Smoking habits predict adverse effects following mRNA COVID-19 vaccine: Empirical evidence from a pilot study

Objectives

The aim of this research was to investigate the possible association between smoking habits and the incidence of adverse effects (AE) following mRNA COVID-19 vaccine.

Study design

A longitudinal observational study was conducted in a sample of Italian healthcare workers (HCW).

Methods

HCWs who were administered mRNA COVID-19 vaccine (either BNT162b2 or mRNA-1273) were evaluated for the occurrence of AEs after three vaccine doses. Multivariate Poisson regression analyses were fitted to predict AE risk according to smoking characteristics – such as number of tobacco cigarettes smoked per day, smoking time and use of electronic cigarette (e-cig).

Results

Out of 320 total participants, 72 (22.5%) smoked cigarettes and 50 (15.6%) used e-cig, 49 of which being dual users. Tobacco smoking significantly increased the risks of muscle and joint pain during the primary COVID-19 vaccination cycle, and of chills during the whole vaccination series. The number of cigarettes smoked per day and vaping variously predicted AE onset during the whole cycle, with a tendency to respectively reduce and increase their risks. Duration of smoking did not affect any AE, except for headache after booster dose. Most results remained significant after Bonferroni adjustment of significance level.

Conclusion

Our pilot study indicated a possible effect of smoking habits on AE onset. Our research offers evidence that helps understanding possible predictors of the interindividual variability in COVID-19 vaccine response, serving as a reference for further studies on the effect smoking on vaccine safety and effectiveness.

AB1265 BIOTECHNOLOGICAL AGENTS IN PEDIATRIC-ONSET SCLERITIS

Background

the term scleritis refers to the inflammation of the sclera, the white outer type I collagen tunic of the eye (1). It may be rarely found in pediatric patients, with the incidence of pediatric scleritis accounting for about 1.2% of all scleritis cases (2). An early diagnosis and an adequate treatment are mandatory to avoid irreversible ocular sequelae (3). In this regard, the experience of biotechnological agents in patients with pediatric scleritis is quite limited at current.

Objectives

To assess the effectiveness of biotechnological agents in terms of scleritis control and glucocorticoid dosage tapering in patients with pediatric-onset scleritis; b) to assess the safety of the biotechnological agents employed and their ability in avoiding new ocular disease complications.

Methods

patients with pediatric-onset scleritis resistant to the conventional therapy and treated with biotechnological agents were retrospectively enrolled and prospectively followed-up. Demographic, clinical, ophthalmologic and therapeutic data were collected. The endpoints of the study consisted in the description of the therapeutic details gathered at the start of the biotechnological agents compared to what was observed at the 6-month, 12-month and last follow-up visits.

Results

5 patients (3 males; 2 females) treated with adalimumab, infliximab, abatacept secukinumab were consecutively enrolled. A remarkable clinical efficacy was observed in 5/5 cases during a 10-to-54 months follow-up period; complete and persistent suppression of ocular inflammation was pointed out in 2/2 patients with active disease at the start of the treatment, while a clinically relevant decrease of scleritis relapses was observed in 5/5 patients after the start of biotechnological treatment, compared to the past years of scleritis activity. In particular, the 5 patients suffered from a total number of 17 scleritis relapses during the 12 months preceding the start of the biologic treatment; the same patients suffered from 2 scleritis relapses within the first 12 months from the start of the treatment and 4 scleritis relapses during the entire follow-up period (median time of 28 months, interquartile range=118 months). These results were obtained despite the progressive and persistent glucocorticoid sparing effect, with a median daily dosage of prednisone or equivalent ranging from 15 (interquartile range =21.75) mg/day at the start of treatment to 2.5 (interquartile range =8.75) mg/day at the 3-month assessment, 2.5 (interquartile range=0) mg/day at 6 month visit, and 0.0 (interquartile range =2.5) mg/day at the last assessment. Regarding the safety profile, one out of five patients experienced an adverse event represented by oral candidiasis, presumably related to the concomitant use of glucocorticoids.

Conclusion

biotechnological agents have shown to be highly effective in controlling pediatric-onset scleritis, allowing a remarkable glucocorticoids sparing effect in patients previously resistant to conventional treatment and recalcitrant to a glucocorticoid-sparing approach. The safety profile was excellent.

References

[1]Yanoff M, Duker JS. Ophthalmology 5th ed. New York: Elsevier; 2019.

[2]Majumder PD, Ali S, George A, et al. Clinical Profile of Scleritis in Children. Ocul Immunol Inflamm 2019;27:535-539. doi: 10.1080/09273948.2017.

[3]Murthy SI, Sabhapandit S, Balamurugan S, et al. Scleritis: Differentiating infectious from non-infectious entities. Indian J Ophthalmol 2020; 68:1818-1828. doi: 10.4103/ijo.IJO_2032_20.

Disclosure of Interests

None declared

POS1373 THE DIAGNOSTIC ROLE OF PATHERGY TEST IN PATIENTS WITH BEHÇET’S DISEASE FROM WESTERN EUROPE

Background

pathergy is the term used to describe the hyper-reactivity of the skin in response to a minimal trauma, as the consequence of an exacerbated response of the innate immune system [1]. Pathergy test has a central role for the diagnosis of Behçet’s disease (BD), especially in doubtful and atypical cases. However, while its incidence has been decreasing over the past few decades, there are significant variations in the frequency of pathergy among different geographic contexts [2]. These aspects affect the diagnostic role of pathergy test for patients with suspected BD.

Objectives

to evaluate the frequency and features of positive pathergy test (PPT) in Italy, its role in the diagnosis of BD, and any association with other BD-related manifestations.

Methods

29 BD patients, 15 patients with spondyloarthritis (SpA) and 19 healthy controls (HCs) underwent two types of pathergy test, which were performed on the hairless part of the volar forearm ipsilaterally: intradermal injection of 0.5 ml normal saline and intradermally needle soaked with fresh self-saliva. Both pricks were done with a monouse 25 gauge hypodermic needle inserted with a vertical approach at a depth of 5 mm into the skin. The needle was withdrawn with a twisting movement. Skin reactions were observed 48 hours after prick. The results of pathergy tests were statistically analysed in the light of demographic, clinical, and therapeutic features of subjects enrolled. The BD activity at the time of the pathergy test was assessed with the Behçet’s Disease Current Activity Form (BDCAF) [3].

