Lesson learned from an outbreak of invasive meningococcal disease: how HTA could have provided an evidence-based approach for public health response

During 2015-2016 an outbreak of invasive meningococcal disease due to Neisseria meningitidis serogroup C ST-11 (cc11) occurred in Tuscany, a Region in Central Italy. Sixty-two cases with 13 deaths (13%) were recorded. Regional Authorities responded through a mass immunization campaign targeting all the age groups by offering free of charge a single dose of the tetravalent (ACWY) meningococcal conjugate vaccine or monovalent meningococcal C conjugate (MCC) vaccine. Nevertheless, the response was fragmented and the campaign did not reach the risk-population groups (i.e. men who have sex with men), that were identified only when a Regional outbreak investigation was implemented. Also linkage between cases (i.e. attending the same gay-venue) were identified at a second stage, not allowing prompt max-prophylaxis interventions. In such a situation, an evidence-based approach as Health Technology Assessment, could have informed public health emergency preparedness and response planning processes, i.e. by identifying through early warning alert systems similar ongoing clusters in Europe among specific population-groups and consequently better targeting the immunization campaign. The objective of this presentation is to explore through a practical example how HTA could provide an evidence-based approach for public health response during a real outbreak underlining lesson learned.

Addressing the challenge of bringing evidence in decision-making for public health emergencies: can HTA reach out to preparedness?

Background

Preparedness is one of the fundamental public health activities as it allows health systems to effectively manage threats. It can be considered a continuous quality improvement process, therefore requiring an assessment both in planning and checking phase. The assessment should consider several aspects spanning contextual factors but also health technologies being used. In order to manage threats, epidemics in particular, several health technologies are generally deployed. Among them, vaccines, antimicrobials, medical devices (i.e. masks), procedures (i.e. quarantine). Indeed, an early and as much as comprehensive evaluation of their value in the mitigation of epidemics' impact is needed. Health Technology Assessment (HTA) could help doing that. It could be also useful to predict the magnitude of the problem and to shed light on alternatives and needs for organizational reengineering. Anyway, what are the actions required to make HTA reaching out preparedness?

Results

In order to do it, several conditions should be brought about. The first one is the recognition of the importance of HTA in projecting health technologies impacts by health authorities and institutions. The second one is the timeliness of the assessment. In fact, HTA is generally a time and resource consuming approach as it is based on the collection of available evidence and data. Nevertheless, an early interaction with all stakeholders, the availability of flexible computer infrastructures for data collection and the preventive development of impact models might allow developing the assessment in a limited time. Furthermore, having dedicated working teams at supranational/national level could help keep down time and efforts to conduct the assessment.

Conclusions

Based on available experiences, advances and barriers in the use of HTA for preparedness might be highlighted and actions to strengthen the role of HTA in this field can be recognized.

The challenge of bringing evidence in decision-making for public health emergencies: can preparedness reach out to HTA?

Evidence-based decision-making is central to public health. Implementing evidence-informed actions is most challenging during a public health emergency as in an epidemic, when time is limited, scientific uncertainties and political pressures tend to be high, and reliable data is typically lacking.

The process of including data for preparedness and training for evidence-based decision making in public health emergencies is not systematic and is complicated by many barriers as the absence of common digital tools and approaches for resource planning and update of response plans. Health Technology Assessment (HTA) is used with the aim to improve the quality and efficiency of public health interventions and to make healthcare systems more sustainable. Many of today's public health crises are also cross-border, and countries need to collaborate in a systematic and standardized way in order to enhance interoperability to share data and to plan coordinated response. Digital health tools have an important role to play in this setting, facilitating use of knowledge about the population that can potentially affected by the crisis within and across regional and national borders. To strengthen the impact of scientific evidence on decision-making for public health emergency preparedness and response, it is necessary to better define and align mechanisms through which interdisciplinary evidence feeds into decision-making processes during public health emergencies and the context in which these mechanisms operate. Activities and policy development in the HTA network could inform this process. The objective of this presentation is to identify barriers for evidence-based decision making during public health emergencies and discuss how standardization in digital health and HTA processes may help overcome these barriers leading to more effective coordinated and evidence-based public health emergency response.

Coronavirus disease (COVID-19) outbreak: can HTA improve preparedness and response in emergencies with a high degree of uncertainty?

