Bone damage after chemotherapy for lymphoma: a real-world experience

BACKGROUND

Despite recent improvements in survival due to advances in treatment, the quality of life of patients with lymphoma may be compromised by the long-term complications of chemotherapy and steroid therapy. Among these, a potentially relevant problem is bone loss and the development of fragility fractures.

AIM

To provide further evidence of clinical or subclinical skeletal complications in correlation with biological variables and markers of bone disease in patients with complete response to therapy.

METHOD

A cross-sectional observational study was conducted on subjects diagnosed with lymphoma with subsequent antineoplastic treatment, disease status after therapy defined as complete response disease for at least a year now. We performed: blood chemistry tests, imaging techniques and screening tools for the assessment of functional status and quality of life (SARC-F and mini-Osteoporosis Quality of Life).

RESULTS

Approximately 50% of patients had osteoporosis, with a prevalence of vertebral fractures of 65.5%. In most patients, we found hypovitaminosis D and high levels of parathyroid hormone (PTH). Furthermore, a statistically significant association was observed between high PTH levels and previous lymphoma treatment. Finally, the Mini-Osteoporosis Quality of life (mini-OQLQ) questionnaire demonstrated a loss of quality of life as a consequence of the change in bone status.

CONCLUSIONS

Patient treatment design for personalized chemotherapy would be desirable to reduce late effects on bone. Also, early prevention programs need to be applied before starting treatment. The most benefited subpopulations could be not only elderly but also young patients.

Genetic Characterization of Apulian Olive Germplasm as Potential Source in New Breeding Programs

The olive is a fruit tree species with a century-old history of cultivation in theMediterranean basin. In Apulia (Southern Italy), the olive is of main social, cultural and economicimportance, and represents a hallmark of the rural landscape. However, olive cultivation in thisregion is threatened by the recent spread of the olive quick decline syndrome (OQDS) disease, thusthere is an urgent need to explore biodiversity and search for genetic sources of resistance. Herein,a genetic variation in Apulian olive germplasm was explored, as a first step to identify genotypeswith enhanced bio-agronomic traits, including resistance to OQDS. A preselected set of nuclearmicrosatellite markers allowed the acquisition of genotypic profiles, and to define geneticrelationships between Apulian germplasm and widespread cultivars. The analysis highlighted thebroad genetic variation in Apulian accessions and the presence of different unique genetic profiles.The results of this study lay a foundation for the organization of new breeding programs for olivegenetic improvement.

Primary Intraosseous Verrucous Carcinoma Developing from a Maxillary Odontogenic Cyst: Case Report

Primary intraosseous carcinoma (PIOC) is an extremely rare lesion, almost always occurring in cranial bones. The origin of this tumor, specific to the maxillae, is associated with the cells of the epithelial rests of Malassez. Among the histotypes which can be included in these neoplasms, verrucous carcinoma is of particular interest due to its rarity: only a single case has been reported to date. After a short survey of the literature, the authors describe a directly observed case of verrucous carcinoma arising from a maxillary odontogenic cyst.

Levofloxacin versus azithromycin for treating legionella pneumonia: a propensity score analysis

OBJECTIVES

Concerns have arisen regarding the equivalence of levofloxacin and some macrolides for treating community-acquired legionella pneumonia (LP). We aimed to compare the outcomes of current patients with LP treated with levofloxacin, azithromycin and clarithromycin.

METHODS

Observational retrospective multicentre study of consecutive patients with LP requiring hospitalization (2000-2014) conducted in two hospitals. The primary outcome assessed was 30-day mortality. To control for confounding, therapy was assessed by multivariate analysis.

RESULTS

We documented 446 patients with LP, of which 175 were treated with levofloxacin, 177 with azithromycin and 58 with clarithromycin. No significant differences in time to defervescence (2 (interquartile range (IQR) 1-4) versus 2 (IQR 1-3) days; p 0.453), time to achieve clinical stability (3 (2-5) versus 3 (2-5) days; p 0.486), length of intravenous therapy (3 (2-5.25) versus 4 (3-6) days; p 0.058) and length of hospital stay (7 (5-10) versus 6 (5-9) days; p 0.088) were found between patients treated with levofloxacin and those treated with azithromycin. Patients treated with clarithromycin had longer intravenous antibiotic treatment (3 (2-5.25) versus 5 (3-6.25) days; p 0.002) and longer hospital stay (7 (5-10) versus 9 (7-14) days; p 0.043) compared with those treated with levofloxacin. The overall mortality was 4.3% (19 patients). Neither univariate nor multivariate analysis showed a significant association of levofloxacin versus azithromycin on mortality (4 (2.3%) versus 9 (5.1%) deaths; p 0.164). The results did not change after incorporation of the propensity score into the models.

