Emerging applications and regulatory strategies for advanced medicines manufacturing - Towards the development of a platform approach

The last decade has seen Advanced Medicines Manufacturing (AMM) progress from isolated product developments to the creation of industry-academic centres of excellence, regulatory innovation progressing leading to new standards, and product commercialisation across multiple product formats. This paper examines these developments focusing on successful applications and strategies presented at the 2023 Symposium of the International Consortium for Advanced Medicines Manufacturing (ICAMM). Despite these exemplar applications, there remain significant challenges to the sector-wide adoption of AMM technologies. Drawing on Symposium delegate expert responses to open-ended questions, our coding-based thematic analysis suggest three primary enablers drive successful adoption of AMM technologies at scale, namely: the ability to leverage pre-competitive collaborations to challenge-based problem solving; information and knowledge sharing through centres of excellence; and the development of AMM specific regulatory standards. Further analysis of expert responses identified the emergence of a 'Platform creation' approach to AMM innovation; characterised by: i) New collaboration modes; ii) Exploration of common product-process platforms for new dosage forms and therapy areas; iii) Development of modular equipment assets that enable scale-out, and offer more decentralized or distributed manufacturing models; iv) Standards based on product-process platform archetypes; v) Implementation strategies where platform-thinking and AMM technologies can significantly reduce timelines between discovery, approval and GMP readiness. We provide a definition of the Platform creation concept for AMM and discuss the requirements for its systematic development.

Rational and practical considerations to guide a Target Product Profile for patient-centric drug product development with measurable patient outcomes - A proposed roadmap

The increasing awareness of acceptability and usability of pharmaceutical drug products by the patient as a key quality requirement continues to drive need for integrating patient centric drug product design into the pharmaceutical development process. The complex matrix of multiple drug product related decisions during the early drug development process often limits patient-centric drug product (PCDP) design options in the final commercial drug product development phase. To integrate the specific needs and perspectives of patients into drug development and product design process, a rational approach integrated into the complex development matrix is required from the start and weighs product development decision options accordingly. The aim of this work was to develop a roadmap for PCDP design in a multidisciplinary approach that leads to better usability, adherence and acceptance of the drug by patients via early integration into the development matrix. The proposed rational approach is based upon regulatory requirements and lessons learned from pediatric and geriatric drug development.

Evaluation of two commercial peach extracts for skin prick testing in the diagnosis of hypersensitivity to lipid transfer protein. A multicenter study

Summary

The clinical usefulness of two commercial peach extracts for SPT (by Lofarma SpA and ALK-Abellò, respectively) was compared in a multicenter study carried out in Italy. Peach allergic patients were tested with the two extracts in parallel and underwent the detection of IgE specific for all three peach allergens currently available (Pru p1, Pru p3, and Pru p4, respectively). The two extracts were almost identical in terms of sensitivity and specificity, being able to detect virtually all patients sensitized to stable peach allergens (lipid transfer protein (LTP) and, presumably, peamaclein) but scoring negative in patients exclusively sensitive to labile allergens (either PR-10 and/or profilin). Thus, the two extracts represent an excellent tool to carry out a preliminary component-resolved diagnosis of peach allergy at the first patient visit.

Severe asthma in adolescents and adults: a national, multicenter registry in real life

Summary

The number of patients with uncontrolled asthma is growing especially in young people. Although current therapies improve the disease management, the heterogeneity of clinical outcomes results in patients whose asthma is refractory to standard therapies. To understand not responsive phenotypes, we instituted a web-registry aimed to collect real life data of adolescent and adult patients. One-hundred and five Italian medical Centers are part of the network. Participants above 14 years and affected by severe asthma will be included in the study. Demographic and clinical data will be collected for 5 years on a dedicated electronic database. For the first time in Italy, our study will provide information on epidemiological, clinical and therapeutic aspects related to the natural course of the disease, filling the gap between adolescents and adults.

RItA: The Italian severe/uncontrolled asthma registry

BACKGROUND

The Italian severe/uncontrolled asthma (SUA) web-based registry encompasses demographic, clinical, functional, and inflammatory data; it aims to raise SUA awareness, identifying specific phenotypes and promoting optimal care.

METHODS

Four hundred and ninety three adult patients from 27 Italian centers (recruited in 2011-2014) were analyzed.

RESULTS

Mean age was 53.8 years. SUA patients were more frequently female (60.6%), with allergic asthma (83.1%). About 30% showed late onset of asthma diagnosis/symptoms (>40 years); the mean age for asthma symptoms onset was 30.2 years and for asthma diagnosis 34.4 years. 97.1% used ICS (dose 2000 BDP), 93.6% LABA in association with ICS, 53.3% LTRAs, 64.1% anti-IgE, 10.7% theophylline, and 16.0% oral corticosteroids. Mean FEV₁ % pred of 75.1%, median values of 300/mm³ of blood eosinophil count, 323 kU/L of serum total IgE, and 24 ppb of FENO were shown. Most common comorbidities were allergic rhinitis (62.4%), gastroesophageal reflux (42.1%), sinusitis (37.9%), nasal polyposis (30.2%), and allergic conjunctivitis (30.2%). 55.7% of SUA patients had exacerbations in the last 12 months, 9.7% emergency department visits, and 7.3% hospitalizations. Factors associated with exacerbation risk were obesity (OR, 95% CI 2.46, 1.11-5.41), psychic disorders (2.87, 0.89-9.30-borderline), nasal polyps (1.86, 0.88-3.89-borderline), partial/poor asthma treatment adherence (2.54, 0.97-6.67-borderline), and anti-IgE use in a protective way (0.26, 0.12-0.53). Comparisons to severe asthma multicenter studies and available registries showed data consistency across European and American populations.

