Real-life use of ropeg-interferon α2b in polycythemia vera: patient selection and clinical outcomes

Ropeginterferon-alfa2b (ropegIFNα2b) is a long-acting IFN formulation with broad FDA/EMA approval as a therapy of polycythemia vera (PV) with no symptomatic splenomegaly. There is currently lack of information on the real-world patient selection, including the impact of local reimbursement policies, and drug management, particularly: type/timing of screening and follow-up tests; absolute/relative contraindications to therapy; ropegIFNα2b dose and combinations with hydroxyurea. As a sub-analysis of the PV-ARC retrospective study (NCT06134102), we here report our monocenter experience with ropegIFNα2b in the period from January 2021, corresponding to drug availability outside clinical trial, and December 2023. Among the 149 patients with EMA/FDA indication, only 55 (36.9%) met the local reimbursement criteria and 18 (12.1%) received ropegIFNα2b. Thanks to appropriate screening, relative/absolute contraindications to ropegIFNα2b were detected and managed in a multidisciplinary manner. Efficacy and safety of ropegIFNα2b was confirmed, with 3 cases of early molecular response. General use of low ropegIFNα2b dose, with frequent need for hydroxyurea combinations, was noted. This real-world experience suggests a significant impact of local regulations on drug prescription and the need for greater real-world data collection on ropegIFNα2b in PV patients. Also, it describes appropriate multidisciplinary screening and monitoring procedures during ropegIFNα2b therapy.

Long-Term Retention Rate of Tofacitinib in Rheumatoid Arthritis: An Italian Multicenter Retrospective Cohort Study

Background: Tofacitinib (TOFA) was the first Janus kinase inhibitor (JAKi) to be approved for the treatment of rheumatoid arthritis (RA). However, data on the retention rate of TOFA therapy are still far from definitive. Objective: The goal of this study is to add new real-world data on the TOFA retention rate in a cohort of RA patients followed for a long period of time. Methods: A multicenter retrospective study of RA subjects treated with TOFA as monotherapy or in combination with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) was conducted in 23 Italian tertiary rheumatology centers. The study considered a treatment period of up to 48 months for all included patients. The TOFA retention rate was assessed with the Kaplan-Meier method. Hazard ratios (HRs) for TOFA discontinuation were obtained using Cox regression analysis. Results: We enrolled a total of 213 patients. Data analysis revealed that the TOFA retention rate was 86.5% (95% CI: 81.8-91.5%) at month 12, 78.8% (95% CI: 78.8-85.2%) at month 24, 63.8% (95% CI: 55.1-73.8%) at month 36, and 59.9% (95% CI: 55.1-73.8%) at month 48 after starting treatment. None of the factors analyzed, including the number of previous treatments received, disease activity or duration, presence of rheumatoid factor and/or anti-citrullinated protein antibody, and presence of comorbidities, were predictive of the TOFA retention rate. Safety data were comparable to those reported in the registration studies. Conclusions: TOFA demonstrated a long retention rate in RA in a real-world setting. This result, together with the safety data obtained, underscores that TOFA is a viable alternative for patients who have failed treatment with csDMARD and/or biologic DMARDs (bDMARDs). Further large, long-term observational studies are urgently needed to confirm these results.

Real life use of prostacyclin analog (iloprost), a multi-centric survey data from the Scleroderma study group Emilia Romagna (Sclero-RER) and review of the literature

BACKGROUND AND AIM

Iloprost is recommend worldwide for the treatment of RP and the healing of DUs. The aim of this study is to report the regimens of Iloprost administered in different rheumatological centers within the same regional Health System Methods: A questionnaire exploring different items related to the use of Iloprost was developed and reviewed by three expert rheumatologists. The questionnaire was distributed as an online survey to all local SSc referral centers in Emilia-Romagna (Italy). Data are reported as percentage or median with interquartile range (IQR), as appropriate. An updated review of world literature on this topic was also carried out.

