Convalescent or standard plasma versus standard of care in the treatment of COVID-19 patients with respiratory impairment: short and long-term effects. A three-arm randomized controlled clinical trial

BACKGROUND

The efficacy of early treatment with convalescent plasma in patients with COVID-19 is debated. Nothing is known about the potential effect of other plasma components other than anti-SARS-CoV-2 antibodies.

METHODS

To determine whether convalescent or standard plasma would improve outcomes for adults in early phase of Covid19 respiratory impairment we designed this randomized, three-arms, clinical trial (PLACO COVID) blinded on interventional arms that was conducted from June 2020 to August 2021. It was a multicentric trial at 19 Italian hospitals. We enrolled 180 hospitalized adult patients with COVID-19 pneumonia within 5 days from the onset of respiratory distress. Patients were randomly assigned in a 1:1:1 ratio to standard of care (n = 60) or standard of care + three units of standard plasma (n = 60) or standard of care + three units of high-titre convalescent plasma (n = 60) administered on days 1, 3, 5 after randomization. Primary outcome was 30-days mortality. Secondary outcomes were: incidence of mechanical ventilation or death at day 30, 6-month mortality, proportion of days with mechanical ventilation on total length of hospital stay, IgG anti-SARS-CoV-2 seroconversion, viral clearance from plasma and respiratory tract samples, and variations in Sequential Organ Failure Assessment score. The trial was analysed according to the intention-to-treat principle.

RESULTS

180 patients (133/180 [73.9%] males, mean age 66.6 years [IQR 57-73]) were enrolled a median of 8 days from onset of symptoms. At enrollment, 88.9% of patients showed moderate/severe respiratory failure. 30-days mortality was 20% in Control arm, 23% in Convalescent (risk ratio [RR] 1.13; 95% confidence interval [CI], 0.61-2.13, P = 0.694) and 25% in Standard plasma (RR 1.23; 95%CI, 0.63-2.37, P = 0.544). Time to viral clearance from respiratory tract was 21 days for Convalescent, 28 for Standard plasma and 23 in Control arm but differences were not statistically significant. No differences for other secondary endpoints were seen in the three arms. Serious adverse events were reported in 1.7%, 3.3% and 5% of patients in Control, Standard and Convalescent plasma arms respectively.

CONCLUSIONS

Neither high-titer Convalescent nor Standard plasma improve outcomes of COVID-19 patients with acute respiratory failure. Trial Registration Clinicaltrials.gov Identifier: NCT04428021. First posted: 11/06/2020.

Six-month humoral and cellular immune response to the third dose of BNT162b2 anti-SARS-CoV-2 vaccine in the patients with solid tumors: a longitudinal cohort study with a focus on the variants of concern

Background

The role and the durability of the immunogenicity of the third dose of vaccine against COVID-19 variants of concern in cancer patients have to be elucidated.

Patients and methods

We have prospectively evaluated the immunogenicity of the third dose of the SARS-CoV-2 BNT162b2 messenger RNA vaccine in triggering both humoral and cell-mediated immune response in patients with solid tumors undergoing active treatment 6 months after the booster. Neutralizing antibody (NT Ab) titers and total anti-spike immunoglobulin G concentrations were measured in serum. Heparinized whole blood samples were used for the SARS-CoV-2 interferon-γ release assay (IGRA).

Results

Six months after the third dose only two patients (2.4%) showed negative spike-specific immunoglobulin G antibody levels (<33.8 BAU/ml). The median level of SARS-CoV-2 NT Abs decreased and only 39/83 (47%) subjects showed maximum levels of NT Abs. T-cellular positive response was observed in 38/61 (62.3%) patients; the highest median level of response was observed 21 days after the third dose (354 mIU/ml, interquartile range 83.3-846.3 mIU/ml). The lowest median level of NT Ab response was observed against the Omicron variant (1 : 10, interquartile range 1 : 10-1 : 40) with a significant reduced rate of responder subjects with respect to the wild-type strain (77.5% versus 95%; P = 0.0022) and Delta variant (77.5% versus 93.7%; P = 0.0053). During the follow-up period, seven patients (8%) had a confirmed post-vaccination infection, but none of them required hospitalization or oxygen therapy.

Conclusions

Our work highlights a significant humoral and cellular immune response among patients with solid tumors 6 months after the third BNT162b2 vaccine dose, although a reduction in neutralizing activity against Omicron was observed.

•

Only two patients (2.4%) showed negative spike-specific IgG antibody levels (<33.8 BAU/ml)

•

Only 39/83 (47%) subjects showed maximum level of neutralizing antibodies (NT Abs).

•

T-cellular positive response was observed in 38/61 (62.3%) analyzed patients.

•

The lowest median level of NT Ab response was observed against the Omicron variant.

•

Seven patients (8%) had a post-vaccination infection; none of them required hospitalization or oxygen therapy.

Immunogenicity and safety after the third dose of BNT162b2 anti-SARS-CoV-2 vaccine in patients with solid tumors on active treatment: a prospective cohort study

BACKGROUND

Although a full course of coronavirus disease 2019 (COVID-19) vaccine is effective in cancer patients, the duration of the protection and the efficacy of a booster dose against the new variants remain unknown. We prospectively evaluated the immunogenicity of the third dose of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) BNT162b2 messenger RNA vaccine in cancer patients undergoing active treatment.

PATIENTS AND METHODS

Patients with solid cancer, vaccinated with a booster dose during active treatment, were enrolled in this study. Patients were classified into SARS-CoV-2 naïve (without previous COVID-19 infection) and SARS-CoV-2 experienced (with previous COVID-19 infection). Neutralizing antibody (NT Ab) titer and total anti-Spike immunoglobulin G (IgG) concentration were quantified in serum. Heparinized whole blood samples were used for SARS-CoV-2 Interferon Gamma Release Assay (IGRA). The primary endpoint was to assess the increase of IgG antibody level between baseline and 3 weeks after the booster.