CONCLUSIONS

An international effort in the implementation of SUA patients' registries could help to better understand the clinical features and to manage severe asthma, representing a non-negligible socioeconomic burden for health services.

Orodispersible films: Towards drug delivery in special populations

Orodispersible films (ODF) hold promise as a novel delivery method, with the potential to deliver tailored therapies to different patient populations. This article reviews the current strides of ODF technology and some of its unmet quality and manufacturing aspects. A topic highlights opportunities and limitations of inkjet printed ODF as a population-specific drug delivery. Overall, this article aims to stimulate further research to fill the current knowledge gap between manufacturing and administration requirements of ODF targeting specific patient subpopulations such as geriatrics.

Near fatal asthma: treatment and prevention

Near-fatal asthma (NFA) is described as acute asthma associated with a respiratory arrest or arterial carbon dioxide tension greater than 50 mmHg, with or without altered consciousness, requiring mechanical ventilation. Risk factors for near fatal asthma have not been fully elucidated. In 80-85% of all fatal events, a phenotype, characterized by eosinophilic inflammation associated with gradual deterioration occurring in patients with severe and poorly controlled asthma, has been identified. Regarding to the management, acute severe asthma remains a significant clinical problem, which needs to be identified to facilitate early and appropriate therapeutic interventions. The assessment relies on clinical signs, but additional information might be obtained from chest radiography or blood gas analysis. No investigation should delay the initiation of appropriate therapy. The goals of therapy are the maintenance of oxygenation, relief of airflow obstruction, reduction of airways edema and mucus plugging (with Increased use of medications such as beta-agonists via metered dose inhalers and nebulizers, oral and/or intravenous (other than by inhalation) corticosteroids and oral or intravenous theophylline) whereas supporting ventilation as clinically indicated. Of course, the emergency physician needs to consider the wide range of potential complications, as attention to these problems when managing severe acute asthma might significantly improve outcome. An understanding of the available agents and potential pitfalls in the management of NFA is mandatory for the emergency physician.

Clinical relevance is associated with allergen-specific wheal size in skin prick testing

Background

Within a large prospective study, the Global Asthma and Allergy European Network (GA²LEN) has collected skin prick test (SPT) data throughout Europe to make recommendations for SPT in clinical settings.

Objective

To improve clinical interpretation of SPT results for inhalant allergens by providing quantitative decision points.

Methods

The GA²LEN SPT study with 3068 valid data sets was used to investigate the relationship between SPT results and patient-reported clinical relevance for each of the 18 inhalant allergens as well as SPT wheal size and physician-diagnosed allergy (rhinitis, asthma, atopic dermatitis, food allergy). The effects of age, gender, and geographical area on SPT results were assessed. For each allergen, the wheal size in mm with an 80% positive predictive value (PPV) for being clinically relevant was calculated.

Results

Depending on the allergen, from 40% (blatella) to 87–89% (grass, mites) of the positive SPT reactions (wheal size ≥ 3 mm) were associated with patient-reported clinical symptoms when exposed to the respective allergen. The risk of allergic symptoms increased significantly with larger wheal sizes for 17 of the 18 allergens tested. Children with positive SPT reactions had a smaller risk of sensitizations being clinically relevant compared with adults. The 80% PPV varied from 3 to 10 mm depending on the allergen.

Conclusion

These ‘reading keys’ for 18 inhalant allergens can help interpret SPT results with respect to their clinical significance. A SPT form with the standard allergens including mm decision points for each allergen is offered for clinical use.

Application of QbD principles for the evaluation of empty hard capsules as an input parameter in formulation development and manufacturing

Understanding the product and process variable on the final product performance is an essential part of the quality-by-design (QbD) principles in pharmaceutical development. The hard capsule is an established pharmaceutical dosage form used worldwide in development and manufacturing. The empty hard capsules are supplied as an excipient that is filled by pharmaceutical manufacturers with a variety of different formulations and products. To understand the potential variations of the empty hard capsules as an input parameter and its potential impact on the finished product quality, a study was performed investigating the critical quality parameters within and in between different batches of empty hard gelatin capsules. The variability of the hard capsules showed high consistency within the specification of the critical quality parameters. This also accounts for the disintegration times, when automatic endpoint detection was used. Based on these data, hard capsules can be considered as a suitable excipient for product development using QbD principles.

The ARGA study with Italian general practitioners: prescriptions for allergic rhinitis and adherence to ARIA guidelines

BACKGROUND

General practitioners (GPs) are the healthcare professionals to whom patients with rhinitis firstly refer for their symptoms.

OBJECTIVE

In the present study, we assessed drug prescriptions for allergic rhinitis (AR) and evaluated prescriptive adherence to ARIA treatment guidelines.

METHODS

Data on 1379 AR patients were collected by 107 Italian GPs. Adherence to ARIA guidelines was evaluated according to AR severity classification.

