Javier de Toro Santos: None declared, JULIO CESAR VAZQUEZ PEREZ-COLEMAN Speakers bureau: Sandoz, Abbvie, Sanofi, Fresenius, Charlotte Both Employee of: Sandoz employee Global Medical Affairs, Fabricio Furlan Employee of: Sandoz employee Global Medical Affairs, Sohaib HACHAICHI Employee of: Sandoz employee Global Medical Affairs, Herbert Kellner: None declared

AB0208 DO LOW CONCENTRATIONS OF CITRATE IN AN ADALIMUMAB FORMULATION IMPACT THE INCIDENCE AND/OR INTENSITY OF INJECTION SITE PAIN? DATA FROM PHASE I AND III STUDIES ASSESSING THE LOCAL TOLERANCE OF GP2017 (ADALIMUMAB BIOSIMILAR, SDZ-ADL) IN HEALTHY VOLUNTEERS, RHEUMATOID ARTHRITIS, AND PSORIASIS PATIENTS

Background:

Adalimumab (ADL) is typically self-administered every 2 weeks (W) as a subcutaneous (s.c.) injection by patients (pts) for diverse indications, including rheumatoid arthritis (RA), psoriatic arthritis (PsA), and psoriasis (PsO). Conflicting evaluations of local tolerance to formulations containing citrate buffer have created insecurities among health care professionals and pts.1,2

Objectives:

To evaluate local tolerance of SDZ-ADL (GP2017), a biosimilar ADL with low citrate concentration (1.2 mM),3 in 466 healthy volunteers (HV) and 408 pts (RA: 177 and PsO: 231 including PsA: 52) from four phase I pharmacokinetic (PK) and two phase III confirmatory studies.

Methods:

HV evaluated their injection site pain (ISP) using a Visual Analogue Scale (VAS) of 0–100 mm. HV received a single 40 mg/0.8 mL s.c. injection and pts received SDZ-ADL every 2W during 48–51W duration of study. Injection site reactions (ISR) as well as adverse events (AEs) were assessed by investigators during the clinical studies. Details of study designs have been reported previously.4–7

Results:

Overall, 456 (97.9%) HV experienced no ISR. Ten HV experienced ISR. These were mostly of mild intensity; only 1 (0.2%) had an ISR of moderate intensity. 96.6% of HV experienced no pain (VAS score 0–4 mm)8 at 1-hour post-dose (Figure 1). In the phase III studies, a low number of ISR/ISP events were observed, which decreased during the course of study. Detailed results are provided in Table 1. No ISR/ISP led to treatment or study discontinuation in any study.

Conclusion:

The proportion of HV and pts experiencing ISR and ISP after administration of SDZ-ADL was low, with no events leading to treatment or study discontinuation. These results call into question the clinical impact of citrate and its concentration in ADL formulations on the incidence and intensity of ISP.

References:

[1]Nash et al. Rheumatol Ther. 2016;3:257–70.

[2]NHS. Regional medicines optimisation committee briefing, best value biologicals: adalimumab update 6. July 2019. https://www.sps.nhs.uk/wp-content/uploads/2019/07/Adalimumab-RMOC-Briefing-6.pdf.

[3]https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/761071lbl.pdf.

[4]Blauvelt A, et al. Br J Dermatol. 2018;179:623–31.

[5]Wiland P, et al. BioDrugs 2020;34:809–23.

[6]Richter OV, et al. Expert Opin Biol Ther. 2019;19:1057–64.

[7]Richter OV, et al. Expert Opin Biol Ther. 2019;19:1075–83.

[8]Hawker GA, et al. Arthritis Care Res. 2011;63:240–52.

Figure 1.

Proportion of HV with ISP in phase I PK studies

Table 1.

ISP and ISR results from phase I PK and phase III confirmatory studies

Phase I PK studiesStudy101(N=73)102(N=108)103(N=178)104(N=107)Pooled studies (N=466)VAS scores (mm) at 1-hour post-doseMean (SD)0.89 (2.07)0.07 (0.52)1.03 (1.71)1.03 (2.49)0.79 (1.84)Median00100ISR scores at 1-hour post-dose, n (%)None73 (100)106 (98.2)178 (100)99 (92.5)456 (97.9)Mild0 (0)1 (0.9)0 (0)8 (7.5)9 (1.9)Moderate0 (0)1 (0.9)0 (0)0 (0)1 (0.2)Phase III confirmatory studiesADACCESS5* (PsO and PsA pts)ADMYRA6* (RA pts)W0–17 (N=231)W0–51 (N=168; including pts re-randomised to continue SDZ-ADL after W17)W0–24 (N=177)W0–48 (N=177; all pts continued SDZ-ADL after W24)DosageInduction 80 mg W0, then 40 mg EoW s.c.40 mg EoW s.c.40 mg EoW s.c.40 mg EoW s.c.Study duration, W17512448AEs - ISR, n (%), events15 (6.5), 349 (5.4), 267 (4.0), 117 (4.0), 12Mild14 (6.1), 309 (5.4), 267 (4.0), 117 (4.0), 12Moderate1 (0.4), 4000AEs - ISP (reported as ISR), n (%)3 (1.3)1 (0.6)2 (1.1)2 (1.1)

*ADACCESS and ADMYRA were switch studies, therefore, only pts exposed to SDZ-ADL throughout the study period are included here. EoW, every other week, N, number of HV or pts

Disclosure of Interests:

Piotr Wiland Speakers bureau: Celltrion, Celgene, Eli Lilly, Novartis, Pfizer, Sandoz, Sanofi-Aventis, Consultant of: Celltrion, Celgene, Eli Lilly, Novartis, Pfizer, Sandoz, Sanofi-Aventis, Andrew Blauvelt Speakers bureau: AbbVie, Almirall, Arena, Athenex, Boehringer Ingelheim, Bristol-Myers Squibb, Dermavant, Eli Lilly and Company, Evommune, Forte, Galderma, Incyte, Janssen, Leo, Novartis, Pfizer, Rapt, Regeneron, Sandoz, Sanofi Genzyme, Sun Pharma, and UCB Pharma., Consultant of: AbbVie, Almirall, Arena, Athenex, Boehringer Ingelheim, Bristol-Myers Squibb, Dermavant, Eli Lilly and Company, Evommune, Forte, Galderma, Incyte, Janssen, Leo, Novartis, Pfizer, Rapt, Regeneron, Sandoz, Sanofi Genzyme, Sun Pharma, and UCB Pharma., Lena Lemke Employee of: Hexal AG, Oliver von Richter Employee of: Hexal AG, Alison Balfour Employee of: Hexal AG, Fabricio Furlan Employee of: Hexal AG, Norman Gaylis: None declared

AB0299 REAL-WORLD ASSESSMENT OF GP2015 (ETANERCEPT BIOSIMILAR, SDZ-ETN): AN INTERIM ANALYSIS OF DATA FROM THE SELF-INJECTION ASSESSMENT QUESTIONNAIRE IN PATIENTS WITH RHEUMATOID ARTHRITIS IN THE COMPACT STUDY

Background:

COMPACT is a non-interventional study to collect real-world evidence in European countries and Canada on effectiveness, safety and quality of life in rheumatoid arthritis (RA), ankylosing spondylitis or psoriatic arthritis patients (pts) treated with SDZ-ETN (GP2015), an approved etanercept biosimilar. The first effectiveness and safety data from the study have been reported earlier1.