RESULTS

All the invited centers completed the survey. There were both local (8) and university hospitals (4). The majority (58%) had a rheumatologist as head physician. All centers used Iloprost: a single monthly administration was the most common treatment (75%). The cycle lasted 1 [IQR 1-2] days with a 0.5-2.0 ng/Kg/min dose according to the drug tolerance of the patients. There were overall 68 spots (beds, reclining armchair, or simple armchair); 2.0 [1.5-4.0] patients were able to receive Iloprost at the same time. University Hospitals had more physicians at their disposal than local hospitals but less paramedic personnel (respectively: 1.8 vs 1.2 physicians, 1.5 vs 2.1 nurses).

CONCLUSIONS

These observations were in line with the majority of previous studies reporting different regimens, comparing similar (but not identical) dose and schedule administration, however, despite differences being at times substantial, no standard infusion method is yet available.

Inflammatory rheumatic diseases with onset after SARS-CoV-2 infection or COVID-19 vaccination: a report of 267 cases from the COVID-19 and ASD group

OBJECTIVES

To better define the spectrum of new-onset post-COVID-19 and post-COVID-19 vaccine inflammatory rheumatic diseases (IRD) from a large multicentric observational study.

METHODS

Consecutive cases of IRD encountered during a 12-month period and satisfying one of the following inclusion criteria: (a) onset of the rheumatic manifestations within 4 weeks from SARS-CoV-2 infection or (b) onset of the rheumatic manifestations within 4 weeks from the administration of one of the COVID-19 vaccines ws recruited.

RESULTS

The final analysis cohort comprised 267 patients, of which 122 (45.2%) in the post-COVID-19 and 145 (54.8%) in the postvaccine cohort. Distribution of IRD categories differed between the two cohorts: the post-COVID-19 cohort had a higher percentage of patients classified as having inflammatory joint diseases (IJD, 52.5% vs 37.2%, p=0.013) while the post-vaccine cohort had a higher prevalence of patients classified as polymyalgia rheumatica (PMR, 33.1% vs 21.3%, p=0.032). No differences were detected in the percentage of patients diagnosed with connective tissue diseases (CTD 19.7% vs 20.7%, p=0.837) or vasculitis (6.6% vs 9.0%, p=0.467). Despite the short follow-up period, IJD and PMR patients' response to first-line therapy was favourable, with both groups achieving a drop in baseline disease activity scores of ~30% and ~70% respectively.

CONCLUSION

Our article reports the largest cohort published to date of new-onset IRD following SARS-CoV-2 infection or COVID-19 vaccines. Although causality cannot be ascertained, the spectrum of possible clinical manifestations is broad and includes IJD, PMR, CTD and vasculitis.

Post-Acute COVID-19 Joint Pain and New Onset of Rheumatic Musculoskeletal Diseases: A Systematic Review

As the number of reports of post-acute COVID-19 musculoskeletal manifestations is rapidly rising, it is important to summarize the current available literature in order to shed light on this new and not fully understood phenomenon. Therefore, we conducted a systematic review to provide an updated picture of post-acute COVID-19 musculoskeletal manifestations of potential rheumatological interest, with a particular focus on joint pain, new onset of rheumatic musculoskeletal diseases and presence of autoantibodies related to inflammatory arthritis such as rheumatoid factor and anti-citrullinated protein antibodies. We included 54 original papers in our systematic review. The prevalence of arthralgia was found to range from 2% to 65% within a time frame varying from 4 weeks to 12 months after acute SARS-CoV-2 infection. Inflammatory arthritis was also reported with various clinical phenotypes such as symmetrical polyarthritis with RA-like pattern similar to other prototypical viral arthritis, polymyalgia-like symptoms, or acute monoarthritis and oligoarthritis of large joints resembling reactive arthritis. Moreover, high figures of post-COVID-19 patients fulfilling the classification criteria for fibromyalgia were found, ranging from 31% to 40%. Finally, the available literature about prevalence of rheumatoid factor and anti-citrullinated protein antibodies was largely inconsistent. In conclusion, manifestations of rheumatological interest such as joint pain, new-onset inflammatory arthritis and fibromyalgia are frequently reported after COVID-19, highlighting the potential role of SARS-CoV-2 as a trigger for the development of autoimmune conditions and rheumatic musculoskeletal diseases.

