Orodispersible ticagrelor use in acute coronary syndrome patients: the Ticagrelor Administered as Standard Tablet or orodispersiblE foRmulation (TASTER) Study

Background

Orodispersible tablet (ODT) is a different tablet formulation that disperse upon contact with the moist mucosal surfaces of the oral cavity and quickly release its components before swallowing; thus drug dissolution and absorption, as well as onset of clinical effect, can be obtained conveniently easily and quickly. Recently, Ticagrelor 90 mg ODT has become available and bioequivalence studies on healthy volunteers documented its effectiveness with consequent approval by the European Medicine Agency. It is unknown whether Ticagrelor ODT might be an effective route of drug administration in high-risk acute coronary syndrome (ACS) patients.

Purpose

The aim of the present study is to evaluate the superiority in platelet inhibition with 180 mg Ticagrelor loading dose (LD) administered as ODT as compared with standard (coated table) Ticagrelor formulation, among 130 ACS patients undergoing PCI.

Methods

Patients presenting within STEMI or very high-risk NSTEMI referred for immediate (<2 hours) angiography were randomly assigned to receive ODT or standard ticagrelor LD. Platelet reactivity was assessed by Platelet Reactivity Units (PRU) VerifyNow 1, 2, 4 and 6 hours after ticagrelor LD. The primary study endpoint was residual platelet reactivity 1 hour after Ticagrelor LD. Safety endpoints were major bleedings and other in-hospital ticagrelor administration-related adverse events across the two different regimens of Ticagrelor administration. Potential morphine-ticagrelor interaction was assessed by stratified randomization according to morphine use. An interim analysis was planned after the enrollment of 50% (n=65 patients) of the entire study population. The study was supported by an unrestricted grant from AstraZeneca.

Results

At the interim analysis, the 2 study group were well matched according to all the baseline characteristics (such as age, sex, diabetes mellitus, chronic renal failure, STEMI at presentation, Killip class, multivessel disease, number of stents implanted, and morphine use). Main pharmacodynamic data are depicted in Figure 1. One hour after LD, PRU (97±99 vs 115±92; p=0.40) was numerically lower, but not statistically different, in the ODT group as compared to standard ticagrelor group. The percentage of platelet inhibition was 55±44% vs 42±44% (p=0.21) in the 2 groups. No significant difference was observed between patients receiving ODT or standard ticagrelor LD regarding in-hospital adverse events or drug side-effects. The study enrollment is ongoing, and final results will be presented at the Congress.

Conclusions

ODT administration might represent the most convenient way of treating lying supine ACS patients in the ambulance, emergency room or on the cath lab. Moreover, in patients with difficulties in swallowing ODT represent an easy way of ticagrelor administration.

Figure 1

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): AstraZeneca S.P.A.

Estimates of Environmental Exposure to Radiofrequency Electromagnetic Fields and Risk of Lymphoma Subtypes

We investigated the association between environmental exposure to radiofrequency electromagnetic fields (RF-EMF) and risk of lymphoma subtypes in a case-control study comprised of 322 patients and 444 individuals serving as controls in Sardinia, Italy in 1998-2004. Questionnaire information included the self-reported distance of the three longest held residential addresses from fixed radio-television transmitters and mobile phone base stations. We georeferenced the residential addresses of all study subjects and obtained the spatial coordinates of mobile phone base stations. For each address within a 500-meter radius from a mobile phone base station, we estimated the RF-EMF intensity using predictions from spatial models, and we performed RF-EMF measurements at the door in the subset of the longest held addresses within a 250-meter radius. We calculated risk of lymphoma and its major subtypes associated with the RF-EMF exposure metrics with unconditional logistic regression, adjusting by age, gender and years of education. In the analysis of self-reported data, risk associated with residence in proximity (within 50 meters) to fixed radio-television transmitters was likewise elevated for lymphoma overall [odds ratio = 2.7, 95% confidence interval = 1.5-4.6], and for the major lymphoma subtypes. With reference to mobile phone base stations, we did not observe an association with either the self-reported, or the geocoded distance from mobile phone base stations. RF-EMF measurements did not vary by case-control status. By comparing the self-reports to the geocoded data, we discovered that the cases tended to underestimate the distance from mobile phone base stations differentially from the controls ( P = 0.073). The interpretation of our findings is compromised by the limited study size, particularly in the analysis of the individual lymphoma subtypes, and the unavailability of the spatial coordinates of radio-television transmitters. Nonetheless, our results do not support the hypothesis of a link between environmental exposure to RF-EMF from mobile phone base stations and risk of lymphoma subtypes.