RESULTS

One hundred and forty-two consecutive patients were recruited. In SARS-CoV-2-naïve subjects, the median level of IgG was 157 BAU/ml [interquartile range (IQR) 62-423 BAU/ml] at T0 and reached a median of 2080 BAU/ml (IQR 2080-2080 BAU/ml) at 3 weeks after booster administration (T1; P < 0.0001). A median 16-fold increase of SARS-CoV-2 NT Ab titer (IQR 4-32) was observed in naïve subjects (from median 20, IQR 10-40, to median 640, IQR 160-640; P < 0.0001). Median interferon-γ level at T1 was significantly higher than that measured at T0 in SARS-CoV-2-naïve subjects (P = 0.0049) but not in SARS-CoV-2-experienced patients. The median level of SARS-CoV-2 NT Abs was 32-fold lower against Omicron compared to the wild-type strain (P = 0.0004) and 12-fold lower compared to the Delta strain (P = 0.0110).

CONCLUSIONS

The third dose is able to trigger both the humoral and the cell-mediated immune response in cancer patients on active treatment. Our preliminary data about the neutralization of the SARS-CoV-2 vaccine against variants of concern seem to confirm the lower vaccine activity.

Analysis of the humoral and cellular immune response after a full course of BNT162b2 anti-SARS-CoV-2 vaccine in cancer patients treated with PD-1/PD-L1 inhibitors with or without chemotherapy: an update after 6 months of follow-up

Background

The durability of immunogenicity of SARS-CoV-2 vaccination in cancer patients remains to be elucidated. We prospectively evaluated the immunogenicity of the vaccine in triggering both the humoral and the cell-mediated immune response in cancer patients treated with anti-programmed cell death protein 1/programmed death-ligand 1 with or without chemotherapy 6 months after BNT162b2 vaccine.

Patients and methods

In the previous study, 88 patients were enrolled, whereas the analyses below refer to the 60 patients still on immunotherapy at the time of the follow-up. According to previous SARS-CoV-2 exposure, patients were classified as SARS-CoV-2-naive (without previous SARS-CoV-2 exposure) and SARS-CoV-2-experienced (with previous SARS-CoV-2 infection). Neutralizing antibody (NT Ab) titer against the B.1.1 strain and total anti-spike immunoglobulin G concentration were quantified in serum samples. The enzyme-linked immunosorbent spot assay was used for quantification of anti-spike interferon-γ (IFN-γ)-producing cells/10⁶ peripheral blood mononuclear cells. Fifty patients (83.0%) were on immunotherapy alone, whereas 10 patients (7%) were on chemo-immunotherapy. We analyzed separately patients on immunotherapy and patients on chemo-immunotherapy.

Results

The median T-cell response at 6 months was significantly lower than that measured at 3 weeks after vaccination [50 interquartile range (IQR) 20-118.8 versus 175 IQR 67.5-371.3 IFN-γ-producing cells/10⁶ peripheral blood mononuclear cells; P < 0.0001]. The median reduction of immunoglobulin G concentration was 88% in SARS-CoV-2-naive subjects and 2.1% in SARS-CoV-2-experienced subjects. SARS-CoV-2 NT Ab titer was maintained in SARS-CoV-2-experienced subjects, whereas a significant decrease was observed in SARS-CoV-2-naive subjects (from median 1 : 160, IQR 1 : 40-1 : 640 to median 1 : 20, IQR 1 : 10-1 : 40; P < 0.0001). A weak correlation was observed between SARS-CoV-2 NT Ab titer and spike-specific IFN-γ-producing cells at both 6 months and 3 weeks after vaccination (r = 0.467; P = 0.0002 and r = 0.428; P = 0.0006, respectively).

Conclusions

Our work highlights a reduction in the immune response in cancer patients, particularly in SARS-CoV-2-naive subjects. Our data support administering a third dose of COVID-19 vaccine to cancer patients treated with programmed cell death protein 1/programmed death-ligand 1 inhibitors.

•

Median spike-specific T-cell response at 6 months was lower compared with 3 weeks after vaccine in SARS-CoV-2-naive subjects.

•

Median reduction of SARS-CoV-2-specific immunoglobulin G concentration was 88% in SARS-CoV-2-naive subjects.

•

The SARS-CoV-2 neutralizing activity was maintained stable in subjects with previous COVID-19.

•

No COVID-19 cases were documented throughout the period of study.

A snapshot of the immunogenicity, efficacy and safety of a full course of BNT162b2 anti-SARS-CoV-2 vaccine in cancer patients treated with PD-1/PD-L1 inhibitors: a longitudinal cohort study

Background

Very few cancer patients were enrolled in coronavirus disease-2019 vaccine studies. In order to address this gap of knowledge, real-world studies are mandatory. The aim of this study was to assess both humoral and cellular response after a messenger RNA vaccination schedule.

Patients and methods

Eighty-eight consecutive cancer patients treated with programmed cell death protein 1/programmed death-ligand 1 inhibitors were enrolled from the beginning of the vaccination campaign for frail patients. Blood samples for humoral and cell-mediated immune response evaluation were obtained before vaccination (T0), before the second administration (T1) and 21 days after the second dose (T2). The primary endpoint was the evaluation of the percentage of participants showing a significant increase in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-specific T cells, measured by an enzyme-linked immunospot assay, after the second dose of BNT162b2 vaccine. The proportion of patients who reached the primary endpoint is computed together with its exact binomial 95% confidence interval.

Results

In SARS-CoV-2-naïve subjects, spike-specific T-cell response was almost undetectable at T0 [median 0.0 interferon-γ (IFN-γ) spot forming units (SFU)/million peripheral blood mononuclear cell (PBMC) interquartile range (IQR) 0-7.5] and significantly increased at T1 and T2 (median 15.0 IFN-γ SFU/million PBMC, 25th-75th 0-40 versus 90 IFN-γ SFU/million PBMC, 25th-75th 32.5-224, respectively) (P < 0.001). Focusing on naïve and experienced SARS-CoV-2 subjects, no differences were reported both in terms of CD4- and CD8-specific T-cell response, suggesting that BNT162b2 is able to elicit both adaptive responses after complete vaccination schedule, regardless of previous SARS-CoV-2 exposure. The level of SARS-CoV-2 neutralizing antibodies was low at T1 in SARS-CoV-2-naïve subjects [median 1 : 5 (IQR 1 : 5-1 : 20)] but reached a significantly higher median of 1 : 80 (25th-75th 1 : 20-1 : 160) at T2 (P < 0.0001). Moreover, no COVID-19 cases were documented throughout the period of study.

