Real-world efficacy and safety of vedolizumab in managing ulcerative colitis versus Crohn's disease: results from an Italian multicenter study

BACKGROUND

Vedolizumab (VDZ) can be used to treat refractory ulcerative colitis (UC) and Crohn's disease (CD). We assessed whether there are differences in treating UC vs CD with VDZ.

RESEARCH DESIGN AND METHODS

 Mayo score in UC and the Harvey-Bradshaw Index (HBI) in CD scored the clinical activity. Achievement and maintenance of clinical remission during the follow-up, and safety were the primary endpoints.

RESULTS

729 patients (475 with UC and 254 with CD), median follow-up of 18 (IQR 6-36) months, were enrolled. Clinical remission at the 6^th month of treatment was achieved in 488 (66.9%) patients (74.4% in CD vs 62.9% in UC, p<0.002) while, during the follow-up, no difference was found (81.5% in the UC group and 81.5% pts in the CD group; p=0.537). The clinical remission at the 6^th month of treatment (p=0.001) and being naïve to biologics (p<0.0001) were significantly associated with prolonged clinical remission. The clinical response was significantly higher in UC (90.1%) vs CD (84.3%) (p=0.023), and surgery occurred more frequently in CD (1.9% in UC vs 5.1% in CD, p=0.016).

CONCLUSION

We found differences when using VDZ in UC vs CD in real life. These parameters can help the physician predict this drug's longterm efficacy.

Assessment of the nutritional status in patients with acute diverticulitis

Background

The study evaluated the implementation of a screening strategy on all hospitalizations for diverticular disease (DD) of the colon with particular reference to acute diverticulitis (AD) regarding nutritional status.

Methods

The Nutritional Risk Security (NRS2002) system, was used, preselecting those with AD by the nurses of the nutrition team on the same day of admission from 1/01 to 31/12/2017 at the S. Eugenio Hospital in Rome. Patients (pts) with positive pre-screening were referred for additional evaluation performed by a dietician.

Results

AD was observed in 133 pts, 58% women, out of a total sample of 4667. The NRS2002 was applied to all, finding a positive screening test in 97 (72.9%) pts of whom a severely compromised nutritional status (NRS2002 score&gt;3) in 61 pts (62.9%). Each patient tested positive was given initial nutritional support: oral supplements (17 pts, 17.52%), enteral nutrition (22 pts 22.68%), total parenteral nutrition (58 pts 59.8%). The mean length of hospital stay was 6.9 days, although was significantly longer for pts with NRS2002 positive (mean of 18 day). NRS2002 score can be a significant predictor of disease severity and outcome, operating independently of BMI, since a total score ≥3 can predict length of hospital stay.

Conclusions

The study confirmed that NRS2002 is a useful screening tool for identifying nutritional risk AD pts in hospital wards and allowed to select pts who needed a more careful monitoring program, diet therapy and possibly nutrition artificial. Furthermore, it showed an increasing and underestimated risk of malnutrition in a large number of pts hospitalized and that NRS2002 screening is a good predictor of some socio-health indicators such as hospital stay.

Key messages

There is an increasing and underestimated risk of malnutrition in a large number of patients hospitalized. NRS2002 is a useful screening tool for identifying nutritional risk and a good predictor of some socio-health indicators such as hospital stay.

From hazardous asbestos containing wastes (ACW) to new secondary raw material through a new sustainable inertization process: A multimethodological mineralogical study

Nowadays, asbestos-containing wastes (ACW) still represent an important environmental problem and a severe health hazard due to the well known pulmonary diseases derived from asbestos fibers inhalation. Except for a very few cases, ACW are currently confined in controlled landfills, giving rise to increasingly high amounts of still hazardous wastes. A promising alternative to landfill confinement is represented by ACW inertization, but the high cost of the inertization processes so far proposed by the scientific community have hampered the creation of actually operative plants. In this paper, we explore the possibility to use an innovative process that ensures the obtainment of asbestos-free inert material in an exceptionally short processing time, thus greatly reducing cost-related problems. The efficacy of the inertization process has been verified through accurate mineralogical investigations on both chrysotile and crocidolite de-activated fibers, through X-ray diffraction, scanning and transmission electron microscopy. Overall mineralogical, microstructural and granulometric characteristics of the inert bulk material suggest that it could be successfully re-used as a secondary raw material in ceramic industries. This innovative inertization procedure could therefore provide an effective and economically sustainable solution for ACW management.