Evidence-based decision-making is central to public health. Implementing evidence-informed actions is most challenging during a public health emergency as in an epidemic, when time is limited, scientific uncertainties and political pressures tend to be high, and irrefutable evidence may be lacking. The Coronavirus disease (COVID-19) outbreak is determining a scenario of uncertainty for public health decision-making with fragmented and different responses also within countries (i.e. regional level), which are implemented quickly, sometimes not fully supported by the necessary body of scientific evidence. In such a situation, following a common line and having a shared tool that would allow to include evidence in public health decision-making, would be strategic to strengthen the impact of interventions, enabling stakeholders and decision makers taking actions based on the best available evidence through a process which is systematic and transparent. The objective of this presentation is to use the example of the COVID-19 outbreak, in order to explore how HTA can improve preparedness and response in emergencies with a high degree of uncertainty, representing the mechanisms through which interdisciplinary evidence feeds into decision-making processes during public health emergencies, addressing the link between scientific evidence and decision-making in public health emergencies, overcoming the key challenges faced by public health experts when advising decision makers, including strengthening and accelerating knowledge transfer through rapid HTA, improving networking between actors and disciplines.

Macrophages in Skin Cancer: Quantitative and Functional Studies

The number of tumor-infiltrating macrophages was estimated in 43 patients with skin cancer, including 18 cases of squamous cell and 25 cases of basal cell carcinoma. Macrophages were identified in cell cultures by 2 assays, namely phagocytosis and resistance to detachment by trypsin. The average percentage of adherent cells for the 2 groups of skin tumors was 4.5 ± 2.6 and 10.2 ± 5.2, respectively, and the difference was statistically significant. Follow-up studies after surgical excision of the primary neoplasm showed a relatively low macrophage content in 2 of the 4 cases in which local recurrences occurred. Preliminary functional studies suggested that soluble factors may be released by neoplastic cells, accounting for the inhibitory effect of tumor cell supernatants on macrophage Chemotaxis in vitro.

Effect of BCG Immunotherapy on Cell-Mediated Cytotoxicity in Bladder Cancer Patients following Surgical Treatment

Peripheral blood lymphocytes from bladder cancer patients display in vitro cytotoxicity against established bladder tumor target cells. Following surgery and after separation of lymphocytes in non-T and T with high affinity and low affinity for sheep erythrocytes fractions, the cytotoxic activity was significantly decreased in all subsets. After BCG therapy the cytotoxic capacity was restored and the effect was equally distributed in the different subpopulations. The monocyte-enriched fraction did not show any change in the cytotoxic activity after treatment.

Is EU/EEA population protected from polio?

The WHO European Region has been declared polio-free since 2002. By 2010, inactivated polio vaccine (IPV) was the only polio vaccine in use in the EU/EEA for the primary vaccination of children. A systematic review of the literature on polio seroprevalence studies, complemented by the analysis of available vaccine coverage data, has been carried out with the aim of assessing the level of protection against polio in the European population. A total of 52 studies, with data from 14 out of the 31 EU/EEA countries, were included in the analysis. This systematic review shows that, overall, seroprevalence for PV1 and PV3 is high in most countries, although seroimmunity gaps have been detected in several birth cohorts. In particular, relatively low immunity status was found in some countries for individuals born in the 60's and 70's. Discrepancies between reported vaccination coverage and immunity levels have been also highlighted. Countries should make sure that their population is being vaccinated for polio to reduce the risk of local poliovirus transmission in case of importation. Moreover, assessing immunity status should be priority for those traveling to areas where wild polioviruses are still circulating.

CLA reduces breast cancer cell growth and invasion through ERalpha and PI3K/Akt pathways

We previously reported that conjugated linoleic acid (CLA), a naturally occurring fatty acid, inhibits the growth of ERalpha(+) MCF-7 and ERalpha(-) MDA-MB-231 human breast cancer cells by negative modulation of the ERK/MAPK pathway and apoptosis induction. Here we show that in these cell lines CLA also down-regulates the PI3K/Akt cascade. In MCF-7 cells CLA also triggers ERalpha/PP2A complex formation reducing the phosphorylation state and transcriptional activity of Eralpha whereas in MDA-MB-231 cells CLA does not induce PP2A activation. Moreover, CLA induces the expression of proteins involved in cell adhesion and inhibits cell migration and MMP-2 activity. These findings suggest that CLA may induce the down-regulation of ERalpha signalling and the reduction of cell invasion through the modulation of balancing between phosphatases and kinases.

Estradiol increases IRS-1 gene expression and insulin signaling in breast cancer cells

This study demonstrates how the potentiating effects of E2 on insulin signaling in ER-positive breast cancer cells are consequent to an enhanced IRS-1 expression [corrected]. It induces an increase of both PI-3K/AKT and ERK1/2 activities. A direct action of E2 in the regulating mouse IRS-1 gene is also investigated in both Chinese hamster ovary and MCF-7 cells that are transfected with mouse IRS-1 regulatory sequences. The authors have reported, for the first time, how E2 induction of IRS-1 mRNA was correlated with a direct positive regulatory role of E2 on the IRS-1 promoter. This effect seems to be not strictly related to the cell type.