Results

pathergy test performed with saline solution resulted always negative in all groups. Skin prick test using self-saliva resulted in the occurrence of a papule in 2 (6.9%) BD patients and in 1 (6.7%) patient with SpA. A ≥15 mm erythematous area surrounding the needle prick site was observed in 12 (41.4%) BD patients, in 4 (26.7%) patients with SpA (including the patient with the papule), and in 1 (5.6%) HCs (p=0.022). The frequency of skin erythema was significantly higher among BD patients compared to HCs (p=0.015); no statistically significant differences were observed between BD and SpA patients (p=0.53) as well as between SpA patients and HC (p=0.21). The occurrence of skin erythema was not associated with any of the BD-related clinical manifestations. No statistically significant differences were observed between BD patients with positive and negative pathergy test according to sex (p=0.873); HLA-B51 positivity (p-value=0.461); age at the pathergy test (p=0.929); and disease duration at the pathergy test (p=0.487). The mean BDCAF was 1.33±0.65 among patients with PPT and 0.82±0.72 among patients with negative pathergy test (p=0.092). Erythema at self-saliva prick test showed a sensitivity of 41.4% (C.I. 23.52%-61.06%) and a specificity of 85.3% (C.I. 68.94%-95.05%); the positive likelihood ratio was 2.81 (C.I. 1.12-7.05) and the negative likelihood ratio was 0.69 (C.I. 0.49-0.96).

Conclusion

this study confirms the lower frequency of PPT in Western European BD patients if considering the development of a papule or a pustule in the site of pathergy test. Conversely, the onset of a ≥15 mm erythematous area surrounding the prick site could be sufficient to unveil the hyper-reactivity of the innate immune system in BD patients from Western Europe. Pathergy test is not pathognomonic of BD, as its positivity can be also observed in other innate immune system disorders, as observed for SpA patients.

References

[1]Gül A, Esin S, Dilsen N, Koniçe M, Wigzell H, Biberfeld P. Immunohistology of skin pathergy reaction in Behçet’s disease. Br J Dermatol 1995;132:901-7. doi: 10.1111/j.1365-2133.1995.tb16946.x.

[2]Davatchi F, Chams-Davatchi C, Ghodsi Z, Shahram F, Nadji A, Shams H, et al. Diagnostic value of pathergy test in Behcet’s disease according to the change of incidence over the time. Clin Rheumatol. 2011;30:1151–1155. doi: 10.1007/s10067-011-1694-5.

[3]Lawton G, Bhakta BB, Chamberlain MA, Tennant A. The Behcet’s disease activity index. Rheumatology (Oxford) 2004;43:73-8. doi: 10.1093/rheumatology/keg453.

Disclosure of Interests

None declared

POS1337 ADULT-ONSET STILL’S DISEASE WITH ELDERLY ONSET, RESULTS FROM A MULTICENTRE STUDY AND ASSESSMENT OF AGE INFLUENCE ON CLINICAL FEATURES AND DISEASE OUTCOMES

Background

Aging is a physiological, multidimensional, and irreversible process, occurring in humans over time. Interestingly, multiple lines of evidence have recently suggested that some diseases, generally affecting young adults, are nowadays described in the elderly, although possibly associated with different symptoms or complications. In this context, a possible occurrence of adult onset Still’s disease (AOSD) in elderly has been suggested. This is a rare inflammatory disorder of unknown origin usually observed in young adults [1-3].

Objectives

In this study, we aimed at describing the clinical characteristics, life-threatening complications occurrence, and mortality of AOSD patients with an elderly onset. The manifestations of these patients were also compared with those with a younger onset. Furthermore, the predictive role of age was evaluated on clinical features and disease outcomes. Finally, in these patients, an assessment of associated comorbidities was also performed.

Methods

A retrospective assessment of prospectively followed patients, from January 2001 to April 2021, was provided to analyse clinical features, life-threatening complications occurrence, and mortality in AOSD patients with onset in elderly. AOSD patients, who were included in multicentre Gruppo Italiano di Ricerca in Reumatologia Clinica e Sperimentale (GIRRCS) cohort, were evaluated.

Results

Out of 221 assessed patients, 37 (16.7%) had an onset of the disease aged over than 60 years. When compared with younger patients, these were characterised by a higher prevalence of pericarditis (p=0.008), comorbidities (p<0.0001), and mortality (p=0.023).

Additionally, our analysis showed that pleuritis and pericarditis positively correlated with age (coefficient=0.227, p=0.001; coefficient=0.213, p=0.001, respectively). Furthermore, the occurrence of parenchymal lung disease was significantly related with age (coefficient=0.168, p=0.012). The presence of comorbidities positively correlated with age (coefficient=0.443, p<0.0001). Moreover, age was negatively related to the polycyclic pattern (coefficient=-0.209, p=0.002). A correlation between mortality and age was also retrieved (coefficient=0.158, p=0.019).

Age predicted the presence of serositis in both univariate (HR: 1.02, 95%CI: 1.01-1.03, p=0.007) and multivariate analyses (HR: 1.02, 95%CI: 1.01-1.04, p=0.007). Age was also a significant predictor of parenchymal lung disease in both univariate (HR: 1.03, 95%CI: 1.01-1.05, p=0.017) and multivariate analyses (HR: 1.03, 95%CI: 1.00-1.05, p=0.048). No significant results were observed assessing the predictive role of age on occurrence of macrophage activation syndrome. Furthermore, age resulted to be a negative predictor of polycyclic pattern only in univariate analysis (HR: 0.99, 95%CI: 0.97-1.00, p=0.048). Finally, age significantly predicted the mortality in both univariate (HR: 1.03, 95%CI: 1.00-1.06, p=0.034) and multivariate analyses (HR: 1.05, 95%CI: 1.01-1.08, p=0.012).