Impact of treatments on fecal microbiota and fecal metabolome in symptomatic uncomplicated diverticular disease of the colon: a pilot study

Symptomatic uncomplicated diverticular disease (SUDD) affects 50% of people having diverticulosis. We performed a pilot study assessing the effect of current treatments on fecal microbiota and metabolome in SUDD. Thirteen consecutive females with SUDD were treated with a 2-week therapeutic trial of 30 g/day fiber supplementation (3 patients), 1.6 g/day of mesalazine (3 patients), 900 billion/day of probiotic mixture VivoMixx® (3 patients), or 800 mg/day of rifaximin (4 patients). Stool samples were collected at entry (T0), at the end of the 2-week therapeutic course (T1), and 30 (T2) and 60 days (T3) after the end of the therapeutic course. Real-time PCR quantified targeted microorganisms. Fecal metabolome patterns were studied by high-resolution proton NMR spectroscopy. At cumulative analysis, symptoms significantly decreased at each time point during follow-up (p less than 0.0001), and only left-lower quadrant pain increased again at T3. The overall bacterial quantity was not altered by the treatments. The amount of Akkermansia muciniphila species was significantly reduced at T1 (p=0.017) and at T2 (p=0.026), while at T3 the reduction was not significant in comparison to enrollment (p=0.090). Fecal molecular profile showed significant changes at T1 and T2, while at T3 it became similar to that of T0. Differences were found for 18 of the quantified molecules (tryptophan, phenylalanine, tyrosine, 4-hydroxyphenylacetate, urocanate, X-6.363, X-5.779, uridylate, galactose, X-4.197, threonine, sarcosine, methionine, 2-oxoisocaproate, 5-aminolevulinate, alanine, leucine, valerate). Metabolome and microbiota changed in patients with SUDD under treatment, confirming a possible role of dysbiosis/dysmetabolome in the pathology.

Decreasing efficacy of the standard seven-day triple therapy containing amoxycillin and clarithromycin in curing Helicobacter pylori infection in clinical setting in Italy: a 10-year follow-up study

AIM

The aim of the present study was to assess the efficacy of the standard triple therapy containing PPI plus amoxycillin and clarithromycin in curing Helicobacter pylori (H. pylori) infection during a long-term period.

METHODS

A retrospective analysis was conducted on 1497 consecutive dyspeptic patients with proven H. pylori infection and enrolled from 1996 to 2006. Patients received a standard triple therapy with proton pump inhibitor (PPI) plus amoxicillin 1 g and clarithromycin 500 mg for 7 days (all twice daily) plus PPI every day for further 4 weeks in case of active peptic ulcer or severe gastritis detected at endoscopy. One month after conclusion of therapy, endoscopy was performed in those patients for whom the examinations were clinically relevant. The remaining patients were checked by ¹³C-urea breath test.

RESULTS

The overall H. pylori eradication rate was 70.41% (on intention-to-treat analysis). However, it decreased significantly during the observation period, ranging from 90% (95% CI 87.14% to 93.91%) in 1996 to 51.11% (95% CI 48.14% to 55.91%) in 2006 (on i-t-t analysis) (P=0.001). No difference in eradicating the was found infection between Puglia and Lazio (1996: P=0.39; 2006: P=0.64).

CONCLUSION

Standard triple therapy does not appear anymore a valid therapeutic strategy for the management of H. pylori infection in clinical practice.

Efficacy, tolerability, and factors affecting the efficacy of the sequential therapy in curing Helicobacter pylori infection in clinical setting

BACKGROUND

Sequential therapy is currently suggested as first-line therapy in curing Helicobacter pylori infection, but results coming from its use in clinical practice are scarce. We evaluated the efficacy of this therapy regimen in our current clinical practice.

METHODS

A retrospective study was conducted on 437 consecutive dyspeptic patients with proven H. pylori infection. Patients received a 10-day sequential therapy with proton pump inhibitor (PPI) plus amoxicillin 1 g for the first 5 days, followed by PPI, clarithromycin 500 mg, and tinidazole 500 mg for the remaining 5 days (all twice daily) plus PPI every day for further 4 weeks in case of active peptic ulcer or severe gastritis detected at endoscopy. One month after conclusion of therapy, endoscopy was performed in those patients for whom the examinations were clinically relevant. The remaining patients were checked by C-urea breath test.

RESULTS

Three-hundred ninety-eight patients (91.08%; 95% confidence interval [CI], 87.91%-93.50%) were fully compliant, 19 patients (4.35%; 95% CI, 2.71%-6.83%) took less than 80% of the prescribed drugs, 11 patients (2.52%; 95% CI, 1.33%-4.60%) were withdrawn because of side effects, and 9 patients (2.06%; 95% CI, 1.01%-4.01%) were lost to follow-up. The H. pylori eradication was obtained in 395 (90.39%, 95% C.I. 87.14% to 92.91%) of 437 and in 362 of 437 (82.84%, 95% C.I. 78.90% to 86.19%) as per-protocol and intention-to-treat analyses, respectively.

CONCLUSIONS

Sequential regimen seems to be a valid therapeutic strategy for the management of H. pylori infection in clinical practice.