CONCLUSIONS

In our study, no significant differences in most outcomes were found between patients treated with levofloxacin and those treated with azithromycin. Due to the small number of deaths, results regarding mortality should be interpreted with caution.

Impact of influenza season and environmental factors on the clinical presentation and outcome of invasive pneumococcal disease

Influenza and meteorological factors have been associated with increases in the incidence of invasive pneumococcal disease (IPD). However, scant data regarding the impact of influenza and the environment on the clinical presentation of IPD are available. An observational study of all adults hospitalized with IPD was performed between 1996 and 2012 in our hospital. The incidence of IPD correlated with the incidence rates of influenza and with environmental data. A negative binominal regression was used to assess the relationship between these factors. Clinical presentation of IPD during the influenza and non-influenza periods was compared. During the study, 1,150 episodes of IPD were diagnosed. After adjusting for confounding variables, factors correlating with the rates of IPD were the incidence of influenza infection (IRR 1.229, 95% CI 1.025-1.472) and the average ambient temperature (IRR 0.921, 95% CI 0.88-0.964). Patients with IPD during the influenza period had a worse respiratory status. A greater proportion of patients had respiratory failure (45.6% vs 52%, p = 0.032) and higher requirements for ICU admission (19.3% vs 24.7%, p = 0.018) and mechanical ventilation (11% vs 15.1%, p = 0.038). When we stratified by invasiveness of pneumococcal serotypes and the presence of comorbid conditions, the increase in the severity of clinical presentation was focused on healthy adults with IPD caused by nonhighly invasive serotypes. Beyond the increase in the burden of IPD associated with influenza, a more severe clinical pattern of pneumococcal disease was observed in the influenza period. This effect varied according to pneumococcal serotype, host comorbidities, and age.

Peginterferon alpha-2b plus ribavirin vs interferon alpha-2b plus ribavirin for chronic hepatitis C in HIV-coinfected patients

Treatment of chronic hepatitis C in human immunodeficiency virus (HIV)-infected patients is associated with low response rates and high incidence of side effects. One hundred twenty-one hepatitis C virus (HCV)-HIV-coinfected patients were randomized to receive interferon alpha-2b (3 MU thrice weekly; n = 61) or peginterferon alpha-2b (1.5 microg/kg/week; n = 60), plus ribavirin (800 mg daily), for 24 (genotype 2 or 3) or 48 weeks (genotype 1 or 4). We assessed early virological response at 4, 8 and 12 weeks to predict sustained virological response (SVR). Safety assessment included frequent blood lactate measurement and relative quantitation of mitochondrial DNA (mtDNA) content in peripheral blood mononuclear cells. In intention-to-treat analysis, the SVR rate was higher in the peginterferon group (55%vs 26%; P = 0.002). The difference for HCV genotypes 1 and 4 was 45%vs 14% (P = 0.009) and 50%vs 27% (P = 0.387), respectively, and for genotype 2 or 3, 71%vs 43% (P = 0.12) Viral response at 4, 8 and 12 weeks of treatment was highly predictive of SVR. Among genotype 3 patients, 17 of 20 (85%) whose HCV RNA was already undetectable at 4 weeks had an SVR after 24 weeks of treatment. Hyperlactataemia occurred in 22 patients and was clinically significant in six, two of whom died. mtDNA decreased significantly 4-12 weeks after the start of treatment in patients developing clinically significant hyperlactataemia. Peginterferon alpha-2b plus ribavirin was more effective than interferon alpha-2b plus ribavirin in HIV-coinfected patients. Frequent monitoring of virological response may be very helpful to optimize treatment compliance, to tailor treatment duration and to minimize side effects.

Methotrexate inhibition of bone mineral density increase in growing rabbits: prevention by folinic acid

OBJECTIVE

Methotrexate (MTX) action on bone metabolism is as yet not completely understood. The results of clinical studies are controversial, since it is difficult to distinguish the side effects of MTX from those of the primary disease. This study assessed the effect of MTX, with and without folinic acid supplementation, on bone mineral density in growing normal rabbits.