Conclusions

Our data have demonstrated that the administration of a full course of BNT162b2 vaccine elicited a sustained immune response against SARS-CoV-2 regardless of the type of cancer and/or the type of immune checkpoint inhibitors.

•

In SARS-CoV-2-naïve subjects, spike-specific T-cell response was significantly increased after the second dose of vaccine

•

In patients treated with chemo-immunotherapy, T-cell response seems to be lower with borderline statistical significance

•

Between naïve and experienced patients, no differences were reported in terms of CD4- and CD8-specific T-cell response

•

In naïve patients, the level of SARS-CoV-2 neutralizing antibodies reached a significantly higher median of 1 : 80 after the second dose

•

No COVID-19 cases were documented throughout the period of study

Positron emission tomography response evaluation from a randomized phase III trial of weekly nab-paclitaxel plus gemcitabine versus gemcitabine alone for patients with metastatic adenocarcinoma of the pancreas

BACKGROUND

In the phase III MPACT trial, nab-paclitaxel plus gemcitabine (nab-P + Gem) demonstrated superior efficacy versus Gem alone for patients with metastatic pancreatic cancer. We sought to examine the feasibility of positron emission tomography (PET) and to compare metabolic response rates and associated correlations with efficacy in the MPACT trial.

PATIENTS AND METHODS

Patients with previously untreated metastatic adenocarcinoma of the pancreas were randomized 1:1 to receive nab-P + Gem or Gem alone. Treatment continued until disease progression by RECIST or unacceptable toxicity.

RESULTS

PET scans were carried out on the first 257 patients enrolled at PET-equipped centers (PET cohort). Most patients (252 of 257) had ≥2 PET-avid lesions, and median maximum standardized uptake values at baseline were 4.6 and 4.5 in the nab-P + Gem and Gem-alone arms, respectively. In a pooled treatment arm analysis, a metabolic response by PET (best response at any time during study) was associated with longer overall survival (OS) (median 11.3 versus 6.9 months; HR, 0.56; P < 0.001). Efficacy results within each treatment arm appeared better for patients with a metabolic response. The metabolic response rate (best response and week 8 response) was higher for nab-P + Gem (best response: 72% versus 53%, P = 0.002; week 8: 67% versus 51%; P = 0.014). Efficacy in the PET cohort was greater for nab-P + Gem versus Gem alone, including for OS (median 10.5 versus 8.4 months; hazard ratio [HR], 0.71; P = 0.009) and ORR by RECIST (31% versus 11%; P < 0.001).

CONCLUSION

Pancreatic lesions were PET avid at baseline, and the rate of metabolic response was significantly higher for nab-P + Gem versus Gem alone at week 8 and for best response during study. Having a metabolic response was associated with longer survival, and more patients experienced a metabolic response than a RECIST-defined response.

CLINICALTRIALSGOV

NCT00844649.

Abstract P4-13-12: Everolimus plus trastuzumab and vinorelbine for trastuzumab-resistant, taxane-pretreated, HER2+ advanced breast cancer: Overall survival results from BOLERO-3

Background

PI3K/AKT/mTOR pathway activation due to PTEN loss may lead to trastuzumab (TRAS) resistance. mTOR inhibition has been shown to restore TRAS sensitivity in PTEN-deficient tumors. This provided the rationale for the BOLERO-3 trial which evaluated the combination of everolimus (EVE), an mTOR inhibitor, plus TRAS and a taxane in HER2+ advanced breast cancer (ABC). The addition of EVE to TRAS plus vinorelbine (VNB) led to a statistically significant prolongation of 1.2 months in median progression free survival (PFS) vs TRAS plus VNB in patients with TRAS-resistant and taxane-pretreated, HER2+ ABC (7.0 months vs 5.78 months; hazard ratio, 0.78; p=0.0067). The final overall survival (OS) analysis from this study is presented here.

Materials and methods

BOLERO-3 is a randomized, double-blind, placebo-controlled, phase 3 trial. Women with HER2+ ABC progressing on prior TRAS and taxane therapy were randomized (1:1) to receive either daily EVE (5 mg) or PBO plus weekly TRAS (2 mg/kg) and VNB (25 mg/m2), in 3-week cycles, stratified by previous lapatinib use. The primary endpoint was PFS by local investigator assessment. Overall survival was a key secondary endpoint.

Results

Overall, 569 patients were enrolled; 284 patients received EVE and 285 patients received PBO. As of April 1, 2015, after a median follow-up of 44.7 months, 388 deaths had occurred, 191 (67.3%) in the EVE arm and 197 (69.1%) in the PBO arm. The median OS in the EVE arm vs PBO arm was 23.5 months vs 24.1 months (HR = 0.96; 95% CI, 0.79-1.17; p = 0.3392). In the HR+ subgroup, the median OS with EVE was 23.5 months (vs 25.5 months with PBO; HR = 1.03; 95% CI, 0.79-1.35); in the HR subgroup, the median OS with EVE was 22.9 months (vs 23.1 months with PBO; HR = 0.86; 95% CI, 0.64-1.17). AEs leading to treatment discontinuation were reported in 81 (28.9%) vs 46 (16.3%) patients in the EVE vs PBO arms. Serious adverse events (SAEs) were reported in 122 (43.6%) vs 58 (20.6%) patients in the EVE vs PBO arms. Overall, 14 on-treatment deaths were observed, 7 (2.5%) in the EVE arm and 7 (2.5%) in the PBO arm; on-treatment deaths due to AEs were balanced between treatment arms (0.7% in each treatment arm). Types of post-progression therapies were balanced across both treatment arms.

Conclusions

In BOLERO-3, EVE showed a statistically significant prolongation of PFS. OS was similar in both treatment arms. The safety profile of EVE was comparable to that observed previously with EVE in breast cancer. (Funded by Novartis; BOLERO-3 ClinicalTrials.gov number, NCT01007942.)

Citation Format: Isaacs C, O'Regan R, Xu B, Masuda N, Arena F, Yap Y-S, Papai Z, Lang I, Armstrong A, Lerzo G, White M, Shen K, Zhang Y, Jappe A, Pacaud LB, Taran T, Ozguroglu M. Everolimus plus trastuzumab and vinorelbine for trastuzumab-resistant, taxane-pretreated, HER2+ advanced breast cancer: Overall survival results from BOLERO-3. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-13-12.