Conclusion

Clinical features of AOSD patients with elderly onset were described in our multicentre cohort. Although the main clinical characteristics were similar comparing older and younger patients, patients aged over 60 years at disease onset were characterised by an increased prevalence of serositis, comorbidities, mostly cardiometabolic, and a higher mortality rate. Age predicted the presence of parenchymal lung disease and mortality, and it could be considered a further negative prognostic factor in AOSD.

References

[1]Mollaeian A, Chen J, et al. BMC Rheumatol. 2021;5(1):12.

[2]Maruyama A, et al. Mod Rheumatol. 2021;31(4):862-868.

[3]Suzuki E, et al. Tohoku J Exp Med. 2021;255(3):195-202.

Disclosure of Interests

None declared

Does smoking have an impact on the immunological response to COVID-19 vaccines? Evidence from the VASCO study and need for further studies

OBJECTIVES

The aim of this study was to investigate the possible impact of smoking on the humoral response to the BNT162b2 mRNA COVID-19 vaccine (also known as the BioNTech-Pfizer COVID-19 vaccine).

STUDY DESIGN

A longitudinal sero-epidemiological study was conducted in sample of Italian healthcare workers (HCWs).

METHODS

HCWs who were administered two doses of the BNT162b2 mRNA vaccine, 21 days apart, between December 2020 and January 2021, were invited to undergo multiple serology tests to identify SARS-CoV-2 S-RBD-specific immunoglobulin G (IgG) antibodies. Participants also responded to questions about their smoking status (i.e. current smokers vs non-smokers) in a survey.

RESULTS

Sixty days after the completion of the vaccination cycle, serological analyses showed a difference in vaccine-induced IgG titre between current smokers and non-smokers, with median antibody titres of 211.80 AU/mL (interquartile range [IQR] 149.80-465.50) and 487.50 AU/mL (IQR 308.45-791.65) [P-value = 0.002], respectively. This significant difference in vaccine-induced IgG titres between current smokers and non-smokers remained after adjusting for age, sex, and previous infection with SARS-CoV-2.

CONCLUSIONS

This study observed that vaccine-induced antibody titres decrease faster among current smokers than non-smokers. Further research to investigate the impact of smoking on the immunological response to COVID-19 and non-COVID-19 vaccines is required.

Field evaluation of BNT162b2 COVID-19 vaccine response in healthcare workers: a 3-month follow-up

Background

Effective and rapid immunologic response to vaccines is a crucial strategy for the control SARS-CoV-2 pandemic. Here, we present the results of an ongoing longitudinal observational study conducted among the healthcare workers (HCWs) of the Pineta Grande Hospital (Castel Volturno, Italy), who were administered the two-dose prime-boost mRNA vaccine BNT162b2.

Methods

Volunteer HCWs underwent either (i) six RT-PCR assay for qualitative detection of SARS-CoV-2 nucleic acid in nasopharyngeal/oropharyngeal swabs; (ii) or six quantitative serology testing for the research of virus-specific immunoglobulins (Ig) through chemiluminescent immunoassay with a reactivity cut-off of an Index of ≥ 1.0. The first tests were taken before the administration of the vaccine and then according to a predefined timeline. An active surveillance follow-up of SARS-CoV-2 infections was set amongst the vaccinees after the end of the study.

Results

Overall, among the 435 HCWs who accepted to participated in the study, 9.3% reported a previous laboratory-confirmed infection with SARS-CoV-2, though all subjects tested negative at the time of first vaccine dose. In the swab cohort, seven subjects tested positive in the first 15 days after the first vaccine dose and one about a week from the second dose. At 45- and 60-day follow-ups all vaccinees tested negative, but two positive tests were registered at the third month. In the second cohort, two weeks after the first vaccine dose anti-SARS-CoV-2 antibodies exceeded the reactivity cut-off in 82.5% the participants. At one-month follow-up, almost all (98.4%) the vaccinees had reached the maximum Index value of 10. No statistically significant associations were found between antibody response and HCWs' characteristics.

Conclusions

Our results showed that surveillance is a critical component of providing safe healthcare during COVID-19 pandemic, also after extended vaccination campaigns, thus enhancing the protection of patients and HCWs.

Key messages

All healthcare facilities should implement continuous post-vaccination surveillance programs in order to ensure patients and healthcare workers safety, and limit in-hospital transmission of SARS-CoV-2.

Longer field follow-ups are indispensable to investigate immunogenicity trends and effectiveness of COVID-19 vaccines over time, and to consider booster doses, especially in high-risk population.

POS1349 THE JOINT INVOLVEMENT IN ADULT ONSET STILL’S DISEASE IS CHARACTERISED BY A PECULIAR MAGNETIC RESONANCE IMAGING AND A SPECIFIC TRANSCRIPTOMIC PROFILE

Background:

Adult onset Still’s disease (AOSD) is a rare systemic autoinflammatory disease and joint involvement is one of its clinical manifestations [1]. Arthritis, either oligoarthritis or bilateral symmetrical rheumatoid arthritis-like polyarthritis, is another common clinical feature of AOSD, with a migrating pattern at the beginning and becoming stable over the time [1].

Objectives:

The aims of the study were to assess joint involvement in AOSD by using magnetic resonance imaging (MRI), to describe main patterns of involvement, and associated clinical characteristics, and to evaluate the global transcriptomic profile of synovial tissues in AOSD to elucidate possible pathogenic pathways involved with.

Methods:

AOSD patients, who underwent to magnetic resonance imaging (MRI) exam on joints, were assessed to describe patterns of joint involvement and associated clinical characteristics. Some synovial tissues were collected for RNA-sequencing purposes.

Results:

In this study, 31 patients with AOSD (mean age 42.3 ± 15.2 years, 54.8% male gender), who underwent to at least one MRI exam on joints, were assessed. The most common MRI finding was the presence of synovitis on 60.5%, mainly in peripheral affected joints. MRI revealed a mild to moderate proliferative synovitis, as thickening of the synovial membrane, with low to intermediate signal intensity on T1-weighted images and intermediate to high signal intensity on T2-fat saturated weighted and STIR images, suggesting the presence of a hyperplastic than of a hypertrophied synovial tissue. Bone oedema and bone erosions were reported on 34.9% and 25.6% MRI exams, respectively. In all patients but one, bone erosions were synchronous with bone oedema, overlapping completely the locations. Assessing clinical characteristics in patients with MRI-erosions, a higher prevalence of splenomegaly, a more frequent chronic disease course, lower levels of erythrocyte sedimentation rate and ferritin was observed.