RESULTS

AR was diagnosed by GPs as mild intermittent for 46.2% of patients, mild persistent for 26.6%, moderate-severe intermittent for 20.2%, and moderate-severe persistent for 7%; 43.7% of AR patients had concomitant asthma. The most frequently prescribed therapeutic groups were antihistamines (anti-H, 76%) and nasal corticosteroids (NCS, 46%). Anti-H were significantly used more often to treat AR alone than AR + asthma (85 vs. 68%, p < 0.001), whereas NCS were used more often to treat AR + asthma than AR alone (50 vs. 42%, p = 0.01). Among patients with only mild intermittent AR, 39% were prescribed combined therapy. Among patients with moderate-severe persistent AR, 30% of those with AR alone and 18% of those with AR + asthma were prescribed monotherapy based on anti-H. GPs were more compliant with ARIA guidelines while treating AR alone (57%) than AR + asthma (46%) patients. The adherence increased according to the severity grade and was satisfactory for moderate-severe persistent AR (89% for AR alone and 95% for AR + asthma).

CONCLUSIONS

Adherence to ARIA guidelines is satisfactory only for treatment of more severe patients, thus GPs often tend to treat patients independently from ARIA guidelines. Since prescription data only provide limited information to judge prescribing quality, some deviation from the gold standard are to be expected.

[Prevalence of contact dermatitis as occupational diseases in a group of construction workers followed up by the 'Territorial Joint Committee of Bergamo' between 2003-2011]

Occupational contact dermatitis is the most represented skin disease within the broad spectrum of occupational dermatoses, that also include skin cancers, skin infections and "scleroderma like disease." The scientific literature has long noted an increase in dermatological disease in the construction industry.

MATERIALS AND METHODS

retrospective evaluation (2003-2011), in a group of construction workers followed by the 'Territorial Joint Committee of Bergamo', of the prevalence of allergic and irritant contact dermatitis.

DISCUSSION AND CONCLUSIONS

The following report confirms the literature data and reaffirms the need for a careful medical surveillance, as a result of a strict cooperation between the different professionals involved (company physicians, dermatologists/allergists, family physicians).

[Energy expenditure in construction industry]

The aim of this study is to show the results obtained from measuring energy expenditure (EE) during work, through portable devices, in a group of male construction workers. After defining cardio-respiratory parameters in laboratory, authors applied to all subjects an heart rate monitor for measuring the heart rate (HR) and, at the same time, a calorimeter for measuring energy expenditure (EE). To analyse data obtained, authors calculate the Relative Aerobic Strain (RAS), both for the measurements of EE and for HR detected. Results confirm that in many of the typical activities of construction industry, in particular in those characterised by an higher component of manual engagement compared to foreman, workloads are exceeding limits of the probable threshold fatigue (33% of RAS), both for energy expenditure than for HR measured.

[Work-related diseases and the fitness to work in construction industry]

The construction industry is characterized by a high number of fatal and nonfatal injuries and even higher prevalence of work-related diseases. The aim of this work is to analyze the results of a research project that has among its objectives the study of the prevalence of work-related diseases and the fitness to work in construction industry. In the period 2003-2011 were evaluated 2069 construction workers, from 218 companies (average age 37.9 years, mean seniority 21.1 years, 17.1 in the construction industry). The prevalence of work-related diseases was 14.06%, in the first place the noise-induced hearing loss, followed by musculoskeletal disorders and entrapment neuropathies. The 24.7% of fitness to work was influenced by the presence of limitations, the 0.6% of the population was not suitable for the specific task. The prevalence of work-related diseases in construction industry is high, with a peak among the elderly, but also significant occurrence among young people. It is important the percentage of the population with health problems that limit the fitness to work.

[Survey on alcohol and construction workers]

On the basis of the data drawn by national and international literature and the introduction of legislation concerning "alcohol and alcohol-related problems" authors studied alcohol consumption in a group of 512 building workers during the periodic health surveillance examination (years 2011-2012). Another group of 209 construction workers were examined for alcohol concentration in expired air and during work on building sites. In the first group, 62.1% of workers refers to drink alcoholic beverages; we found GGT and CTD alterations in about 1/3 of workers who reported high alcohol consumption. Alcohol tests in building sites demonstrated that alcohol consumption during pauses in work is still common.

[Role of ECG screening and cardiologic examinations in occupational health prevention program for construction workers; results of study in the Province of Bergamo]

Aim of this study was to estimate prevalence of resting electrocardiogram (ECG) abnormalities in men with high physical work demand, like construction workers and the prevalence of secondary related cardiovascular examinations. Several guidelines for cardiovascular risk management recommend an ECG in patients with cardiovascular risk but there are no clear indications about the frequency of resting ECG during evaluation for fitness for work. The results of our study confirm the presence of age-related ECG abnormalities with a similar stratified prevalence distribution in all age-classes. Our fundings intend to contribute to further discussion in occupational health policies and periodical medical evaluations.

[Occupational injuries and lifestyle in construction working population workers: which interaction?]

Many factors of organizational, technical, social and human are involved in determining occupational injury. The purpose of this study was to evaluate how the characteristics of the human factor can influence the accident phenomenon. From records of the construction firms involved in the project "Protection of health on construction sites" promoted by CPT Bergamo and Occupational Medicine of Bergamo Hospital were extracted data on lifestyle of workers involved in occupational injuries in the period 2007-2011. The indicators of lifestyles used were the smoking status, alcohol consumption and drugs, body mass index (BMI), physical activity.