AB0725 Scleroderma study group Emilia Romagna (Sclero-RER): real life use of prostacyclin analog. Preliminary data from a multicentric survey

Background

Systemic Sclerosis (SSc) is a complex autoimmune disease characterized by vascular damage, immune activation and fibrosis of skin and internal organs 1. Raynaud phenomenon (RP) is frequently the first symptom of the disease and growing evidences are supporting the hypothesis the SSc may be a vascular disease, with a pivotal role of endothelial cells, particularly in the very early phase2,3. Robust data support the use of vascular active drug to treat RP and to prevent vascular complication4–7.

Objectives

The use of prostacyclin analog (PA) is evertything but standardized, with different regimen used all around the Country. We report data on the use of PA in a multicentric regional reality to understand which regimen are prevalent (and why) and if there is the opportunity to standardized them.

Methods

We collected data from an online survey exploring different items related to the use of PA.

Results

Survey was fullfilled by 12 sites: 5 university hospital and 7 local hospitals, 7 driven by Rheumatologist and 5 from internal medicine specialists with/without concomitant rheumatologists. PA are ubiquitarly used for SSc-related digital ulcers (SSc-DU) and secondary RP but only a half of sites use it for primary RP. Seventy-five percent of sites (9/12) dispense PA at least once a month, but some other (1 each one respectively) on weekly basis, every other month or every 7 weeks. Drug administration may last from 2 to 5 consecutive days (mean 1.91+/- 1.5SD) with drug dose ranging from 0.5 to 2 ng/Kg/min with a minimum variability from site to site. Our regional hospitals may count on overall 68 spots, some available as beds (outpatient or inpatient), some as reclining chair or chair (outpatients only). University centers have usually more assigned personnel than local hospital (on average: 2 versus 1.5 physicians, 2 versus 1.2 nurse). Sites are able to offer meals (except one) and are able to accomodate from 1 to 12 patients at the same time (mean 3.45, +/- 3.2SD).

Conclusion

PA has known benefit in vascular involvement in SSc patients. Despite a multicenter palcebo-control study8 defining time and dose of this drugs and subsequent data based on the same regimen9, there is no homogeneity in treatment administration. The unequal treatment, based on our data, seems due to limited resources and personnel. High variability has been found in regimen duration and administration frequency.

References

[1]Ferri, C. et al. Systemic sclerosis evolution of disease pathomorphosis and survival. Our experience on Italian patients’ population and review of the literature. Autoimmunity Reviews vol. 13 1026–1034 (2014).

[2]Mulligan-Kehoe, M. J. et al. Antiangiogenic plasma activity in patients with systemic sclerosis. Arthritis Rheum.56, 3448–58 (2007).

[3]Wigley, F. M. Vascular disease in scleroderma. Clin. Rev. Allergy Immunol.36, 150–75 (2009).

[4]Brueckner, C. S. et al. Effect of sildenafil on digital ulcers in systemic sclerosis: Analysis from a single centre pilot study. Ann. Rheum. Dis.69, 1475–1478 (2010).

[5]Kowal-Bielecka, O. et al. EULAR recommendations for the treatment of systemic sclerosis: A report from the EULAR Scleroderma Trials and Research group (EUSTAR). Ann. Rheum. Dis.68, 620–628 (2009).

[6]Matucci-Cerinic, M. et al. Bosentan treatment of digital ulcers related to systemic sclerosis: Results from the RAPIDS-2 randomised, double-blind, placebo-controlled trial. Ann. Rheum. Dis.70, 32–38 (2011).

[7]Herrick, A. L. & Wigley, F. M. Raynaud’s phenomenon. Best Practice and Research: Clinical Rheumatology (2020) doi:10.1016/j.berh.2019.101474.