Colistin resistance superimposed to endemic carbapenem-resistant Klebsiella pneumoniae: a rapidly evolving problem in Italy, November 2013 to April 2014

Consecutive non-replicate clinical isolates (n=191) of carbapenem non-susceptible Enterobacteriaceae were collected from 21 hospital laboratories across Italy from November 2013 to April 2014 as part of the European Survey on Carbapenemase-producing Enterobacteriaceae (EuSCAPE) project. Klebsiella pneumoniae carbapenemase-producing K. pneumoniae (KPC-KP) represented 178 (93%) isolates with 76 (43%) respectively resistant to colistin, a key drug for treating carbapenamase-producing Enterobacteriaceae. KPC-KP colistin-resistant isolates were detected in all participating laboratories. This underscores a concerning evolution of colistin resistance in a setting of high KPC-KP endemicity.

[Specific antigen prostatic changes during treatment with finasteride or dutasteride for benign prostatic hyperplasia]

AIM

The aim of this paper was to compare and analyze the therapeutic effects and PSA variation levels with treatment with finasteride-tamsulosin and dutasteride-tamsulosin for benign prostatic hyperplasia for 2 years and the risk to developing prostate cancer for patients with PSA<4 ng/mL.

METHODS

We retrospectively investigated 288 patients who suffered from BPH and PSA>4 ng/mL between January 2003 and July 2010. For treatment groups, we divided the patients into two groups: one was treated with tamsulosin and finasteride and the other with tamsulosin and dutasteride. At the beginning of treatment, the patients underwent transrectal ultrasonography and prostate mapping, measurement of urine flow rate, PSA, and International Prostate Symptom Score (IPSS). A total of 288 patients were able to be.

RESULTS

Both finasteride and dutasteride rduced PSA and prostate volume significantly. The comparison between the 2 groups showed a significant difference at 3 months for IPSS; uroflussimetry and prostate volume in the dutasteride group, but at 6 months did not differ significantly between the groups. Patients with a PSA reduction more than half presented a good response and didn't request surgical theraphy.

CONCLUSION

5 alpha Reductase inhibitors for BPH treatment reduced PSA and prostate volume significantly after 6 months of theraphy and after 3 months only for dutasteride. PSA reduction is directly correlated with response to theraphy. Didn't were evidenced statistically differences on prostate cancer presence during theraphy.

Epidemic diffusion of KPC carbapenemase-producing Klebsiella pneumoniae in Italy: results of the first countrywide survey, 15 May to 30 June 2011

Carbapenem-resistant Enterobacteriaceae (CRE) are emerging as a public health problem in various settings. In Italy, a rapid and remarkable increase of carbapenem-non-susceptible Klebsiella pneumoniae has been reported since 2010. Here we report on the results of a countrywide cross-sectional survey, carried out from 15 May to 30June 2011 to investigate the diffusion of CRE in Italy and to characterise the most prevalent resistance mechanisms and their dissemination patterns. CRE were reported from most (23 of 25) participating laboratories, with an overall proportion of 3.5% and 0.3% among consecutive non-duplicate clinical isolates of Enterobacteriaceae from inpatients (n=7,154) and outpatients (n=6,595), respectively. K. pneumoniae was the most frequent species (proportion of carbapenem-non-susceptible isolates: 11.9%), while a minority of CRE of other species were detected. Carbapenemase production was detected in the majority (85%) of CRE. KPC-type enzymes were by far the most common (89.5% of carbapenemase producers), followed by VIM-1 (9.2%) and OXA-48 (1.3%). KPC-producing K. pneumoniae (KPC-KP) were detected in most centres and contributed majorly to the epidemic dissemination of CRE recently observed in our country. Dissemination of KPC-KP was mostly sustained by strains of clonal complex 258 (ST-258 producing KPC-2 or KPC-3, and ST-512 producing KPC-3), while a minority belonged to ST-101.

Epidemic diffusion of KPC carbapenemase-producing Klebsiella pneumoniae in Italy: results of the first countrywide survey, 15 May to 30 June 2011

Carbapenem-resistant Enterobacteriaceae (CRE) are emerging as a public health problem in various settings. In Italy, a rapid and remarkable increase of carbapenem-non-susceptible Klebsiella pneumoniae has been reported since 2010. Here we report on the results of a countrywide cross-sectional survey, carried out from 15 May to 30 June 2011 to investigate the diffusion of CRE in Italy and to characterise the most prevalent resistance mechanisms and their dissemination patterns. CRE were reported from most (23 of 25) participating laboratories, with an overall proportion of 3.5% and 0.3% among consecutive non-duplicate clinical isolates of Enterobacteriaceae from inpatients (n=7,154) and outpatients (n=6,595), respectively. K. pneumoniae was the most frequent species (proportion of carbapenem-non-susceptible isolates: 11.9%), while a minority of CRE of other species were detected. Carbapenemase production was detected in the majority (85%) of CRE. KPC-type enzymes were by far the most common (89.5% of carbapenemase producers), followed by VIM-1 (9.2%) and OXA-48 (1.3%). KPC-producing K. pneumoniae (KPC-KP) were detected in most centres and contributed majorly to the epidemic dissemination of CRE recently observed in our country. Dissemination of KPC-KP was mostly sustained by strains of clonal complex 258 (ST-258 producing KPC-2 or KPC-3, and ST-512 producing KPC-3), while a minority belonged to ST-101.

Natural history of non-operative treatment for renal injuries in children

AIM

Kidney is one of the solid organs injured in blunt abdominal traumas. Conservative management is well recognized in adults, but is still controversial in children. We performed a retrospective review regarding children with renal injuries observed at our Centre, analyzing the importance of a prompt diagnosis and the role of conservative treatment according to the degree of renal injury and natural history.

METHODS

We reviewed 15 cases of blunt abdominal trauma with renal injuries observed during a period of 11 years. The diagnosis was confirmed by abdominal computed tomography (CT) scan and ultrasonography (US). Conservative treatment started monitoring the hemodynamic stability, the hematocrit value, the hemoglobin, the red cell count, the urine analysis. If necessary blood transfusion was performed. A follow-up from 1 month to 2 years monitored the lesions healing.

