Meningococcal B Vaccine Immunogenicity in Children With Defects in Complement and Splenic Function

BACKGROUND

The capsular group B meningococcal vaccine (4CMenB) is recommended for children with complement deficiencies, asplenia, and splenic dysfunction; however, data on the immunogenicity of 4CMenB in these "at-risk" children are missing.

METHODS

Participants aged 2 to 17 years in Italy, Spain, Poland, the United Kingdom, and Russia with complement deficiencies, asplenia, or splenic dysfunction received 2 doses of 4CMenB 2 months apart, as did healthy children in the control group. Exogenous and endogenous human complement serum bactericidal activity (SBA) was determined at baseline and 1 month after the second immunization against 4 test strains: H44/76 (assessing vaccine antigen factor H binding protein), 5/99 (Neisserial adhesion A), NZ98/254 (Porin A), and M10713 (Neisserial heparin binding antigen).

RESULTS

Of 239 participants (mean age 10.3 years, 45% female), 40 children were complement deficient (9 eculizumab therapy, 4 terminal-chain deficiencies, 27 "other"), 112 children had asplenia or splenic dysfunction (8 congenital asplenia, 8 functional asplenia, 96 splenectomy), and 87 children were in the control group. After immunization, the proportions of complement-deficient participants with exogenous complement SBA titers ≥1:5 were 87% (H44/76), 95% (5/99), 68% (NZ98/254), and 73% (M10713), compared with 97%, 100%, 86%, and 94%, respectively, for asplenic children and 98%, 99%, 83%, and 99% for children in the control group. When testing with endogenous complement, strain-specific bactericidal activity was evident in only 1 eculizumab-treated participant and 1 terminal chain complement-deficient participant.

CONCLUSIONS

4CMenB administration is similarly immunogenic in healthy children and those with asplenia or splenic dysfunction. The significance of the trend to lower responses of SBA titers in complement-deficient children (especially those with terminal chain complement deficiency or those on eculizumab therapy) must be determined by ongoing surveillance for vaccine failures.

Reduced schedules of 4CMenB vaccine in infants and catch-up series in children: Immunogenicity and safety results from a randomised open-label phase 3b trial

BACKGROUND

This study evaluated the immunogenicity and safety of a licensed meningococcal serogroup B vaccine (4CMenB) administered alone according to reduced schedules in infants or catch-up series in children.

METHODS

In this open-label, multicentre, phase 3b study (NCT01339923), infants randomised 1:1:1 received 4CMenB: 2+1 doses at 3½-5-11months or 6-8-11months of age, 3+1 doses at ages 2½-3½-5-11months. Children aged 2-10years received 2 catch-up doses administered 2months apart. Immune responses were measured by hSBA assays against 4 strains specific for vaccine components fHbp, NadA, PorA and NHBA. Sufficiency of immune responses was defined in groups with 2+1 doses schedules as a lower limit ≥70% for the 97.5% confidence interval of the percentage of infants with hSBA titres ≥4, 1month post-dose 2 for fHbp, NadA, PorA. Adverse events were collected for 7days post-vaccination; serious adverse events (SAEs) throughout the study.

RESULTS

754 infants and 404 children were enrolled. Post-primary vaccination, 98-100% of infants across all groups developed hSBA titres ≥4 for fHbp, NadA, PorA, and 48-77% for NHBA. Sufficiency of immune responses in infants receiving 2+1 schedules was demonstrated for fHbp, NadA, PorA after 2 doses of 4CMenB, as pre-specified criteria were met. Following receipt of 2 catch-up doses, 95-99% of children developed hSBA titres ≥4 for 4CMenB components. Similar safety profiles were observed across groups. A total of 45 SAEs were reported, 3 of which were related to vaccination.

CONCLUSION

Reduced infant schedules and catch-up series in children were immunogenic and safe, having the potential to widen 4CMenB vaccine coverage.

FUNDING

GlaxoSmithKline Biologicals SA.