[8]Wigley, F. M. et al. Intravenous iloprost infusion in patients with Raynaud phenomenon secondary to systemic sclerosis: A multicenter, placebo-controlled, double- blind study. Ann. Intern. Med.120, 199–206 (1994).

[9]Cappelli, L. & Wigley, F. M. Management of Raynaud Phenomenon and Digital Ulcers in Scleroderma. Rheumatic Disease Clinics of North America vol. 41 419–438 (2015).

Disclosure of Interests

None declared

AB1407 TELERHEUMATOLOGY AND WORKING VISIT: INITIAL MONOCENTRIC EXPERIENCE ON USE OF TELEVISIT IN THE REGULAR FOLLOW-UP

Background

The COVID-19 pandemic shifted most healthcare to remote delivery methods (telehealth technologies including clinical video televisit) to protect patients, clinicians, and hospital staff. Telerheumatology visits were found to be noninferior to in-person visits and are often more time and cost effective for patients.1

Objectives

Description of an initial integration of video televisit in regular follow-up.

Methods

In cooperation with the ALTEMS Operational Telemedicine Observatory, we built a procedural manual for televisit, whose phases were as much as possible similar to the usual visit scenario. Patients in remission or in mild disease activity at the time of enrolling visit were involved. Clinical characteristics, treatments and televisits’ features were considered for all patients (Table 1). Patient overall satisfaction was evaluated (rating 1 to 5).

Table 1.Patients (n.)74M/F27/47Age (y) median46.2±13.5RA n. (%)19 (25.6)PsA n. (%)21 (28.3)SpA (%)13 (17.5)CTD n. (%)8 (10,4)Vasculitis n. (%)7 (9.4)Other n. (%)6 (8.1)b or tsDMARDs n. (%)20 (62.5)Televisits n.86Mean duration (min.)17±3.5Satisfaction (1-5)4.68Device (PC/smartphone) %62.5/37.5Distance saved, mean (km)77,5Time travel saved, mean (min.)66CO2 saved (kg)866.71€ saved (per patient)44,37Working visit n. (%)5 (15.6)

Results

86 televisits were performed in 74 consecutive patients, with a mean age of 46.2 ± 13.5 years, diagnosed with the most common rheumatic diseases and on chronic immunosuppressive therapy (c-b-ts DMARDs mono or combination therapy). In 5 cases, in-person visit after televisit was required. the average duration of the televisit was 17 ± 3.5 minutes and the average overall satisfaction was 4.68 / 5. The average distance saved (round trip) was 77,5 km, equal to an avoided travel time of 66 minutes and with a total reduction in CO2 production of approximately 866 kg. 5 patients performed video visit from workplace, de facto inventing the “working visit”.

Conclusion

Telemedicine is going to become an essential element of clinical practice in rheumatology,2 especially for active, young, and working patients, helping to minimize the overall impact of the disease on QoL, as far as they are properly selected for clinical characteristics and informatic skills. The possibility to attend to televisit from the workplace will reduce the lost working-hours and the need of travel, thus acquiring undoubted social utility. In the near future, the use of televisit should be also extended to vulnerable patients lacking basic informatic resources, with the help of care-givers or dedicated territorial services.

References

[1]Matsumoto R, Barton JL. Curr Opin Rheum 2021 May; 1;33(3):262-269. doi:0.1097/BOR.0000000000000790.

[2]https://www.salute.gov.it/imgs/C_17_pubblicazioni_2129_allegato.pdf

ALTEMS = Alta Scuola di Economia e Management dei Sistemi Sanitari

Disclosure of Interests

None declared

Susceptibility to COVID-19 in Patients Treated With Antimalarials: A Population-Based Study in Emilia-Romagna, Northern Italy

Objective

To evaluate the susceptibility to coronavirus disease 2019 (COVID‐19) in patients with autoimmune conditions treated with antimalarials in a population‐based study.

Methods

All residents treated with chloroquine (CQ)/hydroxychloroquine (HCQ) from July through December 2019 and living in 3 provinces of Regione Emilia‐Romagna were identified by drug prescription registries and matched with the registry containing all residents living in the same areas who have had swabs and tested positive for severe acute respiratory syndrome coronavirus 2 (SARS–CoV‐2). Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated.