Role of fecal calprotectin in the diagnosis and treatment of segmental colitis associated with diverticulosis

AIM

Information about fecal calprotectin (FC) in segmental colitis associated with diverticulosis (SCAD) is lacking. We assessed FC in SCAD, comparing it healthy controls (HC), irritable bowel syndrome (IBS), diverticular disease (DD), ulcerative colitis (UC). Moreover, we compared FC levels in different degrees of SCAD and assessed FC SCAD before and after treatment.

METHODS

Twenty-seven consecutive patients with a new endoscopic diagnosis of SCAD, and 16 patients for each control group, underwent to FC assessment. FC was assessed by semi-quantitative method.

RESULTS

FC was not increased in HC and in IBS patients, whilst it was increased in DD, SCAD, and UC. FC concentration was higher in SCAD and UC than in DD (SCAD vs. DD, P=0.05). No difference was found in FC concentration between SCAD and UC (P=0.213), as well as between different degree of SCAD (P= 0.178). After treatment, FC values decreased to normal values in all patients obtaining remission (P<0.0005). Three patients experienced still symptoms (one SCAD type B and two SCAD type D patients), and in all of them FC was still detectable.

CONCLUSION

FC may be useful in differentiating SCAD from functional syndromes. Moreover, it may be useful in assessing response to therapy.

Safety and effectiveness of infliximab for inflammatory bowel diseases in clinical practice

BACKGROUND AND OBJECTIVES

Our aim was to assess the efficacy and safety of infliximab (IFX) in clinical practice in three Primary Care, Hospital Centers.

MATERIAL AND METHODS

From September 2004 to December 2008 62 patients (28 males, 34 females, mean age 30.25 years, range 15-55 years), affected by ulcerative colitis (UC) (23 pts) or by Crohn's disease (CD) (39 patients) were treated. Clinical efficacy, safety, mucosal healing and quality of life were assessed both in UC and CD.

RESULTS

A total of 746 infusions were performed. IFX was administered for a mean of 26 months (range 8-44 months). 33/39 (84.61%) pts with CD were in remission under treatment with IFX for a mean time of 19 months (range 12-44 months). Mean Crohn Disease Activity Index (CDAI) score decreased from 295 (range 258-346) to 136 (range 98-136) (p < 0.005). Inflammatory Bowel Disease Quality of Life (IBDQL) improved from 48 (at entry) to 198 (at the end of the study) (p < 0.005). 20/23 (86.95%) patients with UC were in remission under treatment with IFX for a mean of 18 months (range 8-34 months). Mean Disease Activity Index (DAI) decreased from 11 (range 9-12) to < 3 (range 2-3) (p < 0.05). Mean Mayo Subscore for Endoscopy decreased from 3 to < 1 (range 0-1). IBDQL improved from 56 (at entry) to 194 (at the end of the study) (p < 0.005). Only 5 patients (8.06%) experienced side-effects.

CONCLUSIONS

Long-term outpatients treatment with IFX seems to be safe and effective in managing patients affected by IBD in clinical practice.

The clinical picture of uncomplicated versus complicated diverticulitis of the colon

PURPOSE

There is no consensus about the correct definition of uncomplicated diverticulitis (UD) in clinical practice. We evaluated therefore whether clinical picture of UD differs from complicated diverticulitis (CD). Fifty consecutive eligible patients (21 males, 29 females, mean age 63.6 years, range 47-75 years) were studied. Symptoms, the inflammatory indices, and Computerized Tomography (CT) scan of the abdomen were assessed at the time of admission.

RESULTS

Thirty-nine patients classified were affected by UD and 11 patients by CD. CD patients showed more severe clinical picture than UD and required urgent Hospital admission. Conversely, most of the patients affected by UD were treated as outpatients. CD patients showed higher symptom scores than UD patients, except the parameter "diarrhea". All CD patients showed increases in all inflammatory indices. Conversely, all UD patients showed increased ESR, CRP and fibrinogen, but WBC and alpha1-acid glycoprotein were increased in only a few cases. CT scan in CD patients always showed signs of severe colonic and pericolonic inflammation. Conversely, UD patients often showed moderate localized signs of inflammation without complication.

CONCLUSIONS

Clinical, laboratory, and radiological findings may easily differentiate uncomplicated from complicated diverticulitis of the colon. This integrated approach may be helpful in clinical settings.