Immunogenicity and safety of concomitant administration of meningococcal serogroup B (4CMenB) and serogroup C (MenC-CRM) vaccines in infants: A phase 3b, randomized controlled trial

BACKGROUND

After implementation of routine infant MenC vaccination, MenB remains a serious cause of meningococcal disease, yet to be targeted by vaccination programs in several countries. This study (NCT01339923) investigated the immunogenicity and safety of MenC CRM-conjugated vaccine (MenC-CRM) concomitantly administered with MenB vaccine (4CMenB).

METHODS

Infants (N=251) were randomised 1:1 to receive 4CMenB and MenC-CRM (Group 1) or MenC-CRM alone (Group 2) at 3 and 5months (M3, M5) and a booster at 12months of age (M12), and pneumococcal vaccine at M3, M5, M7, M12. Antibody responses to meningococcal vaccines were measured at M3, M6, M12, and M13. Non-inferiority of MenC-CRM response in Group 1 vs Group 2 was demonstrated at M6 and M13, if the lower limit of the 95% confidence interval (LL95%CI) of the difference in percentage of infants with hSBA titres ≥1:8 was >-10%. Sufficiency of MenB response was achieved if LL95%CI of the percentage of infants with hSBA titres ≥1:4 against fHbp, NadA and PorA strains was ≥70% at M6 or ≥75% at M13. Adverse events (AEs) were collected for 7days post-vaccination, and serious AEs (SAEs) and medically attended AEs throughout the study.

RESULTS

Non-inferiority of MenC response in Group 1 vs Group 2 (LL95%CI -6.4% [M6]; -5.2% [M13]) and sufficiency of MenB response in Group 1 (LL95%CI 92%, 90%, 89% [M6]; 97%, 92%, 93% [M13] against fHbp, NadA, PorA, respectively) were demonstrated. Higher rates of mild to moderate solicited AEs were reported in Group 1. Unsolicited AEs and SAEs incidences were similar across groups.

CONCLUSIONS

Concomitant administration of MenC-CRM and 4CMenB in infants was immunogenic, resulting in non-inferior responses against MenC compared to MenC-CRM alone and demonstration of sufficient immune response to MenB, after primary and booster vaccination. Reactogenicity was higher for concomitant vaccines administration, but no safety concerns were identified.

[Malignant fibrous histiocytoma of the penis]

According to the most recent World Health Organization (WHO) guidelines a diagnosis of malignant fibrous histiocytoma (MFH) should be made only for lesions composed of tumor cells without evidence of a specific line of differentiation. This is therefore a diagnosis by exclusion which is why the name of undifferentiated high-grade pleomorphic sarcoma (UPS) should be preferred. Soft tissue sarcomas currently have an incidence in all body regions of approximately 20 cases per 1 million inhabitants per year. Soft tissue tumors of the penis represent approximately 5 % of all penile tumors and the incidence of penile sarcomas is estimated to be approximately 0.6-1 case per 100,000 patients. Only seven cases have so far been reported in the literature. This article describes the case of a 61-year-old Caucasian male who presented with a painless mass sited in the upper part of the corpus cavernosa. An incisional biopsy with a subsequent investigation using an extensive immunohistochemical panel were performed and a high-grade undifferentiated pleomorphic sarcoma or pleomorphic storiform MFH was diagnosed. In addition to the case report a literature review is presented to elaborate the discussion on the differential diagnoses of these kinds of lesions.

Perceived changes and minimum clinically important difference of the Neurological Fatigue Index for multiple sclerosis (NFI-MS)

The determination of the minimum clinically important difference (MCID) is an important aspect of scale development. The Neurological Fatigue Index for multiple sclerosis (NFI-MS) was administered before and after expected change or stability in fatigue in 208 multiple sclerosis (MS) patients. The overall change scores of the NFI-MS accorded with perceived direction of change; importantly, no change was seen when none was perceived. Using the interval level NFI-MS scores, the largest MCID equated to 2.49 points on the Summary scale, 2.36 points on the Physical scale, 0.84 points on the Cognitive scale, 0.97 on the Diurnal Sleep scale and 1.95 on the Nocturnal Sleep scale. Our conclusion is that the NFI-MS responds as expected to changes in fatigue and has desirably small MCID scores.

Supra-molecular association and polymorphic behaviour in systems containing bile acid salts

A wide number of supra-molecular association modes are observed in mixtures containing water and bile salts, BS, (with, eventually, other components). Molecular or micellar solutions transform into hydrated solids, fibres, lyotropic liquid crystals and/or gels by raising the concentration, the temperature, adding electrolytes, surfactants, lipids and proteins. Amorphous or ordered phases may be formed accordingly. The forces responsible for this very rich polymorphism presumably arise from the unusual combination of electrostatic, hydrophobic and hydrogen-bond contributions to the system stability, with subsequent control of the supra-molecular organisation modes. The stabilising effect due to hydrogen bonds does not occur in almost all surfactants or lipids and is peculiar to bile acids and salts. Some supra-molecular organisation modes, supposed to be related to malfunctions and dis-metabolic diseases in vivo, are briefly reported and discussed.

Atypical primary headache responding to finger pressure: possible involvement of the vagus nerve?

We describe a case of atypical primary headache strongly responsive to prolonged pressure in the anterior aspect of the neck. We hypothesize that, at least in this case, the trigemino-cervical system and its connections with the vagus nerve are involved.

Safinamide: From molecular targets to a new anti-Parkinson drug

Ideal treatment in Parkinson's disease (PD) aims at relieving symptoms and slowing disease progression. Of all remedies, levodopa remains the most effective for symptomatic relief, but the medical need for neuroprotectant drugs is still unfulfilled. Safinamide, currently in phase III clinical trials for the treatment of PD, is a unique molecule with multiple mechanisms of action and a very high therapeutic index. It combines potent, selective, and reversible inhibition of MAO-B with blockade of voltage-dependent Na+ and Ca2+ channels and inhibition of glutamate release. Safinamide has neuroprotective and neurorescuing effects in MPTP-treated mice, in the rat kainic acid, and in the gerbil ischemia model. Safinamide potentiates levodopa-mediated increase of DA levels in DA-depleted mice and reverses the waning motor response after prolonged levodopa treatment in 6-OHDA-lesioned rats. Safinamide has excellent bioavailability, linear kinetics, and is suitable for once-a-day administration. Therefore, safinamide may be used in PD to reduce l-dopa dosage and also represents a valuable therapeutic drug to test disease-modifying potential.

Anti-allodynic effect of NW-1029, a novel Na(+) channel blocker, in experimental animal models of inflammatory and neuropathic pain

NW-1029, a benzylamino propanamide derivative, was selected among several molecules of this chemical class on the basis of its affinity for the [(3)H]batracotoxin ligand displacement of the Na(+) channel complex and also on the basis of its voltage and use-dependent inhibitory action on the Na(+) currents of the rat DRG (dorsal root ganglia) sensory neuron. This study evaluated the analgesic activity of NW-1029 in animal models of inflammatory and neuropathic pain (formalin test in mice, complete Freund's adjuvant and chronic constriction injury in rats) as well as in acute pain test (hot-plate and tail-flick in rats). Orally administered NW-1029 dose-dependently reduced cumulative licking time in the early and late phase of the formalin test (ED(50)=10.1 mg/kg in the late phase). In the CFA model, NW-1029 reversed mechanical allodynia (von Frey test) after both i.p. and p.o. administration (ED(50)=0.57 and 0.53 mg/kg), respectively. Similarly, NW-1029 reversed mechanical allodynia in the CCI model after both i.p. and p.o. administration yielding an ED(50) of 0.89 and 0.67 mg/kg, respectively. No effects were observed in the hot-plate and tail-flick tests up to 30 mg/kg p.o. The compound orally administered (0.1-10 mg/kg) was well tolerated, without signs of neurological impairment up to high doses (ED(50)=470 and 245 mg/kg in rat and mice Rotarod test, respectively). These results indicate that NW-1029 has anti-nociceptive properties in models of inflammatory and neuropathic pain.

Ischaemic penumbra: highlights

The ischaemic penumbra was described for the first time in the late 1970s as a ring of hypoperfused zone surrounding the region of complete infarction. The penumbral zone is a functionally silent tissue which is able to regain its function if promptly reperfused. This implies that the ischaemic penumbra is not a static but a "dynamic" and "time-dependent" concept. In this paper we describe the role of neuroimmaging tecniques such as single photon emission tomography (SPET), positron emission tomography (PET), and diffusion-weighted and perfusion-weighted magnetic resonance imaging (DWI and PWI) in the study of ischaemic penumbra. These functional imaging techniques have the advantage of giving "in vivo" quantitative estimate of cerebral blood flow (CBF) as well as information on how the ischaemic tissue metabolic changes develop. It follows that, as therapeutic options for treating acute stroke evolve, neuroimaging strategies are assuming an increasingly important role in the initial evaluation and management of the acute ischaemic patient. In this regard, a wide range of therapeutic approaches have been investigated for either ameliorating the perfusion, or interfering with the pathobiochemical cascade leading to ischaemic neuronal damage, or improving endogenous neuroprotection pathways. The "time windows" required for these treatments to be effective varies being rather short for reperfusion and longer for neuroprotection. Salvaging more penumbra would enhance recovery and thereby allow the most appropriate candidate for therapeutic trials to be selected.

Complement C1q is dramatically up-regulated in brain microglia in response to transient global cerebral ischemia

Recent evidence suggests that the pathophysiology of neurodegenerative and inflammatory neurological diseases has a neuroimmunological component involving complement, an innate humoral immune defense system. The present study demonstrates the effects of experimentally induced global ischemia on the biosynthesis of C1q, the recognition subcomponent of the classical complement activation pathway, in the CNS. Using semiquantitative in situ hybridization, immunohistochemistry, and confocal laser scanning microscopy, a dramatic and widespread increase of C1q biosynthesis in rat brain microglia (but not in astrocytes or neurons) within 24 h after the ischemic insult was observed. A marked increase of C1q functional activity in cerebrospinal fluid taken 1, 24, and 72 h after the ischemic insult was determined by C1q-dependent hemolytic assay. In the light of the well-established role of complement and complement activation products in the initiation and maintenance of inflammation, the ischemia-induced increase of cerebral C1q biosynthesis and of C1q functional activity in the cerebrospinal fluid implies that the proinflammatory activities of locally produced complement are likely to contribute to the pathophysiology of cerebral ischemia. Pharmacological modulation of complement activation in the brain may be a therapeutic target in the treatment of stroke.

[Videolaparoscopic cholecystectomy. Experience, evolution, and comparison of techniques]

The paper broadly outlines the technique of laparoscopic cholecystectomy used by the authors to treat patients suffering from calculosis of the gallbladder. Basing their comments on the French school, the authors review the literature to identify those innovations introduced by individual operators in elation to the original technique which have enabled this method to be extended to those cases complicated by acute cholecystitis, VBP calculosis or sequelae from abdominal surgery. The most important innovations include the use of a laparoscope with oblique 30-degrees vision, which is extremely useful during the dissection of Calot's triangle since it allows VBP to be identified with greater ease and precision, above all in the event of phlogistic sequelae enclosing the peduncle. In addition, laparoscopic suture or ligation using Roeder's running-knot, used by the Dundee school to treat the cystic duct and artery, presents considerable advantages compared to the conventional use of metal clips. The authors also emphasise the growing return to intraoperative cholangiography which is routinely performed by some authors and is of value in identifying anatomic anomalies, iatrogenic lesions and VBP calculi unnoticed by preoperative tests. A second innovation which is highlighted consists of the treatment of choledocholithiasis during the course of laparoscopic cholecystectomy, in addition to pre- and postoperative endoscopic papillo-sphincterotomy.

Evidence for a direct vasoconstrictor effect of big endothelin-1 in the rat kidney

Inhibition of endothelin-1 (ET-1)-converting enzyme has been suggested as a strategy for blocking ET-1-mediated vasoconstriction. However, it is unclear whether its putative substrate, bigET-1, is an inactive precursor. Thus, we compared in the rat the effects of ET-1 and bigET-1 on renal vascular resistance (RVR) in vitro (isolated perfused kidney, n = 15) and in vivo (Doppler shift technique, n = 23) when injected i.v. or in the rat renal artery (i.a.), before and after metalloprotease inhibition with phosphoramidon (30 mg/kg i.v.). In vitro, the ET-1/bigET-1 potency ratio for the RVR increase was 175; in vivo (i.v.) it was approximately 7 (ED50: 99 and 692 pmol/kg, respectively; P < 0.01). Unlike that of ET-1, the bigET-1 effect started slowly (peak effect at 15 min). On i.a. injection, the ED50 of ET-1 was lower but that of big ET-1 was unchanged (ED50: 28 and 706 pmol/kg, respectively). Moreover, the effect of i.a. bigET-1 on RVR was biphasic, with a dose-related rapid increase followed by a slowly developing further rise. Phosphoramidon completely inhibited the hemodynamic effects of i.v. bigET-1, but abolished only the second phase of the response when given i.a. It also significantly enhanced the effect of ET-1. We conclude that in the rat: (1) bigET-1 may affect RVR by both a direct effect and through phosphoramidon-sensitive conversion to ET-1; (2) the direct vasoconstrictor effect of bigET-1 might be expressed during endothelin-converting enzyme inhibition; (3) metalloproteases are involved in ET-1 degradation.

[The prevalence of smoking in psychiatric patients. The effect of "institutionalization"]

The prevalence and other parameters concerning tobacco smoking were assessed in 100 outpatients with psychiatric disorders of axis I and II, according to DSM-III R criteria, and compared with those of 85 male psychiatric inpatients with forensic problems, recruited in a psychiatric hospital. The use of tobacco smoking was increased in psychiatric outpatients vs. the general pupulation and was very heightened in schizophrenic, as reported in earlier investigations; in the forensic sample both schizophrenic and non schizophrenic patients showed a very high prevalence. Therefore, the factor "institutionalization" does not modify the prevalence of tobacco smoking in schizophrenic--whose "smoking disposition" appears independent of the different social environments--while increasing the use in non schizophrenic patients. The positive correlation between tobacco smoking and schizophrenia is largely supported by these data and demands further investigation of its pathophysiologic mechanisms.

[Chronic dialysis and forcing of the ability to fantasize. Evaluation of the alexithymic phenomenon in a group of dialyzed patients]

In order to evaluate personality modifications toward greater concreteness and a consequent reduction of fantasizing in subjects undergoing chronic haemodialytic treatment, the Shalling Sifneos Personality Scale (S.S.P.S.) was administered to a group of patients undergoing dialysis and to two control groups: one consisting of patients with chronic hepatitis and the other of healthy subjects. The S.S.P.S. measures the alexithymic traits of the personality. Subjects undergoing dialysis scored significantly higher than chronic hepatitis patients and healthy subjects; the latter group had the lowest scores. The alexithymic score, moreover, appears to be directly correlated with the duration of dialysis. It is suggested that the prominence of the alexithymic phenomenon may be related to defense mechanisms against recurrent anguish about dying and to the tendency to assume certain characteristics of the particular therapeutic regimen, such as concreteness and rationality, so as to be able to tolerate the aggressive aspects of the treatment.