Characterization of an established endothelial cell line from primary cultures of fetal sheep hypothalamus

Immortalized cell lines from fetal brain are an experimental model for studying the in vitro molecular pathways regulating neural cell differentiation and the development of neural networks. The procedures are described to obtain an established cell line from the 90-day old fetal sheep hypothalamus. Viral oncogene LT-SV40 transformation was used to isolate a stable cell line (ENOS-01) that was characterized immunocytochemically. Immortalized cells can be classified as an endothelial cell line of hypothalamic microvasculature. Furthermore, mRNA expression and immunocytochemical of estrogen receptors α and β were also evaluated. Since it is known that cerebral vessels are directly targeted by sex steroids, our established cell line represents an alternative system to study estradiol/receptor interactions during brain development. Our in vitro model can provide a tool to investigate the complex relationships among the cell types forming the blood-brain barrier, which is known to be involved in the pathogenesis of sheep transmissible neurological diseases.

Neuropeptides and enzymes are targets for the action of endocrine disrupting chemicals in the vertebrate brain

Endocrine-disrupting chemicals (EDC) are molecules that interfere with endocrine signaling pathways and produce adverse consequences on animal and human physiology, such as infertility or behavioral alterations. Some EDC act through binding to androgen or/and estrogen receptors primarily operating through a genomic mechanism regulating gene expression. This mechanism of action may induce profound developmental adverse effects, and the major targets of the EDC action are the gene products, i.e., mRNAs inducing the synthesis of various peptidic molecules, which include neuropeptides and enzymes related to neurotransmitters syntheses. Available immunohistochemical data on some of the systems that are affected by EDC in lower and higher vertebrates are detailed in this review.

Beta-amyloid: a disease target or a synaptic regulator affecting age-related neurotransmitter changes?

The amyloid cascade hypothesis sustains that beta-amyloid (Abeta) is the main pathogenetic factor of Alzheimer's Disease (AD). Although the direct and indirect neurotoxic role of Abeta are unchallenged, recent findings suggest that the peptide may have so far unforeseen physiological roles. In this regard, the observations showing the ability of Abeta to exert synaptic activities in absence of neurotoxicity are very intriguing. In particular, the peptide is able to affect synaptic transmission of different neurotransmitter systems in key brain areas that regulate executive and cognitive functions, an observation that points Abeta as a new neuromodulator. However, in a pathological context, Abeta may drive functional alterations of several neurotransmitter systems in the early phases of the disease, in turn producing subtle cognitive and behavioural disturbances in addition and before the well known neurodegenerative events. On the other hand, advancing age is the most significant risk factor for the development of AD. In fact, during aging increased Abeta levels have been reported. Moreover, several neurotransmitter systems undergo age-related changes in parallel to a decline of cognitive functions. However, the putative neuromodulatory role of Abeta in the context of aging is nowadays unknown. For these reasons, future studies about the spectrum of action of Abeta (brain areas and neurotransmitter systems affected) are particularly interesting since may suggest new therapeutic targets in order to sustain those functions which may be altered during aging.

Specific inhibitory effect of amyloid-beta on presynaptic muscarinic receptor subtypes modulating neurotransmitter release in the rat nucleus accumbens

