Randomised clinical trial: sofosbuvir and ledipasvir in patients with transfusion-dependent thalassaemia and HCV genotype 1 or 4 infection

BACKGROUND

Patients with thalassaemia major depend on blood transfusions. In Italy, up to 80% of thalassaemia patients bear HCV antibodies due to HCV contaminated transfusions before 1990. Thalassaemia patients with HCV infection have high risk of developing HCC. Treatment based on Pegylated-IFN (Peg-IFN) and Ribavirin (RBV) was limited by relevant side effects.

AIM

To evaluate the impact of Sofosbuvir/Ledipasvir (SOF/LDV) fixed dose combination for 12 weeks without RBV, in patients with thalassaemia major and HCV Genotype 1 or 4 (GT1/4).

METHODS

Open label, historically-controlled, nationwide multicentre study in thalassaemia patients including naïve with cirrhosis and prior treatment failure without cirrhosis. SOF/LDV single pill was administered for 12 weeks to 100 patients of whom 16% had cirrhosis. The control group included 96 patients with comparable baseline characteristics treated with Peg-IFN/RBV. The primary end point was sustained virologic response at follow-up week 12 or 24 after IFN-free or Peg-IFN/RBV, respectively.

RESULTS

In the study group, sustained virological response (SVR) was reported in 98% of patients (95% CI 95.3%-100%). Cirrhotic as well as prior treatment failure achieved 100% SVR. In the control group, SVR was 47.9% (95% CI 37.9%-57.9%). Adverse events including fatigue, headache, nausea, decrease in haemoglobin or increase in ferritin levels were rare and significantly less common in the study than in the historical control group.

CONCLUSIONS

In conclusion, SOF/LDV for 12 weeks provides simple, highly effective and safe Peg-IFN/RBV-free treatment for HCV GT1/4 thalassaemia patients. EUDRACT number 2015-002401-1.

Shorter myotomy on the gastric site (≤2.5 cm) provides adequate relief of dysphagia in achalasia patients

The right length of the myotomy on the gastric side for esophageal achalasia is still a debated issue. We aimed to investigate the final outcome after classic myotomy (CM) as compared with a longer myotomy on the gastric side (LM) in two cohorts of achalasia patients. Forty-four achalasia patients who underwent laparoscopic Heller-Dor were considered; patients with a sigmoid-shaped esophagus were excluded. Symptoms were scored using a detailed questionnaire for dysphagia, regurgitation, and chest pain. Barium swallow, endoscopy, and esophageal manometry were performed before and 6 months after the surgical treatment; 24-hour pH-monitoring was also performed 6 months after the procedure. CM was defined as a gastric myotomy length in the range of 1.5-2.0 cm, while LM was 2.5-3 cm in length. The surgical treatment (CM or LM) was adopted in two consecutive cohorts. Treatment failure was defined as a postoperative symptom score >10th percentile of the preoperative score (i.e. >8). Of the 44 patients representing the study population, 20 had CM and 24 had LM. The patients' demographic and clinical parameters (age, sex, symptom score, duration of symptoms, esophageal diameter, and manometric pattern) were similar in the two groups. The median follow up was 24 months (interquartile range 12-39). One patient in each group was classified as a treatment failure. After the treatment, there was a significant decrease in both groups' symptom score, and resting and residual pressure (P < 0.01), with no statistically significant differences between the two groups in terms of postoperative symptom score, resting and residual pressure, or total and abdominal lower esophageal sphincter length and esophageal diameter. Extending the length of the myotomy on the gastric side does not seem to change the final outcome of the laparoscopic Heller-Dor procedure.

