Anti-CD38 targeted nanotrojan horses stimulated by acoustic waves as therapeutic nanotools selectively against Burkitt's lymphoma cells

The horizon of nanomedicine research is moving toward the design of therapeutic tools able to be completely safe per se, and simultaneously be capable of becoming toxic when externally activated by stimuli of different nature. Among all the stimuli, ultrasounds come to the fore as an innovative approach to produce cytotoxicity on demand in presence of NPs, without invasiveness, with high biosafety and low cost. In this context, zinc oxide nanoparticles (NPs) are among the most promising metal oxide materials for theranostic application due to their optical and semi-conductor properties, high surface reactivity, and their response to ultrasound irradiation. Here, ZnO nanocrystals constitute the stimuli-responsive core with a customized biomimicking lipidic shielding, resembling the composition of natural extracellular vesicles. This core-shell hybrid structure provides high bio- and hemocompatibility towards healthy cells and is here proofed for the treatment of Burkitt's Lymphoma. This is a very common haematological tumor, typically found in children, for which consolidated therapies are so far the combination of chemo-therapy drugs and targeted immunotherapy. In this work, the proposed safe-by-design antiCD38-targeted hybrid nanosystem exhibits an efficient selectivity toward cancerous cells, and an on-demand activation, leading to a significant killing efficacy due to the synergistic interaction between US and targeted hybrid NPs. Interestingly, this innovative treatment does not significantly affect healthy B lymphocytes nor a negative control cancer cell line, a CD38- acute myeloid leukemia, being thus highly specific and targeted. Different characterization and analyses confirmed indeed the effective formation of targeted hybrid ZnO NPs, their cellular internalization and the damages produced in Burkitt's Lymphoma cells only with respect to the other cell lines. The presented work holds promises for future clinical applications, as well as translation to other tumor types.

Biomimicking Extracellular Vesicles with Fully Artificial Ones: A Rational Design of EV-BIOMIMETICS toward Effective Theranostic Tools in Nanomedicine

Extracellular Vesicles (EVs) are the protagonists in cell communication and membrane trafficking, being responsible for the delivery of innumerable biomolecules and signaling moieties. At the moment, they are of paramount interest to researchers, as they naturally show incredibly high efficiency and specificity in delivering their cargo. For these reasons, EVs are employed or inspire the development of nanosized therapeutic delivery systems. In this Perspective, we propose an innovative strategy for the rational design of EV-mimicking vesicles (EV-biomimetics) for theranostic scopes. We first report on the current state-of-the-art use of EVs and their byproducts, such as surface-engineered EVs and EV-hybrids, having an artificial cargo (drug molecule, genetic content, nanoparticles, or dye incorporated in their lumen). Thereafter, we report on the new emerging field of EV-mimicking vesicles for theranostic scopes. We introduce an approach to prepare new, fully artificial EV-biomimetics, with particular attention to maintaining the natural reference lipidic composition. We overview those studies investigating natural EV membranes and the possible strategies to identify key proteins involved in site-selective natural homing, typical of EVs, and their cargo transfer to recipient cells. We propose the use also of molecular simulations, in particular of machine learning models, to approach the problem of lipid organization and self-assembly in natural EVs. We also discuss the beneficial feedback that could emerge combining the experimental tests with atomistic and molecular simulations when designing an EV-biomimetics lipid bilayer. The expectations from both research and industrial fields on fully artificial EV-biomimetics, having the same key functions of natural ones plus new diagnostic or therapeutic functions, could be enormous, as they can greatly expand the nanomedicine applications and guarantee on-demand and scalable production, off-the-shelf storage, high reproducibility of morphological and functional properties, and compliance with regulatory standards.

Cargo-loaded lipid-shielded breakable organosilica nanocages for enhanced drug delivery

The recent nanomedicine advancements have introduced a variety of smart nanoparticles in cancer treatment and diagnostics. However, their application to the clinic is still hindered by several challenges related to their biocompatibility, elimination and biodistribution. Here we propose breakable organosilica mesoporous nanoparticles, i.e. nanocages, able to efficiently incorporate cargo molecules and be coated, with different lipid compositions, to enhance their biomimetic behaviour. We exploit the electrostatic interactions between the organosilica surface and the opposite charge of the lipid mixtures in order to obtain an efficient organosilica coverage. The lipid-coated nanocages are proved to have an incredibly high hemocompatibility, significantly increased with respect to pristine nanocages, and excellent colloidal stability and biocompatibility. The cargo-loaded and lipid-coated nanocages are tested and compared in vitro on two different cancer cell lines, demonstrating the key role played by the lipid coating in mediating the internalization of the nanocages, evaluated by the enhanced and rapid cellular uptake. The efficient intracellular delivery of the therapeutic agents is then assured by the destruction of the organosilica, due to the disulfide bridges, introduced into the silica framework, that in reducing media, like the intracellular one, are reduced to thiols causing the breaking of the nanoparticles. The possibility to image and effectively kill cancer cells demonstrates the potentiality of the lipid-coated nanocages as a powerful tool in anticancer research and as a promising smart theranostic platform.

Lipidic Formulations Inspired by COVID Vaccines as Smart Coatings to Enhance Nanoparticle-Based Cancer Therapy

Recent advances in nanomedicine have led to the introduction and subsequent establishment of nanoparticles in cancer treatment and diagnosis. Nonetheless, their application is still hindered by a series of challenges related to their biocompatibility and biodistribution. In this paper, we take inspiration from the recently produced and widely spread COVID vaccines, based on the combinational use of ionizable solid lipid nanoparticles, cholesterol, PEGylated lipids, and neutral lipids able to incorporate mRNA fragments. Here, we focus on the implementation of a lipidic formulation meant to be used as a smart coating of solid-state nanoparticles. The composition of this formulation is finely tuned to ensure efficient and stable shielding of the cargo. The resulting shell is a highly customized tool that enables the possibility of further functionalizations with targeting agents, peptides, antibodies, and fluorescent moieties for future in vitro and in vivo tests and validations. Finally, as a proof of concept, zinc oxide nanoparticles doped with iron and successively coated with this lipidic formulation are tested in a pancreatic cancer cell line, BxPC-3. The results show an astonishing increase in cell viability with respect to the same uncoated nanoparticles. The preliminary results presented here pave the way towards many different therapeutic approaches based on the massive presence of highly biostable and well-tolerated nanoparticles in tumor tissues, such as sonodynamic therapy, photodynamic therapy, hyperthermia, and diagnosis by means of magnetic resonance imaging.