Cytoskeleton-interacting activity of geiparvarin, diethylstilbestrol and conjugates

Geiparvarin, a natural compound isolated from the leaves of Geijera parviflora, inhibits the growth of various tumor cell lines with a mode of action which may be attributed to its anti-microtubular activity. Our previous findings indicated that geiparvarin is able to inhibit the in vitro polymerization of tubulin and to derange the microtubular network in fibroblasts more effectively in the presence of paclitaxel. To further explore its biological activity here we have studied the effects exerted on the other components of the cytoskeleton by geiparvarin and two derivatives obtained by conjugating the 3(2H)-furanone ring of geiparvarin with diethylstilbestrol (DES). Firstly, observations by electron microscopy confirmed anti-microtubular properties, a near-total absence of microtubules is detected when tubulin is incubated with drugs in the presence of paclitaxel, whereas microtubule formation is not inhibited by drugs when assembly is induced by guanosine 5'-triphosphate (GTP). Immunofluorescence assays demonstrated that geiparvarin and DES act in a vinblastine-like fashion, causing a marked depletion of intermediate filaments while the network of microfilaments is not affected. Both the conjugates alter the 'stress fibers' organization of actin and disrupt the vimentin pattern; generally they derange cytoskeleton more markedly than the parent compounds. The cell growth inhibiting effects of geiparvarin and derivatives are dose-dependent; they vary according to the cell line used, when compounds were administered either alone or simultaneously with paclitaxel. Unlike other anti-microtubule agents, they do not exhibit cell-cycle compartment specificity and do not influence thymidine uptake in the cell.

Lumbar disc excision in children and adolescents

STUDY DESIGN

The authors examined a case series of patients under the age of 18 years treated for lumbar intervertebral disc herniation.

OBJECTIVES

To evaluate postoperative and long-term results of surgery in patients younger than 18 years.

SUMMARY OF BACKGROUND DATA

There are only a few series, with controversial results, available on the surgical treatment of disc herniation in growing patients.

METHODS

Between 1975 and 1991, a consecutive series of 129 patients 9-18 years of age (average age, 16.2 years) underwent surgery for lumbar intervertebral disc herniation. Low back pain associated with leg pain was the main clinical symptom in 106 subjects (82%), back pain in 17 (13%), and leg pain in 6 (5%).

RESULTS

Short-term results were excellent or good for 123 cases (95%), with complete pain relief in 97 (75%) and moderate but incomplete relief in 26 (20%). A total of 98 (76%) long-term responses obtained at a mean follow-up of 12.4 years revealed excellent outcomes in 40% of the cases, good in 47%, and poor in 13%. Ten patients (10%) underwent reintervention after 9 years on average (2 fusions and 8 re-explorations for herniated disc).

CONCLUSIONS

Results have confirmed a tendency for outcomes to deteriorate between the short-term and long-term follow-up in young patients treated by discectomy: this tendency and the rate of reintervention (10%) confirmed the need for long-term follow-up of children and adolescents treated for disc herniation.

Antimicrotubular and cytotoxic activity of geiparvarin analogues, alone and in combination with paclitaxel

Geiparvarin is an antiproliferative compound isolated from the leaves of Geijera parviflora, and may represent a new drug which targets tubulin. To better explore the potential use of this agent, we investigated the antimicrotubular and cytotoxic effects of new synthetic aromatic derivatives of geiparvarin. These drugs inhibited polymerization of microtubular protein, particularly when the assembly was induced by paclitaxel. The microtubular network organization of fibroblasts was altered more effectively by some drugs. Normal microtubule architecture completely disappeared when the cells were treated simultaneously with drugs and paclitaxel: microtubules depolymerized or were reorganized into bundles, in a similar but more disarrayed fashion than that observed after treatment with paclitaxel alone. Cytotoxicity studies showed a dose-dependent effect, whereas combined administration of drugs and paclitaxel increased cytotoxicity, more effectively in paclitaxel versus derivatives administration alone.

[Scombroid syndrome with severe and prolonged cardiovascular involvement]

Scombroid poisoning is a form of ichthyosarcotoxism caused by eating spoiled fish, mainly of the scombroid family. Inappropriate storage of these fish can lead to the decarboxylation of histidine in the flesh to histamine by enterobacteria. The symptoms of histamine poisoning mimic those of an IgE-mediated food allergy, as well as flushing, headache, diarrhea and palpitations. However, in some cases, the scombroid poisoning can be characterized by very serious symptoms, as well as cardiovascular compromission. We describe two cases of scombroid poisoning with severe hypotension requiring continuous intravenous dopamine with resolution of symptoms only several hours later.