RESULTS

Age of patients varied from 3 to 15 years (mean age = 6.3). Nine were males and six females. Two patients had an associated spleen lesion, thirteen had an isolated renal injury. Injury grades were classified as follows: grade I, 5 cases; grade II, 3 cases; grade III, 5 cases and grade IV, 2 cases. Non operative management was successful in 14 out of 15 cases; 1 patient with grade IV required a partial nephrectomy. At follow-up good healing of the lesions was observed.

CONCLUSION

Most of renal injury related to abdominal trauma can be successfully and safely managed conservatively. Hemodynamic stability, a prompt clinical and instrumental diagnosis and grading of lesions by CT are necessary to start an effective non operative treatment.

Rapid detection of intestinal carriage of Klebsiella pneumoniae producing KPC carbapenemase during an outbreak

Two different approaches are described for rapid detection of intestinal carriage of Klebsiella pneumoniae producing KPC-type carbapenemase (KPC-KP), based on PCR amplification of DNA extracts from rectal swabs (K-PCR), and on direct plating of rectal swabs on to MacConkey agar with a meropenem disc and a meropenem plus 3-aminophenylboronic acid disc (direct KPC screening test, DKST). K-PCR and DKST were tested with a total of 101 samples from 65 patients, during an outbreak. Although less sensitive, DKST could detect high-level carriage, which appears to be common among infected and colonised patients, while being very cheap and easy to perform, and requiring only basic facilities.

Early metabolic, functional and histological changes in a rat ileal-augmented bladder model

OBJECTIVE

An animal model of female Wistar species of rats was developed to study the early effects of ileocystoplasty.

MATERIALS AND METHODS

Bladder augmentation using ileum and a sham operation (cistostomy) were performed in 14 and 6 female Wistar rats, rispectively. Urine was obtained for culture and urinalysis in all rats at the time of operation and at the time of the sacrifice. Seven rats underwent ileocystoplasty and three shams were sacrificed after one and three months. In all rats sacrificed three months after ileocystoplasty, blood sample drawn for serum electrolytes, blood urea, nitrogen creatine and bicarbonate was performed. Post mortem histopathological examination of the ileal patch and of kidneys was performed.

RESULTS

The cultures of the urine were positive in 1 out 7 (14.3%) and in 4 out 7 (57%) after one and three months after ileocystoplasty, respectively. Urinary pH of the augmented group was significantly higher in treated rats than in shams (p < 0.05). At sacrifice three months post operatively, the serum chloride concentration was significantly higher in augmented than shams (p < 0.05). Bladder calculi were formed in 28.6% of ileocystoplasty. Histopathological examination of the enteropatch showed urothelialization of the graft and kidneys showed a significant glomerular depletion.

CONCLUSION

Our data confirm an early significant enhancement of urinary pH in rats underwent ileocystoplasty and the stone formation is a frequent event. Already three months after ileocystoplasty urothelialization extended from the side of anastomosis towards the central portion of the ileal graft. Moreover, a significant improvement of serum creatine, sign of glomerular overload and progressive glomerular depletion were recorded in treated rats, probably as a consequence of water and electrolyte resoption through the intestinal graft.

Anterior urethral valves in the fossa navicularis in a newborn: report of a case and review of the literature

Anterior urethral valves in the fossa navicularis is an exceptionally uncommon causes of lower urinary tract obstruction in newborn. The authors report a case of anterior urethral valves in thefossa navicularis in an 5 days-old boy, that observation of the voided stream revealed a filiform micturition and marked ballooing of the penile urethra. The meatus was located normally and of normal calibre. Voiding cystourethrography showed obstruction at the fossa navicularis, and a hyghly trabeculated bladder. Ultrasonography showed a severe bilateral hydroureteronephrosis. After a temporary soprapubic cystostomy, the urethroscopy revealed a valve on the floor of the fossa navicularis, excised with tenotomy scissor. Postoperatively ,urethral obstruction was relieved immediately by a good urinary stream. At 6 months follow-up the patient voided with a good stream and ultrasonography revealed complete disappearance of hydroureteronephrosis.

Neonatal intrathoracic gastric volvulus in Marfan's syndrome

Intrathoracic gastric volvulus is extremely rare in the newborn period. The authors describe the case of a newborn with unusual combination of intrathoracic gastric volvulus and Marfan's Syndrome and discuss its management.

An unique case of Y-type urethral duplication associated with posterior urethral valve

This case report is about a 4-year-old patient with a IIA2 ''Y-type'' duplication, with the accessory urethra arising from the anterior orthotopic urethra and exiting in perineal-scrotal position, in association with posterior urethral valves (PUV). Cystourethroscopy through the ventral urethra revealed a type III urethral valve (diaphragm) and this was fulgurated. Duplicated dorsal urethra was excised surgically. Postoperative period was uneventful. This case is unique, because it shows PUV in a child with a very rare type of ''Y-type'' duplication. The presence of PUV in patients with urethral duplication is probably not an incidental finding but, to date, embryology of this rare association is not known.

An uncommon case of associate intrinsic and extrinsic stenosis of the duodenum in newborn

The incidence of congenital combinations of extrinsic and intrinsic compression of duodenum is uncommon. The authors report a rare case of a neonate with a duodenal stenosis due to the contemporary presence of an annular pancreas and wind sock web. The diagnostic strategies and management will be discussed.

[Dutasteride in the treatment of hormone refractory prostate cancer]

AIM

Most patients with advanced prostate cancer respond to androgen inhibition with or without antiandrogens. Progression to androgen-independent prostate cancer takes 5-7 years and is characterized by biochemical or diagnostic changes, despite testosteronemia levels similar to those after castration. Dutasteride, a 5-alfa-reductase types 1 and 2 inhibitor, is used in the treatment of benign prostatic hyperplasia (BPH). In prostate cancer, 5-alfa-reductase type 1 expression is greater than in BPH, but no differences in 5-alfa-reductase type 2 expression have been observed between metastatic prostate cancer and BPH. The higher levels of the two isozymes in metastatic and in recurrent prostate cancer after androgen withdrawal may reflect a selective adaptive mechanism to the amplification of remaining androgen signals. The aim of this prospective study was to evaluate the clinical utility of dutasteride in the treatment of hormone refractory prostate cancer.