Assessing the synovial tissues of some AOSD patients, a moderate perivascular mononuclear infiltrate in the sub-lining stroma of hip synovial tissues was observed, whereas the lining cells were relatively unremarkable. In addition, interleukin (IL)-1β, IL-6, TNF, and heavy ferritin subunit (FeH) were found on AOSD synovial tissues.

An RNA-sequencing analysis assessed the global transcriptomic profile of synovial tissues on AOSD patients and matched-controls. Assessing IL-1 pathway, we found an increased expression of il1a, il1b, il1rap, il1r1, il18r1, and Il18bp on AOSD tissues when compared with controls. In IL-6 pathway, we found an increased expression of il6 and il6st/gp130 on AOSD synovial tissues whereas an increased expression of il6r was shown on the controls. Among genes involved in TNF pathway, tnf, traf1, traf2, tnfaip3 and tnfrsf1a resulted to be more expressed in AOSD synovial tissues than in controls. Finally, fth1 and ftl were more expressed in AOSD patients than controls, when we explored the iron uptake and transport pathway.

Conclusion:

A peculiar MRI pattern of joint involvement in AOSD was reported; the most common finding was the presence of synovitis, characterised by intermediate to high signal intensity on T2-fat-saturated weighted and STIR images. Bone erosions and bone oedema were also observed. This MRI pattern was associated with a hyper-activation of IL-1, IL-6, and TNF pathways together with a hyper-expression of ferritin genes on AOSD synovial tissues.

References:

[1]Giacomelli R, Ruscitti P, Shoenfeld Y. A comprehensive review on adult onset Still’s disease. J Autoimmun. 2018;93:24-36.

Disclosure of Interests:

None declared

Relapsing Bilateral Uveitis and Papilledema in Sinus Histiocytosis with Massive Lymphadenopathy (Rosai-Dorfman Disease)

Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) is a non-hereditary histiocytic proliferative disorder affecting young people, with extranodal manifestations in 28-43% of cases. Eye involvement is infrequent. Lymphoproliferation in the soft tissues of the orbit and in the lids has been reported in 12% of cases but intraocular involvement is rare. We describe the case of a 12-year-old boy affected by Rosai-Dorfman disease with bilateral relapsing uveitis and papilledema that appeared four years before the onset of lymphadenopathy.

Contemporary Chemotherapy and Radiotherapy for Inguinal Metastases of Carcinoma of the Penis: A Case Report

A case is reported of a 76 year old patient with inoperable lymph node metastases from cancer of the penis. Methotrexate and bleomycin chemotherapy and concurrent irradiation were administered. The patient achieved a complete remission and is disease-free 30 months after therapy. The treatment was well tolerated.

Liver Retransplantation for Hepatic Abscess Due to Hepatic Artery Thrombosis: A Case Report

INTRODUCTION

Hepatic artery thrombosis (HAT) is a well-recognized complication of liver transplantation (LT). HAT is an important risk factor for infectious, in particular hepatic abscess, which can cause graft loss and increasing morbidity and mortality.

CASE REPORT

We present a case report of complicated LT in a 52-year-old Caucasian man with primary sclerosing cholangitis. In 2007 the patient was included on the waiting list in Padua for LT. In 2012 the patient underwent percutaneous transhepatic biliary drainage for bile duct stricture, complicated with acute pancreatitis. A diagnostic laparoscopy was performed with choledochotomy and Kehr's T tube drainage. On February 14, 2012, the patient underwent LT with arterial reconstruction and choledochojejunostomy. The postoperative course was complicated with HAT, multiple liver abscesses, and sepsis associated with bacteremia due to Enterococcus faecium despite massive intravenous antibiotic therapy and percutaneous drainages. On November 28, 2012, the patient underwent retransplantation. Four years after transplantation the patient is still in good general condition.

CONCLUSION

Hepatic abscess formation secondary to HAT following LT is a major complication associated with important morbidity and mortality. In selected cases retransplantation should be considered as our case demonstrates.

Thermal Sensitivity in Tourette Syndrome: Preliminary Report

The effects of heat on tic symptoms were studied in a sample of 78 adults with Tourette syndrome. 62 men and 16 women completed a survey concerning the type, onset, and course of their tics. 10 adult male subjects also participated in a thermal challenge during which ambient temperature was raised from 22°C to 35°C following a control period. Of the 78, 24% or 19 reported increased tics upon exposure to heat. Compared to the remaining 59 subjects, there were no differences in sex distribution, current age, or overall course of illness. In the thermal challenge, there was general increase in tics that was correlated with sweat rate ( r = .55, p=.001). This effect was prominent in 5 of 10 subjects ( rs = .29 to .63). There were no mean differences in current age, age of onset, or current severity of symptoms between the five subjects of each group. Tic symptoms in a subgroup of patients with Tourette syndrome may be sensitive to heat. Abnormal heat regulation is not a likely explanation for the observed increase in tics. The increase may be due to normal heat-loss mechanisms through dopaminergic pathways.