Genotype and phenotype in hereditary and sporadic breast cancers

10538

Background: BRCA1 protein is involved in distinct DNA-repair processes. Germline mutations in BRCA1 gene confer cancer susceptibility. A frequent mechanism for epigenetic inactivation is hypermethylation of the CpG island in promoters of tumours suppressor genes. BRCA1 promoter hypermethylation has been found in a variable percentage of breast cancers (15–30%). BRCA1-associated breast cancers are usually high-grade, poorly differentiated and stain negative for HER2/neu, oestrogen and progesterone receptors (ER, PgR). Many studies have shown that hereditary BRCA1 and basal-like sporadic breast tumours have a similar phenotype and gene expression signature. Methods: By clinical criteria, 223 patients were selected and, for each patient, the probability to carry a BRCA1 mutation was calculated using the software BRCAPRO and Manchester Score System. All patients were studied by direct sequencing and MLPA of BRCA1 Open Reading Frames (ORFs). Thirty sporadic breast carcinomas, from women undergone surgery for primary invasive breast carcinoma between 1995 and 2001, were selected on the basis of negative staining for ER, PgR and HER2/neu (“BRCA-like”). In these patients, Methylation Specific-PCR and Bisulfite Sequencing on genomic DNA (obtained from sections of paraffin-embedded tissues and modified with sodium bisulfite) were used to assess the methylation pattern of BRCA1 promoter. BRCA1 immunohystochemical analysis (IHC) was performed in all patients. Results: We identified 17 patients with deleterious germline mutations in BRCA1. In “BRCA-like” patients, 13 methylated and 17 unmethylated cases were found by methylation analysis of BRCA1 promoter. The BRCA1 IHC was performed in all available samples ( table 1 ). Conclusions: Hypermethylation of BRCA1 promoter was found in 43% of “BRCA- like” patients. Expression of BRCA1 seems to correlate with hypermethylation of its promoter. Further studies are in progress to better understand the possible role of BRCA1 promoter hypermethylation in sporadic breast cancers.

[Table: see text]

No significant financial relationships to disclose.

Effectiveness of the CRCAPRO program in identifying patients suspected for HNPCC

Subjects affected by hereditary non-polyposis colorectal cancer exhibit a high susceptibility to colon and extracolonic tumours, due to MMR gene defects. Revised Bethesda criteria are used to select patients as candidates for genetic tests. Recently, the CRCAPRO model has been developed, based on family history of colorectal and endometrial cancers. Our study aims to evaluate the reliability of CRCAPRO in identifying mutation carriers. We used the CRCAPRO program to evaluate carrier probability risk in 99 patients fulfilling Amsterdam or Bethesda guidelines. MLH1 and MSH2 were studied by direct sequencing in all the 99 patients, and the study of microsatellite instability and of MMR proteins expression was performed. Nine MLH1 and nine MSH2 germline mutations were identified. Five out of the nine patients with MLH1 mutation showed a CRCAPRO risk evaluation of less than 20%. The same happened for four out of nine patients with MSH2 mutation. Of the 17 patients with an estimated risk of more than 80%, only four harboured a mutation, all in the MSH2 gene. The highest risk calculated by the CRCAPRO system in the nine carriers of a MLH1 mutation has been 31.7%. In our experience, the CRCAPRO program sensitivity and specificity appears to be low but needs to be further evaluated in larger samples.

Contribution of science to farm-level aquatic animal health management

The contribution of science to farm level disease management is a story of two worlds. The development of effective vaccines has allowed for the control of important salmonid diseases such as furunculosis, yersiniosis and vibriosis and has significantly reduced farmers' reliance on antibiotics. Control of diseases for which cost-effective vaccines have yet to be developed has been achieved through the development of increasingly targeted antibiotics and chemotherapeutants. Increasingly, accurate and rapid diagnostic and water quality tests have allowed farmers to improve farm-level aquatic animal health management. In developed countries, these achievements have been possible thanks to the strong link between science and farm management. This link has been assisted by the presence of strong farmer organizations capable of coordinating research projects and hosting meetings at which scientific information is discussed and disseminated. Although Asia is responsible for the production of about 90% of aquaculture products, it presents a rather different picture from the above. Science has indeed made significant progress in health management but the links with farm management are still weak. Management practices capable of preventing important health problems in shrimp and fish farming are still poorly adopted by farmers. This is largely due to constraints in the dissemination of information to the large number of producers involved, the limited resources of both producers and their countries and the lack of effective farmer organizations capable of liaising with the scientific world. Recently, the Asian region has witnessed some successful examples of aquatic animal health management through the adoption of simple Better Management Practices. Efforts so far have been largely focused on shrimp farming, although activities have been initiated to adopt a similar approach to other commodities. The need for both observational and experimental epidemiological studies to identify simple and affordable farm practices for the control of aquatic animal diseases is highlighted.