METHODS

Three groups of young NZW growing female rabbits were treated with: saline (n = 6) or MTX (0.25 mg/kg/week, n = 5) or MTX (same dose as above) plus folinic acid (0.25 mg/kg/week, n = 6) for a period of 3 months. The dose, duration and frequency of MTX administration were similar to the treatment of RA patients. The animals were submitted to dual-energy absorptiometry densitometry (HologicQDR 2000) before and after treatment; total body and L4-L5 BMD were evaluated. Histomorphometric analysis (L4 vertebrae) was also performed.

RESULTS

Growing control rabbits showed increased total body BMD from a baseline of 0.180 +/- 0.006 to 0.198 +/- 0.007 gm/cm2 (mean +/- S.E.M, p < 0.006). In contrast, no increase in BMD (0.182 +/- 0.006 versus a baseline of 0.184 +/- 0.004, ns) was observed in the group treated with MTX, while the addition of folinic acid resulted in an increase in BMD values similar to controls, from a baseline of 0.181 +/- 0.004 to 0.198 +/- 0.003, p < 0.02), thus preventing adverse MTX bone effects. Average percent variations in BMD were +7.7%, -1% and +8.4% respectively. Spine (L4-L5) BMD showed analogous results, in line with the histomorphometric data.

CONCLUSION

These results strongly support a deleterious action of MTX on bone metabolism, which is prevented by folinic acid supplementation. The potential clinical implications of our data are particularly significant for paediatric therapy.

Pharmacokinetic interaction between nevirapine and rifampicin in HIV-infected patients with tuberculosis

To determine whether rifampicin reduces serum concentrations of nevirapine and whether nevirapine modifies serum concentrations of rifampicin, levels of these agents were determined at steady state by high-performance liquid chromatography in 10 HIV-infected patients with tuberculosis. The median area under the curve (AUC) 0-12h of nevirapine before and after rifampicin was 56.2 and 32.8 microg/ml per hour, respectively ( p =.04). This represents a 31% reduction in serum nevirapine concentrations. The C(max) decreased from 5.6 to 4.5 microg/ml ( p =.04), which represented a 36% reduction. A 21% decrease in the C(min) was not statistically significant. Exposure to rifampicin did not significantly differ between those patients who were receiving and were not receiving nevirapine. However, our study shows that rifampicin reduces serum exposure to nevirapine. The clinical implications for this reduction remain to be established. Given that the lowest trough serum concentration of nevirapine exceeded by more than 40 times the protein binding adjusted median infective dose (IC(50)) of wild-type HIV in all patients, we suggest that there is no need to increase nevirapine dosage when it is given with rifampicin.

Apoptosis in fetal nucleated erythrocytes circulating in maternal blood

The purpose of this study was to determine if apoptosis occurs in fetal cells that have crossed into the maternal circulation, which would potentially explain the difference between the number of intact fetal cells and the amount of fetal DNA detectable in maternal plasma. We flow-sorted fetal nucleated erythrocytes (FNRBCs) using antibody to the gamma chain of fetal haemoglobin and confirmed them to be fetal in origin by FISH analysis using chromosome-specific probes. Fetal cells were then analysed microscopically for the presence of terminal UdTP nuclear end labelling (TUNEL) staining. Apoptotic change was observed in 42.7% of fetal NRBCs (106/246) and 3.5% of maternal cells (29/818). Results of this study indicate that a significant number of fetal cells in maternal blood are undergoing apoptosis at the time of sampling. Apoptosis may be one mechanism by which fetal cells are cleared by the maternal circulation.

Fetal cell recycling: diagnosis of gender and RhD genotype in the same fetal cell retrieved from maternal blood

OBJECTIVE

Our aim was to develop a new technique, which we have termed fetal cell recycling, that combines the 2 powerful methods of fluorescence in situ hybridization and polymerase chain reaction to maximize the genetic information available from a small number of fetal nucleated erythrocytes obtained noninvasively from the blood of pregnant women.

STUDY DESIGN

Blood samples were obtained from 4 Rh-negative women after elective termination of pregnancy at 7 to 17 weeks' gestation. Fetal nucleated erythrocytes were separated by flow sorting with antibody to the gamma chain of fetal hemoglobin. Fluorescence in situ hybridization with chromosome-specific probes was used to diagnose fetal gender. After fluorescence in situ hybridization analysis the fetal nucleated erythrocytes were recycled by a micromanipulation technique and deoxyribonucleic acid diagnosis was performed with polymerase chain reaction amplification of the RhD gene.

RESULTS

Among the 4 case patients we detected a total of 101 fetal nucleated erythrocytes. All targeted cells were successfully retrieved with a micromanipulator. In each case we successfully performed both fluorescence in situ hybridization and polymerase chain reaction analysis. The predicted fetal gender and Rh status corresponded to the results obtained from fetal tissue.

CONCLUSIONS

Fetal cell recycling combines the powers of highly sensitive molecular methods to maximize the genetic information available from a single fetal cell. This technique will permit noninvasive diagnosis of recessively inherited single-gene disorders.

Abnormalities in the biochemical markers of bone turnover in children with juvenile chronic arthritis

OBJECTIVE

To study the biochemical markers of bone turnover in children with juvenile chronic arthritis (JCA) and to compare these parameters with those in healthy children in order to evaluate the relationships between age, disease activity and biochemical variables.

METHODS

Sixty-two children with JCA and 157 healthy children were studied. Serum samples were analyzed for their concentrations of minerals, osteocalcin (OC) and bone-specific alkaline phosphatase (BAP). Urine samples were examined to monitor the excretion of hydroxyproline (HYP) and deoxypyridinoline crosslinks (DPD).

RESULTS

OC, BAP, HYP/Cr, DPD/Cr values were decreased in healthy girls more than 12 years of age and in healthy boys more than 14 years of age compared to younger children from the same population. Lower levels of OC and BAP were observed in younger children with JCA (girls < or = 12 yrs.; boys < or = 14 yrs.) compared to healthy children of the same age. Older girls with JCA (> or = 13 yrs.) were found to have increased HYP/Cr and DPD/Cr values compared to older healthy children.

CONCLUSION

These results indicate that abnormalities of bone metabolism occur in an age-related fashion in JCA. This was demonstrated by a reduction in the markers of bone formation in younger JCA patients. Moreover, in older girls the markers of bone resorption were found to be elevated. Taken together, these findings suggest that bone formation is reduced from early childhood to mid-puberty, while resorption levels increase in children with JCA after this time.

[A retrospective study on the importance of preoperative control in the prognosis of spinocellular carcinoma of the oral cavity]

Surgical treatment of advanced forms of spinocellular carcinoma of the oral cavity (stages 3-4) has been integrated for a number of years with cycles of chemo- and/or radiotherapy both before and after surgery. This chemo-radio-surgical therapeutic protocol consists of four distinct stages, separated by precise treatment-free intervals, which enable the best efficacy to be achieved through synergy. A total of 60 patients were treated by our Ward using this protocol during the period March 1988-June 1992. At the time of surgery a complete negative outcome in the histological picture (pTO) was observed in 40% of cases; lesions had not regressed on only 16% of patients. A retrospective type study has been carried out using Kaplan-Meier's statistical analysis to evaluate the prognostic factors in this population: a significant correlation was found between disease-free time and survival, calculated at 40 months from the completion of the protocol, and histopathological TNM. Non correlation was found with clinical TNM: therefore, rather than the extent of the lesion at the time of diagnosis, its control during preoperative stages appears to be the major prognostic factor.

[Assessment of phonation in patients after oncologic surgery of the oral cavity]

The authors evaluated word articulation ability in 33 patients undergoing integrated (chemo-radio-surgical) treatment for carcinoma of the oral cavity. Speech was intelligible in 22 patients. Severe language distortion was observed in 11 patients.

[Multidisciplinary treatment in advanced stages of spinocellular carcinoma of the oral cavity. Initial results]

As in almost all forms of tumour, the best therapeutic results for those of the oral cavity is obtained following the first treatment which must be incisive and appropriate because it often represents the sole decisive possibility of recovery. In advanced forms (stages III and IV) it is best to establish a close collaboration between surgeon, cancer specialist and radiotherapist: this paper reports the authors' experience over the past 5 years with regard to advanced stages of spinocellular carcinoma of the oral cavity treated according to a chemoradiosurgical therapeutic protocol. Of the 134 cases treated by our unit, 77 were included in the protocol showing a 78% actuarial survival rate over 40 months.

Three cases of idiopathic bronchiolitis obliterans with organizing pneumonia

Three patients with bronchiolitis obliterans organizing pneumonia are described. Chest X-ray films showed peripheral densities and pulmonary function tests a restrictive pattern. In all three cases transbronchial biopsy was not useful for diagnosis and we point out the importance of an open lung biopsy in order to make the differential diagnosis with other infiltrative lung disease with a different prognosis and therapy.

Ofloxacin in miliary tuberculosis

We report one case of severe miliary tuberculosis with liver failure and respiratory insufficiency in a twenty-seven year old patient. We emphasize the presence of hepatic, occular and vestibular toxicities secondary to the treatment and the usefulness of ofloxacin with cycloserine given for nine months.