Objectives:

This interim analysis assessed patient usage behaviour and feelings of self-administered injection in general and with the auto-injector device using the Self-Injection Assessment Questionnaire (SIAQ) at Week 12 in pts with RA.

Methods:

Pts aged ≥18 years for whom treatment with SDZ ETN were initiated are being enrolled. The SIAQ, a patient questionnaire validated for pts with RA, was developed to assess overall pt experience with subcutaneous self-injection2. It assesses the perceived self-confidence on self-injection, potential barriers, as well as satisfaction with self-injection via device before the first self-injection (PRE module) and after dosing (POST module). The POST module used in COMPACT includes 21 items grouped into six hypothetical domains: “feelings about injection”,“self-image”, “self-confidence”, “injection-site reactions”, “ease of use of self-injection device (SD), and “satisfaction with self-injection”. Descriptive statistics were used to summarise SIAQ POST module data. The results for “ease of use of SD” domain are reported here. The “ease of use of SD” was rated by pts on a 6-point scale: 1 (very difficult) to 6 (very easy).

Results:

Of the 430 pts recruited, pts with RA represented the largest group (59.5%, n=256). Majority of pts with RA (77.7%) had comorbidities. Of the 256 pts with RA, 102 (40%) pts who used SD responded to the questionnaire. Majority of the pts found usage of the SD easy or very easy, for each of the domains assessed (Table). 49 % and 14% of the patients were “comfortable” and “very comfortable”, respectively using the SD. A majority of patients reported to be bothered by pain at the injection site “not at all” or only “a little” (69.6%), and to be bothered by redness “not at all” or only “a little” (89.2%), respectively.

Table.

Overall patient experience with usability of self-injection device at Week 12 (RA population)

Domain: Ease of use of self-injection deviceQuestionsCategory, %Very easyEasySome what easySomewhat difficultDifficultVery difficultN/ARemoval of Cap36.334.316.74.93.92.02.0To depress the device34.342.213.72.92.02.92.0To administer without any help42.235.310.82.02.05.92.0Use of self-injection device38.237.311.83.92.93.92.0

Conclusion:

The interim analysis results, although descriptive, show a clear trend for ease of use and good satisfaction with SDZ-ETN SD in pts with RA.

References:

[1]Schmalzing M, et al.Arthritis Rheumatol. 2019;71 (suppl 10).

[2]Keininger D, et al.Health Qual Life Outcomes. 2011,13;9:2.

Disclosure of Interests:

Herbert Kellner: None declared, Ayman Askari Speakers bureau: Eli Lilly, Pfizer, Thomas Kupka: None declared, Hilke Friccius-Quecke Employee of: Sandoz Hexal AG, Fabricio Furlan Employee of: Sandoz Hexal AG, Sohaib HACHAICHI Employee of: Sandoz Hexal AG, Marc Schmalzing Consultant of: Paid consultant for Hexal AG

Detecção molecular de Neospora caninum em macaco-da-noite (Aotus azarae) de vida livre no estado do Mato Grosso: relato de caso

RESUMO Estudos indicam, por meio de infecção experimental, que primatas não humanos são susceptíveis à infecção por Neospora caninum. Relata-se um caso de um macaco-da-noite (Aotus azarae infulatus), que apresentou sinais inespecíficos e não respondeu à terapêutica clínica de suporte, evoluindo a óbito, encaminhado em seguida para exame anatomopatológico. Amostras de tecidos foram coletadas e processadas rotineiramente para confecção de lâminas histológicas. Microscopicamente, a principal lesão foi observada no coração e consistia em miocardite necrótica multifocal por protozoário, com a presença de estruturas compatíveis com o estágio de taquizoítos de protozoários dos gêneros Neospora sp. ou Toxoplasma sp. No sistema nervoso central, predominantemente no tronco encefálico, havia estruturas semelhantes às descritas no coração. Os resultados da reação em cadeia pela polimerase (PCR) foram positivos para N. caninum e negativos para Toxoplasma gondii, usando DNA extraído do sangue e dos tecidos. Este relato de caso fornece evidências histológicas e moleculares de que o primata em questão foi susceptível a uma infecção natural, porém estudos devem ser realizados para investigar o real papel dos primatas no ciclo de vida de N. caninum.

Epilepsia partialis continua and generalized nonconvulsive status epilepticus during the course of argininemia: a report on two cases

Argininemia is a rare inherited disorder of the urea cycle because of a deficiency of the enzyme arginase I causing an increase of arginine and guanidino compounds in the blood, urine, and cerebrospinal fluid. The clinical picture is characterized by a mild cognitive dysfunction, progressive asymmetrical paraparesis, and seizures. Here, we describe two cases of argininemia where either epilepsia partialis continua (EPC) or nonconvulsive status epilepticus (NCSE) were the presenting manifestations of epilepsy. This is the first report of EPC in an urea cycle disorder. In both the cases, status epilepticus resolved with anticonvulsive drugs. EPC was successfully treated with levetiracetam, and NCSE with valproic acid. No side effects were observed. Because hyperammonemia and NCSE may have the same features of stupor, a neurophysiological approach might prove useful in differentiating these two conditions. Overall, our results strongly indicate that a correct NCSE diagnosis is mandatory to prevent further deterioration in these patients.

Intrafamilial phenotypic variability in four families with Anderson-Fabry disease

We analysed the clinical history of 16 hemizygous males affected by Anderson-Fabry Disease, from four families, to verify their intrafamilial phenotypic variability. Seven male patients, ranging from 26 to 61 years of age, died, whereas nine (age range 23-55) are alive. Eleven patients have undergone enzyme replacement therapy (ERT) for a period of 5-10 years. We have found a wide range of intrafamilial phenotypic variability in these families, both in terms of target-organs and severity of the disease. Overall, our findings confirm previous data from the literature showing a high degree of intrafamilial phenotypic variability in patients carrying the same mutation. Furthermore, our results underscore the difficulty in giving accurate prognostic information to patients during genetic counselling, both in terms of rate of disease progression and involvement of different organs, when such prognosis is solely based on the patient's family history.