Vaccination trials of sea bass (Dicentrarchus labrax) against pasteurellosis using oral, intraperitoneal and immersion methods

Photobacterium damsela subsp. piscicida (Phdp) is the aetiological agent of fish pasteurellosis, causing heavy losses in intensive mariculture plants. The present work compares the protective efficacy of five different vaccine formulation: oral, intraperitoneal, immersion, bivalent immersion (Vibrio anguillarum) and immersion associated with immunostimulants. Each of these vaccine formulations containing whole cells of Phdp formalin inactivated (FKC), was administered to 100 sea bass weighing approximately 2 g; 100 non-vaccinated sea bass were used as controls. Protection against pasteurellosis was tested for 40 days after vaccination by intraperitoneal challenge: each fish was inoculated with Phdp cells at a concentration of 2.75 x 10(4) cfu/ml. Mortality was recorded over the following 14 days, vaccine protection was evaluated using a relative percentage survival (RPS) index. The intraperitoneal formulation gave excellent protection (RPS 82.4%). The most effective immersion form was that followed by simple immersion (RPS 23.1%) followed by the group vaccinated with bivalent vaccine (RPS 18.7%). Protection conferred orally (RPS 28.6%) is of interest for practical purposes.

Ethanol-induced decrease of the expression of glucose transport protein (Glut3) in the central nervous system as a predisposing condition to apoptosis: the effect of age

We measured the effect of chronic ethanol administration on the expression of Glut3 in the cerebellum and hippocampus of adult and old rats. Glut3 expression significantly decreased in aging, in ethanol-treated rats vs. age-matched controls, and in adult- vs. old ethanol-treated rats. These findings lend consistent support to the hypothesis that disturbances of glucose metabolism due to ethanol may constitute an unfavorable condition predisposing to neuronal death.

[Non-invasive diagnosis of celiac disease in clinical practice]

Coeliac disease is a permanent intolerance to gluten which requests a quick diagnosis as soon as possible to prevent neoplastic and non-neoplastic complications of the disease, since frequently coeliac disease shows pauci- or asymptomatic forms. We describe herein the most common non invasive diagnostic methods used in clinical practice to diagnose coeliac disease, as well as we describe non invasive methods poorly used or which will play a key role in the non invasive diagnosis of coeliac disease in the future.

Low prevalence of antigliadin and anti-endomysium antibodies in subclinical/silent celiac disease

OBJECTIVE

Endomysial antibodies (EMA) are a well-known hallmark of celiac disease, but some recent studies showed that the prevalence of these antibodies in clinical practice is lower than expected. The aim of our study was to determine the prevalence of antigliadin (AGA) and EMA antibodies on a consecutive series of subclinical/silent celiac patients.

METHODS

We studied 115 consecutive patients with subclinical (92 patients) or silent (23 patients) forms of celiac disease. AGA and EMA were screened in all patients. Histopathology of celiac disease was expressed according to the Marsh classification.

RESULTS

The overall AGA in subclinical form were positive in 77% (14 of 18) of patients with partial villous atrophy (VA), in 84% (21 of 25) of patients with subtotal VA, and in 90% (27 of 30) of patients with total VA, whereas EMA were positive in 88.88% (16 of 18) of patients with partial VA, in 92% (23 of 25) of patients with subtotal VA, and 96.66% (29 of 30) of patients with total VA. On the other hand, AGA were positive in 0% (zero of two) of patients with Marsh I and in 30% (three of 10) of patients with Marsh II, whereas EMA were positive in 0% (zero of two) of patients with Marsh I and in 40% (four of 10) of patients with Marsh II (Marsh I-IIIa vs Marsh IIIb-c, p = < 0.005 in overall AGA-positive patients and p = < 0.0001 in EMA-positive patients). At the same time the overall AGA in silent form were positive in 60% (three of five) of patients with partial VA, in 66.66% (four of six) of patients with subtotal VA, and in 77.77% (seven of nine) of patients with total VA, whereas EMA were positive in 80% (four of five) of patients with partial VA, in 83.33% (five of six) of patients with subtotal VA, and in 88.88% (eight of nine) of patients with total VA. On the other hand, overall AGA were positive in 0% of patients with both Marsh I (zero of one) and Marsh II (zero of two), as well as EMA were positive in 0% with both Marsh I (zero of one) and Marsh II (zero of two) (Marsh I-IIIa vs Marsh IIIb-c, p = < 0.001 in overall AGA-positive patients and p = < 0.007 in EMA-positive patients).

CONCLUSIONS

At this time small bowel biopsy seems to be the only correct procedure to diagnose a case of suspected celiac disease, especially in patients with mild symptoms or suspected for celiac disease, because they belong to high-risk groups.

Prevalence and clinical presentation of subclinical/silent celiac disease in adults: an analysis on a 12-year observation

BACKGROUND/AIMS

In recent years, an increased incidence of subclinical/silent celiac disease has been reported. Thus, we herein describe the prevalence and the clinical presentation of subclinical/silent celiac disease in 252 consecutive diagnosed celiac patients.

METHODOLOGY

From 1988 to 1999 we diagnosed 252 celiac patients (74M and 178F, mean age: 27.9 yrs; range: 15-65 yrs, F/M ratio: 2.4). 144 patients were referred to us due to gastrointestinal symptoms, while 108 were referred to us from other specialists due to unexplained or unresponsive disease. All patients underwent both total immunoglobulin A and antigliadin antibodies antiendomysium antibody and evaluation, followed by gastrointestinal endoscopy with duodenal histological examination.

RESULTS

144 (57.14%) and 108 (42.86%) patients showed classical and subclinical/silent celiac disease, respectively. The most frequent extraintestinal marker of subclinical celiac disease were iron-deficiency anemia (27.77%), alopecia and dermatitis herpetiformis (11.36%), osteoporosis (6.81%) and recurrent aphtous stomatitis (5.68%), while first-degree relatives (30%), Basedow's disease (25%) and insulin-dependent diabetes (20%) were the most frequent in silent celiac disease.

CONCLUSIONS

This study confirms the extremely polymorphic nature of this condition that can affect several organs and apparatus without gastrointestinal symptoms. However, a more precise description of subclinical/silent celiac disease can only emerge from screening studies on general populations.

Loco-regional radioimmunotherapy of high-grade malignant gliomas using specific monoclonal antibodies labeled with 90Y: a phase I study

A Phase I radioimmunotherapy trial was conducted in which radioconjugated monoclonal antibody (MAb) was directly infused into the tumor or postoperative tumoral bed in patients with high-grade malignant glioma. BC-4, a murine MAb that recognizes tenascin, was used in these studies. The MAb was labeled with 90Y, a pure beta emitter with maximum energy of 2.284 MeV, which can penetrate into tissue up to 0.5-0.7 cm. Stable 90Y-labeled MAb conjugates were prepared using the chelator p-isothiocyanatobenzyl derivative of diethylenetriaminepentaacetic acid (ITC-Bz-DTPA), obtaining >95% labeling efficiency and conserving the antibodies' immunoreactivity (>85%). Twenty patients, 2 with anaplastic astrocytoma and 18 with glioblastoma, were included in the study. All of the patients had been treated previously with conventional therapies (surgery, external radiotherapy, and chemotherapy) and presented with progressive disease not amenable to further treatment. A dose-escalation study was performed using doses ranging from 5-30 mCi (185-1110 MBq) of 90Y-labeled MAb BC-4. The protein dose of MAb was always 1 mg. Three patients were treated at the 5, 10, 15, and 20 mCi levels, and the 25- and 30-mCi doses were each administered to 4 patients. Systemic toxicity was completely absent in all of the patients. The maximum tolerated dose to the brain was 25 mCi (925 MBq). The average dose to the tumor was 3200 cGy/mCi. Doses to the liver, bone marrow, and kidneys were below 10 cGy/mCi in all of the cases. Biodistribution studies demonstrated that the 90Y-labeled MAb accreted exclusively in the neoplastic area without any diffusion into the normal brain or other normal organs. No clinical responses were recorded because of the very advanced stage of disease at the time of radioimmunotherapy.

Low plasma cholesterol: a correlate of nondiagnosed celiac disease in adults with hypochromic anemia

OBJECTIVE

Hypochromic anemia is at times attributable to nondiagnosed celiac disease. The aim of this study was to define the correlates of celiac disease in anemic adults without overt malabsorption.

METHODS

One hundred patients with hypochromic anemia and without diarrhea underwent a complete diagnostic work-up, including screening for celiac disease, i.e., upper endoscopy with duodenal biopsy and search of antiendomysium antibodies.

RESULTS

Patients with hypochromic anemia were from two different Divisions and were analyzed as a single group because they were not significantly different for any variable. Hypochromic anemia was attributable to celiac disease in 10 patients. Compared to anemic patients without celiac disease, anemic patients with celiac disease had significant or borderline significant differences for plasma cholesterol (-17.9%), albumin (-9.4%), and body mass index (-11.8%), but not for gender distribution, age, weight, height, blood hemoglobin, mean corpuscolar volume, plasma iron, and ferritin. All anemic patients with celiac disease had plasma cholesterol < 156 mg/100 ml. Within the entire cohort of anemic patients, plasma cholesterol inversely related to prevalence of celiac disease (p < 0.001); also plasma albumin and body mass index inversely related to celiac disease, but coefficients were borderline significant (p = 0.056 and 0.052, respectively).

CONCLUSIONS

The data suggest that among patients with hypochromic anemia, plasma cholesterol in the high-to-normal range could be used to exclude the presence of celiac disease. Other nutritional markers are less sensitive as indices of risk of celiac disease. Hematological indices are not of help to define the risk of celiac disease in anemic patients without signs of malabsorption.