Immunometabolic biomarkers of inflammation in Behçet's disease: relationship with epidemiological profile, disease activity and therapeutic regimens

Behcet's disease (BD) is a systemic inflammatory disease with a still unclear pathogenesis. Although several inflammatory molecules have been studied, current biomarkers are largely insensitive in BD and unable to predict disease progression and response to treatment. Our primary aim was to explore serum levels of soluble CD40 L (sCD40L), soluble intracellular adhesion molecule (sICAM-1), monocyte chemoattractant protein-1 (MCP-1), myeloperoxidase (MPO), leptin, resistin, osteoprotegerin (OPG), soluble type 1 tumour necrosis factor receptor (sTNFR), interleukin (IL)-6 and serum amyloid A (SAA) serum concentration in a cohort of 27 BD patients. The secondary aim was to evaluate potential correlations between the putative circulating biomarkers, demographic profile of patients, the status of disease activity, the specific organ involvement at the time of sample collection and different therapeutic regimens. Serum concentrations of sTNFR (P = 0·008), leptin (P = 0·0011), sCD40L (P < 0·0001) and IL-6 (P = 0·0154) were significantly higher in BD patients than in HC, while no difference was found in MCP-1, MPO and resistin serum levels. Moreover, we observed significantly higher sTNFR serum concentrations in BD patients presenting inactive disease than HC (P = 0·0108). A correlation between sTNFR and age was also found, with higher levels in patients over 40 years than HC (P = 0·0329). Although further research is warranted to elucidate the role of circulating biomarkers, some of that may contribute to the understanding of the physiopathology processes underlying BD activity and damage as well as to provide useful tools for prognostic purposes and a personalized treatment approach.

Human skin-derived fibroblasts used as a 'Trojan horse' for drug delivery

BACKGROUND

Drug toxicity currently represents the main challenge of tumour chemotherapy. Our group recently developed a new method for drug delivery inspired by the 'Trojan Horse' concept. Human mesenchymal stem cells (hMSCs) have been shown to play the role of new 'horses' in delivering anti-tumour agents, without involving any genetic manipulation. As human stromal dermal fibroblasts (hSDFs) represent an interesting alternative to hMSCs, being easy to isolate, they could be an ideal candidate for this kind of procedure.

AIM

To investigate whether hSDFs can take up and deliver paclitaxel (PTX) in sufficient concentrations to inhibit a very aggressive melanoma tumour (IgR39) in vitro.

METHODS

hSDFs were primed with high doses of PTX, and then the effect of drug delivery on IgR39 melanoma proliferation in vitro was evaluated using several assays (antiproliferation, transwell cocultures, rosette assays and colony growth assays). Furthermore, the cell cycle and PTX uptake/release mechanism of hSDFs were studied both under both normal and hypoxic conditions.

RESULTS

hSDFs incorporated PTX and then released it with unaffected pharmacological activity, inhibiting human IgR39 melanoma growth in vitro. The hypoxic conditions did not induce changes in cell cycle pattern and the uptake-release mechanism with PTX was not affected.

CONCLUSIONS

hSDFs can be used as a Trojan horse, as the released drug was functionally active. These results indicated that these cells could be used for clinical treatment as the drug was released into the cellular environment and the primed cells underwent apoptosis.

The common NOD2/CARD15 variant P268S in patients with non-infectious uveitis: a cohort study

BACKGROUND

The etiology of Autoimmune chronic uveitis (ACU) is still unknown; NOD2/CARD15 gene mutations are responsible for the Blau Syndrome and can induce uveitis in animal models.

PRESENTATION OF THE HYPOTHESIS

Aim of our study was to assess if NOD2/CARD15 variants have a role in the etiology or in the clinical course of patients with ACU, either idiopathic or associated with other inflammatory diseases.

TESTING THE HYPOTHESIS

We consecutively enrolled 25 patients (19 pediatric and 6 adults) affected with ACU. For each patient medical history was reviewed and clinical data were recorded. Allelic and genotypic frequencies of NOD2/CARD15 variations were calculated in patients and matched with those of 25 healthy controls. The statistical analysis was performed. Fifteen patients showed the polymorphism P268S/SNP5 (SNP rs2066842) as heterozygous carriers while two patients were homozygous for the same polymorphism; one patient carried also the variant c647 18-16 TCT on intron 3, not previously reported in the literature. Statistical analysis for NOD2/CARD15 genotyping showed significant differences between patients and controls for allelic frequencies (p = 0.04, OR: 4.03, 95 %; CI = 1.2-13.5) but not for genotypic frequencies. We could not identify a significant phenotype-genotype correlation.

IMPLICATIONS OF THE HYPOTHESIS

In our cohort of Italian patients, the NOD2/CARD15 common variant P268S/SNP5 could potentially be significantly associated with ACU.

Survival benefit of transplantation for recurrence of hepatocellular carcinoma after liver resection

BACKGROUND

Liver transplantation (LT) for hepatocellular carcinoma (HCC) can be used for tumor recurrence after liver resection (LR) both for initially transplant-eligible patients as conventional salvage therapy (ST) and for non-transplant-eligible patients (beyond Milan criteria) with a goal of downstaging (DW). The aim of this study was to compare the intention-to-treat (ITT) survival rates of patients who are listed for LT, according to these two strategies.

METHODS

We analyzed a prospective database of 399 consecutive patients who underwent hepatic resection for HCC from 2002 to 2011 to identify patients included in the waiting list for tumor recurrence. Intention-to-treat (ITT) survivals were compared with those of patients resected for HCC within and beyond Milan criteria in the same period and not included in the LT waiting list.

RESULTS

The study group consisted of 42 patients, 28 in the ST group (within Milan) and 14 in the DW group (beyond Milan). The 5-year ITT survival rate was similar between the 2 groups, being 64% for ST and 60% for DW (P=.84). Twenty-five patients (15 ST and 10 DW) underwent LT, 13 (10 ST and 3 DW) were still awaiting LT, 4 (3 ST and 1 DW) dropped out of the waiting list because of tumor progression, and 7 (5 ST [33%] and 2 DW [20%]) had tumor recurrence. The 5-year ITT survival of ST patients was similar to that of 252 in-Milan HCC patients resected only (P=.3), whereas 5-year ITT survival of DW patients was significantly higher (P<.01) than that of 105 beyond-Milan HCC patients resected only.

CONCLUSIONS

LR seems to be a safe and effective therapy both as alternative to transplantation and as downstaging strategy for intermediate-advanced HCC. The survival benefit of salvage LT, however, seems to be higher in the 2nd than in the 1st group.

