Human collecting lymphatic glycocalyx identification by electron microscopy and immunohistochemistry

Blood flow is translated into biochemical inflammatory or anti-inflammatory signals based onshear stress type, by means of sensitive endothelial receptors. Recognition of the phenomenon is of paramount importance for enhanced insights into the pathophysiological processes of vascular remodeling. The endothelial glycocalyx is a pericellular matrix, identified in both arteries and veins, acting collectively as a sensor responsive to blood flow changes. Venous and lymphatic physiology is interconnected; however, to our knowledge, a lymphatic glycocalyx structure has never been identified in humans. The objective of this investigation is to identify glycocalyx structures from ex vivo lymphatic human samples. Lower limb vein and lymphatic vessels were harvested. The samples were analyzed by transmission electron microscopy. The specimens were also examined by immunohistochemistry. Transmission electron microscopy identified a glycocalyx structure in human venous and lymphatic samples. Immunohistochemistry for podoplanin, glypican-1, mucin-2, agrin and brevican characterized lymphatic and venous glycocalyx-like structures. To our knowledge, the present work reports the first identification of a glycocalyx-like structure in human lymphatic tissue. The vasculoprotective action of the glycocalyx could become an investigational target in the lymphatic system as well, with clinical implications for the many patients affected by lymphatic disorders.

AB1433 ASSESSING THE CARDIOVASCULAR RISK IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: QRISK AND GAPSS SCORES HEAD TO HEAD

Background

Cardiovascular diseases (CVDs) represent one of the most life-threatening conditions that can affect SLE patients. Assessing the potential CVD risk of these patients is still a challenge and an important aspect in the clinical practice. Recently the QRISK3 score has attempted to encompass for SLE augmented thrombotic risk by adding items (such as corticosteroid use) that are missing in traditional CVD risk scores.

Objectives

To apply and compare the QRISK3 and the adjusted Global AntiPhospholipid Syndrome Score (aGAPSS), a validated score to assess CVD and overall thrombotic risk in aPL positive patients, in a cohort of SLE patients with and without a concomitant diagnosis of APS.

Methods

25-85 years old patients attending San Giovanni Bosco Hospital (Turin) during a period of 6 months (Sep 2019 – Feb 2020) with a confirmed diagnosis of SLE (2019 ACR/EULAR classification criteria) and/or a diagnosis of SAPS (Sidney criteria) were included in the study. QRISK3 has been calculated using the official online calculator (https://qrisk.org/). aGAPSS has been calculated using the validated point values based on aPL profile and independent risk factors: aCL=5, aβ2GPI=4, LA=4, aPS/PT=3, hyperlipidemia=3, hypertension=1.

Results

The analysis included a cohort of 142 SLE patients: 34 SAPS (23.9%) and 108 SLE patients without APS (76.1%), with a mean age of 48±12.9 (SAPS=51.6±12.8/SLE without APS=46.9±12.8). Table 1 summarizes patients characteristics. When focusing on cerebrovascular/coronary events, we found a statistical significance with respect to aGAPSS (pt with event =10.1±6.2 vs pt without event=5.8±6.1; p=0.007), but not QRISK3. Also, a significant association was observed between the occurrence of these events and high risk aGAPSS: p=0.03 for aGAPSS≥8, p=0.01 for aGAPSS ≥9, p=0.008 for aGAPSS ≥10. Moreover, the aGAPSS but not the QRISK3 resulted to strongly correlate with the occurrence of any thrombotic event, both at the uni- and multivariate analysis (univariate: pt with event =8.17±7.1 vs pt without event= 5.41±5.6; p=0.012 / multivariate: p=0.009). The same was observed for gender: male gender resulted to correlate with the occurrence of any thrombotic event at both uni- and multivariate analysis (p=0.017 and p=0.03, respectively). Finally, when focusing on aPL profile, regardless the diagnosis, we found a statistical significance only with respect to aGAPSS (aPL+ =9.6±6.3 vs aPL- = 4.1±5.1; p<0.001).

Table 1.

Demographic and clinical features of the patients included in the study.

Conclusion

By encompassing factors that can contribute to CVD development in complex/autoimmune diseases, QRISK3 has been shown to be more accurate than traditional risk score in predicting SLE patients CVD risk. Nonetheless, the results of this analysis showed how the aGAPSS still seems to be the most valuable tool for this purpose when facing SLE patients. Moreover, the significance observed when focusing on patients’ aPL profile, suggests that adding this item to the QRISK3 could be a useful strategy to improve the management.