The beneficial effects of early short-term exercise in the offspring of obese mothers are accompanied by alterations in the hypothalamic gene expression of appetite regulators and FTO (fat mass and obesity associated) gene

Maternal overnutrition is implicated in the development of adult metabolic disease, and has been shown to alter the expression of genes involved in energy homeostasis. In the present study, we aimed to test whether a short period of voluntary exercise, followed by a sedentary period, would regulate hypothalamic markers involved in appetite. Adult female Sprague-Dawley rats were fed either normal chow or high-fat diet (HFD) ad lib. for 5 weeks, mated and continued on their assigned diet during gestation/lactation. At weaning males, were separated into chow or HFD groups; half were exercised (running wheels), whereas the remainder were sedentary. At week 10, wheels were removed and rats remained sedentary for 5 weeks, prior to tissue collection. Maternal obesity increased offspring adiposity at 15 weeks and this was exacerbated by postnatal HFD (P < 0.05). Body weight and fat mass were reduced in offspring of obese mothers if they exercised, and this was maintained even after 5 weeks without exercise. At 15 weeks, fasting plasma insulin, leptin and triglyceride concentrations were significantly reduced by exercise in offspring of lean and obese mothers consuming chow, with little benefit in those consuming HFD. Hypothalamic mRNA expression of pro-opiomelanocortin was increased by exercise but only in offspring of lean mothers. Exercise reduced hypothalamic FTO (fat mass and obesity associated) mRNA in offspring of lean dams regardless of diet. A short period of exercise early in life had lasting beneficial effects on body weight, adiposity and hormone profile of male offspring from obese and lean dams, despite being followed by a period of inactivity. The effects of exercise on hypothalamic appetite regulators were more marked in offspring of lean dams.

Endocrine Effects on Heart Function

Among the factors associated with thalassemic heart disease, endocrine disturbance is also a contributing factor. We present a retrospective, cross sectional study, which aims to establish the prevalence of cardiac complications in thalassaemia major (TM) patients with endocrine complications and to evaluate the influence of endocrine disease on cardiac complications. Endocrinological and cardiological parameters were considered on 957 TM patients who are enrolled in the Myocardial Iron Overload in Thalassemia (MIOT) network in 68 sites in Italy. Patients with pubertal hypogonadism (163 males and 175 females), hypothyroidism (192), diabetes mellitus (87) and hypoparathyroidism (61), were compared according to cardiac complications: global heart T2*, cardiac dysfunction, heart failure, arrythmias, pulmonary hypertension and myocardial fibrosis. Control groups were made up according to the age range of patients with the corresponding endocrinopathy. The prevalence of cardiac dysfunction, arrhythmias and heart failure was significantly increased in patients with endocrinopathies. Cardiac complications tended to increase according to the number of endocrinologies affecting the patient. Aim of our retrospective and cross sectional study was to establish the prevalence of cardiac complications in thalassemia major (TM) patients with endocrine diseases and to evaluate the influence of endocrine diseases on cardiac complications.与地中海贫血心脏疾病相关的因素中，内分泌失调也是一个促进因素。 我们进行了回顾和断面研究，旨在患有内分泌并发症的重型地中海贫血患者中建立心脏并发症的患病率，以及评估内分泌疾病对心脏并发症的影响。 曾考虑到意大利地中海贫血心肌铁过载（MIOT）网络的68个站点上注册的957名重型地中海贫血患者的内分泌和心脏病学参数。 根据以下心脏并发症对青春期性腺机能减退的患者（男性163名、女性175名）、甲状腺机能减退患者（192名）、糖尿病患者（87名）和甲状旁腺机能减退患者（61名）进行了比较： 心脏 T2*、心功能障碍、心脏衰竭、心率不齐、肺动脉高血压以及心肌纤维化。 根据相应内分泌病患者的年龄范围建立了对照组。 心功能障碍、心率不齐和心脏衰竭的患病率在内分泌病患者中明显增加。 根据影响患者的内分泌病的数量，心脏并发症倾向于增加。

Thromboembolic events in beta thalassemia major: an Italian multicenter study

Thromboembolic (TE) events have been frequently reported in beta-thalassemic patients in association with known risk factors such as diabetes, complex cardiopulmonary abnormalities, hypothyroidism, liver function anomalies, and postsplenectomy thrombocytosis. In a recent survey involving 9 Italian thalassemic centers, we identified 32 patients with TE episodes in a total of 735 subjects, of whom 683 had thalassemia major and 52 thalassemia intermedia, corresponding to 3.95 and 9.61%, respectively. There was a great variation in localization: the main one (16/32) was CNS, with a clinical picture of headache, seizures and hemiparesis. Other localizations were the pulmonary (3 patients), mesenteric (1 patient) and portal (2 patients) sites. There were 6 cases of deep venous thrombosis (2 in the upper limbs, 4 in the lower ones). Intracardiac thrombosis was found in 2 subjects and clinical and laboratory signs of DIC were observed in 2 others during pregnancy. Since our patients with TE events present a statistically significantly higher incidence of associated dysfunction (cardiomyopathy, diabetes, liver function anomalies, hypothyroidism) than those without TE events (50 vs. 13.8%), we suggest close monitoring of those patients who are at higher risk of developing TE events because of the presence of one or more of these predisposing factors.

Scrapie strain-specific interactions with endogenous murine leukaemia virus

The finding that a senescence-accelerated mouse (SAMP8) shows early brain ageing, with histopathological changes resembling those seen in scrapie, combined with the discovery of high levels of endogenous murine leukaemia virus (MuLV) in brains of SAMP8 mice prompted us to examine the effect of scrapie infection on MuLV titres in this strain and in one of its progenitors, the AKR strain. Three scrapie strains (ME7, 22L and 139A) that had a comparatively short incubation period in SAMP8 and AKR mice caused an increase in brain MuLV titres that was scrapie strain-specific: in each mouse strain, the greatest effect was with 1 39A, and the least with ME7. The 22A scrapie strain, which has a long incubation period in SAMP8 mice, did not affect MuLV titres in brains of this mouse strain. Previous analyses of scrapie incubation periods in AKR, SAMP8 and another strain derived from an AKR cross (SAMR1) showed an inverse relationship between brain MuLV titres and scrapie incubation periods. This finding, combined with the effect of scrapie on MuLV titres, suggests an interaction between the scrapie infectious process and MuLV replication.

Clonal chromosome changes in non-neoplastic ureters

Cytogenetic analysis was performed on 23 samples from non-neoplastic ureters. Clonal chromosome abnormalities were found in eight. They were: loss of Y chromosome, as a single abnormality (five cases) or associated with trisomy 10 and 20 (one case) or with trisomy 2 (one case); and duplication of Y chromosome (one case). Different numerical and structural sporadic abnormalities were found in nine cases. Immunohistochemical analysis and direct observation using the inverted microscope showed that the cells were mainly of the fibroblastic type. FISH analysis with chromosome 7 alpha-satellite probes failed to detect the presence of trisomy 7 in three epithelial cases tested.

[Maps of somatosensory evoked potentials from the arm in patients with neoplasms and post-traumatic brain lesions]

Short-latency somatosensory evoked potentials by the stimulation of the median nerve at the wrist, were recorded in six patients (four with cerebral tumors and two with post-trauma lesions). The electrodes were placed on the scalp following the 10-20 International System. A reference electrode was placed on earlobe contralateral to the site of the stimulation. Eleven normal subjects were used as control (mean age 64.4 +/- 12.05). We used the Brain-Surveyor-Basis Trade system which allowed us to elaborate the results by coloured mapping through linear interpolation of signal amplitudes. The following parameters were investigated: peak latencies of the N13, N20, P22, N30 waves; amplitudes of the post-rolandic P14-N20, N20-P25, pre-rolandic P22-N30 components and the central conduction time N13-N20 (CCT). The evaluation of latencies was not significant in determining the lesion site. On the contrary, the evaluation of amplitudes revealed expressive asymmetry, though it did not define the nature of alteration (increase or decrease due to lesion), and the correlation between these variations and the site of the lesion. The authors discussed the possibility that amplitude abnormalities in patients with tumors were related either to the tumors and/or drug effects.

[Antibiotic therapy in infertile subjects with chronic gonococcal infections: measurement of sperm output]

Several antibiotics of choice for the treatment of Gonorrhoea have proved to be effective in the acute forms of this disease. Men infected with gonococci may not develop or may not notice any symptoms at all: thus, complications of gonococcal infection can cause semen inadequacy and infertility. We are not aware of any previous paper on the treatment of chronic asymptomatic gonorrhoea (IUGC) and the cytotoxic effects in sperm maturation (so called "stress pattern tubular syndrome") and/or motility possibly mediated by some antigonococcal agents after prolonged period of administration. In IUGC the aims of therapy should be both the bactericidal activity and the improvement in the seminal quality. One-hundred eleven out of 785 male partners of infertile marriages were studied. They had negative post coital test and culture positive for N. Gonorrhoea in their semen. They were subdivided in six random groups and were treated with Ceftazidime (CFZ = 20 cases), Cefonicid (CFN = 20 cases) Spectinomycin (SPM = 15 cases), Aztreonam (AZT = 20 cases), Piperacillin (PP = 18 cases) and Doxycycline (DXC = 18 cases) respectively. After 7 days of treatment (C1) seminal cultures became negative in 25 cases (22.5%) and no seminal parameter showed significant variation among groups. When the treatment was repeated other twice (C3. = 1 week every month for 3 months) the antigonococcal efficacy was complete (100%), but various effects on seminal quality (Density, D; Motility, M, Oval forms, O; Sperm precursors, Sp; nemaspermic penetration depth in bovine cervical mucus PN; rate of pregnancies) were observed.

[Radiology of thalassemic syndrome in the transition from the old to the new therapeutic transfusion regimen]

The authors have evaluated the skull, thorax, wrist and hand standard radiographs of 29 patients affected by Cooley's disease who were treated up to 1983 with a low transfusion regimen, rather with a high transfusion regimen (Hb level greater than 9.5 g/dl). The patients have been divided into two groups, according to the prevalence of the first or the second transfusion regimen. Almost all the changes described in the literature have been found in the radiographs, but completely modified; some of these, like rib notchings, in higher percentage than known. In the youngest patients the most significant appearances were ribs and hand changes, that can be considered the most important feature in their radiological monitoring. However this new transitional radiological syndrome will rapidly modify with the establishment "ab initio" of the high transfusional regimen.

[The endocrine complications in thalassemia major]

Based on a review of the literature and personal observation, the authors discuss the most frequent endocrine complication that occur in patients with thalassemia major given blood transfusion and chelating therapy. All the complication are attributed to iron overload in the endocrine glands. The authors conclude that an adequate chelating therapy protects against hemosiderosis and thus against endocrine pathologies.

[Memory changes in herpes virus encephalitis: report of a case]

A case of Herpes Simplex Encephalitis with a benign course was present in a 66-year-old patient. A year after the acute phase of the illness, the patient continued to suffer from inability to fix verbal material in memory. During the acute phase, cerebral NMR revealed a large evolving lesion in the right temporal region, and an old lesion located in the same region of the opposite hemisphere. From the medical history, we learned that the patient, 35 years earlier, suffered a similar episode, including a short-term memory deficit. In the following study, we will discuss this case report in relation to data found in the literature dealing with memory deficit, caused by mono and bilateral, temporal lesions.

Effects of ADP and epinephrine on macaque and human platelets. Implications for studies on human atherosclerosis

The ranges for near-threshold ADP concentrations for the aggregation of macaque and human citrated platelets overlapped. The minimum concentrations of epinephrine, 0.05 microM to 1.0 microM, that at least doubled the aggregation response at threshold ADP concentrations were comparable for macaque and human citrated platelets. Epinephrine (1.0 microM to 10 mM) alone never aggregated macaque citrated platelets. Biphasic aggregation occurred with both macaque and human citrated platelets. The addition of heparin to a final concentration of 2.2 units/ml had no effect on the threshold ADP concentrations or the sensitivity of macaque or human citrated platelets to epinephrine. One microM phentolamine eliminated the potentiating effect of 1 microM epinephrine on ADP-induced aggregation of macaque and human citrated platelets. The threshold concentrations of ADP for macaque platelets were sharply reduced when heparin was used as an anticoagulant rather than citrate. However, epinephrine induced a similar increase in aggregability with both citrated and heparinized platelets, 0.55 +/- 0.09 SEM% and 0.44 +/- 0.09 SEM%, respectively. These data indicate that macaque and human platelets behave in a similar manner in response to ADP and that epinephrine potentiates the ADP-induced aggregation of macaque and human platelets equally well.

Potentiation with epinephrine of macaque platelet aggregation by other agonists: implications for studies on human atherosclerosis

The effects of low concentrations of epinephrine on the aggregation of macaque and human platelets by arachidonic acid (AA), collagen, and thrombin were studied. When epinephrine (0.05 to 1 microM) was added to macaque or human citrated or macaque heparinized platelets, either before or after the addition of near-threshold concentrations of AA, significant increases in aggregability were always seen. Epinephrine alone did not aggregate macaque platelets from citrated blood. When near-threshold concentrations of collagen or thrombin were present in the medium, low concentrations of epinephrine (0.05 to 0.50 microM) potentiated the aggregation of macaque and human citrated platelets and macaque heparinized platelets. The P values for the addition of epinephrine were less than 0.01 in all series. The ability of low epinephrine concentrations to potentiate aggregation of macaque platelets by other agonists is of particular significance because in humans the most important effect of epinephrine on platelets in vivo is probably the potentiation, by low concentrations, of aggregation induced by other aggregatory agents normally present in the blood in low concentrations.

Primary abdominal pregnancy in the spleen: a case report

The spleen was the source of hemorrhage in a 27-yr-old woman, known to be 6 wk pregnant when she presented in acute shock for intra-abdominal bleeding requiring immediate resuscitation and emergency laparotomy. Microscopic examination of the splenectomy specimen demonstrated a primary pregnancy implanted within the subcapsular splenic parenchyma.

Seasonal variation in the junctional component of pigmented naevi

From an assessment of the presence of a junctional component in 8,380 pigmented naevi, and histological review of its extent and the presence of inflammation and regression in a sample of 216 junctional and compound naevi, it was determined that naevi excised in summer were more likely to have a junctional component and evidence of inflammatory response than those excised in winter. It is suggested that a short-term promotional effect of sunlight on cells in the junctional zone of pigmented naevi may, in addition to increased case ascertainment in summer, explain reported seasonal variation in the incidence of malignant melanoma.

Behavioral and pharmacological responses following acrylamide exposure in rats

The onset of acrylamide related toxicity and indications of recovery were evaluated using several behavioral tasks. Rats were chronically housed and tested for the first 15 weeks of the study in running wheels where food and water consumption and activity were continuously monitored. Separate groups of animals were repeatedly tested on at least one additional behavioral task: an operant schedule FR20 GO/NO-GO, spontaneous and drug-induced locomotor activity, drug-induced asymmetric rotation, or splaying of the hindlimbs. Animals were administered acrylamide monomer in their drinking water (100 ppm) for a six week period. Behavioral evaluations were initiated up to six weeks prior to acrylamide exposure and continued up to 12 weeks after termination of the exposure. Operant behavior and spontaneous locomotor activity in an open field were not affected by acrylamide exposure. Nocturnal activity in running wheels was decreased, and hindlimb splay increased by exposure to acrylamide. Subsequent to injections of d-amphetamine locomotor activity in an "open field" was markedly increased following exposure to acrylamide. d-Amphetamine induced asymmetric rotation was also altered following acrylamide exposure. It is suggested that this altered pharmacological response was due to an effect of acrylamide on hepatic mechanisms or on central dopaminergic function.

Hepatitis B virus in diabetic patients

The presence of HBV markers was determined in 149 serum samples obtained from diabetic patients and was compared with a normal population. Diabetics have the same incidence of HBsAg but significantly higher anti-HBc antibodies. These differences were seen in the group of diabetics on oral hypoglycemic therapy. These results cannot yet be explained.