Coexistence of axial spondyloarthritis and thromboangiitis obliterans in a young woman

A peculiar coexistence of axial spondyloarthritis and ischemia of the feet and the fourth finger of the left hand in a young woman, who was a heavy smoker, is discussed in this report. This picture was considered within the context of thromboangiitis obliterans. Positivity of anti-nuclear antibodies and mild elevation of inflammatory parameters were noted. Computed tomography angiograms of upper and lower limbs showed luminal narrowing and occlusion of the left humeral, left anterior/posterior tibial and right anterior tibial arteries. Daily iloprost perfusions were started, and smoking cessation was strongly recommended. Coldness and rest pain in the distal extremities improved within a few weeks. The possibility that spondyloarthritis might precede the clinical picture of thromboangiitis obliterans should be considered in heavy smokers.

Degeneration and plasticity of the optic pathway in Alström syndrome

BACKGROUND AND PURPOSE

Alström syndrome is a rare inherited ciliopathy in which early progressive cone-rod dystrophy leads to childhood blindness. We investigated functional and structural changes of the optic pathway in Alström syndrome by using MR imaging to provide insight into the underlying pathogenic mechanisms.

MATERIALS AND METHODS

Eleven patients with genetically proved Alström syndrome (mean age, 23 years; range, 6-45 years; 5 females) and 19 age- and sex-matched controls underwent brain MR imaging. The study protocol included conventional sequences, resting-state functional MR imaging, and diffusion tensor imaging.

RESULTS

In patients with Alström syndrome, the evaluation of the occipital regions showed the following: 1) diffuse white matter volume decrease while gray matter volume decrease spared the occipital poles (voxel-based morphometry), 2) diffuse fractional anisotropy decrease and radial diffusivity increase while mean and axial diffusivities were normal (tract-based spatial statistics), and 3) reduced connectivity in the medial visual network strikingly sparing the occipital poles (independent component analysis). After we placed seeds in both occipital poles, the seed-based analysis revealed significantly increased connectivity in patients with Alström syndrome toward the left frontal operculum, inferior and middle frontal gyri, and the medial portion of both thalami (left seed) and toward the anterior portion of the left insula (right and left seeds).

CONCLUSIONS

The protean occipital brain changes in patients with Alström syndrome likely reflect the coexistence of diffuse primary myelin derangement, anterograde trans-synaptic degeneration, and complex cortical reorganization affecting the anterior and posterior visual cortex to different degrees.

Alcohol abuse and de novo tumors in liver transplantation

INTRODUCTION

Organ transplant recipients show an increased incidence of cancer ranging from 4% to 16% owing to several causes: immunosuppression, viral infection, individual predisposition, and so on.

MATERIALS AND METHODS

We retrospectively reviewed the records of 43/683 (6.3%) recipients of 734 liver transplants performed from November 1991 to November 2008 who experienced a de novo neoplasm.

CONCLUSION

Alcohol abuse significantly increased the rate of all de novo neoplasms and particularly pharyngogastroesophageal cancers among population of liver transplant recipients. Minimization of immunosuppressive therapy is necessary to reduce the risk of a de novo neoplasm. Strict posttransplant follow-up is required to identify early gastroenteric tumors.

Progression of hepatocellular carcinoma before liver transplantation: dropout or liver transplantation?

BACKGROUND

Tumor progression before liver transplantation (OLT) is the main cause of dropout from the waiting list (WL) of patients with hepatocellular carcinoma (HCC). The aim of this study was to show a correlation between adopted dropout criteria and dropout/intention-to-treat survival rates of WL HCC patients.

METHODS

The study period was 2000 to 2007. The dropout criteria were macroscopic vascular invasion, metastases, or a poorly differentiated tumor. Adult patients with benign chronic liver disease enlisted for primary OLT in the same period represented the control group.

RESULTS

Dropout probability of study (n = 128) versus control group (n = 377) subjects was similar: namely, 12% at 1 year in both groups (P = NS). Intention-to-treat survival curve of the HCC group overlapped that of the benign group (5-year survival rates were 73% and 71%, respectively; P = NS). At the time of listing, 103 study group patients were within the Milan criteria (MC): among these patients, 29 (28%) showed tumor progression beyond MC before OLT. Simulating the dropout of these 29 patients at the time of diagnosis of tumor progression, we compared the dropout probability of the 103 patients within MC with that of the control group. As a result, the 1- and 2-year dropout rates became 37% and 53%, respectively, in the study group, which were significantly higher than those in the controls (P < .01).

CONCLUSION

HCC patients on the WL showed a significantly greater dropout rate than subjects with benign cirrhosis when too restrictive radiologic dropout criteria were used. The adoption of criteria more related to biological aggressiveness of a tumor decreased the dropout risk for HCC patients without impairing their intention-to-treat survival rates.

De novo tumors are a major cause of late mortality after orthotopic liver transplantation

The purpose of this study was to describe de novo post-orthotopic liver transplantation (OLT) malignancies for comparison with incidence rates in Italian cancer registries. Three hundred thirteen OLT patients engrafted from 1991 to 2006 and surviving 12 months without a previous diagnosis of cancer were evaluated for the development of de novo malignancies excluding nonmelanoma skin cancers. During a total follow-up time of 1753 PYs, 40 (12.8%) de novo malignancies were diagnosed in 40 recipients. The most common cancers were non-Hodgkin lymphoma (NHL; 20%), cancer of the head and neck (17%), Kaposi sarcoma (KS; 17%), and esophageal tumors (12%). The 1-, 3-, 5-, and 10-year estimated survival rates were 70%, 56%, 48%, and 39%. Patients with de novo cancers showed a lower 10-years survival rate (P = .0047) than patients without (39% vs 75%). The risk of cancer after OLT was 3-fold higher than that of the general population of the same age and gender (95% confidence interval [CI], 2.0-4.3). De novo tumor sites or types with significantly elevated standardized incidence ratios (SIRs) included KS (SIRs = 212), NHL (SIRs = 13.7), oesophagus (SIRs = 18.7), melanoma (SIRs = 10.1), and head and neck cancers (SIRs = 4.6). Tumors after OLT were associated with lower long-term survival, confirming that cancer is a major cause of late mortality.