Results

A total of 4,408 patients were identified. The prevalence of patients receiving antimalarials was 0.85 per 1,000 men and 3.3 per 1,000 women. The cumulative incidence of testing during the study period was 2.7% in the general population and 3.8% among those receiving CQ or HCQ, while the cumulative incidence of testing positive was 0.55% in the general population and 0.70% among those receiving CQ/HCQ. Multivariate models showed that those receiving CQ/HCQ had a slightly higher probability of being tested compared to the general population (OR 1.09 [95% CI 0.94–1.28]), the same probability of being diagnosed as having COVID‐19 (OR 0.94 [95% CI 0.66–1.34]), and a slightly lower probability of being positive once tested (OR 0.83 [95% CI 0.56–1.23]). None of the differences were significant.

Conclusion

Our findings do not support the use of antimalarials as a prophylactic treatment of COVID‐19.

Diagnosis and treatment of rheumatoid arthritis in the Emilia Romagna region: a prospective population-based study

OBJECTIVES

To perform a population-based study in rheumatoid arthritis (RA) patients, in order to evaluate the efficacy and safety of pharmacologic treatments.

METHODS

1087 patients with RA were enrolled; inclusion criteria were: newly diagnosed RA, already diagnosed RA with high disease activity (HDA) (DAS28≥4.2) starting biologic DMARDs (bDMARDs), already diagnosed RA with HDA continuing with conventional DMARDs (cDMARDs). The following data were collected: demographics, clinical and laboratory features, imaging and prescribed drugs. All parameters except immunology and imaging (performed yearly) were repeated at each follow-up evaluations (after 3, 6 and 12 months, and thereafter every 12 months). In order to evaluate clinical response, the EULAR response criteria were used as the gold standard.

RESULTS

414 (38.1%) newly diagnosed patients with RA, 477 (43.9%) RA patients who started bDMARDs and 196 (18.0%) RA patients who continued with cDMARDs were enrolled from April 2012 to March 2015 at 12 Rheumatology Centres in the Emilia Romagna Region. Statistical analyses showed a relative risk ratio (RRR) for moderate response of 1.65 in RA patients who started bDMARDs (p=0.16) and 2.49 for newly diagnosed RA (p=0.01). Sex, age and Health Assessment Questionnaire were not statistically significant. A RRR of 2.00 has been confirmed for RA patients who started bDMARDs (p<0.0005) for a good response as well as 2.20 for newly diagnosed RA (p<0.0005). An increase in adverse events among bDMARDs was found, but when looking at infections or neoplasia, no differences were highlighted between RA which started bDMARDs and RA who continued with cDMARDs.

CONCLUSIONS

Our results are in line with already published papers from British and Swedish Registries: a greater likelihood to have a good response is demonstrated for not longstanding RA starting cDMARDs or RA with HDA when a bDMARD is started. Also a good safety profile is demonstrated.

Complexity in hospital internal medicine departments: what are we talking about?

Internal medicine (IM) patients are mostly elderly, with multiple complex co-morbidities, usually chronic. The complexity of these patients involves the intricate entanglement of two or more systems (e.g. body and disease, family-socio-economic and environmental status, coordination of care and therapies) and this requires comprehensive, multi-dimensional assessment (MDA). Despite attempts to improve management of chronic conditions, and the availability of several MDA tools, defining the complex patient is still problematic. The complex profile of our patients can only be described through the best assessment tools designed to identify their characteristics. In order to do this, the Federation of Associations of Hospital Doctors on Internal Medicine FADOI has created its own vision of IM. This involves understanding the different needs of the patient, and analyzing diseases clusters and the possible relationships between them. By exploring the real complexity of our patients and selecting their real needs, we can exercise holistic, anthropological and appropriate choices for their treatment and care. A simpler assessment approach must be adopted for our complex patients, and alternative tools should be used to improve clinical evaluation and prognostic stratification in a hierarchical selection of priorities. Further investigation of complex patients admitted to IM wards is needed.