Clinical evaluation of patients with squamous carcinoma of the oral cavity

AIMS

To make a clinical evaluation of patients with squamous carcinoma of the oral cavity.

METHODS

The clinical condition of 72 patients with squamous carcinoma of the mouth, hospitalized at the Institute of Oral and Maxillo-Facial Surgery, 2nd University of Naples, Italy, between 1992 and 1996, were examined. The patients were evaluated system by system, staged by TNM-UICC and classified by ASA and by the Karnofsky and Burchenal and the Zubrod et al. Performance status methods.

RESULTS

Evaluation by the two methods produced different results. Of the patients examined, 34.5% showed more than one systemic disorder. 51.4% were in ASA classes 3-4.

CONCLUSIONS

The presence of a disease with poor prognosis associated with advanced neoplastic stage (stages III-IV; 69.4% of the total) precluded radical surgery in 32% of patients, who were treated with chemotherapy and/or radiotherapy.

Experimental infection by Vibrio anguillarum in mice and guinea pigs

The fish pathogen Vibrio anguillarum causes a lethal infection in farmed fish characterized by hemorrhagic septicemia. There are no reports of experimental laboratory infections in warm-blooded animals. We investigated the effects of an intraperitoneal infection with different doses of a V. anguillarum suspension in mice and guinea pigs. The infection caused a 95-100% of mortality in 24-48 h. Hemorrhagic septicemia was observed at necropsy and confirmed by histological and hematological examination. Immunohistochemically positive bacterial clumps were detected exclusively in vessel lumen in all examined organs, including brain, and V. anguillarum was reisolated in pure culture from all organs, particularly from the kidney. Blood analysis showed erythropenia and leukopenia with granulocytosis in mice, platelet reduction and leukopenia with lymphocytosis in guinea pigs.

[Enteral nutrition in maxillofacial oncology]

The authors present a review regarding knowledge of malnutrition in maxillofacial oncology. The causes of nutritional deficit in head and neck tumor derived from metabolic alteration, consequent to the presence neoplasia and antineoplastic therapy. They analyze how to evaluate clinical status in malnutrition patients and they show different therapeutic strategy. The authors emphasise advantages and disadvantages of EN and TPN and present their nutritional forms, based on the EN, analyzing the characteristics.

Morphological, physico-chemical and biological variations in Vibrio anguillarum cultured at low osmolarity

The Authors studied the morphological, biochemical, physico-chemical and biological characteristics of Vibrio anguillarum cultured on different growth conditions, characterized by low osmolarity and high temperature (37 degrees). One culture was subcultured for several days in tryptone soya agar with 0.5% Nacl at 37 degrees C incubation until the cell morphology was stabilized. The low osmolarity, through an osmotic shock, induced remarkable morphological modifications in the strain, evidenced by optic and electron microscopic studied; in addition SDS-PAGE analysis of saline extracts from the culture at 37 degrees C showed a specific new protein band of about 66KDa. This band was correlated with remarkable differences in outer membrane protein composition (OMPs) evidenced by Ag/Ah cross-reactions with rabbit hyperimmune sera against the modified and the reference V. anguillarum strains. Finally, the modified strain proved to be non pathogenic for trout and sea bass.

[Cervical pain and proprioceptive sensitivity]

With the intent of estimating the proprioceptive sensitivity of the cervical rachis, the Authors subjected 17 healthy volunteers and 20 patients suffering from various cervical disorders to a clinical head positioning test, which was previously experimented upon by several french Authors was modified under certain aspects by our equipe. The test, consists in flexion and extension of the head after maximal rotations to the left and right, then repositioning the head at the starting point "0" which corresponds to the crossing point of two orthogonal axis of a target. The positions are marked on the target by a laser beam situated on the helmet worn by the subject undergoing testing. The results obtained corresponding to the errors committed regarding point "0", permit us to confirm the reliability of the test and significant definitions between the control group and the patients suffering from cervical disorders.

[Pharmacological treatment of delusional depression]