Severe Neonatal Metabolic Decompensation in Methylmalonic Acidemia Caused by CblD Defect

CblD disorder is an autosomal recessive, rare, heterogeneous disease with variable clinical presentations, depending on the nature and location of the MMADHC gene mutations. Mutations in MMADHC lead to three distinct phenotypes: cblD-MMA, cblD-HC, and cblD-MMA/HC. To date, 18 cblD patients have been reported. Six of them were affected by cblD-MMA, but only three had a known clinical history. One of these patients presented with a metabolic decompensation at 11 months; the second one, born prematurely, was diagnosed with cblD after being treated for intracranial hemorrhage, respiratory distress syndrome, necrotizing enterocolitis, and convulsions at birth; the third one was diagnosed at 5 years of age.Here we present a case of a cblD-MMA patient who had an acute neonatal onset with severe hyperammonemia requiring hemodiafiltration. To the best of our knowledge, this is the first cblD-MMA patient who presented acutely in the newborn period. He has developed well upon treatment with B12, carnitine, and hypoproteic diet. At present time, at the age of 7, he shows normal growth and cognitive development. Thus, it is likely that the aggressive treatment of this child with hemodiafiltration might have prevented him from long-term neurological sequelae. Overall, this case shows that even severe, neonatal-onset patients may display a vitamin B12-responsive MMA. Furthermore, it suggests that an early treatment with vitamins might be beneficial for patients presenting with neonatal-onset hyperammonemia regardless of the suspected disease and before receiving the biochemical diagnosis.

Purity and stability of online-prepared hemodiafiltration fluid after storage

BACKGROUND/AIMS

Previous studies have suggested that online hemodiafiltration (OL-HDF) fluid can be used as dialysate for continuous renal replacement therapies, and thus HDF costs can be reduced. The aims of this study were to determine the purity of OL-HDF fluid and to verify the stability of the electrolyte composition and acid-base balance during its storage.

METHODS

OL-HDF fluid was collected in 70 individual bags and stored for up to 7 days. The following tests were performed daily in 10 bags: natural visible precipitation (macrocrystallization), sample collection for chemical analysis and fluid culture, limulus amebocyte lysate endotoxin test, standard culture of NALGENE® filters after passing of the fluid, and molecular analysis of bacterial DNA.

RESULTS

The values of pH and pCO(2) showed a significant change starting at 24 h (p < 0.001); after 72 h, their values were beyond the measurable range. Coefficient of variation for pCO(2) was as high as 25.7%. Electrolyte composition (Na(+), K(+), Cl(-), Ca(2+) and glucose) showed a statistically significant difference over time (p < 0.05); however, their coefficients of variation were low (1.7, 1.4, 0.6, 2.3 and 0.9%, respectively), which might not be considered clinically significant. Negative results were obtained at all points by fluid and filter cultures, endotoxin test and molecular analysis. No macrocrystallization was observed at any time point.

CONCLUSIONS

We demonstrate the microbiological purity of OL-HDF fluid stored for up to 7 days. The electrolyte composition was stable, except for a relevant change in pCO(2) and consequently in pH (first noted at 24 h), emphasizing the need to reassess the acid-base balance in multilayer plastic bags in future studies.

Epilepsy and argininosuccinic aciduria

BACKGROUND

We have reviewed the occurrence of epilepsy in our patients with argininosuccinic aciduria (ASA) (OMIM 207900) and the possible relationship of late epilepsy to symptomatic seizures in the neonatal period, hyperammonaemia and treatments.

METHODS

We retrospectively analysed 11 ASA patients (8 neonatal onset and 3 late onset), 6 of whom had developed epilepsy.

RESULTS

Epilepsy in our sample was frequent (55 %). It developed after a seizure-free period from the onset of the metabolic disease and seizures were responsive to treatment in all cases. Arginine plasma levels were kept in the same range for the 2 groups of patients with and without epilepsy.

CONCLUSIONS

Although epilepsy is reported to be common among patients with ASA, very few long-term follow-up studies are available. The pathophysiological mechanism of epileptogenesis remains unclear. Neither hyperammonaemia nor acute symptomatic seizures at birth seem to be predictive of late epilepsy. Excessive arginine dosages as a cause of epilepsy could be reasonably excluded since our 3 late onset patients developed epilepsy before the diagnosis of ASA, at a time when they were likely to be arginine deficient. Arginine deficiency may not be excluded as cause of epilepsy, but further studies are needed to define its role.

Enzyme replacement therapy with agalsidase alfa in a cohort of Italian patients with Anderson-Fabry disease: testing the effects with the Mainz Severity Score Index

Anderson-Fabry disease (AFD) is a rare X-linked disorder caused by lysosomal storage of several glycosphingolipids, affecting virtually all organs and systems. Enzyme replacement therapy (ERT) for AFD has been available since 2001. Due to the highly variable nature of clinical manifestations in patients with AFD, it is very difficult to assess disease progression and the effects of therapy. We used the Mainz Severity Score Index (MSSI) as a measure of disease severity to study the effects of ERT in a population of 30 patients treated with agalsidase alfa for a median of 2.9 years (range, 1.0-6.2 years). Our data show that the MSSI captures the correlation between disease severity and both gender and age (1 - males performing worse than females at baseline and 2 - severity of diseases progresses with age in both sex). Furthermore, after at least 1 year of ERT, total MSSI scores were significantly lower than those at baseline (p < 0.001), suggesting a marked clinical improvement under ERT. In conclusion, the MSSI is a sensitive and useful tool for monitoring disease progression and assessing the effects of ERT in a population of patients from different treatment centres.

Bilateral nuclear cataracts as the first neonatal sign of Fanconi-Bickel syndrome

A patient with early bilateral nuclear cataracts and subsequent diagnosis of Fanconi-Bickel syndrome is described. Despite impaired galactose and glucose metabolism, cataracts have been reported in only few cases with this disorder. We conclude that Fanconi-Bickel syndrome should be considered in the differential diagnosis of neonatal cataracts. The pathogenesis of this complication has not been fully elucidated.

Characterisation of carotid atherosclerotic plaque: comparison between magnetic resonance imaging and histology

PURPOSE

The aim of this study was to identify and characterise by magnetic resonance imaging (MRI) carotid plaque constituents such as lipid-rich necrotic core, intraplaque haemorrhage and calcification in patients treated with carotid endarterectomy (CEA) using histological evaluation as the reference standard.