Skin signs in acute pancreatitis: a case report

Introduction: Subcutaneous manifestations of severe acute pancreatitis (Cullen’s sign, Gray- Turner’s sign, Fox’s sign, and Bryant’s sign) are often discussed in journals and textbooks, but seldom observed. Although historically associated with acute pancreatitis, these clinical signs have been described in various other conditions associated with retroperitoneal hemorrhage. Case report: We describe the case of a 61-year-old male with no history of alcohol intake, who was admitted for epigastric pain, vomiting, and increasing serum amylase and lipase levels. Five days after admission, ecchymotic skin discoloration was noted over both flanks (Gray-Turner’s sign) and the upper third of the thighs (Fox’s sign). Ten days later, he developed multiorgan failure and was transferred to the ICU for 5 days. Computed tomography revealed a large pancreatic fluid collection, which was subjected to EUS-guided drainage. Cholecystectomy was later performed for persistent obstructive jaundice. After more than 4 months of hospitalization, he died as a result of severe gastrointestinal bleeding. Discussion and conclusions: Skin manifestations of retroperitoneal hemorrhage in a patient with acute pancreatitis indicate a stormy disease course and poor prognosis. The severity of acute pancreatitis is currently estimated with validated scoring systems based on clinical, laboratory, and imaging findings. However, skin signs like the ones discussed above can represent a simple and inexpensive parameter for evaluating the severity and prognosis of this disease.

Internal medicine, complexity, evidence based medicine, almost ‘‘without evidences’’

Background: Internal medicine has been defined as the specialty of the adult medical complex patients. Complexity science suggests that illness (and health) results from complex, dynamic, and unique interactions between different components of the overall system. In a patient, complexity involves the intricate entanglement of two or more systems (e.g.; body-diseases, family, socioeconomic status, therapies). Aim of the study: To evaluate the real applicability of Evidence Based Medicne (EBM) in clinical Departments of Internal Medicine and its critical perspectives. Discussion: Habitually the internist takes decisions in these situations: a) certainty (the ideal decision is adopted and the corresponding strategy follows), b) risk (the more suitable alternative selected can be the determination of the probable value or mathematical hope) and c) uncertainty, in which decisions linked to triple agents: beliefs and personal values of the doctors (I) for their patients (II) in the society (III). In the medical decisions there are often different factors that go beyond the field of technical and scientific knowledge (family, social, economic problems, etc.) and demanding an ethical analysis of the decision. Conclusions: The ‘‘evidence-based medicine’’, as other models of care, has — in itself — some limitations. ‘‘No evidence in medicine’’ matters that the postulates of the EBM are not always applicable to the real patients of Internal Medicine wards, mostly elderly, frail, complex, with comorbidities and polipharmacy, often with cognitive dysfunction and limitation of autonomy, with psycho-emotional, social and economic problems. The interacting effects of overall involved diseases/factors and their management require more complex and individualised care than simply the sum of separate guideline components. Further innovation is required to resolve the need to enhance integration of evidence with our patients’ values at the ‘‘bedside and/or clinic’’ management.

Genetic diversity, structure and individual assignment of Casta Navarra cattle: a well-differentiated fighting bull population

The Casta Navarra lineage was one of the populations used to establish the fighting bull (FB) breed, and it has also been reproductively isolated from the others FBs. A total of 1284 individuals from two generations of 16 Casta Navarra herds were sampled to analyse their diversity, their genetic structure and the ability of 28 microsatellite markers to assign individuals to closely related populations. These animals were compared with closely related phylogenetic (FB) or geographical (Pirenaica and Monchina) populations. Hardy-Weinberg equilibrium analysis showed that 82% of the loci had a significant heterozygote deficit as a consequence of the Wahlund effect. The average proportion of genetic variation explained by farm differences was 9% by Wright's FST index. A phylogenetic tree constructed with a neighbour-joining method based on Reynolds genetic distances and a Bayesian Markov chain Monte Carlo clustering approach revealed clear differences between farm groups that generally corresponded to historical information and could unambiguously differentiate Casta Navarra cattle from the other populations. The percentage of animals correctly assigned to the Casta Navarra population was 91.78% for a q threshold of >0.9. Admixture was only detected in 4.45% (q < 0.8) of the cattle. These results are relevant for the maintenance and development of diversity and conservation in the Casta Navarra population.

Management of chronic obstructive pulmonary disease exacerbations in Internal Medicine

Introduction: Chronic obstructive pulmonary disease (COPD) is the second leading cause of hospitalization in Internal Medicine departments in Italy and the fourth leading cause of death all over the word. By 2020, COPD will be the third leading cause of death and the fifth leading cause of disability. It is — along with chronic congestive heart failure — one of the most common causes of unscheduled hospital readmissions, and as such it represents a significant economic burden for the health-care system. Exacerbations of COPD are important events in the natural history of this prevalent condition. Discussion: This review provides a comprehensive state-of-the-art look at prevention and management of COPD exacerbations. Treatment of these episodes has to be tailored to the severity of the clinical presentation. We now have a wide range of therapeutic available options, based on the results of clinical trials. Management of the acute event should include the necessary measures (mainly the administration of inhaled short-acting bronchodilators, inhaled or oral corticosteroids, and antibiotics), with or without oxygen and ventilator support. Conclusions: To improve the management of COPD exacerbations, the focus of care must be shifted from the episodic acute complications to their systematic prevention. The management of COPD, which is often associated with multiple co-morbidities, is complex and requires a tailored, multifaceted and multidisciplinary approach. Integrated care for COPD also requires that patients be informed about their condition, that they participate actively in their care, and that they have easy access to the necessary health-care services.

Ortner's syndrome: a rare case of cardiovocal hoarseness

Introduction Ortner's syndrome, also known as cardiovocal syndrome, is a rare clinical entity with hoarseness due to left recurrent laryngeal nerve (RLN) palsy owing to a cardiovascular disease. Norbert Ortner ascribed hoarseness of voice RLN palsy in patients with several mitral stenosis, postulating that an enlarged left atrium could be responsible for the recurrent laryngeal nerve palsy. Case report A 63-year-old man with a history of progressive hoarseness of voice developed since over three months. Flexible laryngoscopy revealed a fixed left vocal cord in the paramedian position. The chest enhanced axial computed tomography confirmed a large left ventricular aneurysm. Conclusions Hoarseness has significant public health implications. Patients suffer from social deprivation, depression and a poor quality of life. Several underlying conditions are associated with the cardiovocal syndrome, including iatrogenic, congenital, mitral valve disorders, aortic and ventricular aneurysms. Laryngoscopy is indicated for the assessment of hoarseness if symptoms fail to improve or resolve within three months, or at any time when the clinician suspects a serious underlying disorder.

Development of an ionic liquid-based dispersive liquid-liquid microextraction method for the determination of nifurtimox and benznidazole in human plasma

Dispersive ionic liquid-liquid microextraction combined with liquid chromatography and UV detection was used for the determination of two antichagasic drugs in human plasma: nifurtimox and benznidazole. The effects of experimental parameters on extraction efficiency-the type and volume of ionic liquid and disperser solvent, pH, nature and concentration of salt, and the time for centrifugation and extraction-were investigated and optimized. Matrix effects were detected and thus the standard addition method was used for quantification. This microextraction procedure yielded significant improvements over those previously reported in the literature and has several advantages, including high inter-day reproducibility (relative standard deviation=1.02% and 3.66% for nifurtimox and benznidazole, respectively), extremely low detection limits (15.7 ng mL(-1) and 26.5 ng mL(-1) for nifurtimox and benznidazole, respectively), and minimal amounts of sample and extraction solvent required. Recoveries were high (98.0% and 79.8% for nifurtimox and benznidazole, respectively). The proposed methodology offers the advantage of highly satisfactory performance in addition to being inexpensive, simple, and fast in the extraction and preconcentration of these antichagasic drugs from human-plasma samples, with these characteristics being consistent with the practicability requirements in current clinical research or within the context of therapeutic monitoring.