[The skin cancer in the construction industry]

The risk factors for the development of cutaneous neoplasms are well-known (skin type, ultraviolet rays, familiar occurrence, etc.) and the exposure to ultraviolet light is probably the most important one. Construction workers, due to the characteristics of the work performed (outdoor work), are exposed to UV rays for most of their workday, often in association with the exposure to chemicals (PAHs, solvents) with a role in promoting skin carcinogenesis. The construction industry is therefore a true "test" for the prevention of skin cancer.

MATERIALS AND METHODS

description of skin cancer in the construction workers subject to medical surveillance at the "Territorial Joint Committee of Bergamo" (8 basal cell cancers, 1 squamous cell carcinomas and 4 melanomas).

PURPOSE

review of the medical literature data, evaluation of the exposure to multiple risk factors, prevention proposals in a professional field where the "culture of tanning" is still widespread.

Combining formulation and process aspects for optimizing the high-shear wet granulation of common drugs

The purpose of this research was to determine the effects of some important drug properties (such as particle size distribution, hygroscopicity and solubility) and process variables on the granule growth behaviour and final drug distribution in high shear wet granulation. Results have been analyzed in the light of widely accepted theories and some recently developed approaches. A mixture composed of drug, some excipients and a dry binder was processed using a lab-scale high-shear mixer. Three common active pharmaceutical ingredients (paracetamol, caffeine and acetylsalicylic acid) were used within the initial formulation. Drug load was 50% (on weight basis). Influences of drug particle properties (e.g. particle size and shape, hygroscopicity) on the granule growth behaviour were evaluated. Particle size distribution (PSD) and granule morphology were monitored during the entire process through sieve analysis and scanning electron microscope (SEM) image analysis. Resistance of the wet mass to mixing was furthermore measured using the impeller torque monitoring technique. The observed differences in the granule growth behaviour as well as the discrepancies between the actual and the ideal drug content in the final granules have been interpreted in terms of dimensionless quantity (spray flux number, bed penetration time) and related to torque measurements. Analysis highlighted the role of liquid distribution on the process. It was demonstrated that where the liquid penetration time was higher (e.g. paracetamol-based formulations), the liquid distribution was poorer leading to retarded granule growth and selective agglomeration. On the other hand where penetration time was lower (e.g. acetylsalicylic acid-based formulations), the growth was much faster but uniformity content problem arose because of the onset of crushing and layering phenomena.

[Plastering: assessment of risk for upper limb biomechanical overload and of energy expenditure]

This work analyzes the activities carried out by a plaster construction worker, describing the data obtained from the assessment of risk for upper limb biomechanical overload, through the application of checklist and the OCRA method, and the operator's energy expenditure, measured using portable calorimeter. By analyzing the pattern of energy expenditure in relation to the actions performed we observe a direct correlation between posture, force employed, and metabolic rate. The activity of plastering involves biomechanical overload of upper extremity and high energy expenditure.

GA2LEN skin test study III: minimum battery of test inhalent allergens needed in epidemiological studies in patients

BACKGROUND

The number of allergens to be tested in order to identify sensitized patients is important in order to have the most cost-effective approach in epidemiological studies.

OBJECTIVE

To define the minimal number and the type of skin prick test (SPT) allergens required to identify a patient as sensitized using results of the new Pan-European GA(2)LEN skin prick test study.

METHOD

In a large Pan-European multicenter (17 centers in 14 countries) patient based study, a standardized panel of 18 allergens has been prick tested using a standardized procedure. Conditional approach allowed to determine the allergens selection.

RESULT

Among the 3034 patients involved, 1996 (68.2%) were sensitized to at least one allergen. Overall, eight allergens (grass pollen, Dermatophagoides pteronyssinus, birch pollen, cat dander, Artemisia, olive pollen, Blatella and Alternaria) allowed to identified more than 95% of sensitized subjects. However, differences were observed between countries, two allergens being sufficient for Switzerland (grass pollen and cat dander) as opposed to nine for France (grass pollen, Dermatophagoides pteronyssinus, olive pollen, cat dander, Blatella, cypress, dog dander, alder and [Artemisia or Alternaria]). According to country, up to 13 allergens were needed to identify all sensitized subjects.

CONCLUSION

Eight to ten allergens allowed the identification of the majority of sensitized subjects. For clinical care of individual patients, the whole battery of 18 allergens is needed to appropriately assess sensitization across Europe.

GA(2)LEN skin test study II: clinical relevance of inhalant allergen sensitizations in Europe

BACKGROUND

Skin prick testing is the standard for diagnosing IgE-mediated allergies. A positive skin prick reaction, however, does not always correlate with clinical symptoms. A large database from a Global Asthma and Allergy European Network (GA(2)LEN) study with data on clinical relevance was used to determine the clinical relevance of sensitizations against the 18 most frequent inhalant allergens in Europe. The study population consisted of patients referred to one of the 17 allergy centres in 14 European countries (n = 3034, median age = 33 years). The aim of the study was to assess the clinical relevance of positive skin prick test reactions against inhalant allergens considering the predominating type of symptoms in a pan-European population of patients presenting with suspected allergic disease.

METHODS

Clinical relevance of skin prick tests was recorded with regard to patient history and optional additional tests. A putative correlation between sensitization and allergic disease was assessed using logistic regression analysis.