MATERIALS AND METHODS

Nineteen patients (13 men and six women) scheduled for CEA between March and August 2004 were imaged on a 1.5-T scanner (Magnetom Symphony, Siemens, Erlangen, Germany). The protocol included four types of sequences [T1, T2, proton density (PD) and three-dimensional time of flight (3D-TOF)]. Images were reviewed for integrity of the fibrous cap, presence of lipid-rich necrotic core, intraplaque haemorrhage and calcification. Signal intensity was assessed relative to the adjacent sternocleidomastoid muscle. Four cross-sections for each lesion were compared with the corresponding histological specimens and independently reviewed by two radiologists and one pathologist.

RESULTS

MRI detected lipid-rich necrotic core with a sensitivity and specificity of 91.6% and 95.0%, respectively, whereas it defined intraplaque haemorrhage alone with a sensitivity and specificity of 91.6% and 100%, respectively. Calcification was recognised with a sensitivity and specificity of 80% and 93.7%, respectively.

CONCLUSIONS

MRI is able to identify signs of carotid plaque instability with a high sensitivity and specificity. Therefore, it may be useful in evaluating and guiding the treatment of haemodynamically nonsignificant stenoses with a potential embolic risk and, in the future, to assess coronary plaque.

A direct link between expression of urokinase plasminogen activator receptor, growth rate and oncogenic transformation in mouse embryonic fibroblasts

In addition to its role in invasion and metastasis of several tumors, the multifunctional urokinase receptor uPAR (urokinase plasminogen activator receptor) is directly involved in the growth of several cancer cells in vitro and in vivo. We have compared growth rate and oncogenic transformation in wild-type (wt) or uPAR-/- mouse embryonic fibroblasts (MEFs). Surprisingly, uPAR-/- MEFs grew faster than wt MEFs. This agreed with elevated levels of cell cycle mediators like extracellular signal-regulated protein kinase, p38, AP1 and Cyclin D1. Infection with a uPAR retrovirus reverted the effect, decreasing the growth rate. When MEFs were transformed with H-Ras(V12) and E1A oncogenes, the efficiency of transformation in uPAR-/- MEFs was higher than in wt. UPAR-/- MEFs grew faster at low serum, produced more colonies in agar and produced tumors in vivo in nude mice with a lower latency period. The properties of the heterozygous uPAR+/- MEFs were always intermediate. We conclude therefore that in MEFs uPAR concentration controls cell proliferation and the transforming activity of some oncogenes.

Interneurons transiently express the ERG K+ channels during development of mouse spinal networks in vitro

During spinal cord maturation neuronal excitability gradually differentiates to meet different functional demands. Spontaneous activity, appearing early during spinal development, is regulated by the expression pattern of ion channels in individual neurons. While emerging excitability of embryonic motoneurons has been widely investigated, little is known about that of spinal interneurons. Voltage-dependent K+ channels are a heterogeneous class of ion channels that accomplish several functions. Recently voltage-dependent K+ channels encoded by erg subfamily genes (ERG channels) were shown to modulate excitability in immature neurons of mouse and quail. We investigated the expression of ERG channels in immature spinal interneurons, using organotypic embryonic cultures of mouse spinal cord after 1 and 2 weeks of development in vitro. We report here that all the genes of the erg family known so far (erg1a, erg1b, erg2, erg3) are expressed in embryonic spinal cultures. We demonstrate for the first time that three ERG proteins (ERG1A, ERG2 and ERG3) are co-expressed in the same neuronal population, and display a spatio-temporal distribution in the spinal slices. ERG immuno-positive cells, representing mainly GABAergic interneurons, were present in large numbers at early stages of development, while declining later, with a ventral to dorsal gradient. Patch clamp recordings confirmed these data, showing that ventral interneurons expressed functional ERG currents only transiently. Similar expression of the erg genes was observed at comparable ages in vivo. The role of ERG currents in regulating neuronal excitability during the earliest phases of spinal circuitry development will be examined in future studies.

Efficacy of ACE-inhibitor therapy on renal disease in glycogen storage disease type 1: a multicentre retrospective study

BACKGROUND

The efficacy of ACE-inhibitors in decreasing microalbuminuria and proteinuria has been reported in a few patients with glycogen storage disease type 1 (GSD1); however, no case-control study has ever been published.

AIM

The aim of the current study was to evaluate the efficacy of ACE-inhibitors in reducing glomerular hyperfiltration, microalbuminuria and proteinuria, and in delaying the progression of renal damage.

PATIENTS AND METHODS

Ninety-five patients (median age at the time of the study: 14.5 years) were enrolled from nine Italian referral centres for metabolic diseases. A retrospective study of a 10-year follow-up was conducted in order to compare the evolution of these parameters in treated patients with those who were not treated with ACE-inhibitors.

RESULTS

A significant and progressive decrease of glomerular filtration rate was observed in treated patients vs. those who were not treated with ACE-inhibitors (P < 0.05). No difference was observed for microalbuminuria and proteinuria between the two groups of patients. Moreover, the ACE-inhibitors significantly delayed the progression from glomerular hyperfiltration to microalbuminuria, but not that from microalbuminuria to proteinuria.

CONCLUSIONS

The results of the present study underline the importance of a strict follow-up of renal function in GSD1 patients. The detection of glomerular hyperfiltration suggests precocious initiation of ACE-inhibitor treatment to delay the progression of renal damage. A randomized prospective study is needed to establish for certain the real effectiveness of this treatment in GSD1 patients.

Initial clinical experience using a diode red laser (670 nm) in the treatment of retinal disease

AIM

To investigate the clinical use of a 670-nm diode red laser in the treatment of a number of retinal conditions.

METHODS

In all, 17 eyes of 17 patients were treated for conditions such as proliferative diabetic retinopathy, retinal neovascularization in central retinal vein occlusion, rhegmatogenous retinal lesions and retinal breaks, and prophylactic peripheral retinopexy prior to silicone oil removal after three port pars plana vitrectomy.

RESULTS

Regression of neovascularization was observed in all the eyes treated for vascular proliferation at the 3-month follow-up visit. Adhesive pigmented scars were observed in the remaining eyes 1 month after treatment. No major complications were recorded.

CONCLUSIONS

In this pilot study, the 670-nm diode laser appears to be a promising modality for laser photocoagulation of the retina.

Proliferation, differentiation and apoptosis in connexin43-null osteoblasts

Osteoblasts are highly coupled by gap junctions formed primarily by connexin43 (Cx43). We have shown that interference with Cx43 expression or function disrupts transcriptional regulation of osteoblast genes, and that deletion of Cx43 in the mouse causes skeletal malformations, delayed mineralization, and osteoblast dysfunction. Here, we studied the mechanisms by which genetic deficiency of Cx43 alters osteoblast development. While cell proliferation rates were similar in osteoblastic cells derived from calvaria of Cx43-null and wild type mice, camptothecin-induced apoptosis was 3-fold higher in mutant compared to wild type osteoblasts. When grown in mineralizing medium, Cx43-null cells were able to produce mineralized matrix but it took one week longer to reach the same mineralization levels as in normal cells. Likewise, expression of alkaline phosphatase activity per cell--a marker of osteoblast differentiation--was maximal only 2 weeks later in Cx43-null relative to wild-type cells. These observations suggest that Cx43 is important for a normal and timely development of the osteoblastic phenotype. Delayed differentiation and increase programmed cell death may explain the skeletal phenotype of Cx43-null mice.