METHODS

Between March 2005 and December 2007, 8 patients with hormone refractory prostate cancer were evaluated prospectively. Following antiandrogen withdrawal and subsequent increase in PSA, 5 patients received docetaxel plus prednisone and 3 received ketoconazole plus hydrocortisone. The regimen was a single administration of 2 tablets of 0.5 mg dutasteride/die. Therapeutic response was defined as a >50% reduction in PSA or a 75% reduction at 4 weeks after the start of therapy.

RESULTS

The mean duration of follow-up was 9 months (range, 21-24 months). A reduction >50% or >75% in PSA was noted in 4 and 6 patients, respectively. Bone scintigraphy detected no normalization of bone lesions; computed tomography scanning showed no partial response to treatment. The mean duration of response was 6.9 months (range, 0-21 months). Two (25%) of the 8 patients died at 6 and 10 months, respectively, neither of which had responded to dutasteride treatment. Only 1/8 patients reported experiencing dyspepsia during the study period.

CONCLUSION

The activity of 5-alfa-reductase types 1 and 2 is expressed in the epithelial cells of the prostate, the stroma, and the prostate tumor. The genetic expression of fatty acid synthesis is influenced by dutasteride, which inhibits it by blocking the pathway that regulates sterol protein binding which, in turn, regulates androgen stimulation. The addition of a dual inhibitor of 5-a-reductase types 1 and 2 to antiandrogen therapy may further inhibit tumor growth, thus reducing the concentration of intracellular dihydrotestosterone, which is the primary androgen mediator of PSA gene expression in prostate tumor cell lines. These data support the rationale for the use of dutasteride in the treatment of hormone refractory prostate cancer. The study findings show that dutasteride is useful in the treatment of hormone refractory prostate cancer.

Case report of congenital fistula of the penile urethra

Isolated congenital fistula of the penile urethra is extremely rare. A case of congenital urethral fistula with an intact glandular urethra without chordee is reported with a discussion of the possible etiology and management.

Management of "open" syringocele based on urodynamic findings

INTRODUCTION

Depending on the type and size of the syringocele and the age of the patient, syringocele is treated medically or surgically, with endoscopy or open surgery. We report our experience in 10 "open" consecutive cases of syringocele, propose a clinical classification and discuss the management.

MATERIAL AND METHODS

In all patients (pts), diagnosis was achieved through voiding cystourethrography. All pts performed multichannel urodynamic studies. Pts with impaired compliance and/or detrusor instability (4 pts out of 10) underwent endoscopic unroofing. They were followed up until to 24 months after the endoscopic procedure. Pts with normal urodynamic findings were treated medically and followed with clinical examination. All pts performed an urinalysis every 2 weeks for the first three months and monthly for an year.

RESULTS

In endoscopic treated pts, voiding cystourethrography showed a normal profile of the urethra at 3 months follow-up. Pts with UTI, but with normal urodynamic parameter were treated with antibiotic therapy. At serial follow-up, all pts were completely symptom-free. Urinalysises were normal, negative for infection or haematuria.

DISCUSSION

In the literature to date, there isn't accordance if and when treated "open" syringoceles. In our opinion, it is useful to classify "open" syringocele based on urodynamic findings. Syringocele needs endoscopic surgical treatment if it is obstructed or a cause of dysfunctional alteration of the bladder, in order to avoid unnecessary surgery in syringocele without urodynamic abnormality.

Amifostine pretreatment for patients with advanced colorectal cancer receiving folfox chemotherapy

19663

Background: Oxaliplatin plays a key role in the treatment of advanced colorectal cancer (CRC) but is associated with dose- limiting peripheral neuropathy (PN) in >20% of patients. We investigated the effects of amifostine, a cytoprotective agent, on the prevention of PN in patients receiving oxaliplatin in combination with 5-fluorouracil (5-FU) and leucovorin (LV) (FOLFOX) for the treatment of advanced (stage =III) CRC. Methods: In this ongoing prospective observational study, patients with stage =III CRC are assigned to receive FOLFOX alone (oxaliplatin 85 mg/m2, 5-FU 400 mg/m2 bolus, 5-FU 1.2 or 2.4 g/m2 continuous infusion over 46 h, LV 200 or 400 mg/m2) or FOLFOX plus 500 mg subcutaneous amifostine 30 minutes before chemotherapy. Some patients also receive bevacizumab and/or panitumumab. All patients receive Ca/Mg infusion (1 g each/100 mL normal saline) before and after oxaliplatin treatment. Incidence and degree of PN are assessed during biweekly patient interviews and graded using National Cancer Institute Common Toxicity Criteria Version 3. Results: Sixteen patients have enrolled to date (9 nonamifostine, 7 amifostine; mean age, 60.2 y [range, 33–81 y]; 81% men). Currently, data for 6 patients (3 per group) who have completed 12 cycles of therapy are available. Two of 3 patients in the nonamifostine group reported PN grade =2 during treatment; 1 of these patients required multiple treatment interruptions because of grade 3 PN. The third nonamifostine patient reported grade 1 PN on only 2 occasions during treatment but experienced grade 2 PN at 3-month follow-up. No patient in the amifostine group reported grade =2 PN during the treatment period. One amifostine patient required a reduction in oxaliplatin dose after 8 cycles because of neutropenia. At 3-month follow-up, 1 amifostine-treated patient reported grade 1 tingling in his hands and is currently receiving treatment with pregabalin. Conclusions: The use of amifostine for the prevention of oxaliplatin-induced PN is investigational. Patients with advanced CRC who received amifostine with FOLFOX chemotherapy had a decreased incidence and severity of PN compared with patients who did not receive amifostine. Updated data will be available at the time of presentation; study enrollment continues.

No significant financial relationships to disclose.