In this study we investigate on the effect of amyloid-beta1-40 (A beta 1-40) on the oxotremorine (OXO)-induced release of [(3)H] dopamine (DA), [(3)H]GABA and [(3)H]acetylcholine (ACh) from synaptosomes in the rat nucleus accumbens (NAc). OXO in presence of himbacine (HIMBA) was able to increase the basal release of [(3)H]GABA. The OXO-elicited [(3)H]GABA overflow was significantly antagonized by atropine (A; 94%), by the M3 antagonists DAU5884 (96%) and 4-DAMP (70%), and by A beta 1-40 (65%). Exposure of NAc synaptosomes to OXO produced a dose-dependent increase of [(3)H]DA overflow which was antagonized by A, partially inhibited by A beta 1-40 (100 nM) but unaffected by DAU5884 and 4-DAMP. The K(+)-evoked [(3)H]ACh overflow was inhibited by OXO. This effect was counteracted by the M2 antagonist AFDX-116 but not by the selective M4 antagonist mamba toxin 3 (MT3). The K(+)-evoked [(3)H]GABA overflow was also inhibited by OXO but conversely, this effect was counteracted by MT3 and not by AFDX-116. A beta 1-40 (100 nM) did not modify the inhibitory effect of OXO both on the K(+)-evoked [(3)H]ACh and [(3)H]GABA overflow. The results show that in the rat NAc, A beta 1-40 selectively inhibits the function of the muscarinic subtypes which stimulate neurotransmitter release and not those which modulate negatively the stimulated release.

Effects of xenoestrogens on the differentiation of behaviorally-relevant neural circuits

It has become increasingly clear that environmental chemicals have the capability of impacting endocrine function. Moreover, these endocrine disrupting chemicals (EDCs) have long term consequences on adult reproductive function, especially if exposure occurs during embryonic development thereby affecting sexual differentiation. Of the EDCs, most of the research has been conducted on the effects of estrogen active compounds. Although androgen active compounds are also present in the environment, much less information is available about their action. However, in the case of xenoestrogens, there is mounting evidence for long-term consequences of early exposure at a range of doses. In this review, we present data relative to two widely used animal models: the mouse and the Japanese quail. These two species long have been used to understand neural, neuroendocrine, and behavioral components of reproduction and are therefore optimal models to understand how these components are altered by precocious exposure to EDCs. In particular we discuss effects of bisphenol A and methoxychlor on the dopaminergic and noradrenergic systems in rodents and the impact of these alterations. In addition, the effects of embryonic exposure to diethylstilbestrol, genistein or ethylene,1,1-dichloro-2,2-bis(p-chlorophenyl) is reviewed relative to behavioral impairment and associated alterations in the sexually dimorphic parvocellular vasotocin system in quail. We point out how sexually dimorphic behaviors are particularly useful to verify adverse developmental consequences produced by chemicals with endocrine disrupting properties, by examining either reproductive or non-reproductive behaviors.

[Neuroendocrine carcinoma of the skin]

Merkel cell carcinoma is an unusual neuroendocrine tumour that arises in the derm. The case reported seemed to deserve the author's attention because of the clinical features, pathological findings and natural history (local recurrence, regional lymph node metachronous metastases, distant metastases). The authors believe that a differential diagnosis between Merkel cell carcinoma and other tumours located in the subcutaneous tissue is mandatory, in order to perform specific immunohistochemical and ultrastructural study.

Primary T cell CD30-positive anaplastic large-cell lymphoma associated with adult-onset celiac disease and presenting with skin lesions

We report the case of a 52-year-old woman with primary CD30+ anaplastic large-cell lymphoma of T cell phenotype with skin involvement, stage IVB, fulfilling almost all the clinical, histopathologic and immunophenotypic criteria for this disease, associated with adult-onset celiac disease. The diagnoses of malignancy and celiac disease were made during the same clinical episode. The clinical course of the patient has been extremely favorable and she is in complete remission, 15 months after finishing consolidation therapy.

[Anaplastic carcinoma of the thyroid. Our experience]

Nineteen patients, 12 females and 7 males, with mean age of 66 years, with anaplastic carcinoma of the thyroid, were treated between 1976 and 1990. At diagnosis, in 4 patients disease presented as intraglandular mass, in 11 as infiltration of the adjacent structures and as distant metastases in 4 cases. A preceding history of goiter was found in 7 patients. Total thyroidectomy was performed in 9 patients, subtotal thyroidectomy in 1 and a diagnostic biopsy only in 4 cases. All patients received external radiotherapy (4000-6000 rads). Median global survival was 6 months with no difference between patients receiving thyroidectomy plus RT or biopsy plus RT. All patients died of tumor except 1 who is alive and free of disease at 120 months. Combination modality treatment of anaplastic carcinoma of the thyroid represent, at times, a rational palliative therapeutic approach, even if, in selected patients with early intraglandular disease, total surgery may represent a curative therapy.