RESULTS

While an overall rate of >or=60% clinically relevant sensitizations was observed in all countries, a differential distribution of clinically relevant sensitizations was demonstrated depending on type of allergen and country where the prick test was performed. Furthermore, a significant correlation between the presence of allergic disease and the number of sensitizations was demonstrated.

CONCLUSION

This study strongly emphasizes the importance of evaluating the clinical relevance of positive skin prick tests and calls for further studies, which may, ultimately, help increase the positive predictive value of allergy testing.

GA(2)LEN skin test study I: GA(2)LEN harmonization of skin prick testing: novel sensitization patterns for inhalant allergens in Europe

BACKGROUND

Skin prick testing is the standard for diagnosing IgE-mediated allergies. However, different allergen extracts and different testing procedures have been applied by European allergy centres. Thus, it has been difficult to compare results from different centres or studies across Europe. It was, therefore, crucial to standardize and harmonize procedures in allergy diagnosis and treatment within Europe.

AIMS

The Global Asthma and Allergy European Network (GA(2)LEN), with partners and collaborating centres across Europe, was in a unique position to take on this task. The current study is the first approach to implement a standardized procedure for skin prick testing in allergies against inhalant allergens with a standardized pan-European allergen panel.

METHODS

The study population consisted of patients who were referred to one of the 17 participating centres in 14 European countries (n = 3034, median age = 33 years). Skin prick testing and evaluation was performed with the same 18 allergens in a standardized procedure across all centres.

RESULTS

The study clearly shows that many allergens previously regarded as untypical for some regions in Europe have been underestimated. This could partly be related to changes in mobility of patients, vegetation or climate in Europe.

CONCLUSION

The results of this large pan-European study demonstrate for the first time sensitization patterns for different inhalant allergens in patients across Europe. The standardized skin prick test with the standardized allergen battery should be recommended for clinical use and research. Further EU-wide monitoring of sensitization patterns is urgently needed.

Chronic hepatitis C in the advanced adult and elderly subjects

Aging is associated with a complex remodeling of the immune system. While adaptive immune responses show impairment with aging, innate immune responses tend to improve it. Low numbers of CD3+, CD4+ and CD8 T cells have been observed in aged individuals. B lymphocytes tend to diminish as well. However, an increase in NK cells and effector T lymphocytes (CD28- CD8) can be shown. Effector T lymphocytes are characterized by: 1) expression of markers of cytotoxicity; 2) high levels of NK activity; 3) expression of the same inhibitory receptors as NK cells; 4) no cytokine production. For effector T lymphocyte-mediated cytotoxicity of virus-infected cells to occur, viral epitopes need to be exposed on the cell surface in the absence of MCH class I molecule expression, just as it has been shown with NK cells. Indeed, chronic infection with intracellular parasites is known to hinder MHC class I expression on cell surface. In elderly patients with chronic hepatitis C, infected hepatocytes can be shown to express a wide variety of HCV antigens, reflecting latency or active replication, as opposed to low or absent MHC class I expression. This favors elimination of infected hepatocytes by NK cells and effector T lymphocytes. A negative correlation has been observed between outcome of hepatitis and patients' age. Liver biopsies from elderly patients generally show chronic active hepatitis or cirrhosis, which are far less commonly observed in young patients or young adults. Overproduction of proinflammatory cytokines, namely TNF-alpha, IL-1 and IL-6, is responsible for enhanced immuno-phlogosis and underlies a more extensive damage to liver parenchyma. Since interferon-alpha has been shown to upregulate MHC class I molecule expression on infected hepatocytes, it may turn useful as a tool to inhibit NK cell- and effector T lymphocyte-mediated cytotoxicity. Thus, a rationale exists to recommend interferon-a administration in hepatitis C patients, especially in elderly patients. If the data presented here can contribute to foster research into interferon-a treatment of elderly patients with hepatitis C, our goal will be reached.

Nerve growth factor localization in the nasal mucosa of patients with persistent allergic rhinitis

BACKGROUND AND OBJECTIVES

Nerve growth factor (NGF) and NGF receptors have been shown to be expressed by structural and infiltrating inflammatory cells in the human allergic bronchial mucosa and conjunctiva. In the nose, a positive immunostaining for NGF was recently reported in biopsies of subjects undergoing surgery for refractory nasal obstruction. This study was aimed at studying by immunohistochemistry NGF expression and localization in the nasal mucosa from subjects with moderate/severe persistent allergic rhinitis and natural allergen exposure.

METHODS

Immunostaining for NGF, tryptase and eosinophil cationic protein was performed in human nasal turbinate sections of 25 patients affected by persistent allergic rhinitis and sensitization to Dermatophagoides pteronyssinus.

RESULTS

NGF was consistently expressed in the epithelium and in the submucosa of allergic rhinitic subjects, preferentially localized in eosinophils and mast cells. A strong NGF immunostaining was found in mucous cells of the epithelial lining and in the submucosal glands.

CONCLUSIONS

As previously shown for allergic asthma and allergic conjunctivitis, NGF is also detectable in the nasal mucosa of patients with persistent allergic rhinitis. The preferential NGF localization in mucous cells of the epithelial lining and in the submucosal glands suggests a possible role for NGF in modulating secretion in allergic rhinitis and possibly other allergic diseases.

A case-control study of the relation between plasma selenium and asthma in European populations: a GAL2EN project

BACKGROUND

There is evidence that selenium levels are relatively low in Europe and may be falling. Low levels of selenium or low activity of some of the enzymes dependent on selenium have been associated with asthma.