Phase II trial of nab-paclitaxel (nanoparticle albumin-bound paclitaxel (ABX)) + capecitabine (XEL) in first-line treatment of metastatic breast cancer (MBC)

1053

Background: ABX and XEL both have substantial single agent activity in MBC. Taxane and anti-metabolite doublets improve response rate and TTP and longer survival. ABX administered weekly has an excellent safety and efficacy profile with maintenance of dose intensity. This study was designed to test the safety and efficacy of ABX + XEL given in a novel combination schedule. Methods: This phase II, multicenter open label study utilized ABX 125 mg/m2 IV on day 1, 8 and with no premeds and capecitabine 825 mg/m2 PO BID days 1–14 on a Q 3 week cycle. The primary endpoint is objective response rate, with evaluation performed after every 2 cycles. Entry criteria include measurable MBC by RECIST criteria, age >18, PS 0–2, no prior chemo for metastatic disease, > 6 months since adjuvant fluoropyrimidine and/or paclitaxel. Results: The full sample of 50 patients (pts) have been enrolled; data from 43 pts are available for analysis. Median age is 58 (range 23.7–90.6). 37% received prior adjuvant anthracycline and 33% prior adjuvant taxane. Median number of metastatic sites is 2 (range 1–7), with most common sites of disease liver, 53.5%; bone, 51.2%; and lung, 14%. 226 cycles of therapy have been delivered. 5 pts required a dose reduction in XEL (3 pts to 650 mg/m2; 2 to 550 mg/m2) and 4 pts had dose reduction in ABX to 100 mg/m2. XEL dose reductions occurred due to hand-foot syndrome (3), neutropenia (1), and fatigue (1). ABX dose reductions occurred due to mucositis, diarrhea, fatigue, and neuropathy (1 pt each). 10 pts had grade 3–4 non-hematologic AEs: 3 hand-foot syndrome, 4 fatigue, and 3 GI. Hematologic AEs included 4 with grade 3 and 1 with grade 4 neutropenia, and 2 with grade 4 febrile neutropenia. The most common AEs of any grade were GI (30), dermatological (23), fatigue (15), neuropathy (12), and hand-foot syndrome (11). The incidence of Grade 1–2 neuropathy was 25% (no grade 3–4). Of 38 pts available for analysis of response, the overall response rate is 47.5%: PR 39.5%, CR 8%. Total of 15 pts have stable disease, 20 pts have completed 6+ cycles.

No significant financial relationships to disclose.

C-kit positive interstitial cells of Cajal network in primary obstructive megaureter

AIM

Recent reports have shown an altered density of interstitial cells of Cajal (ICCs) and peripherin immunoreactive nerve fibres in uretopelvic junction obstruction. The aim was to investigate ICCs immunoexpression and ureteral innervation in primary obstructive megaureter (POM).

METHODS

Eight specimens of POM were obtained during tailoring. Restricted segments of ureters were divided from dilated segments. C-kit and peripherin immunohistochemistry were performed.

RESULTS

A normal distribution of ICCs was observed in both the circular and longitudinal muscle layers of the dilated segments. Marked muscle hypoplasia and sparse or no ICCs occurred in the longitudinal muscle layer of the restricted ureteral segments. A normal distribution of peripherin positive fibres was present in both the dilated and restricted segments.

CONCLUSIONS

Our data confirm defective muscularization in restricted aperistaltic POM. The lack of ICCs in the longitudinal muscular layer is probably due to the absence of c-kit positive muscle embryological precursors. No alteration in the peripherin immunoreactive nerve fibres network was observed in either the dilated or the restricted ureteral segments.

Gynecological screening for HPV infection

HPV infection is the most common sexually transmitted disease today and is strongly related to cervical cancer. We studied 1500 women in a limited area of the Calabria region to determine the best method of screening for cevical cancer.

Small bowel intussusception by local recurrence of an inflammatory myofibroblastic tumor: report of a case and review of the literature

Inflammatory myofibroblastic tumor (IMT) of the ileum is a rare, usually solitary lesion, that frequently presents small-intestinal intussusception and obstruction. We describe an IMT of the ileum in a 4.5-year old child who presented a small bowel intussusception. During laparotomy, an annular mass around the ileum was resected, and the IMT was histologically diagnosed. Three months after the operation, the patients were hospitalized with the symptoms of intestinal obstruction. Laparotomy showed a ileal intussusception. Along the previous suture line of anastomosis, a smooth polypoid tumor was evident. Segmental resection of the ileum, including the tumor mass, was performed. The IMT was immunohistochemically diagnosed. The patient was asymptomatic at 3 year follow-up. A review of the literature for this rare entity emphasizes the importance of immunohistochemical confirmation of its benign nature. Because of the risk of local recurrence, IMT cases should have a long-term follow-up.

A case of bilateral prenatal testicular torsion: Ultrasonographic features, histopathological findings and management

OBJECTIVES

The aim of this study was to demonstrate the ultrasonographic features of prenatal bilateral torsion of the testis, and its histological correlation and management.

PATIENT

A newborn presented at delivery with both testes enlarged, swollen and tender. Prenatal ultrasound (US) showed enlarged, hyperechoic testes. Colour Doppler US examination was performed.

RESULTS

US revealed both testes to be heterogeneous. Colour Doppler US did not reveal any flow signal. On inguinal exploration both testes appeared necrotic. Histology showed recognizable seminiferous tubules and Leydig cells.

CONCLUSION

We believe that both testes should be left in situ after bilateral detorsion even if their macroscopic appearance is necrotic.

Surgical correction of penoscrotal transposition associated with hypospadias and bifid scrotum: our experience of two-stage repair

OBJECTIVE

To assess the results of surgical correction of incomplete penoscrotal transposition and bifid scrotum using the Glenn-Anderson technique, and its impact on subsequent definitive urethroplasties and final outcome.

PATIENTS AND METHODS

We retrospectively reviewed 31 children that underwent two-stage repair for incomplete penoscrotal transposition with severe hypospadias and bifid scrotum. Patient age at stage 1 ranged from 12 to 24 months (average 16 months). The operative principle was based on achieving a normal anatomical position of the penis and scrotum using the Glenn-Anderson technique. In cases with associated scrotal or perineal hypospadias this was transformed into a penoscrotal hypospadias. Final stage urethroplasty was performed after a period of 6 months with a modified Thiersch-Duplay technique.

RESULTS

Cosmetic and functional results of the Glenn-Anderson operation were excellent. No major complications were observed. Of 31 patients, 12 (38%) had complications secondary to urethral repair.

CONCLUSION

The Glenn-Anderson technique for reconstruction of penoscrotal transposition and bifid scrotum is a simple technique, free of major complications. The purpose of this intervention is to improve the cosmetic appearance and function of the penis. A minimum period of 6 months between consecutive urethroplasties is important. The final stage guarantees good functional and cosmetic results preserving the prepuce.