Deep tissue biopsy vs. superficial swab culture monitoring in the microbiological assessment of limb-threatening diabetic foot infection

AIMS

The results of ulcer swabbing vs. deep tissue biopsy have been compared prospectively in 29 diabetic patients with limb-threatening foot infection, to investigate the effectiveness and reliability of each method, and to evaluate whether any of the two could be more suitable for the microbiological follow-up of severe lesions.

METHODS

Microbiological samples were collected by using both methods at fixed intervals after therapy commencement (i.e. at day 0, 7, 14, and 30). Statistical comparison was performed between the results of each sampling procedure after the end of follow-up.

RESULTS

At enrolment, the mean number of isolates per patient was 2.34 by swabbing and 2.07 by tissue biopsy sampling; the rate of isolation for anaerobes with the two methods was 35% and 25%, respectively; no statistical differences could be observed between the two procedures in terms of either species or frequency of isolation. Anaerobic species were never detected after the first 2 weeks of appropriate treatment, and those ulcers which were still active at day 30 yielded almost exclusively Gram-positive bacteria. At the end of follow-up, deep tissue cultures appeared to exhibit a higher diagnostic sensitivity with respect to swabs.

CONCLUSIONS

Swabbing and deep tissue cultures appear to be equally reliable for the initial monitoring of antimicrobial treatment in severe diabetic foot infection. However, our experience seems to suggest that deep tissue might be more sensitive than swabbing for monitoring those isolates that have been selected for antibiotic resistance, i.e. those from ulcers that are still active after 30 days of treatment.

Connexin43 deficiency causes delayed ossification, craniofacial abnormalities, and osteoblast dysfunction

Connexin(Cx)43 is the major gap junction protein present in osteoblasts. We have shown that overexpression of Cx45 in osteoblasts expressing endogenous Cx43 leads to decreased cell-cell communication (Koval, M., S.T. Geist, E.M. Westphale, A.E. Kemendy, R. Civitelli, E.C. Beyer, and T.H. Steinberg. 1995. J. Cell Biol. 130:987-995) and transcriptional downregulation of several osteoblastic differentiation markers (Lecanda, F., D.A. Towler, K. Ziambaras, S.-L. Cheng, M. Koval, T.H. Steinberg, and R. Civitelli. 1998. Mol. Biol. Cell 9:2249-2258). Here, using the Cx43-null mouse model, we determined whether genetic deficiency of Cx43 affects skeletal development in vivo. Both intramembranous and endochondral ossification of the cranial vault were delayed in the mutant embryos, and cranial bones originating from migratory neural crest cells were also hypoplastic, leaving an open foramen at birth. Cx43-deficient animals also exhibited retarded ossification of the clavicles, ribs, vertebrae, and limbs, demonstrating that skeletal abnormalities are not restricted to a neural crest defect. However, the axial and appendicular skeleton of Cx43-null animals were essentially normal at birth. Cell to cell diffusion of calcein was poor among Cx43-deficient osteoblasts, whose differentiated phenotypic profile and mineralization potential were greatly impaired, compared with wild-type cells. Therefore, in addition to the reported neural crest cell defect, lack of Cx43 also causes a generalized osteoblast dysfunction, leading to delayed mineralization and skull abnormalities. Cell to cell signaling, mediated by Cx43 gap junctions, was critical for normal osteogenesis, craniofacial development, and osteoblastic function.

Incidence of secondary Helicobacter pylori resistance to antibiotics in treatment failures after 1-week proton pump inhibitor-based triple therapies: a prospective study

BACKGROUND

Antibiotic-resistant Helicobacter pylori strains are becoming increasingly prevalent, although it is not clear to what extent the new resistant organisms will spread.

AIM

To evaluate the incidence of secondary Helicobacter pylori resistance to metronidazole, clarithromycin and/or amoxycillin after one-week proton pump inhibitor based triple therapy failure in patients who were, before therapy infected with Helicobacter pylori strains susceptible to these antibiotics.

PATIENTS AND METHODS

Enrolled in the study were 97 consecutive Helicobacter pylori-positive subjects infected by Helicobacter pylori strains susceptible to metronidazole, clarithromycin and amoxycillin. Activity of tested antibiotics was determined by means of the E-test. Patients were treated for seven days with a proton pump inhibitor, omeprazole 20 mg twice daily or pantoprazole 40 mg once daily, plus clarithromycin 250 mg twice daily and metronidazole 250 mg four times daily; or with a proton pump inhibitor plus amoxycillin 1 g twice daily and clarithromycin 500 mg twice daily. Two months after completion of therapy, endoscopy and gastric biopsies for histology, rapid urease test and culture were repeated.

RESULTS

Four patients were dropped from the study Overall Helicobacter pylori cure rates expressed as both intention-to-treat and per-protocol analyses, were, respectively 80% (40/50) and 81.6% (40/49) with proton pump inhibitor, clarithromycin and metronidazole and 76.6% (36/47) and 81.8% (36/44) with proton pump inhibitor amoxycillin and clarithromycin. No significant differences were observed between the two treatments. Subjects in whom treatment failed were significantly younger and had less active ulcer than cured patients. Of treatment failures, 70.6% (12 out of 17 subjects) de veloped a secondary resistance to metronidazole (35.33% and/or clarithromycin (64.7%). Secondary antibiotic resistance occurred in 77. 8% of treatment failures treated with proton pump inhibitor, clarithromycin and metronidazole and in 62.5% of those treated with proton pump inhibitor, amoxycillin and clarithromycin. Considering all patients treated, the overall incidence of secondary metronidazole and/or clarithromycin resistance after therapy was reported in 12.9% of subjects (12 out of 93 treated patients).

CONCLUSIONS

Secondary Helicobacter pylori resistances to metronidazole and/or clarithromycin occurred in large percentages in patients with treatment failure after the one-week proton pump inhibitor-based triple therapies, proton pump inhibitor, clarithromycin and metronidazole and proton pump inhibitor, amoxycillin and clarithromycin. It is likely that new antibiotics or treatment strategies will be needed in the near future to successfully treat Helicobacter pylori infection.

Transforming growth factor-beta1 gene polymorphism, bone turnover, and bone mass in Italian postmenopausal women

Transforming growth factor beta1 (TGF-beta1) is abundant in bone and is an important regulator of the osteoclastic-osteoblastic interaction (coupling). The sequence variation, 713-8delC in the TGF-beta1 gene has previously been found to be associated with very low bone mass in osteoporotic women and with increased bone turnover in both osteoporotic and normal women. The possible association of this polymorphism with bone mass and bone turnover has now been investigated in 256 postmenopausal Italian women. A significant association of TGF-beta1 with bone mass was detected in the populations. Subjects carrying the sequence variation 713-8delC (Tt) genotype showed a significantly lower bone mineral density (BMD) at the hip than those without sequence variation in the genotype (TT). Individuals carrying the tt genotype have a more severe osteoporosis (P=0.0001 vs. TT and Tt genotypes). The frequency of the fragility fractures was significantly lower in individuals with TT genotype than in those with the Tt and tt genotypes (X2=21.9; P=0.006). Furthermore a significant association was found between 713-8delC and bone turnover. The results suggest a strong evidence for an association among the 713-8delC allele of the TGF-beta1 gene and the femoral BMD, the prevalence of osteoporotic fractures, and finally a high bone turnover in a sample of Italian postmenopausal women.

Noninvasive diagnosis of Helicobacter pylori infection in older subjects: comparison of the 13C-urea breath test with serology

BACKGROUND

The potential influence of cognitive status, physical activities, comorbidity and cotreatments on the feasibility and diagnostic accuracy of two noninvasive diagnostic tests for Helicobacter pylori (Hp) infection, i.e., the 13C-urea breath test (13C-UBT) and serology (immunoglobulin G [IgG] anti-Hp antibodies), in older subjects is not known.

METHOD

The study involved 100 consecutive symptomatic elderly subjects (mean age, 78.3 years; range, 65-96 years), who had undergone an upper gastrointestinal endoscopy. Patients were considered Hp positive if at least two of the three invasive methods, i.e. histology, culture, and/or the rapid urease test were positive for Hp infection. Patients were considered Hp negative if all three invasive methods were negative. The 13C-UBT was performed according to the European standard method and the assaying of IgG anti-Hp antibodies by enzyme-linked immunosorbent assay. Cognitive status and functional activities were determined by the Mini-Mental State Examination (MMSE), the activities of daily living (ADLs) and instrumental ADLs (IADLs).

RESULTS

According to invasive methods, 49 patients were Hp positive and 47 were Hp negative (4 subjects were excluded from the study). Hp-positive patients demonstrated a significantly higher prevalence of peptic ulcers (p =.02) and activity of chronic gastritis (p<.0001) than Hp-negative subjects. The 13C-UBT demonstrated a sensitivity of 100%, a specificity of 95.7%, and a diagnostic accuracy of 97.9%. Serology had significantly lower sensitivity (74.4%), specificity (59%), and diagnostic accuracy (67%, p<.001) than the 13C-UBT. The feasibility and the diagnostic accuracy of the 13C-UBT were not altered by the cognitive status (MMSE) and functional activities (ADL, IADL) of the patients, their drug consumption, or the prevalence of concomitant diseases.

CONCLUSIONS

In older subjects, the 13C-UBT had a significantly higher diagnostic accuracy than serology without influence of cognitive function, disability, comorbidity and cotreatments. This method may be considered an excellent, clinically useful, noninvasive test for the diagnosis of Hp infection in older subjects.

Urinary galactosyl-hydroxylysine in postmenopausal osteoporotic women: A potential marker of bone fragility

Alterations of the collagen matrix, e.g., increased hydroxylation and glycosylation of lysyl residues in collagen I, were found in human osteoporotic bone, and it was suggested that they could alter the mechanical properties of skeleton. To test this hypothesis, we evaluated the content of galactosyl-hydroxylysine (GHYL) in bone collagen, as assessed by its urinary excretion, and related it to the occurrence of fracture. Two hundred and fifteen unselected postmenopausal women with osteoporosis were divided in two subgroups (comparable for age, age of menopause, bone mineral density, and biochemical parameters of bone turnover) on the basis of the history of fragility fracture; 115 patients had suffered no fracture and 100 patients had suffered one or more fractures 3 or more years before. Four urinary markers of bone turnover (hydroxyproline, cross-linked N-telopeptide, free deoxypyridoline, and GHYL) were evaluated in all patients. There was no difference between the two groups with regard to all the parameters studied except for GHYL, which was significantly higher in the group with a history of fracture (1.35 +/- 0.82 mmol/mol of creatinine [Cr] versus 1.03 +/- <0.48 mmol/mol Cr, p < 0.001); this marker did not correlate with other markers of bone remodeling in the fracture group, indicating a possible defect in bone collagen. In conclusion, provided that increased levels of urinary GHYL do reflect overglycosylation of hydroxylysine in bone collagen, the GHYL may be considered a marker of bone collagen quality. Our results, showing higher urinary GHYL in osteoporosis patients with fracture, seem to confirm this suggestion.

[Echo-guided compression in the treatment of femoral pseudoaneurysms secondary to cardiological interventional procedures]

PURPOSE

To analyze perspectively a set of 13 patients affected by femoral artery pseudoaneurysm treated with Us-guided compression.

MATERIAL AND METHODS

From January to December 1997 we observed 13 patients (7 females and 6 males; mean age: 67.4 years old) affected by femoral artery pseudoaneurysm which were treated with Us-guided compression. The compression was repeated for 15 minutes up to complete closure of the pseudoaneurysm. Every patient was followed up 24 hours after the procedure, before the discharge and every 3 months.

RESULTS

In 6 cases the cardiologic procedure had diagnostic purposes while in 7 cases had interventional purposes. The pseudoaneurysm was located in the common femoral artery in 10 cases, in the superficial femoral artery in 2 cases and in the profunda femoris in the last case. The fistula between the aneurysmatic chamber and the arterial lumen had a mean length of 1 centimeter (range: 0.5-2.5 cm) and the mean diameter of the pseudoaneurysm was 3 centimeters (range: 1.5-6 cm). The mean length of the compression was 34 minutes (range: 10-120 min). The technical success rate was 92.3% with one case of failure in the unique localization in the profunda femoris. The procedure was well tolerated from the patients, with minimal discomfort. After the treatment the mean hospital stay was 2 days and to date we have had no recurrences after a mean follow-up of 18 months.

CONCLUSIONS

In accordance with the data of the literature, Us-guided compression is the treatment of choice of femoral pseudoaneurysms after cardiac catheterization. The procedure is well tolerated in almost all the patients and it deters the need of surgery with reduction of complications, costs and hospital stay.

The effect of antibiotic resistance on the outcome of three 1-week triple therapies against Helicobacter pylori

BACKGROUND

Resistance of Helicobacter pylori to antibiotics may be a major reason for treatment failure.

AIM

To evaluate the effect of primary H. pylori resistance to antibiotics on the cure rates of three anti-H. pylori 1-week triple therapies.

METHODS

One hundred and sixteen consecutive patients diagnosed H. pylori-positive by gastric histology, rapid urease test and culture were enrolled. Activity of tested antibiotics was determined by means of the E-test. Patients were treated for 7 days with: (i) pantoprazole 40 mg o.d. plus amoxycillin 1 g b.d. and metronidazole 250 mg q.d.s. (PAM); (ii) pantoprazole 40 mg o.d. plus clarithromycin 250 mg b.d. and metronidazole 250 mg q.d.s. (PCM); or (iii) pantoprazole 40 mg o.d. plus amoxycillin 1 g b.d. and clarithromycin 250 mg b.d. (PAC). Two months after completion of therapy, endoscopy and gastric biopsies were repeated.

RESULTS

Primary resistance rates to metronidazole, clarithromycin and amoxycillin were 17.2, 6.9 and 0%, respectively. Overall H. pylori cure rates expressed as intention-to-treat and per protocol analyses were, respectively, 79% and 86% with PAM, 82% and 89% with PCM, and 85% and 85% with PAC. Significantly lower cure rates were observed in metronidazole-resistant patients treated with PAM (56% vs. 96%, P = 0.01) or PCM (50% vs. 97%, P = 0.01). A trend towards lower H. pylori cure rates was observed in clarithromycin-resistant patients treated with PCM (67% vs. 91%, P = 0.74) or PAC (50% vs. 87%, P = 0.68).

CONCLUSION

Primary resistance to metronidazole influences the H. pylori cure rate of anti-H. pylori proton pump inhibitor-based triple therapies which include this antibiotic. A similar trend exists for primary clarithromycin resistance.

Cytotoxin-associated gene A-positive Helicobacter pylori infection in the elderly. Association with gastric atrophy and intestinal metaplasia

To evaluate if the infection with strains of cytotoxin-associated gene A (CagA)-positive Helicobacter pylori is associated with either peptic ulcer and gastric atrophy or intestinal metaplasia in the elderly, we studied 71 H. pylori-positive patients older than 62 years old (34 men, 37 women; mean age, 77.5 years; range, 62-89 years) affected with gastric ulcer (GU) (n = 10), duodenal ulcer (DU) n = 22), or chronic gastritis (CG) (n = 39). H. pylori infection was documented by means of gastric histology, rapid urease test, and polymerase chain reaction (PCR) assay performed on gastric biopsies using two sets of primers: one for the ureC gene specific for H. pylori, and the second specific for the CagA gene. H. pylori-CagA positivity was significantly more common in patients with GU (9 of 10, 90%) than with DU (11 of 22, 50%; p < 0.05) or CG (17 of 39, 43.5%; p = 0.01). Gastric atrophy and intestinal metaplasia were significantly more common in CagA-positive patients than in CagA-negative patients (gastric atrophy: 40.54% vs 11.76, p = 0.007; intestinal metaplasia: 40.54% vs 14.70%, p = 0.01). No difference in prevalence of gastric atrophy and intestinal metaplasia was found in patients divided according to pathology (GU, DU, or CG). Logistic regression demonstrated that gastric atrophy and intestinal metaplasia were independent factors significantly associated with CagA-positivity (gastric atrophy: odds ratio = 4.53, 95% confidence interval 1.25-16.4; intestinal metaplasia: odds ratio = 3.44, 95% confidence interval 1.01-11.7). Our findings help to confirm the hypothesis that an infection with CagA-positive H. pylori strains may be catalytic in inducing gastric changes which can evolve into malignancies.

[Criteria for utilization and indications for use of permanent and short- and medium term temporary endocaval filters. Personal experience and review of the literature]

Screening and prophylaxis of the population at risk is the most correct approach to thromboembolic disease. Caval filters play a major role in the prevention of pulmonary embolism, but their use remains widely controversial, even if they are an alternative or additional method to medical therapy and not antithetical to it. July, 1990, to September, 1995, seventy-seven permanent vena cava filters (59 LGM, 13 Filcard and 5 titanium-Greenfield), 22 short-duration temporary vena cava filters (11 LGT, 6 Filcard, 3 Filcard-Emanuelli and 2 Lysofilter) and 10 mid-duration temporary vena cava filters (Tempofilter) were inserted in 109 patients (55 men and 54 women) aged 17-88 years. An inferior vena cavogram was always made before filter insertion to "map" the inferior vena cava and its tributaries (renal veins) and to assess caval size. This is a mandatory step to exclude or confirm the presence of endocaval thrombi. Sixty-eight filters were inserted percutaneously via a right internal transjugular approach, 40 via a common transfemoral approach (34 right and 6 left) using the same route as inferior cavography and digital pneumoangiography. One temporary filter was inserted via a right transhumeral approach. Sixty-three patients (57.8%) (44 with a permanent filter, 14 with a temporary filter and 5 with a Tempofilter) had medical diseases, 7 patients (6.4%) (4 with a permanent filter, one with a temporary filter and 2 with a Tempofilter) had surgical conditions; 10 patients (9.2%) (7 with a permanent filter and 3 with a Tempofilter) were surgical-orthopedic patients. Twenty-seven patients (24.8%) (22 with a permanent and 5 with a temporary filter) had cancer. Two patients (1.8%) with a temporary filter were breast feeding. All the patients had deep venous thrombosis of the lower limbs, including the inferior vena cava and the right renal vein in two patients. A proximal floating thrombus and a pulmonary thromboembolism was diagnosed in 41 (37.6%) and 34 (31.2%) cases, respectively. The temporary filters remained in situ 1-4 days and the Tempofilters 3-5 weeks. A pelvic hematoma developed (because of heparin?) after the insertion of a temporary filter and a Tempofilter branch detached and migrated into a lower branch of the left pulmonary artery were reported as immediate and short-term consequences. There were no early or late consequences for the patients. An axillary hemorrhage was observed in the site of previous surgery, during fibrinolysis with a Lysofilter, as well as the incomplete opening of a titanium-Greenfield filter and of two permanent LGM filters, partly trapped within endocaval thrombi. No further consequences to the patients due to permanent filters were observed, nor any case of symptomatic pulmonary thromboembolism, in patients with permanent or temporary filters. With reference to the relative literature and to their own experience, the Authors propose a detailed and rational synthesis of the diagnostic-instrumental approach protocol to thromboembolic disease.

Acute cholecystitis: ultrasonographic staging and percutaneous cholecystostomy

Experience in the treatment of acute cholecystitis with percutaneous cholecystostomy in 29 high-risk and elderly patients is reported. The treatment group included 14 men and 15 women, 21 of whom were over 70 years of age. The suspected clinical diagnosis of acute cholecystitis was confirmed in all cases by ultrasonography (accuracy: 95.6%). The percutaneous cholecystostomy was successful in 27 of 29 cases and these patients had a sudden improvement in their clinical condition; failure of the procedure was due in one patient to dislodgement of the catheter and in another patient to the guide-wire slipping out of the gallbladder. Six patients complained of pain radiating to the right shoulder which disappeared within 30-60 minutes after the procedure. Twenty-three of the 27 patients subsequently underwent elective cholecystectomy. In 22 patients the ultrasonographic findings were compared with the histology; thus enabling us to establish an ultrasonographic staging of acute cholecystitis related to the seriousness of the disease. Percutaneous cholecystostomy is the treatment of choice in high-risk patients, in the elderly, as well as in young patients with impending perforation.

[The treatment of acute cholecystitis by percutaneous cholecystostomy]

The authors report on their personal experience with percutaneous cholecystostomy (PC) in 36 cases of acute cholecystitis (AC). PC was successful in 34 cases, improving the clinical condition of the patients within the first hour following treatment and normalizing the laboratory data within 24-48 hours. Twenty-seven patients with calculous AC underwent cholecystectomy within 4-15 days. In 6 cases (3 calculous and 3 acalculous ACs) PC was the only treatment performed; in one case (calculous AC) PC was combined with lithotomy, the stone fragments being extracted via the cholecystostomy. According to literature reports, to date PC has been performed mainly--as an alternative to surgical cholecystostomy--on the patients unsuitable for cholecystectomy due to their age or to severe impairment of their conditions. In our experience, the procedure can be performed on a wider range of patients as a final (notably in acalculous AC) or temporary step (notably in calculous AC where it may allow cholecystectomy to be delayed and thus performed under better clinical conditions, with decreased morbidity and mortality risks).

[Hepatic abscess]

The Authors review the medical records of 9 patients with liver abscess over a 15-year period from 1975 to 1989. They report on 5 pyogenic abscess, 3 amebic abscess and one case of tuberculosis of the liver. The most common initial diagnosis was fever of unknown origin, abdominal pain and hepatomegaly. The treatment consisted of 6 percutaneous transhepatic drainage, 2 open surgical drainage, and one explorative laparotomy (tbc infection). The Authors had no mortality and recommend the percutaneous transhepatic drainage as first-choice treatment.

[The echo-guided percutaneous therapy of dysontogenetic liver cysts]

Congenital hepatic cysts are a frequent disease, symptomatic in 16-18% of the cases. The Authors report their personal experience about 4 cases and they make a review about 56 cases treated with ultrasonically-guided therapy. In 20 cases the therapy was simple aspiration, in 39 was alcohol sclerotherapy and in 1 was external percutaneous drainage. All the 20 cysts treated with simple aspiration recurred after 0.5-24 months. All the 39 patients treated with alcohol sclerotherapy presented a complete remission of symptoms and are disease-free after 1-48 months. The patient treated with percutaneous drainage, is disease-free after 10 months from the procedure. The alcohol sclerotherapy is the treatment of choice for the congenital hepatic cysts. The simple aspiration is an effective procedure only from a diagnostic point of view but not therapeutic. The external percutaneous drainage is the treatment of choice in case of infected cysts. Surgery is indicated only in the cysts with acute presentation, with biliary content and in case of failure of alcohol sclerotherapy.

[The role of echo-guided percutaneous cholecystectomy in acute cholecystitis]

Personal experience in the treatment of acute cholecystitis with percutaneous cholecystostomy in high risk patients and in elderly patients is reported. Between January 1989 and November 1990, 28 patients affected by acute cholecystitis were treated with percutaneous cholecystostomy at Emergency Surgery Department, Verona University Hospital. The patients treated included 13 men and 15 women; 8 of them were under 70 years old, 5 between 70th and 75th and the remaining patients over 75 years old. The suspected clinical diagnosis of acute cholecystitis was confirmed in all cases by ultrasonography (accuracy 95.4%). The percutaneous cholecystostomy was successful in 26 over 28 cases. In all these cases patients had a sudden improvement of their clinical conditions. In one case we failed because the guide-wire slipped out of the gallbladder and we couldn't perform a second attempt for the patient's refuse; in an other case there was the dislodgment of the catheter after less than 12 hours from the cholecystostomy and the patient was operated on. Twenty-two of 26 patients whose conditions were improved by percutaneous cholecystostomy, subsequently underwent elective cholecystectomy. In 2 cases of acalculous cholecystitis the patients did not undergo the operation; in 2 cases because of the elderly age of the patients and their bad cardiorespiratory conditions we preferred not to perform the operation. We had not major complications; 6 patients complained pain irradiating to right shoulder which disappeared within 30-60 minutes from the end of the procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

[The conservative treatment of hepatic abscesses with echo-guided transcutaneous drainage]

Liver abscesses are a rare disease with 80-100% mortality in untreated cases. The advent of ultrasound in the clinical practice has improved the prognosis. Surgery for this disease has a percentage of complications of 15-52% and a mortality of 12-33%. In a review of the literature about 200 liver abscesses treated with ultrasound-guided percutaneous drainage the complications were 7.5% and the mortality was 3%. The authors report their personal experience about 21 hepatic abscesses in 13 patients. Nineteen abscesses were treated with ultrasound-guided percutaneous drainage and two with antibiotics. Six patients had pyogenic liver abscesses, two amebic and in five patients the cultures were sterile. In 9 cases the location was in the right lobe of the liver, in 3 was in the left lobe. One patient had multiple abscesses. The size of the abscesses ranged from 0.5 to 13 cm. We drained with Seldinger technique or direct procedure with Trocar's needle under ultrasound guidance without serious complications and without mortality. In 6 cases the patients had pain during the procedure and in 3 cases medical therapy was necessary. In one case we had a pleuritis for the puncture of costophrenic space. All the patients treated had a complete resolution of the abscesses. The ultrasound-guided percutaneous drainage is the treatment of choice for liver abscesses. But other reports with more patients are necessary to clarify the indications and the ultrasound criteria of recovery.

[The therapy of symptomatic and/or complicated dysontogenetic liver cysts]

Congenital hepatic cysts are a frequent disease, symptomatic in the 16-18% of the cases. The authors report a review of the literature of the last 20 years about 135 treated surgically patients with symptomatic and/or complicated hepatic cysts. They analyse the different models of treatment both surgical and conservative, referring in special way about the alcoholization of the cysts. The authors finally report their personal experience about eight cases.