Artificial and Naturally Derived Phospholipidic Bilayers as Smart Coatings of Solid-State Nanoparticles: Current Works and Perspectives in Cancer Therapy

Recent advances in nanomedicine toward cancer treatment have considered exploiting liposomes and extracellular vesicles as effective cargos to deliver therapeutic agents to tumor cells. Meanwhile, solid-state nanoparticles are continuing to attract interest for their great medical potential thanks to their countless properties and possible applications. However, possible drawbacks arising from the use of nanoparticles in nanomedicine, such as the nonspecific uptake of these materials in healthy organs, their aggregation in biological environments and their possible immunogenicity, must be taken into account. Considering these limitations and the intrinsic capability of phospholipidic bilayers to act as a biocompatible shield, their exploitation for effectively encasing solid-state nanoparticles seems a promising strategy to broaden the frontiers of cancer nanomedicine, also providing the possibility to engineer the lipid bilayers to further enhance the therapeutic potential of such nanotools. This work aims to give a comprehensive overview of the latest developments in the use of artificial liposomes and naturally derived extracellular vesicles for the coating of solid-state nanoparticles for cancer treatment, starting from in vitro works until the up-to-date advances and current limitations of these nanopharmaceutics in clinical applications, passing through in vivo and 3D cultures studies.

Routine treatment pathways of patients with major depression and active suicidal ideation with intent in Italy: interim results from the ARIANNA observational study

Introduction

Major depressive disorder (MDD), especially in case of suicidal risk, is a psychiatric emergency, associated with high patient burden and healthcare resource utilization. Although active and urgent treatment is crucial, little is known on comprehensive care management of this condition in Italy.

Objectives

Here we report the ARIANNA study [NCT04463108] interim results to primarily describe the treatment utilization pathways of patients with MDD and active suicidal ideation with intent in the current clinical practice in Italy.

Methods

This observational prospective cohort study included adult patients with a moderate-to-severe major depressive episode (MDE) and active suicidality from 24 Italian sites. Real-world data on patient characteristics, treatments, clinical outcomes, and healthcare utilization were collected during a 90-day follow-up. Data collection is still ongoing.

Results

Sixty-four evaluable patients were considered for this interim analysis: 41 (64.1%) females, mean [SD] age 46.0 [15.4] years, a concomitant psychiatric diagnosis in 7 (10.9%), and other comorbidities in 26 (40.6%). The baseline mean [SD] MADRS total score was 37.5 [7.2], with severe MDE and prior suicidal behavior in 30 (46.9%) and 21 (32.8%) patients, respectively. Median [25th;75th percentiles] duration of current MDE was 1.1 [0.3;2.1] months. Acute inpatient hospitalization was provided for 43 (67.2%) patients. Antidepressant augmentation with mood stabilizers and/or antipsychotic drugs and optimization were the most frequent early standard-of-care treatment regimens in 32 (53.3%) and 24 (40.0%) patients with available data (N=60), respectively.

Conclusions

Our preliminary results suggest that initial treatment approaches in this critical population are mostly polypharmacological and delivered as inpatient care, with consequent intensive resource utilization.

Disclosure

The ARIANNA study was sponsored by Janssen-Cilag SpA, Italy. DD and MA are employees of Janssen-Cilag SpA. DA and BR are employees of MediNeos S.U.R.L., a company subject to the direction and coordination of IQVIA Solutions HQ Ltd.

Prevalence and features of delirium in older patients admitted to rehabilitation facilities: a multicenter study

BACKGROUND

Delirium is thought to be common across various settings of care; however, still little research has been conducted in rehabilitation.

AIM

We investigated the prevalence of delirium, its features and motor subtypes in older patients admitted to rehabilitation facilities during the three editions of the "Delirium Day project".

METHODS

We conducted a cross-sectional study in which 1237 older patients (age ≥ 65 years old) admitted to 50 Italian rehabilitation wards during the three editions of the "Delirium Day project" (2015 to 2017) were included. Delirium was evaluated through the 4AT and its motor subtype with the Delirium Motor Subtype Scale.

RESULTS

Delirium was detected in 226 patients (18%), and the most recurrent motor subtype was mixed (37%), followed by hypoactive (26%), hyperactive (21%) and non-motor one (16%). In a multivariate Poisson regression model with robust variance, factors associated with delirium were: disability in basic (PR 1.48, 95%CI: 1.17-1.9, p value 0.001) and instrumental activities of daily living (PR 1.58, 95%CI: 1.08-2.32, p value 0.018), dementia (PR 2.10, 95%CI: 1.62-2.73, p value < 0.0001), typical antipsychotics (PR 1.47, 95%CI: 1.10-1.95, p value 0.008), antidepressants other than selective serotonin reuptake inhibitors (PR 1.3, 95%CI: 1.02-1.66, p value 0.035), and physical restraints (PR 2.37, 95%CI: 1.68-3.36, p value < 0.0001).

CONCLUSION

This multicenter study reports that 2 out 10 patients admitted to rehabilitations had delirium on the index day. Mixed delirium was the most prevalent subtype. Delirium was associated with unmodifiable (dementia, disability) and modifiable (physical restraints, medications) factors. Identification of these factors should prompt specific interventions aimed to prevent or mitigate delirium.