[Hürthle-cell tumors of the thyroid]

In the last 10 years 20 patients with Hürthle tumors were observed at Institute of Surgery and Oncology of Cagliari University. 17 were females and 3 males with a median age of 42 years. Tumors were malignant in 7 cases and benign in 13. A total thyroidectomy was performed in all patients with carcinoma and in 2 with adenoma because of concurrent goiter. The remaining patients were treated with a less extensive surgery. Two patients with carcinoma had a cervical node metastases at 12 and 67 months, treated by surgery (followed by radioiodine therapy in one). All patients are alive and disease free at 72 months of median follow-up. None of patients with benign adenomas recurred at 47 months of median follow-up. A longer-term follow-up is necessary in order to evaluate the benignity of adenomas.

[Short near-fainting in children with or without loss of conscience]

Short near-faints with or without loss of consciousness have different etiologies and pathogenesis and, according to these, they recur with various frequency. This subject was reported on several publications and here is again examined with the contribute of personal experience and the description of distinct cases. The following causes were examined: vagal hypertonia, digestive troubles (gastroesophageal reflux), metabolic troubles (cyclic ketosis, hypoglycemia and hypocalcemia with peculiar clinic manifestations). Among the neurological causes were examined: epilepsy, benign paroxysmal vertigos and, particularly, the so called breath-holding spells and the migraine, about that were reported a few examples of "migraine accompagnée". Among the cardiovascular causes (ischaemic cerebral crisis), -particular attention was dedicated to orthostatic hypotension syncope. A short hint about hysteria ends the exposition of psychical causes of short near-faints.

Modifying influence of fasting on liver hyperplasia induced by lead nitrate

Previous studies by our laboratory have shown that lead nitrate when injected intravenously as a single dose to rats, induces a hyperplastic response in the liver. Liver hyperplasia was accompanied by an increase in cholesterol synthesis, an accumulation of cholesterol esters and by a stimulation of hexose-monophosphate (HMP) shunt enzyme activities. In the present report, hepatic DNA, mitotic index, cholesterol metabolism, as well as glucose-6-phosphate dehydrogenase (G6PD) and 6-phosphogluconate dehydrogenase (6PGD) activities, were investigated during liver hyperplasia induced by lead in fasted rats. Fasting was chosen as an experimental model characterized by a very strong depression of those metabolic pathways (cholesterol synthesis and HMP shunt) that we have found related to liver hyperplasia. The mitogenic response, even if at minor extent, also occurs in liver of fasted rats. A stimulation of cholesterol synthesis and HMP shunt enzyme activities, was also observed in lead-treated fasted rats, adding further support to the fact that an endogenous source of newly synthesized cholesterol together with a suitable increase of HMP shunt enzyme activities is needed during hepatic cell proliferation.

[Primary lymphoma of the thyroid gland]

On the basis of a case of thyroid primary lymphoma observed and in the light of the literature. The distinctive features of this rare pathology are discussed.

[Action of various mitogens (phytohemagglutinin, cocanavalin A, pokeweed mitogen) on a purified human B- and T-lymphocyte population mediating spontaneous rosette formation]

The activity of various most widely used "polyclonal" mitogens, such as PHA, Con A and PWM on human peripheral blood lymphocyte subpopulations, after separation into the two main functional classes (B and T), was investigated. For separating the lymphocyte subclasses, the E-rosette formation technique has been followed, using the gradient centrifuged pellet and supernatant respectively. For the mitogens' activity evaluation, micro-culture system has been performed and 3H thymidine uptake has been assessed. The PHA has been shown to be much more active on the T lymphocyte subclass, though the mitogen cannot be kept very selective. Very much higher activity on the T subclass shows the Con A, which could be considered selective, if we hypothesize an at least partial receptor competition at lymphocyte membrane level between the mitogen and sheep erythrocytes. The PWM has been found very little active and not specific for either lymphocyte subclass.