Cellular uptake and cytotoxicity of solid lipid nanospheres (SLN) incorporating doxorubicin or paclitaxel

Solid Lipid Nanospheres (SLN) are colloidal therapeutic systems proposed for several administration routes and obtained by dispersing warm microemulsions in cold water. SLN as carriers of doxorubicin and paclitaxel have been previously studied. In this study, the cellular uptake of SLN and the cytotoxicity of doxorubicin and paclitaxel incorporated into SLN were investigated on two cell-lines, human promyelocytic leukemia (HL60) and human breast carcinoma (MCF-7). Cellular uptake of SLN was determined by incorporating 6-coumarin as fluorescent marker. The cellular uptake of fluorescent SLN was clearly evidenced by fluorescence microscopy. The cytotoxicity of doxorubicin incorporated in SLN was higher compared to the conventional doxorubicin solution, even at the lower concentrations. Paclitaxel in SLN was about 100-fold more effective than free paclitaxel on MCF-7 cells, while on HL60 cells a lower sensitivity was achieved with paclitaxel in SLN. Unloaded SLN had no cytotoxic effect on HL60 and MCF-7 cells.

[Pancytopenia caused by ticlopidine treated with filgrastim. Description of a case]

Ticlopidine is an antiplatelet agent that is used to reduce the occurrence of atherothrombotic arterial events, but it can sometime cause severe haematological side-effects. We describe the case of a 79-year old woman suffering from ischaemic cardiopathy and chronic cerebral vasculopathy treated with ticlopidine, who developed a rare pancytopenia on the 26th day of ticlopidine treatment. The patient was successful treated with intravenous antibiotics and with filgrastim, with complete reversion of the pancytopenia.

Long-term follow-up of patients with anti-HBe/HBV DNA-positive chronic hepatitis B treated for 12 months with lamivudine

BACKGROUND/AIMS

Interferon alpha provides benefit in only a limited number of patients with chronic anti-HBe-positive hepatitis B. The aim of this study was to verify the long-term efficacy of lamivudine treatment of these patients and the incidence of lamivudine-resistant hepatitis B virus mutants.

METHODS

Fifteen consecutive patients with chronic anti-HBe-positive hepatitis B were treated with lamivudine 100 mg once daily for 52 weeks. Levels of alanine aminotransferase, HBV DNA, hepatitis B surface antigen, and IgM antibodies to hepatitis B core antigen were monitored during therapy and 12-month follow up. The polymerase gene was amplified by polymerase chain reaction and the region coding for YMDD amino acid motif was directly sequenced.

RESULTS

Only 2/15 patients (13%) had a sustained virological and biochemical response and improved histologically. Eleven out of 15 (74%) showed inhibition of viral replication and normalization of alanine aminotransferase levels during lamivudine treatment but relapsed 1-12 months after terminating therapy. In the two remaining patients (13%), HBV DNA initially became negative but reappeared in the serum after 24 weeks, and in both patients the emergence of YMDD mutants was demonstrated.

CONCLUSIONS

Our data confirm the antiviral efficacy of lamivudine in anti-HBe-positive patients, but response to a 1-year course was only transient as the majority of patients relapsed after therapy withdrawal. The lack of a sustained effect and the emergence of lamivudine-resistant mutants suggest that therapy for chronic hepatitis B should be based on a combination of several therapeutic agents.

Posterior surgery for the treatment of thoracolumbar pathologic fractures in metastatic patients

A total of 25 pathologic fractures in patients affected with thoracolumbar vertebral metastases associated with neurologic deficit are reported. None of the pathologic fractures were stable, while 14 were unstable and 11 were very unstable. Decompression with intralesional excision of the neoplastic mass compressing the dural sac was performed in all of the cases. Posterior stabilization was performed in the first cases using systems of sublaminar segmental fixation, and thereafter using systems of pedicle fixation. Removal of the vertebral body followed by anterior fusion after preventive posterior stabilization was performed in 2 cases. Pain symptoms regressed in 85% of the cases and in more than 50% of the patients there was improvement in the neurologic findings and in vertebral deformity consequent to fracture. Mean survival rate was 12 months. Despite the limited number of cases posterior stabilization of pathological fractures is a good choice of treatment in patients with severe neurologic deficit.

Geiparvarin and derivatives in combination with taxol: effect on microtubular organization in 3T3 fibroblasts

Geiparvarin, a natural product that exhibits antiproliferative activity, inhibits the growth of various tumour cell lines with a mechanism of action so far unknown. Our preliminary findings showed that geiparvarin and some derivatives obtained from its conjugation with diethylstilboestrol and meso-hexestrol significantly inhibit taxol-induced in vitro polymerization of both tubulin and microtubular protein. In this study we investigated the effect of geiparvarin and of the oestrogen-combined derivatives on the cellular microtubular network of fibroblasts. Geiparvarin altered the microtubular organization of fibroblasts and strengthened the derangement of the microtubular pattern in cells exposed simultaneously to taxol. However, the microtubular network remained quite well organized in fibroblasts exposed to geiparvarin and preincubated with taxol, which in this case prevented the deranging effect of the former. The antimicrotubular activity of the oestrogen-combined derivatives was more similar to that of geiparvarin than to that of the oestrogens, and often this activity was stronger than that of each reference drug alone; the cytotoxic activity examined in the same experimental conditions generally confirmed the microscopic analysis.