Real-world evidence from a European cohort study of patients with treatment resistant depression: Healthcare resource utilization

BACKGROUND

Treatment resistant depression (TRD) is diagnosed when patients experiencing a major depressive episode fail to respond to ≥2 treatments. Along with substantial indirect costs, patients with TRD have higher healthcare resource utilization (HCRU) than other patients with depression. However, research on the economic impact of this HCRU, and differences according to response to treatment, is lacking.

METHODS

This multicenter, observational study documented HCRU among patients with TRD in European clinical practice initiating new antidepressant treatments. Data regarding access to outpatient consultations and other healthcare resources for the first 6 months, collected using a questionnaire, were analyzed qualitatively according to response and remission status. The economic impact of HCRU, estimated using European costing data, was analyzed quantitatively.

RESULTS

Among 411 patients, average HCRU was higher in non-responders, attending five times more general practitioner (GP) consultations and spending longer in hospital (1.7 versus 1.1 days) than responders. Greater differences were observed according to remission status, with non-remitters attending seven times more GP consultations and spending approximately three times longer in hospital (1.7 versus 0.6 days) than remitters. Consequently, the estimated economic impacts of non-responders and non-remitters were significantly greater than those of responders and remitters, respectively.

LIMITATIONS

Key limitations are small cohort size, absence of control groups and generalizability to different healthcare systems.

CONCLUSION

Patients with TRD, particularly those not achieving remission, have considerable HCRU, with associated economic impact. The costs of unmet TRD treatment needs are thus substantial, and treatment success is fundamental to reduce individual needs and societal costs.

The association between low skeletal muscle mass and delirium: results from the nationwide multi-centre Italian Delirium Day 2017

Introduction

Delirium and sarcopenia are common, although underdiagnosed, geriatric syndromes. Several pathological mechanisms can link delirium and low skeletal muscle mass, but few studies have investigated their association. We aimed to investigate (1) the association between delirium and low skeletal muscle mass and (2) the possible role of calf circumference mass in finding cases with delirium.

Methods

The analyses were conducted employing the cross-sectional “Delirium Day” initiative, on patient 65 years and older admitted to acute hospital medical wards, emergency departments, rehabilitation wards, nursing homes and hospices in Italy in 2017. Delirium was diagnosed as a 4 + score at the 4-AT scale. Low skeletal muscle mass was operationally defined as calf circumference ≤ 34 cm in males and ≤ 33 cm in females. Logistic regression models were used to investigate the association between low skeletal muscle mass and delirium. The discriminative ability of calf circumference was evaluated using non-parametric ROC analyses.

Results

A sample of 1675 patients was analyzed. In total, 73.6% of participants had low skeletal muscle mass and 24.1% exhibited delirium. Low skeletal muscle mass and delirium showed an independent association (OR: 1.50; 95% CI 1.09–2.08). In the subsample of patients without a diagnosis of dementia, the inclusion of calf circumference in a model based on age and sex significantly improved its discriminative accuracy [area under the curve (AUC) 0.69 vs 0.57, p < 0.001].

Discussion and conclusion

Low muscle mass is independently associated with delirium. In patients without a previous diagnosis of dementia, calf circumference may help to better identify those who develop delirium.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-021-01950-8.

Real-world evidence from a European cohort study of patients with treatment resistant depression: Treatment patterns and clinical outcomes

BACKGROUND

Treatment resistant depression (TRD) characterizes a subgroup of 10-30% of patients with major depressive disorder, and is associated with considerable morbidity and mortality. A consensus treatment for TRD does not exist, which often leads to wide variations in treatment strategies. Real-world studies on treatment patterns and outcomes in TRD patients in Europe are lacking and could help elucidate current treatment strategies and their efficacy.

METHODS

This non-interventional cohort study of patients with TRD (defined as treatment failure on ≥2 oral antidepressants given at adequate dose and duration) with moderate to severe depression collected real-world data on treatment patterns and outcomes in several European countries. Patients were started on a new treatment for depression according to routine clinical practice.

RESULTS

Among 411 patients enrolled, after 6 months, only 16.7% achieved remission and 73.5% showed no response. At Month 12, while 19.2% achieved remission and 69.2% showed no response, 33.3% of those in remission at Month 6 were no longer in remission. Pharmacological treatments employed were heterogenous; 54 different drugs were recorded at baseline, and the top 5 treatment types according to drug classes accounted for 40.0% of patients. Even though remission rates were very low, at Month 12, 60.0% of patients had not changed treatment since enrolment.

CONCLUSIONS

The heterogeneity of treatments highlights a lack of consensus. Moreover, despite low response rates, patients often remained on treatments for substantial periods of time. These data further support existence of an unmet treatment need for TRD patients in Europe.

The role of GSK-3 in mood disorders: Preliminary data from an experimental study

Introduction

The identification of potential biomarkers is crucial to improve the management and treatment of mood disorders. Glycogen synthase kinase-3 (GSK-3) is a multifunctional enzyme with an important role in the etiology of mood disorders. Recent findings suggested GSK-3 as a putative biomarker in mood disorders.

Objectives

The aims of the study are: - to evaluate GSK3 as potential biomarker for differential diagnosis (MDD and BD); - to analyze the regulation of GSK3 by psychopharmacological treatments.

Methods

Patients included fulfill the following criteria: (a) principal diagnosis of MDD or BD (DSM-5); (b) age ≥ 18 years; (c) drug-free for at least 4 weeks before the inclusion. For each patient included a healthy control is enrolled, matched by gender and age. All included subjects at the study entry point (t0) are assessed through: - semistructured clinical interview and clinical rating scales (Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale; Young Mania Rating Scale, Clinical Global Impression) - blood draw, to measure GSK-3 levels Patients with MDD or BD are assessed again after 1 week (T1) and after 2 month (T2) of specific pharmacological treatment.

Results

So far, we enrolled 16 patients and 16 healthy controls. The enrollment is still ongoing.

Conclusions

We expect to find GSK-3 levels differently expressed between healthy controls, patients with DDM and patients with BD. This finding would be crucial as it could contribute to the improvement of differential diagnosis. Moreover, we expect to observe a change in GSK-3 levels after psychopharmacological treatments.

Bipolar disorder and peripartum mood episodes: Epidemiology and clinical correlates

Introduction

It is known that the peripartum period is a high-risk period of recurrence in bipolar disorder (BD). However, data on correlations between reproductive life events, such as age at menarche and peripartum period, are mixed in BD.

Objectives

The aims of this retrospective study are to investigate the lifetime rate of peripartum mood episodes, the clinical correlates and the relationship between age at menarche and peripartum episode in a sample of women with BD.

Methods

The study focused on comparisons between women with vs. without peripartum mood episodes (n = 292). Socio-demographic and clinical characteristics between women with vs without BD peripartum episode were examined through descriptive statistics.Adjusted logistic regression analysis was run to examine the association between variables.

Results

In our sample, 30% had at least one BD peripartum episode. Women with peripartum episode had significantly earlier age at menarche, earlier onset of BD and longer duration of untreated disorder compared to women without peripartum episode. After adjustment, the late menarche (>15 years) was associated with lower probability of BD episodes during the peripartum period compared to normal menarche (12-14 years).

Conclusions

Peripartum mood episodes are common in BD and are correlated with early onset of BD and long duration of untreated disorder. Moreover, age at menarche may be related to the risk of peripartum mood episodes. The results deserve to be deepened in further studies.

Real-world evidence from a European cohort study of patients with treatment resistant depression: Baseline patient characteristics

BACKGROUND

Treatment resistant depression (TRD; failure to respond to ≥2 treatments) affects ~20% of patients with major depressive disorder (MDD). Real-world data could help describe patient characteristics and TRD disease burden, to assess the unmet needs of TRD patients in Europe.

METHODS

This observational study collected data from adults with moderate to severe TRD initiating a new treatment for depression, according to local standards of care. At baseline, socio-demographic characteristics, medical history, prior and current treatments were recorded. Disease severity, health-related quality of life (HRQoL), functionality and productivity were assessed.

RESULTS

Overall, 411 eligible patients were enrolled across seven European countries. Mean (standard deviation [SD]) patient age was 51.0 (10.8) years; 62.3% were female. Long-term sick leave was reported by 19.0% of patients; 30.2% were unemployed. The mean (SD) duration of the current episode was 2.6 (3.9) years. At baseline, mean (SD) HRQoL scores for EuroQoL 5-dimension 5-level (UK tariff) and EQ-Visual Analog Scale were 0.41 (0.25) and 41.1 (18.7), respectively. The Work Productivity and Activity Impairment questionnaire demonstrated mean (SD) absenteeism of 57.0% (44.9%) and presenteeism of 54.7% (29.5%); mean (SD) overall work impairment was 60.5% (29.9%).

LIMITATIONS

Key limitations are small cohort size, absence of a control group and generalizability to countries with different healthcare models.

CONCLUSIONS

TRD patients had a high disease burden, low HRQoL and reduced function and productivity, with a substantial proportion unable to work. This demonstrates an unmet treatment need in TRD patients that, if addressed, could reduce the heavy personal and societal burden.

Factors associated with involuntary admissions: a register-based cross-sectional multicenter study

BACKGROUND

Despite the EU recommendations on mental health, involuntary admission has been under researched in Italy for a long time and the overall picture of involuntary admission still appears fragmentary. The aims of this study are to evaluate involuntary admission rates in the Piedmont Region (Italy) and to investigate clinical and service-related variables associated with involuntary admission.

METHODS

This is a cross-sectional retrospective multicenter study involving all psychiatric inpatients units of the general hospitals of Piedmont Region. Data on hospitalizations during 2016 were collected by consulting hospital discharge registers. The analyses were performed on two samples: 6018 patients (data analysis was run on first hospitalization during the study period for those with multiple admissions) and 7881 inpatient episodes. The association between involuntary admission and socio-demographic and clinical characteristics was examined through t-test for continuous variables, and Pearson's Chi-square test for categorical variables. Multilevel modeling was applied in logistic regression models with two levels: for the first model center and participants and for the second model center and inpatient episodes.

RESULTS

Of 6018 inpatients, 10.1% were admitted involuntarily at first hospitalization, while the overall compulsory treatment rate was slightly lower (9.1%) in the inpatient episodes sample (n = 7881). The involuntary admission rates ranged from 0.8 to 21% among study centers. Involuntary admissions were primarily associated with younger age, diagnosis of schizophrenia or substance use disorders, longer duration of hospital stay, mechanical restraint episodes, and fewer subsequent hospitalizations during the study period.

CONCLUSIONS

The rate of involuntary admission in the Piedmont Region was lower than the mean rate across countries worldwide. There were noteworthy differences in rates of involuntary admission among psychiatric units, although no relationship was found with characteristics of the psychiatric wards or of the areas where hospitals are located.

OP0256-PARE A PAW? YES, THANK YOU AN ANIMAL ASSISTED INTERVENTION (AAI) PILOT PROJECT FOR CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS (JIA)

Background:

Animal-Assisted Interventions (AAI) is the new way to indicate what was previously known as “Pet Therapy”, as activities can be done either with the conventional “pets” (dogs, cats and rabbits) or with horses and donkeys.

Children with JIA have several problems in terms of adherence both due to the atavistic fear of the needle and due to nausea and vomiting - the most important side effects of Methotrexate – often since the 2-3 days before the assumption to immediately after it.

Sure that animals can help children to forget this fear and to avoid the psycological conditions which enhance nausea, for the first time in Italy (and probably in Europe) it was designed a specific AAI program for these children.

Objectives:

To promote a general state of psycho-physical well-being in children and families about:

manage of therapy; reduce discomfort and anxiety caused by entering hospital; improve self-esteem and the response to the stress generated by the execution of therapy and disease management; strengthen communication and socialization; stimulate the affective area through the activities of animal care.

Methods:

Dogs and cats are part of the recreational activities once a week in an equipped area in the OIRM Hospital (no alternative gateway was needed).

Paediatric Rheumatologists selected two different groups of children: the first one (5 children in the pilot study) every 15 days; the second one (5 children) every month; the selection was made looking at the therapeutic scheme.

Every session, one hour, has 3 clearly distinct stages:

Welcome and organization: children say hello to dogs and cats, open the toolkits specifically designed for the intervention, express their state of mind and are encouraged to tell their own stories.

Therapy:parents prepare and inject the drug to their children under medical or Health Professional control without discontinuation of the activities with animals.

Play and socializing:children are involved in petting and other activities with animals; they are also involved in manipulative activities (design, puppets shows, modelling clay, animal care, ball retriving, etc). This step has the aim to relieve stress and discomfort due to medical procedures.

Visual Analogic Scales (VAS) were part of the toolkit, to let the researchers evaluate the effects of the activity directly from the children experience.

For the first time, we will control also the animal health status and wellness condition monitoring behavioural parameters and salivary cortisol level during each session.

Results:

The pilot project started in October 2019 and nowaday we closed 12 meetings, 4 on October, 4 on November, 3 on December and 2 on January, with the participation of 2 dogs (Golden and Labrador Retriever) and 1 cat (Devon Rex) in each one.

All children love to play with animals, seek their closeness at the time of therapy and enjoy playing all together with the dogs; no one cry or refuse therapy and, since the third session, no one has nausea before, during or after the injection. Parents have reached a certain level of confidence: they stay quietly in the waiting room or go away to have a drink or to run an errand (it becomes a moment of relaxing for them too).

Animals remain in healthy and wellness conditions during the activity.

Conclusion:

These preliminary data seem that AAI to be useful in helping patients in JIA to overcome some problems related to their pathology.

Disclosure of Interests:

UGO VIORA: None declared, Patrizia Ponzio: None declared, Maria Teresa Mascarino: None declared, Barbara Picco: None declared, Paolo Guiso: None declared, Eleonora Battista: None declared, Silvana Martino: None declared, Davide Montin Speakers bureau: Not relevant for the topic, Marta Dellepiane: None declared, Germana Rosso: None declared

Study of Sentinel Lymph Node in Breast Cancer: Our Experience in 46 Cases

At the Surgery Department of Biella 46 patients were enrolled in a study on the sentinel lymph node (SN) in the period from 1 January 1999 to 30 September 1999. The aim of the study was to determine, on the basis of our own experience, the percentages of accuracy and concordance, and compare them with case series abroad and in Italy; in addition, we sought to establish a possible correlation between certain features of breast cancer and positivity of the axilla. The method utilized was lymphoscintigraphy and gamma probe. Fifteen cases with positive axillary lymph nodes and 12 cases with positive sentinel lymph nodes were found; there were no false positive and three false negative results. No migration of the tracer was observed with lymphoscintigraphy in two cases. The percentage of concordance obtained was 93.2% in the complete series and 96.5% in the subseries that excluded the learning curve. Comparing the percentage of concordance of our case series with those abroad and in Italy, an average overlapping percentage was obtained. The percentage of accuracy obtained in our study was 95.7%, which is slightly higher than the average of percentages of the case series abroad and in Italy.

Obstructive sleep apnea syndrome: a literature review

Obstructive sleep apnea syndrome (OSAS) is a complete or partial airway obstruction that can cause significant physiologic disturbance with various clinical impacts. The etiology is multifactorial and its clinical manifestations are night snoring, headache when patient wakes up, day-time sleepiness and degrease of cognitive performance. Some recent international studies suggest that the OSAS prevalence is 2-4% in men and 1-2% in women of average age. The aim of this work was presenting a literature review in Medline concerning Obstructive sleep apnea syndrome. A review of the articles ranging from 1980 to 2014 has been done. Over 2000 articles were found and those which give useful information about etiology, diagnosis, therapy and found results after the study were selected and evaluated. In literature there is no unanimous opinion on the treatment of OSAS. According to the majority of the authors it should be multidisciplinary. The choice of therapy is predicated on the etiology, severity and natural history of the increased upper airway resistance. The importance of a praecox diagnosis and orthodontic therapy in order to re-establish normal function is underlined, since OSAS is linked with high risk of hypertension, cardiovascular diseases, daytime sleepiness, home and work-related accidents, with consequent worsening of life quality.

A randomized, single-blind, comparison of duloxetine with bupropion in the treatment of SSRI-resistant major depression

INTRODUCTION

For patients who continue to experience depressive symptoms despite an adequate antidepressant SSRI trial, across-class switch is considered one of the best treatment options. The goal of the present work was to compare in terms of efficacy two different dual-action compounds, duloxetine and bupropion, in patients who failed to respond in two consecutive antidepressant trials with SSRIs.

METHODS

The patients were allocated randomly to duloxetine (120 mg daily) or bupropion extended release (300 mg daily). The intended medication period was 6 weeks. The primary measure of efficacy was depressive symptoms severity.

RESULTS

A total of 49 participants were randomly assigned to duloxetine 120 mg (n=27) or bupropion 300 mg (n=22). The ITT efficacy patient sample consisted of 46 patients. Relatively high response and remission rates in treatment groups were found: from 60 to 70% of patients responded to treatment, and approximately 30 to 40% were in remission by the endpoint (week 6). No statistically significant difference emerged between the two groups at any post-baseline assessment, neither on mean scores of rating scales nor on qualitative efficacy measures.

LIMITS

Limitations of the study are the lack of a placebo arm, difficult to include owing to ethical reasons, and the relatively small size of the sample.

CONCLUSIONS

These preliminary results seem to support the hypothesis that in patients unresponsive to SSRIs the administration of antidepressants with different mechanisms of action is an effective switching strategy. Further studies are needed in light of the challenge posed by resistant depression.

Blood rheology and renal transplantation: an intriguing relationship for assessing cardiovascular risk

Renal transplant recipients (RTRs) are at increased risk of cardiovascular complications. An altered hemorheological profile may determine both cardiovascular complications and progression of renal failure in RTRs. We performed this study to evaluate the rheologic status in 239 RTRs at least 12 months after transplantation with stable and normal renal function compared with 90 control subjects. In RTRs, a significantly higher hematocrit-adjusted, but not native, whole blood viscosity was found (P < .0001). Moreover, plasma viscosity and red blood cell deformability were significantly higher in patients than in control subjects (P < .0001), whereas no difference in erythrocyte aggregation between patients and control subjects was observed (P = .5). Fibrinogen, but not hematocrit, significantly increased in RTRs (P = .001). This preliminary study provides evidence of an altered hemorheologic profile in RTRs.

Reticulated platelets and platelet reactivity in renal transplant recipients receiving antiplatelet therapy

INTRODUCTION

Renal transplant recipients are at increased risk of cardiovascular morbidity and mortality. We assessed platelet reactivity and reticulated platelets (RPs) in 90 recipients, 51 (56.6%) of whom were not receiving acetylsalicylic acid (ASA) therapy (group A) and 39 (43.3%) who were receiving ASA therapy, 100 mg (group B), and in 60 healthy controls (group C).

METHODS

Reticulated platelets were measured using a hematology automated analyzer (XE-2100; Sysmex Corp, Kobe, Japan) and were expressed as the percentage of RPs in the total optical platelet count (immature platelet fraction [IPF]), as the percentage of highly fluorescent RPs, and as the absolute number of RPs (IPF#). Platelet function was assessed using optical aggregometry (platelet aggregation) induced using 1 mmol/L of arachidonic acid, 2 or 10 micromol/L of adenosine diphosphate, or 2 microg/mL of collagen.

RESULTS

Group A demonstrated significantly higher values of RP compared with group B or group C. Group B demonstrated a substantially higher percentage of RPs compared with group C, which was significant only for the IPF parameter. Multiple regression analysis demonstrated that IPF and IPF# were significantly and positively related to collagen-induced platelet aggregation.

CONCLUSION

We documented the presence of higher concentrations of RPs in transplant recipients compared with a control population, and a significant association between RPs and platelet function.

Conservation of Erectile Function following Brachytherapy for Low-Risk Prostate Cancer

Brachytherapy (BT) is an effective option to treat low-risk prostate cancer (CaP). While oncological results are consistent with those reported following radical retropubic prostatectomy (RRP), attention may be given to the advantages in terms of functional results that a less invasive approach can ensure.

The aim of this study is to assess the impact of the conservation of erectile function (EF) in patients who underwent BT with a short and medium term follow-up.

Materials and Methods

Between May 1999 and January 2005, 170 patients underwent BT for low-risk CaP (intracapsular prostate cancer, PSA, 10 ng/mL, Gleason score, 6). Among them, 58 patients (average age 65.6) with good preoperative erectile function (IIEF>22) and a minimum follow-up of 5 years were selected. The results were evaluated by comparing the values of pre- and postoperative IIEF questionnaire at 3 months, 1 and 5 years of medium follow-up.

Results

At a mean 3-month follow-up, a spontaneous recovery of EF (IIEF> 17), strongly influenced by urinary irritative disorders, was reported by 34/58 patients (58%). At 1 and 5 years, good EF (IIEF >22) was reported by 45/58 (78%) and 39/58 (68%) patients, respectively.

Discussion and Conclusions

The recovery of EF was good one year after BT (78%). Urinary disorders are a significant limiting factor on this recovery. The deterioration of EF during the follow-up, which was already described in literature, is due not only to ageing but also to a delayed radioactive effect on pelvic structures.

[Conservation of erectile function following brachytherapy for low-risk prostate cancer]

Brachytherapy (BT) is an effective option to treat low-risk prostate cancer (CaP). While oncological results are consistent with those reported following radical retropubic prostatectomy (RRP), attention may be given to the advantages in terms of functional results that a less invasive approach can ensure. The aim of this study is to assess the impact of the conservation of erectile function (EF) in patients who underwent BT with a short and medium term follow-up. MATERIALS AND METHODS. Between May 1999 and January 2005, 170 patients underwent BT for low-risk CaP (intracapsular prostate cancer, PSA , 10 ng/mL, Gleason score , 6). Among them, 58 patients (average age 65.6) with good preoperative erectile function (IIEF>22) and a minimum follow-up of 5 years were selected. The results were evaluated by comparing the values of pre- and postoperative IIEF questionnaire at 3 months, 1 and 5 years of medium follow-up. RESULTS. At a mean 3-month follow-up, a spontaneous recovery of EF (IIEF> 17), strongly influenced by urinary irritative disorders, was reported by 34/58 patients (58%). At 1 and 5 years, good EF (IIEF >22) was reported by 45/58 (78%) and 39/58 (68%) patients, respectively. DISCUSSION AND CONCLUSIONS. The recovery of EF was good one year after BT (78%). Urinary disorders are a significant limiting factor on this recovery. The deterioration of EF during the follow-up, which was already described in literature, is due not only to ageing but also to a delayed radioactive effect on pelvic structures.

Chronic kidney disease is still present after renal transplantation with excellent function

According to a k/DOQI work group, chronic kidney disease (CKD) can be present also in subjects with glomerular filtration rate (GFR) >90 mL/min or a serum creatinine (sCr) below 1.3 mg/dL. The aim of this study was to document the prevalence of clinical or biologic abnormalities among 190 cadaveric renal transplant patients with excellent and stable renal function at 6 months after transplantation as well as 5 years later. The recipients were 82 women and 108 men of mean age at transplantation of 44.56 +/- 11.73 years. All patients were on Neoral-based immunosuppression with at least 5-year follow-up. Mean sCr was 1.18 +/- 0.2 mg/dL. Mean GFR was 78.57 +/- 27.06 mL/min. Systolic blood pressure was >130 mm Hg in 56.6%, although 78.3% of patients were on antihypertensive therapy; 34.3% were anemic; 75.4% had serum cholesterol >200 mg/dL; 62.2% had serum triglyceride levels >170 mg/dL. Serum intact parathyroid hormone >100 pg/mL was observed in 38% of patients and 43% were on vitamin D supplementation, and 11.4% had developed posttransplant diabetes mellitus. With respect to controls, von Willebrand factor was higher in 81.2% (P < .0001; RR = 11); serum homocysteine levels in 75% (P < 0.001; RR = 7.61); PAI-1 in 37.5% (P = .0009; RR = 4). At 5 years posttransplantation we observed an overall improvement in these abnormalities. The vast majority of renal transplant patients with excellent graft function belong to stage 1 of CKD being affected by hypertension, dyslipidemia, anemia, and residual hyperparathyroidism. Markers of endothelial dysfunction were largely abnormal, a condition that could predispose to cardiovascular events.

Systemic lupus erythematosus: mortality and survival in Argentina. A multicenter study

OBJECTIVE

To analyze the factors associated with mortality, survival and causes of death in patients with systemic lupus erythematosus (SLE) in Argentina.

PATIENTS AND METHOD

A series of 366 patients with SLE (45 men and 321 women), mean age 29 y (range 11-70 y) and mean disease duration 6 y, was evaluated from 1990 to 1998. A total of 57 clinical, serological and therapeutic variables were studied.

RESULTS

Five- and 10-year survival was 91% and 85% respectively. Forty four patients died (12%): 54% due to sepsis and 32% due to active SLE. Mortality risk factors included heart involvement CRR 3.82), hyperlipidemia (RR 2.72), renal damage (RR 2. 62), infections (RR 2.44), lung disease (RR 2.20) and myositis (RR 2. 07). High-dose prednisone (RR 3.4) or cyclophosphamide (RR 9.19) treatments increased the risk of sepsis (P=0.003) as a cause of death. However, corticosteroids, antimalarial agents and accumulated cyclophosphamide doses proved to be protective factors in overall mortality figures (RR <1).

CONCLUSIONS

The main risk factors of death in SLE were heart involvement, hyperlipidemia and renal damage. Treatment with steroids, antimalarial agents and cyclophosphamide improved survival. High-dose corticosteroids and cyclophosphamide were associated with sepsis as a cause of death.

[Breast carcinoma in men. The surgical treatment of a case under our observation]

A case of male breast carcinoma in a very young subject (seventeen years old) is described. Breast carcinoma in male is infrequent, and at a so young age it is really rare. The patient was subjected to "Patey" mastectomy with removing the lymph nodes of the breast with the tumor, and subcutaneous mastectomy at the opposite side breast. As agreed with the oncologist other therapy was carried out.

Biliopancreatic diversion: clinical experience

BACKGROUND

Biliopancreatic diversion (BPD), by ad hoc stomach resection (AHS-BPD) has been accepted as an effective surgical treatment for morbid obesity.

METHODS

Between 1.1.1992 and 31.7.1996, 59 patients (54 females, five males, mean age 40.3 years, range 23-61 years) underwent AHS-BPD. Mean preoperative body-weight was 121.2 kg (range 94-160), with a mean body mass index of 48.6 (range 35-64). Three of these patients were converted from a previous vertical banded gastroplasty to AHS-BPD (one patient with stomach preservation). After at least 36 months follow-up, seven patients underwent abdominal dermolipectomy (five with associated incisional hernia repair, one with thigh dermolipectomy).

RESULTS

Mean post-operative hospital stay was 13 days (range 10-30 days). Follow-up is currently in progress in all patients. Excess body weight-loss was 78% in 33 patients with 24 months follow-up, with excellent long-term weight loss maintenance. Protein deficiency was the main specific complication, encountered in two patients (3.4%). Mortality was one patient (1.7%), due to pulmonary embolus.

CONCLUSIONS

This clinical experience supports the effectiveness and safety of AHS-BPD, despite some criticism. This procedure appears to be suitable for patients with clinically severe obesity who will poorly tolerate food intake restriction but will accept long-term follow-up. Careful preoperative clinical assessment and selection of patients who will be reliable in long-term follow-up are the keys to success with AHS-BPD, both in terms of weight loss and reduction of specific metabolic complications.

Critical Aspects of Sedimentary Phosphorus Chemical Fractionation

Sequential leaching procedures have been widely used as an environmental tool to quantify sedimentary P reservoirs. Nevertheless, they still present important issues that need to be investigated such as readsorption of leached ions and organic P hydrolysis. Bottom sediments of a lagoonal environment were analyzed following some selected extraction procedures that are based on chelating agents at the same pH as the sediment (GB) or a mixture of reducing and acid extractants (AAC and SEDEX). Readsorption was estimated by washes with MgCl₂ after each extraction, and turned out to be significant in the step of the SEDEX sequence that quantifies the authigenic Ca-bound P. Here, readsorbed P accounted for up to 46% of the fraction. In contrast, in the GB sequence readsorbed P accounted for only 1.7 to 4.3% of the Fe-bound P and Ca-bound P. The AAC and SEDEX sequences yielded relative organic P contents ranging from 24.5 to 30.5% of the total P, and the GB sequence yielded values of 41.3 to 50.7%. Despite the large difference between the two sequences, the relative proportions among the samples were consistent. The difference may result from the combination of hydrolysis sedimentary organic P by some extractants (mostly citrate dithionite bicarbonate [CDB] and HCl) in the AAC and SEDEX sequences, and of incomplete dissolution of Ca-bound phases by the relevant chelating agent (Na-EDTA [ethylene dinitrilo tetracetic acid]) in the GB sequence. In fact, when detrital apatite of magmatic origin was used as an analogue phase, only about 48% of it was leached during two Na-EDTA extractions. The undissolved detrital apatite was therefore wrongly attributed to the organic P reservoir and produced values of organic P overestimated by 2.9 to 8.8%. The organic P values obtained with the different sequences, although corrected for this effect, still showed differences of 5.4 to 13.9%, that were attributed to the hydrolysis of labile organic compounds. These results point out that the best sequence to use should be chosen taking into account the peculiarities of each sequence and the contents of detrital apatite and organic matter of the sediments under study.