References

[1]Hippisley-Cox J, Coupland C, Brindle P. Development and validation of QRISK3 risk prediction algorithms to estimate future risk of cardiovascular disease: prospective cohort study. BMJ. 2017 May 23;357:j2099. doi: 10.1136/bmj.j2099.

[2]Radin M, Sciascia S, Erkan D, et al. The adjusted global antiphospholipid syndrome score (aGAPSS) and the risk of recurrent thrombosis: Results from the APS ACTION cohort. Semin Arthritis Rheum. 2019 Dec;49(3):464-468. doi: 10.1016/j.semarthrit.2019.04.009.

Disclosure of Interests

None declared

AB1283 HOW TO COUNSEL A WOMAN WITH BEHÇET’S DISEASE: RESULTS FROM A MONOCENTRIC COHORT OF WOMEN DIAGNOSED DURING CHILDBEARING AGE

Background

Patients with autoimmune diseases require appropriate pregnancy counceling, as their disease can negatively impact both maternal and fetal outcomes. In regards to Behçet’s disease (BD), although commonly diagnosed during the childbearing age, only few studies focused on its impact on gestation, with contradictory results.

Objectives

We aimed to collect new data on BD and its impact on pregnancy by designing a single-center cohort study, reporting the pregnancy and maternal outcomes in BD patients attending the Multidisciplinary Centre for Immunopathology and Rare Diseases at Giovanni Bosco Hospital (Turin, Italy).

Methods

We retrospectively included 26 women diagnosed with BD followed at our center. Out of 26 patients, data from 33 pregnancies in 16 women were collected. Ten patients were never pregnant. Table 1 shows the demographical and clinical characteristics and the pregnancy outcomes of the enrolled patients.

Table 1.

Clinical characteristics and pregnancy outcome of the Behçet’s disease patients enrolled in the study.

Patients(tot=31)Nulliparous; n (%)10/26 (38,46%)Primigravida; n (%)16/26 (61,54%)DemographicsAge at BD diagnosis; mean± S.D.40,56±11,42Age at first pregnancy; mean ± S:D.24,86 ± 6,56Clinical characteristics of BDOral ulcers; n (%)26/26 (100 %)Genital ulcers; n (%)21/26 (80,76%)Folliculitis; n (%)15/26 (57,69%)Erythema nodosum; n (%)6/26 (23,08%)Ocular manifestations; n (%)11/26 (42,31%)HLA B-51+; n (%)13/26 (50%)Pregnancy outcomeRate of live births; n (%)27/33 (81,81%)Any complications; n (%)12/33(36,36%) Early miscarriage before 10 weeks of gestation; n (%)6/33 (18,18%) Gestational diabetes; n (%)3/33 (9,09%) Placental abruption; n (%)2/33 (6,06%) Vaginal bleeding before 20 weeks of gestation; n (%)1/33 (3,03%)Worsening of oral and genital ulcerations; n (%) *2/ 11 (18%)

* This information was available only for 11/33 pregnancies.

BD – Behçet’s disease

S.D – Standard deviation

Results

All included patients fulfilled the international criteria for BD (1), with a median age at the time of diagnosis of BD and first pregnancy of 40,56±11,42 and 24,86±6,86 respectively. The frequency of clinical manifestations was oral ulcers (100%), genital ulcers (80,76%), erythema nodosum (23,08%), folliculitis (57,69%), ocular manifestations (42,31%) and HLA B-51+ (50%), respectively.

The overall rate of live births was 81,81% (27/33). Twelve women experienced pregnancy complications (36,36%), in particular we report one case of vaginal bleeding before 20 weeks of gestation, six miscarriages before the 10th week of gestation, three cases of gestational diabetes and two placental abruptions. Among the analyzed pregnancies, a worsening of oral and genital ulcerations was observed in the 18% of them, while in the remaining cases a subjective amelioration of aphtosis and other concurrent symptoms was reported by the patients. No systemic flare, worsening of ocular complications and VTE was reported during pregnancy and in the post-partum period.

Conclusion

The results of our study highlight an overall favorable rate of life births in BD women and a positive rate of disease remission in pregnancy. Currently, the studies focusing on pregnancy outcomes in BD are scarce, however it might be appropriate to give a specialized counseling to a BD woman planning for a pregnancy and follow these patients with a multidisciplinary approach.

References

[1]Chan T-M, Meng &, Chiou J, Kuo C-F. Adverse pregnancy outcomes in women with Behçet’s disease: population-based registry linkage study in Taiwan. Available from: https://doi.org/10.1007/s10067-021-05688-6

[2]Davatchi F, Assaad-Khalil S, Calamia KT, Crook JE, Sadeghi-Abdollahi B, Schirmer M, et al. The International Criteria for Behçet’s Disease (ICBD): A collaborative study of 27 countries on the sensitivity and specificity of the new criteria. J Eur Acad Dermatology Venereol [Internet]. 2014 Mar [cited 2021 May 1];28(3):338–47. Available from: https://pubmed.ncbi.nlm.nih.gov/23441863

Disclosure of Interests

None declared

POS0507 TAILORING ORAL THERAPY IN RHEUMATOID ARTHRITIS: THE TuTOR APP

Background

Medication non-adherence has a significant impact on the health and well-being of individuals with chronic diseases. Indeed, with respect to important risk factors of Rheumatoid Arthritis (RA), such as cardiovascular risk factors, it is known that up to 50% of patients will stop taking medication for these conditions during the first year of prescription [1].

Objectives

To support the management of RA patients treated with Tofacitinib, we designed the TuTOR (Tailoring Tofacitinib Oral therapy in Rheumatoid arthritis) Mobile App.

Methods

A prospective-controlled study evaluated the impact of TuTOR App on medical adherence in 20 RA patients, that began treatment with Tofacitinib jointly with the App. We used a crossover design alternating Paper-Diary and TuTOR App, with monthly clinical assessments.

Results

Seventeen patients with RA (mean age at inclusion 59±13yrs; 88% females) the study. A statistically significant decrease of DAS28 was observed since the first month of therapy with Tofacitinib (mean DAS28 at baseline 3.9±1 vs. 1° month 3.1±1, p=0.0016). Similarly, Numerical Rating Scale(NRS) of perceived activity of disease (5.8±2.1 vs.3.7±2.5, p=0.02), and subjective fatigue (6.1±2.3 vs 4.3±2.6; p=0.01) progressively decreased. No differences were reported in DAS28 and in all the NRS between the use of the TuTOR App and the Paper-Diary. A significant decrease was observed also in HAQ during the follow-up (baseline 1.38±1.11 vs.six months 0.83±0.9; p=0.01).

Most of the patients (82%) when filling out the self-reporting questionnaires preferred the TuTOR App in helping them to remember to take the pills. Further 82% of patients used the TuTOR App regularly (vs.53% Paper-Diary) and 76% of patients would use it in the future (vs.53% Paper-Diary). Three patients suspended the therapy with Tofacitinib due to gastrointestinal intolerance.

Conclusion

Both digital- and paper-devices can help maximize the adherence to therapy, leading to an improvement in disease’s activity, highlighting the need of supports for medication adherence.

References

[1]BJ van den B, HE Z, CH van den E. Medication adherence in patients with rheumatoid arthritis: a critical appraisal of the existing literature. Expert Rev Clin Immunol 2012;8:337–351. Available at: https://pubmed.ncbi.nlm.nih.gov/22607180/. Accessed July 13, 2021.

Table 1.

Baseline demographic and clinical characteristics of the patients enrolled in the study, who completed follow-up. RA – Rheumatoid Arthritis

Patients with RA(N=17)DEMOGRAPHICSAge (mean ± S.D.)59,4 ± 13,5Sex (n; %)M (2; 11,8), F (15; 88,2)Etnicity (caucasian; n; %)16; 94Etnicity (Hispanic; n; %)1; 6CLINICAL CHARACTERISTICSAge at diagnosis (mean ± S.D.)44,7±14,47Follow-up length (years; mean ± S.D.)6,33± 5,17Positive Rheumatoid Factor (n; %)17; 100Positive Anti-Cyclic citrullinated peptides (n;%)15; 88.2Structural articular damage at radiography (n; %)11; 7Figure 1.

Decrease of disease activity assessed by DAS28 in the paper-diary and TuTOR App groups.

Disclosure of Interests

Massimo Radin Grant/research support from: The study is supported by the Investigator-Initiated Research Studies Grant—CREARE (Pfizer)., Marta Arbrile: None declared, Irene Cecchi Grant/research support from: The study is supported by the Investigator-Initiated Research Studies Grant—CREARE (Pfizer)., Alice Barinotti: None declared, Simone Baldovino: None declared, Elisa Menegatti: None declared, Daniela Rossi Grant/research support from: The study is supported by the Investigator-Initiated Research Studies Grant—CREARE (Pfizer)., Savino Sciascia Grant/research support from: The study is supported by the Investigator-Initiated Research Studies Grant—CREARE (Pfizer)., Dario Roccatello Grant/research support from: The study is supported by the Investigator-Initiated Research Studies Grant—CREARE (Pfizer).

POR polymorphisms are associated with 21 hydroxylase deficiency

PURPOSE

Genotype-phenotype correlation in congenital 21 hydroxylase deficiency is strong but by no means absolute. Indeed, clinical and hormonal features may vary among patients carrying similar CYP21A2 mutations, suggesting that modifier genes may contribute to the phenotype. Aim of the present study was to evaluate whether polymorphisms in the p450  oxidoreductase (POR) gene may affect clinical features in patients with 21 hydroxylase deficiency METHODS: Sequencing of the POR gene was performed in 96 patients with 21 hydroxylase deficiency (49 classic, 47 non-classic) and 43 control subjects.

RESULTS

Prevalence of POR polymorphisms in patients with 21 hydroxylase was comparable to controls and known databases. The rs2228104 polymorphism was more frequently associated with non-classic vs classic 21 hydroxylase deficiency (allelic risk 7.09; 95% C.I. 1.4-29.5, p < 0.05). Classic 21 hydroxylase-deficient carriers of the minor allele in the rs2286822/rs2286823 haplotype presented more frequently the salt-wasting form (allelic risk 1.375; 95% C.I. 1.138-1.137), more severe Prader stage at birth (allelic risk 3.85; 95% C.I. 3.78-3.92), higher ACTH levels, and younger age at diagnosis.

CONCLUSIONS

Polymorphisms in the POR gene are associated with clinical features of 21 hydroxylase deficiency both as regards predisposition to classic vs non-classic forms and severity of classic adrenal hyperplasia.

POS0172 THROMBIN GENERATION ASSAY AND LUPUS ANTICOAGULANT IDENTIFY DIFFERENT POPULATIONS OF PATIENTS WITH ANTIPHOSPHOLIPID ANTIBODIES

Background:

Risk stratification in patients with antiphospholipid antibodies (aPL) remains a clinical challenge [1].

Objectives:

We aimed to evaluate the role of Thrombin Generation Assay (TGA) in distinguishing various populations of aPL positive patients (with and without lupus anticoagulant - LA) and its association with β2GPI-dependent and anti-phosphatidyl-serine/prothrombin(aPS/PT) antibodies.

Methods:

One-hundred-and-eight patients were tested with TGA and divided as follows: 21 patients with aPS/PT IgG/IgM (Group 1), 29 with aβ2GPI IgG/IgM (Group 2), 31 with aPS/PT and aβ2GPI IgG/IgM (Group 3), 27 with aPS/PT and/or aβ2GPI IgM low-titers (Group 4). Table 1 resumes the clinical characteristics of the APS patients (excluding aPL asymptomatic). Thirty-one healthy donors (HDs) and 24 controls treated with VKA were also included.

Results:

The most deranged TGA and LA profile was observed in patients with both aPS/PT and aβ2GPI when compared to those with an isolated positivity for aPS/PT or aβ2GPI and patients with aPS/PT and/or aβ2GPI IgM at low titres (Figure 1). Similarly, patients with aPS/PT and/or aβ2GPI at medium/high titres presented with the higher rate of clinical manifestations.

When comparing the TGA curves of APS patients, asymptomatic aPL positive (aPL+) subjects, HDs and controls treated with VKA, we observed that aPL+ patients (particularly those with a confirmed diagnosis of APS) showed a characteristic profile.

Differences among groups were confirmed also when comparing APS clinical manifestations. When comparing Group 1 and Group 4 we found significant differences with respect to the number of thrombotic events (21vs.15,p<0.05), the number of venous events (9vs.3,p<0.05), the recurrence of thrombosis (19%vs.0%,p<0.05). Group 2 and Group 4 showed differences in the occurrence of venous thromboses (50vs.20,p<0.05), and in the occurrence of DVT (8vs.2,p<0.05). Group 3 and Group 4, had higher number of thrombotic events (36vs15, p<0.05), the occurrence and the number of venous events (46%-15vs20%-3,p<0.05), the occurrence of TIA and DVT (4-11vs0-2,p<0.05).

When analysing the cumulative frequency of extra-criteria APS manifestations, Group 1,2 and 3 were comparable, while comparing Group 3 and those positive for aβ2GPI and/or aPS/PT IgM at low titres (Group 4) we found a statistically significant difference (71%vs13%,p<0.05).

Conclusion:

TGA seems a valuable approach to stratify aPL+ patients according to their risk profile. The differences among groups and different populations of autoantibodies specificities obtained from this test can be considered a translational validation of the increased thrombotic risk of patients with triple or tetra aPL positivity.

References:

[1]Miyakis S et al. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J. Thromb. Haemost. 2006;4(2):295–306.

Table 1.

“Classical” and “Extra-criteria” APS clinical manifestations of each group (considering solely patients with a confirmed diagnosis of APS).

Group 1: isolated aPS/PT+ IgG/IgM (16)Group 2: isolated aβ2GPI+ IgG/IgM(20)Group 3: aPS/PT+ and aβ2GPI+ IgG/IgM (24)Group 4: aPS/PT+ and/or aβ2GPI+ IgM low titres (15)APS clinical manifestationsThrombosis (Y/N), n (%)14 (87,5%)16 (80%)21 (87,5%)13 (86,6%)N of thrombotic events21233615Arterial thrombosis (Y/N), n (%)10 (62,5%)9 (45%)14 (58,3%)11 (73,3%)Arterial events, n13102112Venous thrombosis (Y/N), n (%)6 (37,5%)10 (50%)11 (45,8%)3 (20%)Venous events, n913153Pregnancy morbidity, n (%)3 (18,8%)4 (20%)3 (12,5%)2 (13,3%)Recurrent thrombosis (Y/N), n (%)3 (18,8%)3 (15%)7 (29,1%)0Livedo reticularis, n (%)1 (6,2%)1 (5%)4 (16,6%)0Thrombocytopenia, n (%)4 (25%)4 (20%)6 (25%)2 (13,3%)Valvular, n (%)1 (6,2%)02 (8,3%)0Peripheral artery disease, n (%)03 (15%)4 (16,6%)0Diffuse alveolar hemorrhage, n (%)001 (4,1%)0Figure 1.

Graphical representation of the differences between TGA and LA profiles between groups.

Disclosure of Interests:

None declared

AB0008 APPLYING WHOLE EXOME SEQUENCING TO FAMILIAL ANTIPHOSPHOLIPID SYNDROME: NEW PLAYERS IN A RARE DISEASE?

Background:

Antiphospholipid Syndrome (APS) is an autoimmune disease whose precise aetiology is still unknown, but the high heterogeneity of its manifestations and clinical course is presumably due to the occurrence of different mechanisms and alterations at different levels and pathways [1]. The first genetic studies in APS focused primarily on the human leukocytes antigen system region, but more recent data highlighted a role of other genes in APS susceptibility, primarily those involved in the immune response and in the haemostatic process.

Objectives:

We aimed to deepen the investigation of APS genetic background starting from a case of familial APS, analysing two siblings with thrombotic APS (Table 1), both triple positive for antiphospholipid antibodies (aPL).

Table 1.

Main clinical and laboratory characteristics of the patients included in the study.

PatientAgeaPL ProfileRelevant Clinical History1 (F)51Triple positive (LA, aCL IgG, aβ2GPI IgG)Two episodes of ischemic stroke, one episode of CAPS (renal thrombotic microangiopathy, visual impairment, ischemic stroke)2 (M)47Triple positive (LA, aCL IgG, aβ2GPI IgG)Three episodes of deep vein thrombosis, regardless ongoing well conducted therapy vitamin k antagonist and additional retinal vein thrombosis

LA: lupus anticoagulant; aCL: anti-cardiolipin antibodies; aβ2GPI: anti- β2 glycoprotein I antibodies; CAPS: catastrophic APS.

Methods:

Genomic DNA was extracted from peripheral blood and the samples underwent Whole Exome Sequencing (WES). Sequencing was done on a 100X coverage, and reads have been aligned to the human reference genome (GRCh37/hg19 assembly) using the Burrows–Wheeler Alignment tool (BWA). The mean sequencing depth on target regions was 170X for patient 1, 205X for patient 2, moreover, 99.50% of the targeted bases had at least 10X coverage for all the three donors. The resulting single nucleotide polymorphisms (SNPs) have been analysed through a step-by-step process based on their frequency population (using Genome Aggregation Database), their predicted effects on the protein (using VarSome) and a literature research about the genes carrying them. Moreover, genes previously associated with a pro-thrombotic tendency and with APS have been analysed in the two patients.

Results:

Starting from more than 120000 SNPs for each patients, the analysis led to reduce the list of SNPs of interest to 27 missense mutations. The complete literature research regarding the genes carrying these mutations allowed to further reduce the number of selected genes, focusing on those that exert a role potentially involved in APS pathogenesis and development. In particular, these genes (PLA2G6, HSPG2, BCL3, ZFAT, ATP2B2, CRTC3 and ADCY3) take part in the immune response and the vascular homeostasis. The list of the DNA missense variants of interest found in our cases of familial APS is resumed in Figure 2.

Figure 2.

List of DNA missense variants of interest found in patient 1 and 2. Genes potentially involved in APS pathogenesis and development are highlighted in bold.

No mutations on genes known to be associated with a pro-thrombotic state (F5, F2, MTHFR, F13A1, PROC, PROS1, FGB and SERPINE1), or on genes previously associated with APS (B2GPI, PF4V1, SELP, TLR2, TLR4, GP Ia, GP1BA, F2R, F2RL1, TFPI, F3, VEGFA, FLT1, and TNF) have been found in the WES analysis.

Conclusion:

To some extent, this can be seen as a proof of concept of the complexity of APS. Efforts to interpret the genetic risk factors involved in the heterogeneous clinical features of the syndrome, for instance, the integration of WES and network-based approaches might help to identify and stratify patients at risk of developing APS.

References:

[1]Iuliano A, Galeazzi M, Sebastiani GD. Antiphospholipid syndrome’s genetic and epigenetic aspects. Autoimmun Rev. 2019;18(9).

Disclosure of Interests:

None declared

Investigation of cerebral venous outflow in microgravity

OBJECTIVE

The gravitational gradient is the major component to face when considering the physiology of venous return, and there is a growing interest in understanding the mechanisms ensuring the heart filling, in the absence of gravity, for astronauts who perform long-term space missions.

APPROACH

The purpose of the Drain Brain project was to monitor the cerebral venous outflow of a crew member during an experiment on the International Space Station (ISS), so as to study the compensatory mechanisms that facilitate this essential physiological action in subjects living in a microgravity environment. Such venous function has been characterized by means of a novel application of strain-gauge plethysmography which uses a capacitive sensor.

MAIN RESULTS

In this contribution, preliminary results of our investigation have been presented. In particular, comparison of plethysmography data confirmed that long duration spaceflights lead to a redistribution of venous blood volume, and showed interesting differences in the amplitude of cardiac oscillations measured at the level of the neck veins.

SIGNIFICANCE

The success of the experiment has also demonstrated that thanks to its easy portability, non-invasiveness, and non-operator dependence, the proposed device can be considered as a novel tool for use aboard the ISS. Further trials are now under way to complete the investigation on the drainage function of the neck veins in microgravity.

Different disulfide bridge connectivity drives alternative folds in highly homologous Brassicaceae trypsin inhibitors

Low-molecular-mass trypsin inhibitors from Arabidopsis thaliana, Brassica napus var. oleifera, and Sinapis alba L. (ATTI, RTI, and MTI, respectively) display more than 69% amino acid sequence identity. Among others, the amino acid sequence Cys-Ala-Pro-Arg-Ile building up the inhibitor reactive site, and the eight Cys residues forming four disulfide bridges are conserved. However, the disulfide bridge connectivity of RTI and MTI (C1-C3, C2-C4, C5-C6, and C7-C8) is different from that of ATTI Cys (C1-C8, C2-C5, C3-C6, and C4-C7). Despite the different disulfide bridge connectivity, the reactive site loop of ATTI, RTI, and MTI is solvent exposed permitting trypsin recognition. Structural considerations here reported suggest that proteins showing high amino acid sequence identity and common functional properties could display different three-dimensional structures. This may reflect high inhibitor plasticity in relation to plant-pathogen interactions, plant tissue development as well as the different redox potential of cell compartments.

Ultrastructure of internal jugular vein defective valves

OBJECTIVES

To study the ultrastructure of intraluminal defects found in the internal jugular vein by using a scanning electron microscopy.

METHODS

Using a scanning electron microscopy, intraluminal septa and/or defective valves blocking the flow in the distal internal jugular vein of seven patients were studied together with the adjacent wall and compared with control specimen.

RESULTS

The internal jugular veins' wall showed a significant derangement of the endothelial layer as compared to controls. