Viral hepatitis micro-elimination: models of care and barriers to implementation in 5 EU/EEA prisons

Introduction

Coverage of essential prevention and control services and adequate monitoring schemes for viral hepatitis are often suboptimal in prison settings. Yet, evidence shows that targeted interventions are feasible and effective in reducing viral hepatitis burden and decreasing virus circulation among people living in prison and the community at large. To promote transferability and improvement of prison health quality in EU/EEA the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) will identify and disseminate models of care for viral hepatitis elimination in prisons.

Methods

The models of care were gathered using a data collection tool that has been designed for this purpose based on the literature review and agreed with an expert advisory group. Based on the results of the data collection, a survey for healthcare staff working in 5 selected prison institutions in the EU/EEA has been developed.

Results

The following models of care were collected: HCV micro-elimination in prison; transitional care for HCV treatment or HBV prevention/treatment; HCV or HBV care services tailored to women living in prison; HBV or HAV/HBV vaccination in prison settings. Harm reduction and drug treatment services in the prison are essential at all steps of the prevention and continuum of care. Among barriers identified were: engagement of people living in prison and prison governance structure, availability of infrastructural and human resources, daily prison organisation, inter-sectorial collaboration within prison and between prison and community services, training for prison staff and lack of systematic monitoring.

Conclusions

Evidence of effective and acceptable interventions in prison to prevent and control viral hepatitis is essential to foster inclusion of prison setting within national elimination programmes. Intra-EU benchmarking may help promote awareness, to allocate adequate resources, monitor of impact and ultimately the achievement of the elimination goal.

Overview of availability of harm reduction interventions in European prisons

Introduction

Prisons are high-risk environments for the transmission of drug related infections, due to over-incarceration of people who inject drugs; often inadequate healthcare, substandard prison conditions; and others. An overview of the availability and coverage of prison-based harm reduction interventions in Europe is presented.

Methods

National Focal Points of the EMCDDA (30) collected 2019 data, which were integrated with findings from the European funded project HA-REACT (Joint Action on HIV and Co-infection Prevention and Harm Reduction).

Results

Prison based harm reduction interventions are available in European countries, but only few of them are available in most countries and often with a low coverage (e.g. less than 10% of prison population in Opioid Substitution Treatment (OST) in most countries). Interventions available in most countries (20 or more) include: HIV, HBV, HCV testing (29), OST continued from community (29), Referral to HIV treatment upon release (28), HIV treatment (27), Referral to HCV treatment upon release (25), HCV antiviral treatment (25), Testing for TB (23), HBV antiviral therapy (25), OST initiated in prison (22), Treatment for TB (21), Vaccination for HBV (20). Interventions available in 10 to 19 countries are: condom distribution (19), OST (re)initiated before release (17), prison/community guidelines for implementation of OST (13). Interventions provided in < 10 countries include: distribution of disinfectant (9), condom with lubricant (9), take-home naloxone (5), needles and syringes programs (3).

Conclusions

Compared to the community, the availability and coverage of harm reduction interventions in European prisons are limited and large information gaps exist. Scaling up harm reduction in prison can achieve important individual and public-health benefits.

Prevalence of injected drug use and access to OAT in prison: survey in 7 EU countries, 2014-2018

Background

People in prison report high rates of drug use and drug-related problems and people who use or inject drugs (PWUD) have higher rates of offending and an increased likelihood of spending part of their lives in prison. They represent a vulnerable population with high burden of diseases, socio-economic disadvantages and limited access to healthcare. In this study, we aimed to describe the lifetime prevalence (LTP) of heroin use, injected drug use and opioid agonist therapy (OAT) among people living in prison.

Methods

Individual data collection was carried out in seven European countries (Czech Republic, Latvia, Lithuania, Poland, Portugal, Slovenia, Spain) between 2014 and 2018 with a model European Questionnaire on Drug use among people in Prison. Risk factors analysis was carried out using multivariate logistic regression model.

Results

The analysis of EQDP data found that the LTP of heroin use was overall 22.4% (ranged from 7.3% in Poland to 27.5% in Spain). Female, recidivist offenders, individuals aged below 44 and with an history of mental health condition had a higher likelihood of being heroin user (p-value<0.05). The LTP of injected drug use was overall 20.6%(2176/10,587), while the prevalence of injected drug use in prison was 8.1%(745/9273) (with higher prevalence in countries that did not allow OAT initiation in prison: 17.5% in Latvia, 22.1% in Lithuania and 26.7% in Czech Republic). Among those who used heroin, 44.5%(772/1735) had access to OAT and among them 95.8(566/591) had access to OAT in prison.

Conclusions

Despite the heterogeneity of the results, there is a clear evidence that people in prison have a high prevalence of heroin and injected drug use. Prisons are an important point of access to OAT, and where treatment is available there is a reduction in risk behaviour. It is also important to implement tailored preventive interventions among vulnerable social groups at the community level.

Key messages

• People in prison in Europe have a high prevalence of heroin and injected drug use. Prisons can represent a point of access to integrated prison-community healthcare and social services for PWUD.

• In order to plan adequate healthcare interventions, there is an urgent need to assess and monitor the prevalence of drug use also in other European countries.

Impact of COVID-19 on drug use disorders and provision of drug related interventions in prison

Introduction

With the emergence of the COVID-19 epidemic, most European countries implemented measures to prevent the spread of infections inside prison, including: use of personal protective equipment (PPE), hygiene practices, limits to mobility, reduction of overcrowding. Their implementation affected the drug related interventions. The EMCDDA has conducted a rapid assessment to evaluate the impact of those measures on the provision of drug treatment and harm reduction services in the European prisons of 15 countries between March and June 2020.

Methods

The study was based on a mixed method approach that triangulated the results of an on-line survey, the outcome of a focus group with prison and drugs experts and case studies from four European countries.

Results and discussion

Most countries reported a reduction in the provision of drug treatment and, to a lesser extent, of harm reduction interventions inside prison during the early phase of the pandemic. The drug services tried to adapt to the new context. Innovations were introduced, including the use of telemedicine in counselling and pharmacological treatment, a better partnership between security and health staff and a more individualised approach to drug treatment. Concerns were expressed around reduction of some interventions, such as group-based interventions, services provided by external agencies, interventions in preparation for release, continuity of care and possible reduction in testing and treatment of drug related infections such as HIV, HCV and HBV due to the priority given to the COVID-19 emergence.

Conclusions

With the emergence of COVID-19, drug services had to address various challenges, making efforts to maintain the provision of drug-related interventions inside prison, while introducing the COVID-19 containment measures. Ensuring the equivalence and continuity of health care provision for those in prison with drug problem remains of central importance.

Women offenders in Europe: drug problems and drug offences and/or gender-based violence

Worldwide the proportion of women in prison for drug-related offences is higher than that of men. In Europe (27 Member States, Norway, United Kingdom and Turkey) it varies considerably, between 5 % in Bulgaria, approximately 25 % in Denmark, Finland and Sweden, 33 % in Italy and 40 % in Spain. Women are reported to have less dominant roles in drug trafficking, often occupying the lowest level of the drug supply chain. There are, however, recent indications of involvement of women in higher levels of supply chains

The prevalence of illicit drug use before incarceration is much higher among prison population as compared to the general population. This excess is substantially higher among women. The patterns of drug use among women in prison are similar to those reported by men, with majority reporting having used cannabis in their lifetime. Prevalence is also high for other illicit substance use, such as heroin (19% - 49%), cocaine (21% - 41%), and amphetamines (17% -64%). Inside prison drug use is often reduced, but exists. The reduction in drug use is in many countries smaller among women then among men.

Reasons for this high prevalence of drug use among women in prison are likely to be related to the high proportion of women incarcerated for drug related offences and their high level of vulnerability. Targeted interventions for women with drug related problems who experience imprisonment are needed and should be implemented with a comprehensive and multidisciplinary approach to tackle their physical, mental health and social needs.

The presentation will discuss the latest European data on drug related problems among women in prison and available targeted interventions.

Effectiveness of bone marrow aspirate concentrate (BMAC) as adjuvant therapy in the surgical treatment of congenital pseudoarthrosis of the tibia: a retrospective comparative study

Congenital pseudoarthrosis of the tibia (CPT) is a rare disease characterised by the onset of bone anomalies or fractures, leading to deformities in paediatric patients. The aetiology of this pathology is unknown. The main theories include the presence of hamartomatous tissue related to Neurofibromatosis type 1, vascularisation deficit of the periosteum and alterations in the numbers and functions of the osteoblasts and osteoclasts in loco. Surgical treatment generally requires multiple operations during the patient's childhood and adolescence. The best outcomes seem to occur when using intramedullary nailing, vascularised fibular transplant and external fixation with the Ilizarov technique. The purpose of this paper is to evaluate the effectiveness of in-situ injections of Bone Marrow Aspirate Concentrate (BMAC) as an adjuvant therapy for congenital pseudoarthrosis of the tibia in patients treated with external fixation and that of radiographic healing over time compared to external fixation treatment alone. We performed a retrospective review of clinical and radiographic records of patients affected by CPT and treated in the Paediatric Orthopaedics and Traumatology Department of the Gaetano Pini Orthopaedic Institute with in-situ injections of bone marrow aspirate concentrate (BMAC) on the pseudoarthrosis site, in addition to pseudoarthrosis site excision and application of circular external fixator frame in compression (Group A). The time needed to reach the radiological consolidation of the resection site was recorded and compared to that needed for patients treated with only pseudoarthrosis site excision and application of circular external fixator frame in compression (Group B). There is a statistically relevant improvement of healing time in patients affected by congenital pseudoarthrosis of the tibia treated with external fixation and bone marrow aspirate concentrate compared to patients affected by the same pathology treated with external fixation only. Injection of MSC in the pseudoarthrosis site after focus removal in combination with circular external fixation achieves faster bone healing compared with external fixation only, and the lower refracture percentage may be associated with the better quality and structure of the new bone. However, it would be desirable to have a longer followup to determine if the results of the BMC as adjuvant therapy will hold up over time.

Histological changes of the meniscus following an osteochondral lesion

In the last few years, different tissue engineering strategies have been developed for the repair of osteochondral lesions. When the osteochondral scaffold is implanted on the femoral condyle, the meniscus might be affected by the implant and might undergo a progressive degeneration. The aim of our study is to analyze the morphological changes of the meniscus following an osteochondral lesion and the implant of a biphasic scaffold. A critical osteochondral defect was generated in the medial femoral condyle of mature sheep. Three defects were left untreated, the remaining lesions were divided into three groups and treated with a biphasic substituted formed by collagen type I and Wollastonite or Wollastonite/Hydroxyapatite. Animals were sacrificed after 6 months and menisci were isolated and analyzed by arthro-CT, macroscopic evaluation and histology. The results demonstrated that the osteochondral lesion negatively affects meniscus morphology and that the osteochondral substitute only partially mitigates the meniscus degeneration.

Crystalline Microporous Organosilicates with Reversed Functionalities of Organic and Inorganic Components for Room-Temperature Gas Sensing

A deepened investigation on an innovative organic-inorganic hybrid material, referred to as ECS-14 (where ECS = Eni carbon silicates), revealed the possibility to use them as gas sensors. Indeed, among ECS phases, the crystalline state and the hexagonal microplateletlike morphology characteristic of ECS-14 seemed favorable properties to obtain continuous and uniform films. ECS-14 phase was used as functional material in screen-printable compositions and was thus deposited by drop coating for morphological, structural, thermal, and electrical characterizations. Possible operation at room temperature was investigated as technological progress, offering intrinsic safety in sensors working in harsh or industrial environments and avoiding high power consumption of most common sensors based on metal oxide semiconductors. Electrical characterization of the sensors based on ECS-14 versus concentrations of gaseous analytes gave significant results at room temperature in the presence of humidity, thereby demonstrating fundamental properties for a good quality sensor (speed, reversibility, and selectivity) that make them competitive with respect to systems currently in use. Remarkably, we observed functionality reversal of the organic and inorganic components; that is, in contrast to other hybrids, for ECS-14 the functional site has been ascribed to the inorganic phase while the organic component provided structural stability to the material. The sensing mechanism for humidity was also investigated.

What to Do, and What Not to Do, When Diagnosing and Treating Breakthrough Cancer Pain (BTcP): Expert Opinion

Clinical management of breakthrough cancer pain (BTcP) is still not satisfactory despite the availability of effective pharmacological agents. This is in part linked to the lack of clarity regarding certain essential aspects of BTcP, including terminology, definition, epidemiology and assessment. Other barriers to effective management include a widespread prejudice among doctors and patients concerning the use of opioids, and inadequate assessment of pain severity, resulting in the prescription of ineffective drugs or doses. This review presents an overview of the appropriate and inappropriate actions to take in the diagnosis and treatment of BTcP, as determined by a panel of experts in the field. The ultimate aim is to provide a practical contribution to the unresolved issues in the management of BTcP. Five ‘things to do’ and five ‘things not to do’ in the diagnosis and treatment of BTcP are proposed, and evidence supporting said recommendations are described. It is the duty of all healthcare workers involved in managing cancer patients to be mindful of the possibility of BTcP occurrence and not to underestimate its severity. It is vital that all the necessary steps are carried out to establish an accurate and timely diagnosis, principally by establishing effective communication with the patient, the main information source. It is crucial that BTcP is treated with an effective pharmacological regimen and drug(s), dose and administration route prescribed are designed to suit the particular type of pain and importantly the individual needs of the patient.

The physical phenotype of frailty for risk stratification of older medical inpatients

OBJECTIVES

To determine the usefulness of physical phenotype of frailty, cognitive impairment, and serum albumin for risk stratification of elderly medical impatients.

DESIGN

Prospective, observational cohort study.

SETTING

A general internal medicine unit of a university hospital in Italy.

PARTICIPANTS

Inpatients with an average age of 80.8 ± 7.5 yr (N = 470).

MEASUREMENTS

Frailty was defined using the Study of Osteoporotic Fractures Index, a parsimonious version of the physical phenotype (two of the following markers: weight loss, inability to rise five times from a chair, and exhaustion). Two frailty markers from non-physical dimensions were also evaluated: cognitive impairment (Mini-Cog score < 3) and low serum albumin on ward admission (< 3,5 gr/dl). Logistic regression adjusted for preadmission and admission-related confounders was used to investigate whether the physical phenotype of frailty and the two non-physical markers were associated with ward length of stay and unfavorable discharge (death plus any other ward discharge disposition different from direct return home). Areas Under the receiver operating characteristic Curve (AUCs) and Likelihood Ratios (LRs) were used for evaluation of discriminatory ability and clinical usefulness of significant predictors.

RESULTS

The physical phenotype of frailty was associated with both study outcomes (p < 0.010) but the association was mainly mediated by chair standing ability. Non-physical markers were associated only with unfavourable discharge (p < 0.001). All of these predictors, either alone or in combination, had poor discriminatory ability (AUCs < 0.70) and poor clinical usefulness (+LRs near 1) for the study outcomes.

CONCLUSIONS

The physical phenotype of frailty appears of limited clinical use for risk stratification of older medical inpatients. Combination with markers from non-physical dimensions does not improve its prognostic abilities.

First Report of Rust Caused by Puccinia psidii on Eucalyptus dunnii in Uruguay

Eucalypt rust caused by Puccinia psidii Winter represents a major disease affecting eucalypt production in South America, and is threatening myrtaceous hosts worldwide. In Uruguay, it was first detected infecting Eucalyptus globulus in 2001 (4) and later on E. grandis, Myrrhinium atropurpureum, and Myrcianthes pungens, two myrtaceae hosts native to Uruguay (3). Over the summer 2013, bright orange-yellowish pustules were detected on stock plants of E. dunnii in a nursery located in western Uruguay, province of Paysandú. A severe and explosive epidemic was readily observed. Affected leaves were taken to the laboratory and examined under the microscope. Uredinia and urediniospores were similar with those described previously in Uruguay on other hosts (3,4). Uredioniospores were 18 to 25 × 15 to 21 μm, yellow, unicellular, spherical to elliptical, base truncate, finely and uniformly echinulate with spines up to 1 μm long, with an evident bald patch without spines. To confirm identity of this fungus, genomic DNA was extracted from single-pustule urediniospores, and ITS region was amplified using primers PR1 and PR2 (1) with PCR conditions previously described (3). Forward and reverse sequences from three single pustules were obtained, assembled, and compared with those available in GenBank using BLAST searches. Obtained sequences showed to be identical to those analyzed by Pérez et al. (2011) collected from E. grandis and E. globulus, with no variation found in the analyzed region. A 100% identity was found with isolates UY1374 and UY1375 obtained from E. globulus, and with isolate UY1731 obtained from E. grandis (FJ710805, FJ710806, and FJ710807, respectively). Sequences were deposited in GenBank with accession numbers KM083129, KM083130, and KM083131. Even though this pathogen is known to occur in a wide variety of myrtaceous species, to our knowledge, this is the first natural infection record of P. psidii on E. dunnii in Uruguay and worldwide. This report confirms previous studies that indicated the susceptibility of E. dunnii when inoculated under controlled conditions (2,5). E. dunnii is being widely planted in Uruguay, eastern Argentina, and southern Brazil, with increasing significance to the pulp industry. Although the consequences of this finding have yet to be realized, scouting plantations is essential to estimate the real impact of this pathogen on this tree species. Our study contributes to expand the host range known for this globally important pathogen. References: (1) S. R. H. Langrell et al. Plant Pathol. 57:687, 2008. (2) L. Morin et al. PLoS ONE 7:e35434, 2012. (3) C. A. Pérez et al. Mycol. Progress 10:273, 2011. (4) N. Telechea et al. Plant Pathol. 52:427, 2003. (5) E. A. V. Zauza et al. Australas. Plant Pathol. 39:406, 2010.