Von Willebrand factor abnormalities in IgA nephropathy

BACKGROUND

Plasma concentration of von Willebrand factor (vWF) has been used as an index of endothelial dysfunction. Increased release of vWF from endothelial cells has been reported in several conditions, and there is also evidence that dysfunctioning endothelial cells synthesize defective molecules. In fact, unusually large vWF multimers have been described and related to the pathogenesis of some microangiopathic diseases. Abnormal levels of vWF have been reported in primary glomerulitis, but this was no referred to histological diagnosis. Furthermore, no qualitative vWF analysis was performed in these glomerulopathies. Therefore the aim of our study was to analyse quantitatively and qualitatively vWF in patients with IgA (IgAN) and non-IgA mesangial proliferative glomerulonephritis (PGN).

METHODS

Fourteen IgAN patients, eight PGN patients, seven subjects with different glomerulonephritides, and 10 healthy controls formed the basis of this study. On peripheral venous blood collected in the presence of protease inhibitors, vWF parameters were investigated. vWF antigenic activity (vWF:Ag) was measured by electroimmunodiffusion. vWF subunits mobility was studied by crossed immunoelectrophoresis (CIE) and in some patients vWF multimeric analysis was performed by SDS-agarose gel electrophoresis.

RESULTS

Mean vWF:Ag was significantly higher in PGN patients as compared to controls, while there was no significant difference between PGN and IgAN patients and between IgAN and controls. CIE revealed a pre-peak in 12 of 14 IgAN patients and a migration index which did not differ between controls, IgAN, and PGN subjects. No pre-peak was observed in PGN and in other glomerulonephritides. Analysis of plasma vWF multimeric pattern by SDS-agarose gel electrophoresis disclosed in four IgAN patients abnormally large vWF multimers that were not documented in PGN subjects.

CONCLUSIONS

This study, by showing the presence of a pre-peak and of large vWF multimers in IgAN patients, suggests an altered postsecretory handling of the vWF in IgAN and possibly a different role of the vWF in IgAN in respect to PGN.

Interaction of geiparvarin and related compounds with purified microtubular protein

Geiparvarin is an antiproliferative compound whose mechanism of action has not yet been identified. We have investigated the biochemical action on purified microtubular protein, as well as on tubulin, of geiparvarin and of some derivatives resulting from its conjugation with two synthetic oestrogens, diethylstilboestrol and meso-hexoestrol, in comparison with the antimicrotubular action of the reference oestrogens. Geiparvarin and derivatives did not inhibit colchicine binding to tubulin nor did they significantly influence GTP-induced polymerization. On the contrary, they effectively counteracted the stimulating effect of taxol on microtubule formation, both in the presence and in the absence of microtubule-associated proteins. A competitive inhibition mechanism at the taxol binding site of tubulin may thus be proposed to explain the antimicrotubular action of geiparvarin.

Antimicrotubular effect of calvatic acid and of some related compounds

A structure-activity relationship has been established between calvatic acid and some related synthetic compounds, and their ability to inhibit GTP-induced microtubular protein polymerization in vitro. These compounds were effective in a dose- and a time-dependent manner. The most active drug was the p-chloro substituted compound, which showed its inhibitory activity without any preincubation period, which the others needed. Since if cysteine was present, polymerization was no longer affected, an involvement of titratable -SH groups of tubulin could be suggested. In contrast, taxol-induced polymerization was only slightly inhibited by these compounds, and colchicine-binding activity was not generally impaired.

Interactions between calvatic acid and related compounds with rat liver microsomes

In this study we examined the interactions of liver microsomes with the antibiotic calvatic acid and with structural analogues, some of which had shown antimicrotubular properties. These drugs decreased cytochrome P-450 content differently according to the substitutions on the azoxy function and the ethoxycarbonyl derivatives were found to be the most effective ones. The decrease in cytochrome P-450 could be prevented by addition of cysteine or GSH, suggesting an involvement of sulphydryl groups. Furthermore, chromatographic analyses showed that ethoxycarbonyl derivatives were completely metabolized, and this would explain the different behaviour of these compounds towards microtubular protein when they were incubated with purified bovine brain protein or with liver or hepatoma extracts.

Mild balanoposthitis

AIM

To identify and study cases of mild balanoposthitis (MBP) with penile pathology among patients observed at a dermatology clinic over an 18-month period.