Is resectable hepatocellular carcinoma a contraindication to liver transplantation? A novel decision model based on "number of patients needed to transplant" as measure of transplant benefit

BACKGROUND & AIMS

Number-needed-to-treat is used in assessing the effectiveness of a health-care intervention, and reports the number of patients who need to be treated to prevent one additional bad outcome. Although largely used in medical literature, there are no studies measuring the benefit of liver transplantation (LT) over hepatic resection (HR) for hepatocellular carcinoma (HCC) in terms of "Number of patients needed to transplant (NTT)."

EXCLUSION CRITERIA

Child-Turcotte-Pugh (CTP) Classes B-C, very large (>10 cm) and multi-nodular (>2 nodules) tumours, macroscopic vascular invasion and extra-hepatic metastases.

STUDY POPULATION

1028 HCC cirrhotic patients from one Eastern (n=441) and two Western (n=587) surgical units. Patient survival observed after HR by proportional hazard regression model was compared to that predicted after LT by the Metroticket calculator. The benefit obtainable from LT compared to resection was analysed in relationship with number of nodules (modelled as ordinal variable: single vs. oligonodular), size of largest nodule (modelled as a continuous variable), presence of microscopic vascular invasion (MVI), and time horizon from surgery (5-year vs. 10-year).

RESULTS

330 patients were beyond the Milan criteria (32%) and 597 (58%) had MVI. The prevalence of MVI was 52% in patients within Milan criteria and 71% in those beyond (p<0.0001). In the 5-year transplant benefit analysis, nodule size and HCC number were positive predictors of transplant benefit, while MVI had a strong negative impact on NTT. Transplantation performed as an effective therapy (NTT <5) only in oligonodular HCC with largest diameter >3cm (beyond conventional LT criteria) when MVI was absent. The 10-year scenario increased drastically the transplant benefit in all subgroups of resectable patients, and LT became an effective therapy (NTT <5) for all patients without MVI whenever tumor extension and for oligonodular HCC with MVI within conventional LT criteria.

CONCLUSIONS

Based on NTT analysis, the adopted time horizon (5-year vs. 10-year scenario) is the main factor influencing the benefit of LT in patients with resectable HCC and Child A cirrhosis.

A Bayesian methodology to improve prediction of early graft loss after liver transplantation derived from the liver match study

BACKGROUND

To generate a robust predictive model of Early (3 months) Graft Loss after liver transplantation, we used a Bayesian approach to combine evidence from a prospective European cohort (Liver-Match) and the United Network for Organ Sharing registry.

METHODS

Liver-Match included 1480 consecutive primary liver transplants performed from 2007 to 2009 and the United Network for Organ Sharing a time-matched series of 9740 transplants. There were 173 and 706 Early Graft Loss, respectively. Multivariate analysis identified as significant predictors of Early Graft Loss: donor age, donation after cardiac death, cold ischaemia time, donor body mass index and height, recipient creatinine, bilirubin, disease aetiology, prior upper abdominal surgery and portal thrombosis.

RESULTS

A Bayesian Cox model was fitted to Liver-Match data using the United Network for Organ Sharing findings as prior information, allowing to generate an Early Graft Loss-Donor Risk Index and an Early Graft Loss-Recipient Risk Index. A Donor-Recipient Allocation Model, obtained by adding Early Graft Loss-Donor Risk Index to Early Graft Loss-Recipient Risk Index, was then validated in a distinct United Network for Organ Sharing (year 2010) cohort including 2964 transplants. Donor-Recipient Allocation Model updating using the independent Turin Transplant Centre dataset, allowed to predict Early Graft Loss with good accuracy (c-statistic: 0.76).

CONCLUSION

Donor-Recipient Allocation Model allows a reliable donor and recipient-based Early Graft Loss prediction. The Bayesian approach permits to adapt the original Donor-Recipient Allocation Model by incorporating evidence from other cohorts, resulting in significantly improved predictive capability.

Expanding spectrum of TNFRSF1A gene mutations among patients with idiopathic recurrent acute pericarditis

Although idiopathic recurrent acute pericarditis (IRAP) is generally presumed to derive from an autoimmune process, increasing interest is currently being devoted to autoinflammatory diseases, a group of disorders of the innate immune system caused by mutations of genes involved in the regulation or activation of the inflammatory response, without any apparent involvement of autoimmunity. The tumour necrosis factor receptor-1-associated periodic syndrome is the most common autosomal dominant autoinflammatory disorder and is caused by mutations in the TNFRSF1A gene encoding the 55-kD receptor for tumour necrosis factor-α. IRAP patients carrying TNFRSF1A gene mutations have been recently described. We report herein the first IRAP patients carrying the rare R104Q and D12E TNFRSF1A gene mutations, thus expanding the spectrum of tumour necrosis factor receptor-1-associated periodic syndrome mutations in IRAP patients.

White mulberry supplementation as adjuvant treatment of obesity

Body weight is controlled by our genes and managed by a neuro-hormonal system, in particular by insulin and glucagon. The meristematic extract of Japanese white mulberry blocks the alpha-glucosidase and then the intestinal hydrolysis of polysaccharides, thereby reducing the glycaemic index of carbohydrates. The target of our research was to evaluate the adjuvant slimming effect of the extract of white Japanese mulberry in the dietetic treatment of some patients who are obese or overweight. 46 overweight people were enrolled and divided into two subgroups: the subjects of both subgroups were given an identical balanced diet of 1300 kcal: subjects of the subgroup alpha received 2400 mg of white Japanese mulberry extract, the subgroup b subjects receive placebo. Each subgroup was followed-up every 30 days at 30, 60 and 90 days of treatment. Both in the periodic inspections and in the final inspection measurements of body weight and waist circumference in all the subjects and thigh circumference in women only were repeated. All subjects repeated blood tests. In the subgroup alpha, weight loss was about 9 kg in 3 months, equal to approximately 10 percent of the initial weight, significantly higher than subgroup beta (P<0.0001); moreover, the plasma insulin and glucose curves of the volunteers in this subgroup at the end of the trial were lower than those performed at the time of enrolment. In the 20 women of the beta subgroup treated with only low-calorie diet and with placebo, weight reduction was globally of 3.2 kg, approximately equal to 3 percent of the initial weight; moreover, the blood glucose curves and the insulin curves showed a slight decline compared to baseline, but not so significantly as was the case for group alpha. Waist circumference and thigh circumference (in women) decreased in all participants, obviously more evidently in subjects who lost more kg. The extract of white Japanese mulberry may represent a reliable adjuvant therapy in the dietetic treatment of some patients who are obese or overweight.