Upper limb evaluation with robotic exoskeleton. Normative values for indices of accuracy, speed and smoothness

BACKGROUND

Robotic rehabilitation devices for upper limb function (ULF) provide global indicators of a patient's ability, but the temporal evolution of motion related to motor control is disregarded.

OBJECTIVE

To determine normative values for indices of accuracy, speed and smoothness in the evaluation of upper limb function.

METHODS

Twenty-five healthy individuals performed the Armeo®Spring device "Vertical Capture" task. Custom stand-alone software was developed to provide the following indices: global Hand Path Ratio (HPR), local HPR in the target area (locHPR), vertical and horizontal overshoot (vertOS, horOS), maximum and mean velocity (maxVel, meanVel), mean/maximum velocity, number of peaks in velocity profiles (NVelPeaks) and normalized jerk (NormJerk). The dependence of indices on task characteristics was analyzed by an ANCOVA test. Indices inner relationships were assessed by a correlation and a factor analysis. Normative values were then provided.

RESULTS

4,268 single reaching movements were analyzed. Four indices were not affected by movement direction. Indices were minimally influenced by the difficulty level. Based upon correlation and factor analysis indices and can be grouped into three assessment fields, dealing with precision, velocity and smoothness.

CONCLUSIONS

We have developed a tool to assess ULF in dynamic condition. Normative values were obtained to be used as references in assessing patients.

Variation of B-type natriuretic peptide concentrations and intrauterine growth restriction: mother, fetus and newborn

To evaluate maternal, fetal, neonatal B-type natriuretic peptide (BNP) concentrations related to Intra Uterine Growth Restriction (IUGR). BNP concentrations in 43 IUGR and 35 healthy, Appropriate for Gestational Age (AGA) infants/paired mothers have been compared, from delivery/birth to first month of life. Maternal and IUGR cord BNP concentrations were coupled to fetal ultrasonography. Neonatal echocardiography was performed too. On delivery BNP was higher in all IUGR mothers, suffering or not from gestational hypertension, than in AGA (median 37.14 vs 11.1 pg/ml p=0.002). Maternal BNP was not associated to cord/neonatal BNP or fetal ultrasonographic parameters. Cord BNP was higher in IUGR than AGA newborns (median 23.9 vs 11.4 pg/ml p=0.0007) independently of gestational age, while varied with amniotic fluid (p=0.0044) and umbilical artery flowmetry (p=0.0121). Earlier drop of BNP on day 3 was reported in IUGR neonates (p=0.0001).Ventricular mass change/body weight varied positively in AGA newborns (p<0.001), while declined in IUGR ones (p=0.003). Carrying IUGR fetus is a stress factor resulting in high maternal BNP concentration. Altered fetal ultrasonographic parameters in IUGR newborns lead to higher BNP cord levels. A rapid BNP drop and probable ventricular mass adjustment of IUGR newborns may indicate earlier post-natal cardiovascular adaptation than AGA infants.

Feasibility and reliability of Doppler flow recordings in the fetal aortic isthmus: a multicenter evaluation

OBJECTIVES

To evaluate the performance of three different centers with respect to their ability to identify the fetal aortic isthmus (AoI) adequately and place a Doppler sample volume in the AoI correctly, and to address the reproducibility of the isthmic flow index (IFI) calculated from Doppler waveforms recorded in the three centers.

METHODS

The three collaborating centers sent several ultrasonographic recordings taken at random over a 6-week period to the Saint-Justine Fetal Cardiology Unit (StJ-FCU). A performance quotient ((number of total readings - number of unsatisfactory results)/number of total readings) was calculated for each center by each of three judges, who were experienced fetal cardiologists, to assess the ability of each center to identify the isthmus and to place the Doppler sample volume (DSV) adequately. Intraclass correlation coefficients (ICC) were computed to quantify the variability of IFI measurements ((systolic + diastolic)/systolic flow velocity integrals).

RESULTS

Fifty-five recordings were available for this study. Concerning isthmus identification, there was 100% agreement between the three judges from StJ-FCU and the performance quotients of Centers A, B and C were: 0.90, 0.95 and 1.00, respectively. For DSV positioning, agreement between the judges varied; for Judge 1 vs. Judge 2, kappa = 0.836 (95% CI, 0.651-1.000); for Judge 1 vs. Judge 3, kappa = 0.773 (95% CI, 0.557-1.000); for Judge 2 vs. Judge 3, kappa = 0.941 (95% CI, 0.805-1.000). The performance quotients of the three centers for DSV positioning were consistently lower than were those for identification of the isthmus, being 0.85, 0.76 and 0.92, respectively. The ICC between the first and second measurements of the IFI by Rater 1 was 0.96 (95% CI, 0.93-0.98, P < 0.001) and that between Raters 1 and 2 was 0.97 (95% CI, 0.95-0.99, P < 0.001).

CONCLUSION

Adequate imaging of the fetal AoI can be achieved easily by a trained sonographer, while DSV positioning is challenging. The intra- and interrater variability of the IFI are low.

Drug use and pregnancy – challenges for public health

Problem drug use in pregnancy affects a sizeable population in Europe. A literature review was carried out of articles in PubMed, European Monitoring Centre for Drugs and Drug Addiction publications, and related documents in order to assess public health challenges and possible intervention strategies related to problem drug use and pregnancy in Europe. It revealed the following: Involving pregnant drug users in drug treatment is likely to decrease the chances of pre- and perinatal complications related to drug use and to increase access to prenatal care. Timely medical intervention can effectively prevent vertical transmission of human immunodeficiency virus, hepatitis B virus as well as certain other sexually transmitted diseases, and would allow newborns infected with hepatitis C virus during birth to receive immediate treatment. Pregnancy may be a unique opportunity to also help women with dual diagnosis (substance use combined with mental illness) and enrol them into special treatment and support programmes. Issues related to homelessness and intimate partner violence can also be addressed with appropriate interventions. Treatment and care for pregnant drug users should offer coordinated interventions in several areas: drug use, infectious diseases, mental health, personal and social welfare, and gynaecological/obstetric care.

Drug use and pregnancy - challenges for public health

Involving pregnant drug users in drug treatment is likely to decrease the chances of pre- and perinatal complications related to drug use and to increase access to prenatal care. Timely medical intervention can effectively prevent vertical transmission of human immunodeficiency virus, hepatitis B virus as well as certain other sexually transmitted diseases, and would allow newborns infected with hepatitis C virus during birth to receive immediate treatment.

Can crude oils be distinguished by different component distribution obtained by laser desorption ionization mass spectrometry and evaluated by chemometrics?

Fourteen different crude oil samples were analyzed as collected by mass spectrometry. For two of them the results obtained by means of different techniques, i.e. electrospray ionization, atmospheric pressure chemical ionization, laser desorption/ionization, were compared. The latter technique leads to the best results: even if unable to give specific information on heteroatom-containing components, it allows a general view to be obtained of the panorama of the oil composition in terms of molecular weight distribution. The statistical evaluation of the mass spectrometry data by multivariate techniques, such as cluster analysis (Average Linkage) and correspondence analysis, allows evidence for the differences and similarities among the crude oils under study.

Prevalence of undiagnosed autoimmune rheumatic diseases in the first trimester of pregnancy. Results of a two-steps strategy using a self-administered questionnaire and autoantibody testing

OBJECTIVE

To evaluate the prevalence of undiagnosed rheumatic diseases in the first trimester of pregnancy.

DESIGN

We screened for rheumatic diseases in 1210 consecutive pregnant women during the first trimester of pregnancy using a 10-item questionnaire.

SETTING

A university hospital in northern Italy.

POPULATION

One hundred and thirty-seven (11.3%) women who answered positively to at least one question constituted the cases and were compared with 107 negative controls.

METHODS

Cases and controls were tested for rheumatic autoantibodies (antinuclear antibody, anti-double-stranded DNA, anti-extractable nuclear antigen, anticardiolipin antibody, anti-beta2-glycoprotein I antibodies and lupus anticoagulant) and were evaluated by a rheumatologist for a definite diagnosis of rheumatic disease.

MAIN OUTCOME MEASURES

Prevalence of undiagnosed rheumatic disease in the first trimester of pregnancy.

RESULTS

The overall rate of positivity to the antibodies tested was 43.1% (59/137) among cases and 9.3% (10/107) in the controls (P < 0.001). A definitive diagnosis of rheumatic disease was made in 35 cases (25.5%) and in none of the controls (P <0.001). In stepwise logistic regression analysis, photosensitivity (adjusted OR 5.72; 95% CI 2.38-13.8), erythema or malar rash (adjusted OR 3.91; 95% CI 1.53-10) and history of two or more miscarriages (adjusted OR 5.6; 95% CI 1.55-20.6) were independent predictors of a definitive diagnosis of rheumatic disease (area under receiving operator curve = 0.814; 95% CI 0.76-0.86). Birthweight was lower (3180 g +/- 475 compared with 3340 g +/- 452, P= 0.008), and overall serious pregnancy complications (miscarriage, fetal growth restriction, delivery before 34 weeks of pregnancy and severe pre-eclampsia) were higher among cases (12/137) than controls (2/107) (adjusted OR 5.60; 95% CI 1.29-24.3; P= 0.021).

CONCLUSIONS

A two-step screening process with a self-administered questionnaire proved to be a useful method to screen for undiagnosed rheumatic diseases during the first trimester of pregnancy.

Laser desorption/ionization techniques in the characterization of high-molecular-weight oil fractions--Part 2: De-asphalted oils

The composition of the de-asphalted oil fraction obtained from two different Italian fields was studied by laser desorption/ionization mass spectrometry. These fractions were treated with different solvent mixtures, and subfractions containing saturates, aromatic and polar compounds were obtained and analyzed by the same instrumental approach.The investigation showed clear differences between the samples coming from the two oils. The instrumental approach did not lead to an accurate description of the different components in terms of elemental composition and structures; however, valid information could be obtained on the molecular weight distribution of the components of the different fractions.

Laser desorption/ionization techniques in the characterization of high molecular weight oil fractions. Part 1: asphaltenes

The molecular weight distribution of the asphaltene fractions of two types of crude oils from two different Italian fields (samples 1 and 2) was investigated. The analytical tools used to perform these analyses were matrix assisted laser desorption ionization (MALDI) and laser desorption ionization (LDI) mass spectrometry. After observing that the use of the matrix (as well as the addition of Ag+) did not improve the quality of the data compared to that obtained in LDI conditions, all further measurements were performed with the latter technique. Operating under usual conditions of laser power and delay time, a very low resolution was observed, showing only macroscopic differences between the two samples in the molecular weight distribution of the different components. An accurate study on the possible reasons of this undesirable behavior indicates that it can originate from space charge phenomena occurring either in the ion source region or during the flight. A valid parameterization of the delay time and the laser power allowed higher quality spectra to be obtained. Surface-enhanced laser desorption ionization (SELDI) measurements were also performed using normal phase (silica) as the sample holder surface. Under these conditions, better results are obtained, proving that the sample-surface interaction is important to achieve, by means of laser irradiation, a homogeneous set of product ions. Both asphaltene samples were fractionated in five subfractions by gel-permeation chromatography (GPC) to obtain a better separation of the molecular weight distributions; the related spectra confirmed these findings. By using different approaches, relevant and reproducible differences between the asphaltene fractions of the two oil samples were observed.