MATERIALS

The study included 321 patients with penile pathology. The term MBP was used to describe balanoposthitis of a localised, inflammatory nature with few, non-specific symptoms and a tendency to become chronic or recur. Two hundred and seventy had diseases clearly identifiable by clinical examination or laboratory tests; 51 cases were diagnosed as MBP and these patients had blood tests (to evaluate immune status) and microbiological examination; when these proved negative, a series of patch tests was also used.

RESULTS

Of the 51 patients diagnosed as having MBP, the cause was ascertained in 34 cases (infection, mechanical trauma, contact irritation, contact allergy, etc.), whereas no specific aetiological factor was detected to explain the symptoms in the remaining 17 cases.

Lumbosacral fusion with pedicular osteosynthesis

A total of 40 patients affected with lumbosacral degenerative pathology and submitted to pedicular synthesis and laminectomy were followed-up. There was an 86% success rate after an average of 2 years. The authors conclude by recognizing the effectiveness of pedicular fixation, and the need to associate laminectomy with fusion because of the frequent association of instability and stenosis in degenerative low back pain.

Familial idiopathic hyperphosphatasia (FIH): response to long-term treatment with pamidronate (APD)

A 5-year-old child suffering from familial idiopathic hyperphosphatasia (FIH) was treated by: (1) intravenous infusion of pamidronate (APD) (3 h) (0.75 mg/kg/day) for 5 days; and (2) oral administration of APD (8 mg/kg/day) for 1 year, in association with calcium (1 g/day) as calcium gluconate. A decrease of both serum calcium and phosphate, and a slight PTH increase were observed immediately after the IV treatment; serum alkaline phosphatase did not change, but a marked and rapid decline in the hydroxyprolinuria was observed: basal 659 +/- 207 during IV treatment 169 +/- 59 (mean +/- SD mg/24 h, P < 0.005). At the end of one year of oral APD treatment clinical and radiological findings showed a remarkable improvement. Serum calcium, phosphate and PTH returned to the initial values. Plasma alkaline phosphatase levels showed a 70% decrease: basal 1370 IU/l, 1 year 410 IU/l whereas the hydroxyprolinuria values were similar to those determined at the end of the intravenous treatment (212 +/- 13 mg/24 h), but still significantly lower than the basal levels (P < 0.01). No side-effects were observed. APD appears to be a promising treatment for patients with FIH.

The in vitro metabolic inversion of R(-) to S(+) indoprofen

The paper reports a study on the metabolic inversion of indoprofen (2-[4-(2-isoindolinyl-1-one)-phenyl]-propionic acid) following incubation of the drug with liver microsomes from non-induced and phenobarbital-induced rats. The enantiomeric composition of the drug was determined after different incubation times of the racemate and the individual isomers. The S(+)/R(-) ratio was evaluated by densitometry following HPTLC separation of the R(+)-1-phenylethylamides. After incubation of the racemate and the individual isomers, no detectable amounts of indoprofen catabolites were extracted from the acidified incubation mixture. An appreciable enrichment in the S(+) enantiomer was observed after incubation of both racemate and R(-)-indoprofen; the S(+)/R(-) ratio reached a maximum after 1 h. Values were higher in the case of induction. After incubation of S(+)-indoprofen, a small but statistically significant decrease of the S(+)/R(-) ratio was observed. The increase of the S(+)-isomer concentration observed following incubation of R(-)-indoprofen can be ascribed to metabolic inversion by phenobarbital-inducible liver enzymes.

Intraoperative ultrasonography imaging in spinal surgery (technique and indications)

Intraoperative ultrasonography was conducted in 20 patients; the technique of intraoperative ultrasonography for use in spinal surgery is described. The authors emphasize that this non-invasive method obtains real time images of considerable diagnostic importance, allowing for a significantly minor use of image intensifier, with a consequent reduction in doses for both the patient and the staff.

Aldehyde-induced modifications of the microtubular system in 3T3 fibroblasts

The molecular structure of aldehydes is closely related to their antimicrotubular effect. Morphological modifications of the microtubular system in living cells after incubation with certain aldehydes are consistent with biochemical alterations detected in previous research. The microtubular arrangement was visualized by an immunofluorescence technique with antitubulin antibodies, while the content of tubulin in the cells was evaluated by a colchicine binding assay. 2-Nonenal behaved similarly to 4-hydroxynonenal, a lipid peroxidation product, disorganizing microtubular network in 3T3 fibroblasts and decreasing the amounts of tubulin able to bind labelled colchicine. Nonanal did not significantly impair the tubulin characteristics in the cells, despite the fact that it has been shown to be active on the purified microtubular system; benzaldehyde was ineffective. This would appear to explain the mechanisms of interaction of aliphatic aldehydes which might be suitable for use as antimicrotubular drugs.

Interaction of C-9 aldehydes with microtubular protein in vitro and in cultured cells in the presence of taxol

Some aldehydes have previously been shown to alter the microtubular system in a concentration-dependent manner. This paper examines the effects of taxol on the impairment of in vitro functionality of microtubular protein and of cytoplasmic microtubules by C-9 aliphatic aldehydes. Taxol-induced polymerization was inhibited by aldehydes in a similar way to GTP-induced polymerization, even though to a different degree. The addition of taxol restored the ability of aldehyde-impaired tubulin to polymerize, but only in the presence of nonanal. Colchicine binding activity in the presence of taxol was slightly modified by aldehydes at 20 degrees C, while it increased at 37 degrees C, compared to controls. Immunofluorescence showed a low disruption of microtubules in fibroblasts incubated with aldehydes and pretreated with taxol, probably as a consequence of its stabilizing activity. Anyway, aldehydes studied behaved differently, indicating a structure-activity relationship.

Effects of some aldehydes on brain microtubular protein

4-Hydroxynonenal is one of the main breakdown products of lipid peroxidation. It has an antiproliferative effect, which may partly be the consequence of an interaction with cytoskeletal structures. Its effects on microtubular protein are compared with those of homologous aldehydes with the same number of carbon atoms, and with that of benzaldehyde. Unlike the other aliphatic aldehydes, this latter aldehyde does not impair microtubular functions at every concentration in the range. Nonanal has the greatest effect on tubulin polymerization, whereas it only slightly impairs colchicine binding activity. 2-Nonenal and 4-hydroxynonenal have less inhibiting effect on tubulin polymerization; their effect on colchicine binding activity is dose-dependent. The targets of 4-hydroxynonenal on tubulin are -SH groups; the action mechanism of other aldehydes has not yet been identified.

Effect of calvatic acid and its analogs on ornithine decarboxylase activity in tumour cells

Calvatic acid (p-carboxyphenylazoxycyanide) is an antibiotic containing an azoxycyano group that displays carcinostatic activity. In the present work it has been shown that in AH-130 hepatoma and K562 leukemia cells the antibiotic, at low concentration, decreases ornithine decarboxylase (ODC) levels. The change depends on two summative effects of the drug, impairment of overall protein synthesis and inhibition of enzyme activity. Some analogs of calvatic acid have been tested in order to gain more insight into the structure-activity relationship. The decarboxylated derivative phenylazoxycyanide proved to be more effective in reducing protein synthesis and ODC activity in the whole tumor cells. The rapidly growing K562 cells displayed high sensitivity to this compound. Calvatic acid analogs devoid of the cyano group were less effective on the same parameters.

4-Hydroxynonenal interacts with tubulin by reacting with its functional -SH groups

4-Hydroxynonenal, which is one of the most important products of lipid peroxidation, alters microtubular organization and structure in 3T3 fibroblasts. Changes in cell shape and the disappearance of microtubules are observed by immunofluorescence after incubation with the aldehyde, and the colchicine binding activity of tubulin from 3T3 cells is modified. Moreover, the aldehyde determines a decrease in the ability of purified tubulin to polymerize and to bind colchicine. These effects may be related to the interaction of the aldehyde with functional -SH groups of tubulin which are necessary for protein integrity and functions. Indeed, the addition of cysteine protects against the damaging effects of the aldehyde.

Arylsulphatase in echinoderm immunocompetent cells

Two peaks of arylsulphatase activity were detected biochemically in coelomocyte lysate preparations of seven different Echinodermata species. Both peaks were inactivated by sulphite and sulphate ions, indicating that Type II arylsulphatase is present in the coelomocytes of the species tested. Arylsulphatase was localized histochemically in the granules of spherula cells, suggesting that in echinoderms a common cell type with granulocyte-like functions is present. The enzyme was also localized in the amoebocytes of echinoid species.

Phenylazoxycyanide damages microtubular protein more than its reference antibiotic, calvatic acid

The effect of phenylazoxycyanide and calvatic acid, its reference antibiotic, on some functions of tubulin obtained from different sources has been studied. Our purpose was to establish a possible correlation between the antitumour activity of these drugs and their antimicrotubular action. Microtubules are subcellular structures involved in proliferation and maintenance of the cell shape and probably in malignant transformation; indeed most antimitotic drugs influence the stability of microtubules through the interaction with tubulin, their main protein. In this work we found phenylazoxycyanide impairs, more than calvatic acid, polymerization of purified tubulin from calf brain. It also damages, in a dose-dependent manner, colchicine-binding ability of tubulin derived from rat liver and AH-130 Yoshida ascite hepatoma cells. Compounds displaying an azoxycyano group may represent new antimicrotubular agents and their effect could be modulated by the different polarity and structural characteristic of the molecule.