METHODS

The GA(2)LEN network has organized a multicentre case-control study in Europe to assess the relation of plasma selenium to asthma. The network compared 569 cases in 14 European centres with a diagnosis of asthma and reporting asthma symptoms in the last 12 months with 576 controls from the same centres with no diagnosis of asthma and no asthmatic symptoms in the last 12 months.

RESULTS

All cases and controls were selected from the same population defined by age and place of residence. Mean plasma selenium concentrations among the controls ranged from 116.3 microg/l in Palermo to 67.7 microg/l in Vienna and 56.1 microg/l among the children in Oslo. Random effects meta-analysis of the results from the centres showed no overall association between asthma and plasma selenium [odds ratio (OR)/10 microg/l increase in plasma selenium: 1.04; 95% confidence interval (CI): 0.89-1.21] though there was a significantly protective effect in Lodz (OR: 0.48; 95% CI: 0.29-0.78) and a marginally significant adverse effect in Amsterdam (OR: 1.68; 95% CI: 0.98-2.90) and Ghent (OR: 1.35; 95% CI: 1.03-1.77).

CONCLUSION

This study does not support a role for selenium in protection against asthma, but effect modification and confounding cannot be ruled out.

[Diagnosis and insurance compensation of occupational diseases in construction industry]

The aim of this study is to evaluate the outcome of 302 occupational diseases in building workers detected by UOOML Ospedali Riuniti of Bergamo and notified to INAIL from 2000 to 2005. The 41.3% of cases were accepted as work-related. Among remaining cases (58.7%), INAIL rejected 40.9% for lack or absence of documentation. 59.1% for no adhesion to legal medicine criteria. By analysis of occupational diseases detected in the last 5 years, we found an increase of muscle-skeletal disorders, for which, now, diagnostic procedure and insurance evaluation are difficult. This work shows a wide gap between reported occupational diseases of buildings workers and compensation given by INAIL. These results underlines the need of comparison among involved institutions in order to standardize statistical and diagnostic instruments.

Nonspecific provocation of target organs in allergic diseases: EAACI-GA(2)LEN consensus report

It is widely accepted that nonspecific tissue reactivity is a distinct pathophysiological hallmark of allergic diseases, influenced by genetic and environmental factors different from those involved in causing sensitization and allergen response of target organs. This consensus document aims at reviewing procedures currently used for nonspecific provocation of the bronchi, nose and eye and for measuring their responsiveness to nonspecific stimuli.

Interferon-gamma: biologic functions and HCV terapy (type I/II) (2 of 2 parts)

PURPOSE

To discuss exhaustively: 1) the interferon-gamma in inducing and modulating of immune responses; 2) impairment of IFN-gamma production that plays an important role in the persistence of infection, chronicity of inflammation, evolution in fibrosis; 3) in "vivo" effects of combination treatment with recombinant interferon-gamma and alpha in chronic HCV-infection.

DESIGN

We reviewed the most important recent studios on relationship between IFN-gamma and chronic course of hepatitis C.

OVERVIEW

IFN-gamma is also a potent activator of macrophages. Exposure to IFN-gamma greatly enhances the microbicidal (and, to a lesser degree, citotoxic) activity of macrophages and induces them to secrete nitric oxide and monokines such as IL-1, IL-6, IL-8, and TFNalpha. It also activates neutrophils, NK cells, and vascular endothelial cells. Although IFN-gamma tends to promote the differentiation of B cells and CD8 T cells into immunologically active effectors, it does not promote lymphocyte proliferation. It enhances the activity of Thl cells, but inhibits the production of Th2 cells. IFN-gamma not only decreases the production of IL-4 by Th2 cells but also potently blocks the effects of IL-4 on B cells, promoting IgG1 production at the expense of IgE production. The inadequate Thl immunity as well as the weak HCV-specific T-cell response at the site of inflammation is associated with failure to clear the virus and a chronic course of disease. The production of IL-12 is critical for induction of Thl immunity, directed towards elimination of intracellular pathogenes and viruses. The core protein of HCV seems to have a suppressive action on IL-12 production at the transcriptional level. The specific Thl cell defect is correlated with insufficient Th and CTL responses, and lower production of type 1 cytokine (IL-2, IFN-gamma, lymphokine-activated killer cells). Taken together, these results are probably responsible for non-eradication of HCV infection. Particularly the effects of interferon-gamma may include inhibition of HCV virion production by an effect on viral RNA and protein synthesis, enhancement of immune lysis of HCV infected cells, inhibition of hepatic fibrosis by an effect on TGF-beta, and an effect on HCV induced carcinogenesis. These data suggest an HCV-related cellular immune defect in patients with hepatitis C that can be restored in most patients by IL-12.

CONCLUSIONS

The efficacy of IFN monotherapy in the HCV replicon system has been reported using IFN-alpha, IFN-gamma and IFN-beta. A recent clinical study to treatment chronic HCV involving sequential administration of IFN-alpha followed by IFN-gamma (IFN-alpha2b + IFN-gamma) showed a greater improvement over IFN monotherapy. This type of approach may lead to significant improvements in the therapeutic arsenal against chronic HCV infection.

Interferon-gamma: biologic functions and HCV therapy (type I/II) (1 of 2 parts)

PURPOSE

This review is aimed at exhaustively presenting and discussing the interferon-gamma (IFN-gamma), a cytokine that plays an important role in inducing and modulating an array of immune responses.