Evaluation of skin permeability of sesquiterpenes of an innovative supercritical carbon dioxide Arnica extract by HPLC/DAD/MS

Recently, a supercritical carbon dioxide dried extract of Amica flower, with a very high sesquiterpene content was developed. In view of using this extract in formulations for cutaneous application, the ability of sesquiterpenes to permeate the skin was evaluated by HPLC/DAD/MS using the following permeation enhancers: oleic acid (OA), dimethylsulfoxide (DMSO), lauroglycol, isopropyl myristate and Tween 80. A skin permeation study was performed using a modified Franz diffusion cell and the human stratum corneum and epidermis as membrane. Solutions of the enhancers were directly analysed after dilution with methanol or DMSO. A simple RP-HPLC-DAD-MS method for the quantification of the sesquiterpenes was developed and the method showed no interference with the other substances extracted from the skin and the permeation enhancers. The study evidenced that among the selected skin permeation enhancers, DMSO and OA canbe considered as good candidates to be used in preparations for cutaneous application.

Poly(lactide-co-glycolide) microspheres containing bupivacaine: comparison between gamma and beta irradiation effects

The beta- and gamma-irradiation effects on stability of microspheres made of poly(lactide-co-glycolide) 50:50 copolymer (PLGA) containing bupivacaine (BU) were studied. Microspheres containing 10, 25, and 40% w/w, respectively, of BU were prepared by spray drying and irradiated in air with beta- and gamma-irradiation at a dose of 25 kGy. Morphology (atomic force microscopy, particle-size analysis), physico-chemical characteristics (DSC and FT-IR spectroscopy), drug content and in vitro dissolution profile of microspheres were all determined; the stability of irradiated microspheres was evaluated over a 9-month period. The decrease of BU content in gamma-irradiated microspheres was almost always constant independent of the amount of BU per sample, therefore it was in inverse proportion to drug loading (range between 5 and 15%). BU release rate increased immediately after irradiation and increased slightly until 90 days of storage. As far as beta-irradiated microspheres are concerned, BU content decreased in a significant way (approximately 3%) only in microspheres containing 10% w/w of BU. Immediately after irradiation, drug release rate in beta-irradiated microspheres increased less than in the corresponding gamma-irradiated microspheres, and it did not change further over the following storage period. BU-loaded microspheres have been shown to be more stable against beta- than gamma-irradiation. AFM revealed that the surface roughness of the irradiated microspheres increases depending on irradiation. As such, if a parameter is quantifiable, it is proposed as a marker of degradation due to ionizing radiation.

Formulation study and anti-inflammatory efficacy of topical semi-solids containing a nitro ester of flurbiprofen

A new nitro-oxybutylester of flurbiprofen (NO-FP) is a promising anti-inflammatory drug in the treatment of dermatological disorders, and the feasibility of its cutaneous administration was evaluated. Four different semi-solid formulations were evaluated in order to assess the influence of the composition on the drug amount retained in the stratum corneum and epidermis (SCE). The lipophilic ointment induced the highest NO-FP amount retained in the SCE and, therefore, skin permeation enhancers (Transcutol), Lauroglycol), oleic acid and isopropyl myristate) were added to this formulation. The in vitro NO-FP amounts retained in the SCE were correlated with the solubility parameters, and a good linear correlation was found (r(2) = 0.925). The formulation of the lipophilic ointment was optimized, and the activity of this preparation was verified in methyl-nicotinate-induced contact urticaria and UV-induced erythema obtaining good results in terms of efficacy and safety.

Polymethacrylate salts as new low-swellable mucoadhesive materials

The sodium and potassium salts of the methacrylic copolymers Eudragit L100 and Eudragit S100 were prepared with the aim to develop new low-swellable mucoadhesive materials intended for the preparation of buccal dosage forms. The physico-chemical characterization of the copolymers and the corresponding sodium and potassium salts was performed by using Fourier-transform infrared (FT-IR) spectroscopy and thermal analysis. When ionization occurred, the carboxylic acid group absorption band (1730 cm(-1)) was replaced by another characteristic band at 1560 cm(-1). After salification the T(g) of the two polymers shifted towards higher values and it was not significantly influenced by the contraion nature. The intrinsic dissolution rate at infinite rotation speed (7.354<G( infinity )<9.196) was about 6- to 7-fold higher than that of a low nominal viscosity hydroxypropylmethylcelluloses (HPMC). Moreover, the Eudragit salts did not show an evident swelling layer and their dissolution is governed by erosion. The adhesion properties of these materials, evaluated by texture analysis, overlapped with those of Carbopol 934P. On the basis of the in vivo bioadhesion test, the prepared methacrylic salts can be considered interesting for the preparation of both buccal tablets and patches with good patient compliance due to their low swelling properties.

Characterization of nifedipine solid dispersions

The sublingual administration of nifedipine (NIF) is currently used in clinical practice. The sublingual administration of NIF solid dispersions (SD), by using a suitable dispenser, appears an interesting approach in the treatment of moderate and severe hypertensive emergencies. With this aim nine SD made of NIF and a low viscosity hydroxypropylmethylcellulose (HPMC) in different ratio were prepared by means of spray-drying technique and their structure was studied. Moreover, the drug dissolution properties from SD were verified. The characteristic peaks of crystalline NIF were not detectable by using the X-ray analysis when the NIF/HPMC ratios were lower than 50/50 w/w. In thermograms obtained from SD, the NIF melting endothermic peak disappeared when NIF/HPMC ratios were lower than 30/70 w/w; the experimental Tg values of SD were lower than the Tg values predicted by Gordon Taylor equation suggesting some type of non-ideality of mixing. In the SD FTIR spectra the NH stretching vibrations and the C=O stretch in esteric groups of NIF shift to free NH and C=O regions indicating the rupture of intermolecular hydrogen bond in the crystalline structure of NIF. The prepared SD improved the NIF dissolution rate in comparison with that of commercial NIF or NIF/HPMC physical mixtures. Moreover, the concentration of NIF in the dissolution medium increased decreasing the NIF content.

Gamma irradiation effects and EPR investigation on poly(lactide-co-glycolide) microspheres containing bupivacaine

The effects of gamma radiation on the stability of microspheres made of a polylactide-co-glycolide 50:50 copolymer (PLGA) and loaded with 40% bupivacaine (BU) were studied. The radiolysis mechanisms of BU and BU-loaded microspheres were investigated by using electronic paramagnetic resonance (EPR) analysis. Microspheres were prepared by means of a spray drying method. Gamma Irradiation was carried out in the open, at the dose of 25 kGy, by using a 60Co source. The stability of BU-loaded microspheres was evaluated over a 1-year period on the basis of drug content and dissolution profile. Non-irradiated microspheres were stable over the whole period under consideration. Immediately after irradiation the amount of BU released after 24 h from irradiated microspheres increased from 17 to 25%; in the following 3 months of storage it increased to about 35%, and then it kept constant for 1 year. Radicals generated by BU irradiation were identified by EPR analysis; the sensitivity to gamma radiation of BU was about four times lower than that of PLGA. Furthermore, the EPR spectra of loaded microspheres showed that the relative abundance of BU radicals plus PLGA radicals was proportionate to the electronic fractions of the components; this implies that no spin transfer BU/PLGA had occurred during gamma irradiation.

Gamma irradiation effects on stability of poly(lactide-co-glycolide) microspheres containing clonazepam

This work was aimed at evaluating the effects of gamma irradiation on the stability of microspheres made of a poly(lactide-co-glycolide) copolymer (PLGA) and loaded with 15% w/w of clonazepam (CLO). The influence of CLO on PLGA radiolysis mechanisms and the identification of possible irradiation markers were also investigated. Microspheres were prepared by means of a spray-drying method. gamma Irradiation was carried out either under vacuum or in air, at a dose of 25 kGy, by using a 60Co source. The stability of CLO loaded microspheres was evaluated over a 6-month period on the basis of drug content and dissolution profile. Radiolysis mechanisms were investigated by using electronic paramagnetic resonance (EPR) analysis. The microspheres irradiated under vacuum were stable over the considered period of time. After irradiation in air, CLO release rate increased by approximately 10%, and did not change further in the following period of storage. The EPR analysis showed some radicals arising from both the polymeric matrix and the active ingredient. Polymer/CLO spin transfer reactions suggest that CLO had a radio-stabilising effect on the polymeric matrix. In the loaded microspheres, the intensity in time of the CLO radical signal is sufficient for its possible use as irradiation marker.

Development of patches for the controlled release of dehydroepiandrosterone

Dehydroepiandrosterone (DHEA) and its sulfate conjugate (DHEAS) are the major secretory steroidal products of the adrenal gland. Some epidemiologic studies have found an association between low DHEA serum levels in patients and many important diseases. To prevent all such pathological conditions and, in any case, in aging, a DHEA supplementation has been proposed. DHEA shows a low oral bioavailability; taking the bioavailability obtained by the subcutaneous route as 100%, it was estimated that the potencies of DHEA by the percutaneous and oral routes were approximately 33% and 3%, respectively. Thus, transdermal patches could be considered a promising formulation as a continuous and controlled delivery of DHEA in replacement therapy is desired. With the aim of evaluating the effect of the matrix composition in terms of polymers and enhancers on the DHEA skin permeation flux, 10 types of monolayer self-adhesive patches containing 0.25mg/cm2 of active ingredient were designed. The matrices were based on three different acrylic copolymers: an acrylate-vinylacetate copolymer, a polyaminomethylmethacrylate (PAMA), and a polymethylmethacrylate. Transcutol (TR), mint essential oil, Lauroglycol, Brij 58, and propylene glycol (PG) were evaluated as DHEA skin permeation enhancers. All prepared patches were characterized by drug content, light microscopy, and in vitro skin permeation, performed using a modified Franz-type diffusion cell and human stratum corneum and epidermis as a membrane. The in vitro skin permeation studies are particularly significant in the development studies of DHEA patches as the in vivo determination of DHEA is affected b the fact that the endogen substance in the plasma is not constant over time. Among the testedpatches, highest DHEA fluxes were obtained using the formulation based on PAMA. Moreover, the introduction in the matrix of binary mixtures of TR and PG, used also for their plasticizer properties, permitted enhancing DHEA skin permeation. On the basis of these studies, the transdermal administration of DHEA using patches seems feasible.

Systemic nicotine exposure in tobacco harvesters

Several epidemics of nicotine intoxication have been described among tobacco harvesters; however, little is known about nicotine absorption under typical working conditions. To assess systemic nicotine absorption during a regular working shift, the authors performed an observational field study. Included in the study were 10 healthy, nonsmoking, female tobacco harvesters and a control group of 5 healthy, nonsmoking, female hospital workers. Nicotine and cotinine were measured in sequential samples of blood and urine during a regular workshift. Blood nicotine levels rose from a nadir value of 0.79 +/- 0.12 ng/ml to a peak value of 3.45 +/- 0.84 ng/ml (p < .05 [Tukey's modified t test]) in the exposed group. In the control group, levels were stable at 0.1 +/- 0.1 ng/ml (p < .01). Moreover, the mean blood nicotine level measured 3 mo following the end of exposure in 6 of 10 exposed subjects was 0.24 +/- 0.12 ng/ml (p < .01). Corresponding higher values of urine nicotine and urine cotinine were observed in the exposed versus control group (comparative p values were < .01 and < .05, respectively). Overall, tobacco harvesters absorbed approximately 0.8 mg of nicotine daily. Given that nicotine can induce adverse health effects, the authors believe that prevention of nicotine absorption in tobacco harvesters should be sought and that workers should be informed about occupational risks.