Immunoexpression of aquaporin-1 in adolescent varicocele testes: Possible significance for fluid reabsorption

OBJECTIVES

To investigate the immunoexpression of aquaporin-1 (AQP-1), a major transmembrane water channel, in high-grade varicocele testes, which are known to imply an unbalanced transmembrane water flow, in both tubular and extratubular compartments.

METHODS

Light microscopy and AQP-1 immunohistologic examination were carried out on incisional testicular biopsies from 20 adolescent boys, aged 13 to 18 years, with grade 2 or 3 idiopathic varicocele. Testicular tissue from 4 autopsied subjects of matched age were also investigated as parallel controls.

RESULTS

At microscopic examination, the tubular lumina and extracellular matrix were expanded and venular profiles dilated. Cytoplasmic vacuoles were frequent in the Sertoli cells, spermatogonia, and spermatocytes, together with premature sloughing of germ cells and residual cytoplasmic droplets inside the spermatozoa, if present. Diffuse AQP-1 positivity occurred at venular endothelial cell membranes and, unexpectedly, at the cell membranes of the Sertoli cells, diploid germ cells, and haploid cells. In the control testes, focal AQP-1 immunolabeling was confined to the microvessel endothelial cells, without any positive reaction in the tubular or extratubular compartments.

CONCLUSIONS

This is the first report showing AQP-1 cell expression in adolescent varicocele testes in both tubular and extratubular compartments. It was associated with the main histologic features of unbalanced water flow in the tubular and interstitial compartments of the testis. Immunocytochemical patterns revealed AQP-1 as a possible critical reabsorption factor, acting to reduce abnormal fluid retention in endotubular cells and the extracellular matrix and, to a lesser extent, in Leydig cells.

[Fetal pseudohypoaldosteronism: rare cause of hydramnios]

PHA is a rare cause of hydramnios, characterized by increased amniotic fluid levels of aldosterone and sodium. Two distinct genetic entities (PHA type I and PHA type II) are included. Both are stemmed by a target organ defect with diminished renal tubular responsiveness to aldosterone. The AA present a case in which pregnancy resulted in a preterm infant with severe hydramnios, metabolic acidosis, hyponatriemia, hyperkaliemia. Salt and fluid replacement significantly improved clinical and metabolic condition. However a growth deficiency (-2 SDS) persists at follow-up.

Bilateral neonatal adrenal abscess. Report of two cases and review of the literature

Neonatal adrenal abscess is an extremely rare condition. 32 cases, 4 bilateral, have been described in the world literature. We treated successfully other two bilateral cases. We report on this rare condition and review the world literature. In our Department we observed two patients in the neonatal period with abdominal distension, vomiting, irritability and fever. Abdominal ultrasound (US), plain x-ray of the abdomen, intravenous pyelography and computed tomography (CT) of the abdomen were performed. In both cases bilateral suprarenal cystic masses were identified. Vanilmandelic acid, Homovanillic acid and cathecolamines were normal. The two neonates underwent a surgical exploration. Abscesses were found and drained releasing a moderate amount of haemorrhagic and purulent materials from the adrenal glands. Post-operative histology on the surgical specimen showed in both cases an abscess in partial haemorrhagic adrenal glands. No neoplastic cells were observed. The recovery was uneventful and at six months follow-up both patients were well and without signs of adrenal insufficiency. Haematogenous bacteria seeding a normal gland or abscess formation in a previous haemorrhagic gland are the most accredited theories. Neuroblastoma, Wilm's tumor and renal duplication with dilatation of the upper segment must be considered in the differential diagnosis. Percutaneous drainage (+/- biopsy) under CT or US guide should be considered the treatment of choice, followed by surgical exploration when diagnosis is not clear.

[Respiratory diseases in infants hospitalized during the 1st 2 years of life for viral lower respiratory tract infections: a one-year follow-up]

BACKGROUND

Epidemiologic data suggest strong links between hospitalisation with bronchiolitis in infancy and subsequent higher risk of developing lower respiratory tract infections (LRTI) and/or hyperreactive airway diseases. The aim of this study was to evaluate in an Italian population the natural history of respiratory diseases in children hospitalised for LRTI when they were <2 years.

METHODS

An observational, perspective, longitudinal study was performed through telephone interviews. Nine pediatric tertiary care centres participated to the study evaluating a population of 187 children, hospitalised in the previous year (November 1999-April 2000) for bronchiolitis or pneumonia when they were <2 years of age and participated to a previous study on the prevalence of infant LRTI in Italy (RADAR).

RESULTS

Twenty-three (12.3%) children had a gestational age <36 weeks. In the 12 months following the first hospitalisation, an elevated frequency of respiratory symptoms was found. Indeed, 152 (81.3%) children suffered from not-requiring-hospital-admission respiratory infections and 21 (11.2%) were hospitalized again for LRTI: 11.6% had bronchiolitis, 23.5% bronchitis and 35.2% pneumonia. In addition, 1.2% had gs;3 infectious episodes and 21.4% gs;6: 68 (36.4%) showed wheezy bronchitis and 17 (9.1%) were reported to have asthma; 132 children (71%) took antibiotics during the last year, 19.4% >3 times; 111 (59.4%) bronchodilators and 49 (26.2%) oral corticosteroids. One year after the first hospitalisation, 19 subjects (10.2%) were found to be positive to at least one class of allergens by prick test or RAST.

CONCLUSIONS

Thus, the demonstration of a high morbidity rate for LRTI, wheezing and asthma in this study group during the first year follow-up after hospital admission further support the need for prophylactic interventions to reduce the morbidity and severity of sequelae of LRTI, in particularly in premature children and/or with additional risk factors.

[Acute urine retention: early clinical sign of a rhabdomyosarcoma of the bladder or prostate in children: report of three cases]

Acute urine retention can be the first clinical sign of a rabdomyosarcoma (RMS) of bladder and prostate. This is particularly evident in the age group comprised between 2 and 4 years. The Authors report their experience on three cases of 2 years old males admitted for acute urine retention. One case was diagnosed to have an prostate RMS, the other two a RMS of the bladder. The prostate RMS refused the operation dying 2 years after operation. Of the two cases of RMS of the bladder, one was treated successfully by polychemotherapy treatment, the second, after polychemotherapy underwent a partial cystectomy. The Authors conclude affirming the importance of a ultrasonography of the lower urinary tract in all patients with acute retention of urine, since this could be the first sign of a RMS of prostate or bladder.