[Long term study on the efficacy and safety of lornoxicam in rheumatoid arthritis]

BACKGROUND

To assess the long term safety and therapeutic action of lornoxicam, a new non steroidal anti-inflammatory agent, in rheumatoid arthritis.

METHODS

Open trial was carried out on different dosage schedules of lornoxicam (4 or 8 mg bid and 4mg tid) administered for six to twelve months. Patients of both sexes were enrolled, with classical or definite rheumatoid arthritis according to the A.R.A. criteria.

RESULTS

Thirty-four patients (28 F, 6 M) were admitted, mean age (+/- SD) 53.9+/-14.2 years, mean duration of illness 9.2+/-10.7 years. Lornoxicam 8-16 mg/day showed good safety and therapeutic activity in long term treatment. Clinical improvement was limited, but progression of the disease was controlled. No adverse events were complained.

CONCLUSIONS

Lornoxicam presented a worth-while therapeutic action and a good tolerability in rheumatoid arthritis long term treatment.

Comparative study of divalent metals and amines as silanol-blocking agents in reversed-phase liquid chromatography

In this work we compare the silanol-blocking ability of different alkaline earth metal cations, including calcium, magnesium and barium, and strong amine silanol blockers, such as triethylamine and octylamine, using six basic probe solutes at pH 7 on a conventional octadecylsilane phase. Some amines are better blocking agents than the metal cations but this varies with the amine and analyte structure. Among the metals, barium is the best blocker. For certain solutes barium is as effective at blocking silanols as some of the amine blockers. It produces short retention times and good peak shapes with satisfactory peak symmetry factors. However, amines with long alkyl chains, such as octylamine, are better blocking agents than barium. Peak symmetry is still poor for some solutes even in the presence of the strongest blocking agent in the eluent.

Comparative study of hydrocarbon, fluorocarbon, and aromatic bonded RP-HPLC stationary phases by linear solvation energy relationships

The retention properties of eight alkyl, aromatic, and fluorinated reversed-phase high-performance liquid chromatography bonded phases were characterized through the use of linear solvation energy relationships (LSERs). The stationary phases were investigated in a series of methanol/water mobile phases. LSER results show that solute molecular size and hydrogen bond acceptor basicity under all conditions are the two dominant retention controlling factors and that these two factors are linearly correlated when either different stationary phases at a fixed mobile-phase composition or different mobile-phase compositions at a fixed stationary phase are considered. The large variation in the dependence of retention on solute molecular volume as only the stationary phase is changed indicates that the dispersive interactions between nonpolar solutes and the stationary phase are quite significant relative to the energy of the mobile-phase cavity formation process. PCA results indicate that one PCA factor is required to explain the data when stationary phases of the same chemical nature (alkyl, aromatic, and fluoroalkyl phases) are individually considered. However, three PCA factors are not quite sufficient to explain the whole data set for the three classes of stationary phases. Despite this, the average standard deviation obtained by the use of these principal component factors are significantly smaller than the average standard deviation obtained by the LSER approach. In addition, selectivities predicted through the LSER equation are not in complete agreement with experimental results. These results show that the LSER model does not properly account for all molecular interactions involved in RP-HPLC. The failure could reside in the V2 solute parameter used to account for both dispersive and cohesive interactions since "shape selectivity" predictions for a pair of structural isomers are very bad.

[4 cases of Horton's temporal arteritis. Hypothesis on the possible correlations with rheumatic polymyalgia]

Giant cell arteritis (GCA) or temporal arteritis is an entity of unknown aetiology and uncertain autonomy for the close relationship with polymyalgia rheumatica (PMR). This work describes four patients with GCA alone. All patients had clinical and laboratoristic evidence of the disease and were treated with steroids. The distribution of HLA antigens showed an increased occurrence of DR4 and B8 antigens. Unfortunately, the small number of patients and the short period of observation don't allow to prove the exact nature of the link between GCA and PMR.