Delusional depression is characterised by the presence of symptoms such as hallucinations (typically auditory) and delusions either mood congruent and incongruent. Most commonly the content of delusions is consistent with the depressive themes: guilt, unworthlessness, poverty, death. Hallucinations, when present, are not elaborate and may involve voices that berate the patient for shortcomings or sins. Mood incongruent psychotic symptoms include persecutory delusions, delusions of thought insertion or thought broadcasting. Several pharmacological studies have demonstrated a differential response pattern in delusional depression and in nondelusional depression. Delusional depressives in fact, have a much lower response rate to tricyclic antidepressant treatment alone (20-25%) than nondelusional depressives (70-80%). The combination treatment with tricyclic and neuroleptic drugs leads to a dramatic improvement in the response rate in these patients (68-95%). The drugs most widely used are, for tricyclics, amitryptiline (150-215 mg/day) and desipramine (150-200 mg/day), and for neuroleptics, perphenazine (30-50 mg/day), but good results have also been reported with haloperidol (8-20 mg/day). The better results obtained with the tricyclic-neuroleptic association seem to be related to 3 factors: an increased tricyclic plasma level due to a competitive hynibition in the hepatic hydroxilation processes caused by neuroleptic agents: a dopaminergic blockade and an increased serotonergic and noradrenergic activity. Treatment with neuroleptics alone improves the symptomatology only in 19-50% of the patients. If the patient does not show a good response to the combination of tricyclics and neuroleptics, lithium augmentation (600-1200 mg/day) notably ameliorates the rates of clinical response (80-90% of cases). The treatment of delusional depressive patients with amoxapine leads to positive results in 70-80% of cases. Very good results have also been noted with bupropione (300-750 mg/day) after only a week of therapy. A complete symptomatological remission has been observed with 1-Dopa (1000 mg/day). The relatively low number of delusional depressive patients treated with SSRI to date does not allow to draw any consistent and definite conclusion on their real efficacy in this severe form of depression. For the continuation treatment it is recommended to continue the tricyclic-neuroleptic treatment for at least 6 months, at the lowest neuroleptic dosage which allows a long lasting clinical remission. Once the clinical remission is complete, the neuroleptic agent can be gradually tapered in some months, unless the patient had previous recurrence with the tricyclic agent alone. To the patients who show a symptomatological re-exacerbation during neuroleptic tapering, must be given again the combination treatment. In these cases it is important to assess more often and carefully the patient because of the increased risk of tardive diskinesia. Inconsistent results have been reported regarding the role of lithium in preventing relapses and recurrences: some authors suggest a prophylactic treatment with lithium and/o tricyclics in monotherapy to avoid the risks linked to a long-lasting neuroleptic treatment; others authors have documented a higher risk of relapse with lithium and/o tricyclics in monotherapy than with the tricyclic-neuroleptic combination treatment.

[Recurrent brief depression]

The initial conception of manic depressive illness by Kraepelin included short and mild depressive and hypomanic states in the nosologic category of affective illness. The concept of recurrent brief depression was further confirmed in recent community and general practice studies. The diagnostic criteria for recurrent brief depression requires the presence of at least five of nine depressive symptoms analogous to the symptoms of major depression, yet a duration of less than two weeks (in general 1 to 3 days), a recurrence of at least 12 times a year, and the evidence of work impairment. The 1-year prevalence in the general population is about 5% and the lifetime prevalence 16%. Recurrent brief depression may develop into major depression and vice versa in about the same percentage of cases. Patients with combined major and recurrent brief depression are more severely affected, have a higher suicide attempt rate, and have an increased frequency of treatment--seeking than patients with only one condition. Recurrent brief depression is typically characterized by monthly occurring short-lived depressive episodes, with an erratic, relapsing and chronic course and significant suicide risk. The duration of these episodes in clinical samples was of 3-5 days on average, with a medium number of episode a year of 20. The onset of episodes is sudden and patients progress rapidly to the severe levels of depression. Resolution of the symptoms also tends to be rapid. The suddeness of the episodes may contribute to the relationship reported with suicidal behaviour. This is a disabling illness because of the frequency with which the episodes recur reported as erratic "irregularly regular".(ABSTRACT TRUNCATED AT 250 WORDS)

[Contribution of clinical, biohumoral, morphological and instrumental parameters to the diagnosis of some chronic liver diseases]

A comparative study concerning the diagnostic importance of clinical, humoral, morphological and instrumental parameters had been carried out on 105 patients affected by chronic liver disease (51 cases with liver cirrhosis, 15 with metastatic tumors, 10 with liver steatosis and 29 with chronic hepatitis). The final diagnosis of the patients used for the comparison was formulated considering the greatest numbers of data. The results of this study can be drawn as follows: --clinical and laboratory data show satisfactory diagnostic value principally in patients suffering from liver cirrhosis (90 per ceny) and metastatic tumors (93 per cent); --peritoneoscopy appears to be generally the most useful procedure with the most significance value above all in cirrhotic patients; --morphological examination in biopsy specimen results of the greatest importance in patients affected by chronic hepatitis and hepatosteatosis while rather high has been the percentage of false negatives in secondary tumors of the liver (40 per cent) and cirrhosis (68 per cent); --scintiphotoscanning is generally less useful as a diagnostic tool than peritoneoscopy a part of the cases of metastatic tumors. In such a condition the diagnostic power of both the procedures results to be identical; --it may be concluded that an integrating diagnostic information generally results to be the most precise and maximally capable of reducing the number of false negatives. In individual cases, of course, the less important procedure shows to have the maximum of diagnostic capacity.