Evaluation of adhesive properties of transdermal therapeutic systems containing nitroglycerin

The patch performances and the success of the transdermal drug delivery can be significantly affected by the quality of contact between the patch and the skin. Poor adhesion will dramatically reduce percutaneous delivery. In this study the adhesive properties (peel force and creep resistance) of three monolayer self-adhesive nitroglycerin (NTG) patches available on the market, Deponit, Minitran, and Triniplas, were compared. The patches were characterized also in terms of in vitro drug release and ex vivo skin permeation. The creep resistance values verified in the case of Deponit and Triniplas indicated a low cohesion of these matrices. The peel force values were in the accepted range, even if Triniplas and Deponit showed values double that shown by Minitran. The percentage of NTG released in vitro after two hours in all cases exceeded ninety percent. The ex vivo permeation profiles were similar, even if the three patches had different loaded amounts and surface areas. The measured permeated amount, 11 mg permeated in 24 h, was predictive of the claimed in vivo release (10 mg in 24 h).

Porous ceramic bodies for drug delivery

An approach to the production of ceramic drug delivery devices is proposed. Two examples of possible ceramics are dealt with: hydroxyapatite weakly modifiable by living tissue and the bioinert alumina. The possibility to control the formed porosity was taken into consideration for both materials. The ratio between the acquired porosity and the quantity and quality of the agents inducing porosity is also described and discussed. A test on the role of porosity was performed on the obtained porous ceramic bodies and a study was made on the release of a substance with pharmacological activity from previously impregnated porous ceramic bodies. This paper is preliminary to a planned work targeted to the preparation of ceramic drug delivery systems.

Acitretin and treatment of the oral leucoplakias. A model to have an active molecules release

AIMS

The aim of this study was to investigate the effectiveness of acitretin in a new topical formulation (mucoadhesive two-layer tablets) for the treatment of oral leucoplakias.

METHODS

Twenty-one volunteers, 16 men, five women, with oral leucoplakia (histologically diagnosed), were included in this double-blind placebo-controlled study. Patients were randomized in three groups (A, B, C) of seven patients each. Groups A and B received tablets with different in vitro release profiles, and group C subjects (controls) received tablets without acitretin. The acitretin dose was 20 mg/day (two 10 mg tablets daily). Serum aspartate aminotransferase, alanine aminotransferase, cholesterol and triglycerides were evaluated before and after treatment. At the end of therapy the concentrations of acitretin in plasma, saliva and tissue were measured by high-performance liquid chromatography.

RESULTS

At the end of the study 71% (groups A and B) of patients showed clinical remission or marked improvement. No improvement was noted in the control subjects (group C). These results were further confirmed by histological findings. There were no significant changes in laboratory values in the three groups. The acitretin concentration in plasma and tissue ranged from 0 to 50 mg with no difference between groups A and B, and it was very high in saliva (ranging from 4.9 to 43 mg) with higher concentrations in group A than in group B (due to a longer adhesion time in group A). Patients' compliance was excellent. The results show that mucoadhesive tablets of topical acitretin are efficacious in the treatment of oral leucoplakia without systemic side-effects.

Impact of delirium on the short term prognosis of advanced cancer patients. Italian Multicenter Study Group on Palliative Care

BACKGROUND

The objective of this study was to evaluate the impact of delirium on the survival of advanced cancer patients also assessed with a validated prognostic score (the palliative prognostic [PaP] score).

METHODS

The study population was a prospective multicenter consecutive case series of advanced cancer patients for whom chemotherapy was no longer considered viable and who were referred to palliative care programs. Clinical and biologic prognostic factors included in the PaP score were assessed at study entry. The Confusion Assessment Method criteria were applied to screen patients presenting with delirium. Survival times were measured from time of enrollment and death taken as an outcome. Survival curves were traced with the Kaplan-Meier method and comparison were based on log rank tests.

RESULTS

Delirium was found in 109 cases among 393 consecutive patients (27.7%). The diagnosis of delirium was independently associated with male gender, central nervous system metastases, lower performance status, worse clinical prediction of survival, and progestational treatment. The survival curve of patients with delirium was significantly different from the nondelirious patients curve (log rank, 31.6, P < 0.0001). The median survival time was 21 days (95% confidence interval [CI], 16-27) for the delirious patients and 39 days (95% CI 33-49) for the others. Multivariate analysis showed that the diagnosis of delirium and PaP score were independently associated with prognosis.

CONCLUSIONS

The diagnosis of delirium significantly worsens life expectancy prognosticated with the PaP score. By using the PaP score together with the assessment of cognitive status, physicians can correctly predict patients 30-day survival in greater than 70% of cases.

Impact of delirium on the short term prognosis of advanced cancer patients. Italian Multicenter Study Group on Palliative Care

BACKGROUND

The objective of this study was to evaluate the impact of delirium on the survival of advanced cancer patients also assessed with a validated prognostic score (the palliative prognostic [PaP] score).

METHODS

The study population was a prospective multicenter consecutive case series of advanced cancer patients for whom chemotherapy was no longer considered viable and who were referred to palliative care programs. Clinical and biologic prognostic factors included in the PaP score were assessed at study entry. The Confusion Assessment Method criteria were applied to screen patients presenting with delirium. Survival times were measured from time of enrollment and death taken as an outcome. Survival curves were traced with the Kaplan-Meier method and comparison were based on log rank tests.

RESULTS

Delirium was found in 109 cases among 393 consecutive patients (27.7%). The diagnosis of delirium was independently associated with male gender, central nervous system metastases, lower performance status, worse clinical prediction of survival, and progestational treatment. The survival curve of patients with delirium was significantly different from the nondelirious patients curve (log rank, 31.6, P < 0.0001). The median survival time was 21 days (95% confidence interval [CI], 16-27) for the delirious patients and 39 days (95% CI 33-49) for the others. Multivariate analysis showed that the diagnosis of delirium and PaP score were independently associated with prognosis.

CONCLUSIONS

The diagnosis of delirium significantly worsens life expectancy prognosticated with the PaP score. By using the PaP score together with the assessment of cognitive status, physicians can correctly predict patients 30-day survival in greater than 70% of cases.