Liver transplantation in children with congenital cardiac defects: a case report and a short literature review

Advances in surgical techniques and follow-up of patients with complex congenital heart disease who were corrected in childhood increasingly survive to adolescence or adulthood. Increasingly anesthesiologists encounter these cases for major noncardiac surgery, including orthotopic liver transplantation (OLT) wherein there is an augmented risk of significant perioperative hemodynamic instability. We performed a successful OLT in a 12-year-old boy with end-stage cryptogenetic liver fibrosis and hepatopulmonary syndrome who was born with a double outflow right ventricle, pulmonary atresia, and pulmonary artery hypoplasia corrected at the age of 1 month. By the time he was considered for OLT his altered pulmonary valve apparatus resulted in severe pulmonary regurgitation, dilated right atrium and ventricle, and elevated right heart pressures. After a temporarily successful angioplasty he was at first placed on the waiting list, then removed, and finally relisted following implantation of a prosthetic pulmonary valve that resulted in significant reduction of right heart pressures.

The Use of Zoledronic Acid in Patients with Bone Metastases from Prostate Carcinoma: Effect on Analgesic Response and Bone Metabolism Biomarkers

Zoledronic acid is a bisphosphonate that is effective in the treatment of complications of metastatic bone disease. We have carried out a perspective study on 24 consecutive patients with prostate cancer metastatic to bone to verify the effect of zoledronic acid on analgesic response and a possible relationship with the levels of bone metabolism biomarkers. Eligibility for this study required prostate cancer patients with metastatic bone disease and pain not controlled by analgesics. Patients were excluded from the study if they were receiving cytotoxic chemotherapy or radiation therapy within three months. Eighteen patients (75%) were considered responder to acid zoledronic, only 6 patients did not respond. Before starting treatment (T0) mean Visual Analogue Scale was 7.8 (SE +/- 0.29), after 1 month therapy (T1) was 3.6 (SE +/- 0.3) and after three months (T2) was 3.1 (SE +/- 0.4) with a significant difference between T0 and T1 (p<0.0005) and between T0 and T2 (p<0.0005). Visual Analogue Scale improvement was positively correlated with decrease of C-telopeptide and bone phosphatase alkaline (p<0.05) serum levels.

Childhood versus adulthood-onset autoinflammatory disorders: myths and truths intertwined

Autoinflammatory disorders are characterized by spontaneous episodes of systemic inflammation deriving from inherited defects of the innate immune system. Childhood is usually the lifetime involved in most inherited autoinflammatory disorders, but a moderate number of patients may experience disease onset during adulthood. Herein we report our experience in the clinical and genetic approach to the diagnosis of autoinflammatory disorders in regard of the first 500 pediatric and adult patients evaluated during the period 2007-2012 in our Center, due to histories of periodically-recurring inflammatory attacks, giving emphasis to the differences observed according to patients'age and to the most relevant data differentiating child and adult-onset autoinflammatory disorders in the medical literature.

Liver autotransplantation for the treatment of unresectable hepatic metastasis: an uncommon indication-a case report

Ex situ ex vivo liver surgery represents a method to expand the surgical indications to treat otherwise unresectable liver tumors. We report the case of a 38-year old woman with hepatic metastasis from a pancreatoblastoma that was judged to be unresectable due to the involvement of the three hepatic veins. To treat the primary tumor, she underwent a pancreaticoduodenectomy, adjuvant chemotherapy, and thermal ablation of a liver metastasis. After appropriate preoperative study and with the permission of the ethics committee, she underwent ex situ ex vivo liver resection. The hepatectomy was performed by removing the whole liver en bloc with the retrohepatic vena cava. The inferior vena cava was reconstructed by interposition of a prosthetic graft. The ex situ ex vivo hepatic resection, a left hepatic lobectomy included the lesion in segments 1-5-7-8. The two hepatic veins were reconstructed using patches of saphenous vein. The organ was preserved continuously for 6 hours using hypothermic perfusion with 4°C Celsior solution. The liver was then reimplanted performing an anastomosis between the reconstructed hepatic veins and the caval prostheses. The patient was discharged at postoperative day 22 and is currently disease-free at 8 months after surgery and 44 months after the initial diagnosis. Ex situ, ex vivo liver surgery offers an additional option for patients with both primary and secondary liver tumors considered to be unresectable using traditional surgical approaches.

Shaken baby syndrome: pathogenetic mechanism, clinical features and preventive aspects

The shaken baby syndrome (SBS) is an extremely serious form of child abuse and a leading cause of death and disability in childhood. The syndrome usually occurs in infants younger than 1 year when a parent or a care-giver tries to stop the baby from crying by vigorous manual shaking. The repetitive oscillations with rotational acceleration of the head can result in injuries of both vascular and neuronal structures. The most frequent injuries associated with SBS include encephalopathy, retinal hemorrhages, and subdural hemorrhage. Fractures of the vertebrae, long bones, and ribs may also be associated with the syndrome. Victims of abuse have various presenting signs and symptoms ranging from irritability, decreased responsiveness and lethargy to convulsions, and death. Diagnosis is often difficult because usually parents or caregivers not tell the truth about what has happened to their child and because usually there is no external evidence of trauma. However, the syndrome might be suspected if the information provided are vague or changing and when the child presents with retinal hemorrhages, subdural hematoma, or fractures that cannot be explained by accidental trauma or other medical conditions. Of infants who are victims of SBS, approximately 15% to 38% die and 30% are at risk of long-term neurologic sequelae, including cognitive and behavioural disturbances, motor and visual deficits, learning deficits and epilepsy. Parents and caregivers must be warned about the dangers of shaking infants.