[Observations in sclerosing cholangitis]

Sclerosing cholangitis is a rare liver disease of unknown etiology with a slow but progressive course. The authors report their experience and illustrate some surgical procedures to preserve bile duct patency in view of a liver transplantation program.

[Enteral nutrition in the pre- and postoperative therapy of gastric neoplasms. Comments on 21 cases]

Results of personal experience of the application of enteral nutrition in a group of patients (21) submitted to surgery for gastric cancer are reported. Enteral nutrition proved easy to perform, provided a significant improvement in some of the parameters considered in the study, was without significant complications and presented acceptable management costs.

[Primary neoplasms of the gallbladder. Remarks on a case series]

Data relating to a series of 22 patients suffering from primary gallbladder cancer are reported. In 8 cases the condition was benign, in 14 malignant. In 21 cases, concomitant presence of gallbladder calculosis was encountered. Survival in patients with gallbladder carcinoma was poor and significant in only 2 cases in which the tumour was observed at a non-advanced stage.

[Conservative intervention in tumors of the papilla of Vater. Apropos of 2 new cases]

On the basis of two new cases of cancer of the papilla of Vater, stress is laid on the indication for and value of duodeno-cephalopancreatectomy as the sole radical intervention. Conservative papillectomy should be confined to special cases (advanced age, general condition poor) with good long-term results.

[The role of cytology by needle aspiration in the diagnosis of thyroid nodules. Examination of 179 cases]

Since May 1981, fine needle biopsies have been used for cytological examination of thyroid nodules that were barely or not recorded by scintiphotography. By February 1984, a total of 179 patients had been examined. The biopsies were repeated on 12 patients where the first sample produced no diagnostic material. In 57 cases, a histological control existed in the form of material removed surgically by enucleoresections, partial and total thyroidectomies. Histological examination confirmed the cytological diagnosis in 7 out of 8 cases (88%) of malignant neoplasias with varying degrees of differentiation. A cytological diagnosis of adenoma was reached in 80% of cases, and of nodular struma in 82% of cases. Microscopic aspects of the cases are described together with the consequent cytological diagnostic criteria, while the characteristics and importance of the technique are also discussed.

[Usefulness of sequential isotopic cholangiography in biliary surgery follow-up]

Personal experience in the follow-up of 39 patients subjected to bile duct surgery is reported. The results indicated that sequential isotopic cholangiography is less effective as a supplementary examination in the postoperative period by comparison with its use in preoperative diagnosis. It does, in fact, constitute the only possibility of visualising the main biliary pathway in subjects who have been operated for biliodigestive anastomosis, with the exception of invasive methods, such as PTC, itself out of the question in the execution of periodic postoperative controls.

[Our experience with cysts of the pancreas]

The Authors produced their series of pancreatic cysts and pseudocysts. In order to a correct surgical therapy they deem it essential to do the Wirsungraphia or the cysto-wirsungraphia to recognize the "communicating cyst" and the "non communicating cyst". The simple resection and the cystoparenchimal resection are the operations of choice but the cystoanastomosis provides suitable and definitive results in the same way. Whereas the marsupialization and the external drainage are operations to reserve for the high risk patients, for the hazard of the pancreatic fistula particularly in the "communicating cyst".

[Breast needle-biopsy. Personal experience]

A personal series of 133 mammary needle biopsies is presented. Cytological specimens were obtained by aspiration via a thin needle from solid neoformations. The causes in which this form of examination was used are described and the extent to which the findings influenced surgery is explained. The method was found to be diagnostically sound and easy to perform. It may be regarded as a useful addition to other instrumental techniques in the diagnosis of breast swellings and in reducing the percentage of error.

[Emergency or deferred treatment of perforated and bleeding gastroduodenal ulcer]

The treatment of perforated peptic ulcer, according to the experience of the Authors (327 cases), must be very pressing and always surgical. The closure of the perforation, the simplest treatment, seems the most suitable and the least dangerous for the survival of the patient, even though 68% of these patients will have to undergo surgery again in the course of 10 years. The radical treatment of resection, is reserved to few and carefully chosen cases, because it is loaded with sufficient risk. Acute bleeding peptic ulcer (86 cases) requires the operation: immediate or delayed according to the importance of the hemorrage: very serious, serious, moderate.

[Value of thermography in the postoperative control in direct arterial surgery]

21 patients suffering from arteriopathy of the lower extremities and treated with a variety of surgical techniques and arterial recanalization have been studied by means of pre- and post-operative angiography and thermography. After analysing the results, the value of thermography, particularly as regards assessment of the surgical results and subsequent long-term controls, is confirmed.

[Notes on 4000 surgical operations for biliary tract calculosis. I. Papillotomy and papillosphincterotomy. Indications and results]

Personal experience with papillotomy and papillosphincterotomy in calculosis of the PBD is reported. The indications and results obtained are discussed. The techniques employed are described and an assessment is made of the extent to which these operations can be performed without causing unnecessary damage to the sphincter.

[4,000 surgical operations for calculosis of the biliary tract. II. Bilio-digestive shunts: indications and results]

Personal experience with biliodigestive derivations in calculosis of the principal bile way is reported. The operating technique is presented and indications and results discussed. It is concluded that biliodigestive anastomosis must be carried out with an appropriate technique and in the presence of particular bile duct lesions, primarily choledochic ectasia.