Microtubular protein impairment by pentanal and hexanal

Pentanal and hexanal are some of the aldehydes produced by lipid peroxidation, that causes damage to several subcellular structures. Lipoperoxidation products may directly attack cytoskeleton structures, the integrity of which is required for secretion mechanisms, e.g. 4-hydroxy-alkenals after microtubular integrity and function. Purified microtubular protein incubated with pentanal and hexanal at different concentrations revealed a tubulin-aldehyde interaction affecting the polymerization reaction and the colchicine-binding activity. These reactions apparently do not involve sulphydryl groups, and the addition of mercaptoethanol does not protect microtubules from the action of aldehydes, the effect of which is however more homogeneous, as only small differences can be noticed among the various aldehyde concentrations used.

Some biological effects of calvatic acid and its analog on isolated hepatocytes

Calvatic acid is a new antibiotic with both a carboxylic group and an azoxy function in the benzene ring. The relationship between structure and biological activity in this substance and one of its analog, phenylazoxyxyanide, was investigated. Isolated hepatocytes were used as an experimental system: the release of lactate dehydrogenase and the colchicine-binding activity of tubulin were first evaluated; effects were dose and time dependent. micromolar concentrations of these drugs determined a significant decrease of the glucose-6-phosphatase activity and a slight inhibition of aminopyrene demethylation. A toxic effect at the microsomal level and an interaction with the microtubular system are thus possible.

Impaired chemiluminescence response by neutrophils in patients with multiple myeloma

Neutrophil chemiluminescence (CL) as a measure of oxygen-dependent killing activity was evaluated in 3 groups of patients: (a) 63 patients with multiple myeloma (MM); (b) 31 subjects with monoclonal gammopathy of undetermined significance (MGUS); (c) 32 healthy controls. Neutrophil CL response was shown to be significant reduced both in patients with MM (p less than 0.001) and in subjects with MGUS (p less than 0.001). A significant difference was also observed between the results obtained in MM and those of MGUS (p less than 0.001). Treated MM patients showed a more severe impairment of neutrophil chemiluminescence response than that observed in untreated patients (p less than 0.001). It is suggested that the impairment of neutrophil CL response, possibly related to decreased killing activity, may play a role, along with other known causes, in the increased susceptibility to infection observed in MM patients.

Double (IgA kappa + IgG kappa) paraproteinaemia in a single patient: immunofluorescence evidence for a common plasma cell clone 'frozen' at the switch phase

We present a patient with multiple myeloma and double (IgA kappa + IgG kappa) paraproteinaemia in the serum. Immunofluorescence analysis of bone marrow plasma cell with fluorochrome-conjugated goat antibodies specific for mu, delta, gamma or alpha immunoglobulin heavy chain and kappa or lambda light chains revealed the presence of a plasma cell clone synthesizing simultaneously gamma, alpha and kappa chains. A minority of plasma cells synthesized gamma or alpha chains separately. Moreover, in the patient's peripheral blood, a few cells with the morphology of lymphoplasmoblasts and simultaneously positive for gamma, alpha and kappa chains were also detected. These results indicate that in this patient, the neoplastic plasma cell clone was 'frozen' at the differentiative step of the switch from IgG to IgA synthesis.

4-Hydroxy-alkenals interaction with purified microtubular protein

4-Hydroxy-alkenals effect on microtubular system has been investigated, comparing the activity of both biogenic and non-biogenic aldehydes. As these aldehydes react essentially with sulphydryl groups, their action on titratable thiol groups microtubular protein was studied. These compounds evidenced an inhibitory effect on this parameter and on tubulin polymerization, where sulphydryls are essential. 4-Hydroxy-alkenals inhibit tubulin polymerization in a dose-dependent manner (0.1-1 mM), with the exception of 4-hydroxy-octenal, that shows an inhibitory action only in concentrations from 0.5 mM up. Its behaviour is very anomalous: in fact the tubulin-colchicine binding, is stimulated rather than inhibited, whereas such binding is inhibited by the other tested aldehydes. Our present results give then a support for an interaction between 4-hydroxy-alkenals and microtubular protein.

Effect of methylglyoxal on tumour microtubular protein

Methylglyoxal inhibits cell division, exerting an antiproliferative action on tumour cells. Supernatants from ascites hepatoma cell homogenate, previously incubated with the aldehyde, showed a decrease in colchicine binding activity dependent on methylglyoxal concentration. In contrast, in vivo treatment of tumour-bearing rats apparently did not cause a significant impairment of microtubular protein, suggesting that the aldehyde interaction with microtubules cannot be considered responsible for its carcinostatic action.

Effect of lipid peroxidation on microtubular protein

CCl4 and ADP-Fe3+ determine an increased microsomal lipid peroxidation in liver tissue which is related to an impairment of the tubulin molecule in the case of CCl4 while no alteration is evident with ADP-Fe3+. Such difference could be explained in terms of different intermediate or end products towards which the tubulin molecule shows a different susceptibility.