DESIGN

A review of the most significant and recent clinical trials was performed.

OVERVIEW

Although IFN-gamma has some antiviral activity, it is much less active in this regard than type I IFNs. IFN-gamma is involved in the regulation of nearly all phases of the immune and inflammatory responses, including the activation and differentiation of T cells, B cells, NK cells, macrophages, and others. It is therefore best regarded as a distint immunoregulatory cytokine. IFN-gamma secretion is a hallmark of Th1 lymphocytes. It is also secreted by nearly all CD8 T cells, by some Th0 cells, and by NK cells. Each of these cell types secretes IFN-gamma only when activated, usually as part of immune response and especially in response to IL-2 and IL-12. IFN-gamma production is inhibited by IL-4, IL-10, TGFbeta, glucocorticoids, cyclosporin A and FK506. Nearly all cell types express the heterodimeric receptor for IFN-beta and respond to this cytokine by increasing the surface expression of class I MHC proteins. As a result, virtually any cell in the vicinity of an IFN-beta-secreting cell becomes more efficient at presenting endogenous antigens and hence a better target for cytotoxic killing if it harbors an intracellular pathogen. Unlike the type I IFNs, IFN-gamma also increases the expression of class II MHC proteins on professional APCs, and so promotes antigen presentation to helper T cells as well. It also induces de novo expression of class II MHC proteins on venular endothelial cells and on some other epithelial and connective tissue cells that do not otherwise express them, thus enabling these cell types to function as temporary APCs at sites of intense immune reactions. The effector functions of NK cells are to lyse virus-infected cells and to secrete IFN-gamma, which activates macrofages to destroy phagocytosed microbes. The mechanism of NK cell-mediates cytolysis is essentially the same as that of cytolysis by CTLS. NK cells lyse virally infected cells before antigen specific CTLS came become fully active, that is, during the first few days after viral infection. NK cells are expanded and activated by cytokines of innate immunity, such as IL-12 and IL-15, and they kill infected cells, especially those that display reduced levels of class I molecoles. Some tumors, especially those of hematopoietic origin, are targets of NK cells, perlevels or types of class I MHC molecules. Therefore, IFN-gamma serves critical functions in innate immunity and in specific cell-mediated immunity (in addition, IFN activates neutrophilis and stimulates the cytolitic activity of NK cells). Many IFNs-gamma induced effects result in heigtened immune surveillance.

CONCLUSIONS

IFN-gamma is a remarkable cytokine that orchestrates many distinct cellular programs through transcriptional control over large numbers of genes. Many IFNs-gamma-induced effects resulting in heightend immune surveillance and immune system function during infection have been discussed in this review. As the pathogens (microorganism with the potential to cause tissue injury or disease) augment local IFN-gamma production, and IFN-gamma augments the immune system response, an important function of IFN-gamma during in vivo infection is suggested. IFN-gamma is primarily secreted by activated T cells and natural killer cells, and can promote macrophage activation, mediate antiviral e antibacterial immunity, enhance antigen presentation, orchestrate activation of the innate immune system, coordinate lymphocyte-endothelium interaction, regulate Th1/Th2 balance, and control cellular proliferation and apoptosis.

Role of hemochromatosis genes in chronic hepatitis C

PURPOSE

Hereditary hemochromatosis is commonly associated with iron overload and hepatitis C virus (HCV). Association between hemochromatosis C282Y or H63D mutation has been observed, although not uniformly, and iron overload is also commonly found in chronic HCV hepatitis. This study explored the contribution of genetic hemochromatosis to iron accumulation in hepatitis C.

DESIGN

Review of current literature.

RESULTS

The prevalence of increased serum iron stores in patients with HCV infection is 28% (patients having an elevated ferritin or transferrin saturation). Patients with elevated serum iron markers have more active chronic hepatitis with more liver fibrosis. In the opinion of the experts HFE mutations are not associated with a high hepatic iron content. No relation was detected between hepatic iron stores and HFE gene mutation. Significant iron deposition in the liver was uncommon and overall the quantity of iron that was detectable histologically and biochemically was unrelated to the grade and stage of HCV related liver injury. The mechanism by which liver iron accumulates in patients is unclear.

CONCLUSIONS

Carriage of HFE mutations does not have a role in the accumulation of iron or the liver disease in HCV. These findings do not support a role for iron depletion in patients with chronic HCV infection, including these with elevated serum studies.

Standard skin prick testing and sensitization to inhalant allergens across Europe--a survey from the GALEN network

Skin prick testing (SPT) is the standard method for diagnosing allergic sensitization but is to some extent performed differently in clinical centres across Europe. There would be advantages in harmonizing the standard panels of allergens used in different European countries, both for clinical purposes and for research, especially with increasing mobility within Europe and current trends in botany and agriculture. As well as improving diagnostic accuracy, this would allow better comparison of research findings in European allergy centres. We have compared the different SPT procedures operating in 29 allergy centres within the Global Allergy and Asthma European Network (GA(2)LEN). Standard SPT is performed similarly in all centres, e.g. using commercial extracts, evaluation after 15-20 min exposure with positive results defined as a wheal >3 mm diameter. The perennial allergens included in the standard SPT panel of inhalant allergens are largely similar (e.g. cat: pricked in all centres; dog: 26 of 29 centres and Dermatophagoides pteronyssinus: 28 of 29 centres) but the choice of pollen allergens vary considerably, reflecting different exposure and sensitization rates for regional inhalant allergens. This overview may serve as reference for the practising doctor and suggests a GA(2)LEN Pan-European core SPT panel.

Nerve growth factor and asthma

An increasing body of evidence shows that nerve growth factor (NGF) exerts biological activity not only on the central and peripheral nervous system, but also on the immune system thereby influencing allergic diseases and asthma. (1) NGF circulating levels are increased in patients with allergic diseases and asthma, and are related to the severity of the inflammatory process and disease. In vernal keratoconjunctivitis, NGF plasma levels correlate with the number of mast cells infiltrating the conjunctiva, and NGF mRNA is increased in nasal mucosal scrapings of patients with allergic rhinitis who have high levels of NGF in serum and nasal fluids; NGF is further increased in nasal fluids after specific allergen challenge. (2) NGF is produced and released by several modulatory and effector cells of allergic inflammation and asthma, for example T-helper 2 lymphocytes, mast cells and eosinophils. (3) NGF receptors are expressed on the conjunctival epithelium of patients with allergic conjunctivitis and the number of NGF-receptor positive cells is increased in the conjunctiva of these patients. Indeed, local administration of NGF induces fibroblast activation and healing processes of human corneal ulcers, which suggests that NGF plays a role in tissue remodelling processes occurring in asthma. (4) NGF increases airway hyperreactivity to histamine in an animal model of asthma, while anti-NGF treatment reduces airway hyperreactivity induced by ovalbumin topical challenge in the sensitized mouse.

Virus-induced asthma

Clinical and experimental investigations indicate that respiratory viral infections are important triggers for asthma attacks. Viral upper respiratory infections have been associated with 80% of asthma exacerbations in children and 50% of all asthma episodes in adults. Human Rhinovirus (HRV) has been implicated as the most common virus associated with asthma episodes. The observation that the great majority of wheezing lower respiratory tract illnesses in early life are associated with acute viral infections suggests that viruses may also alter the development of the lungs or of the immune system, acting as co-factors for the inception of asthma. Whilst there is no doubt that viruses are important asthma exacerbation factors, the role of viral infections in the development of asthma still remains controversial.

[CT in findings intestinal carcinoids]

CT findings in intestinal carcinoids are various. While recognition of the primary tumour is a rare event, the contribution of CT in evaluating patients with suspected intestinal carcinoid is relevant, both for loco-regional staging and during long-term follow-up. Moreover, in the relatively frequent cases with an aspecific clinical onset, CT may be findings useful to direct diagnosis.

[Morphological imaging of gastroenteropancreatic neuroendocrine tumours]

Biologically active neuroendocrine tumours produce early symptoms and are often difficult to diagnose owing to their small dimensions (<1 cm), whereas biologically inactive forms are often coarse and sometimes found by chance. As well as identifying the lesion, locoregional staging is also particularly important for therapeutic planning. Morphological imaging plays an important role in the identification of gastroenteropancreatic neuroendocrine tumours, providing an anatomic substrate for receptorial imaging which usually precede it in the diagnostic work-up, whereas it plays a primary role in the locoregional staging of these neoplasms for which surgery is the first and essential therapeutic approach. In the case of endocrine tumours of the pancreas alone, the most accurate method of diagnosis is currently echo-endoscopy using high-frequency probes. Two-phase spiral CT and dynamic MR have proved equally effective means of identifying endocrine tumours of the pancreas with slightly higher sensitivity for MR, both playing a role in the locoregional staging of biologically active and inactive tumours. Traditional radiology also plays a role in the identification of intestinal carcinoids.

Rhinosinusitis in severe asthma

BACKGROUND

Chronic rhinosinusitis is a common comorbidity of asthma. However, sinonasal involvement in severe steroid-dependent asthma is still undefined.

OBJECTIVE

The aim of the study was to evaluate chronic rhinosinusitis in 35 patients with severe steroid-dependent asthma by using a clinical score and coronal computed tomography (CT) scanning.

METHODS

Thirty-five subjects (16 female subjects) with severe asthma requiring daily doses of oral corticosteroids were compared with 34 patients (19 female patients) with mild-to-moderate asthma. Sinonasal involvement was studied by using clinical and CT scores. Airflow obstruction, therapy requirement, and asthma triggering factors were carefully assessed.

RESULTS

The proportion of patients with symptoms of rhinosinusitis was similar in both groups of asthmatic subjects (74% in patients with severe steroid-dependent asthma and 70% in patients with mild-to-moderate asthma). All subjects with steroid-dependent asthma versus 88% of subjects with mild-to-moderate asthma had abnormal CT scan results. The clinical (P <.05) and CT scan (P <.0005) severity scores were higher in the subjects with severe steroid-dependent asthma. In both groups the CT scan scores were correlated to the clinical scores (P <.0001 and P <.006), but only in the mild-to-moderate group were both scores correlated with high significance (P <.002 and P <.0005) to the absolute number of blood eosinophils.

CONCLUSION

Frequency of rhinosinusitis in patients with mild-to-moderate or severe steroid-dependent asthma is similar; however, sinonasal involvement, as evaluated by clinical symptoms and CT scan imaging, is significantly greater in the patients with severe steroid-dependent asthma than in those with mild-to-moderate asthma.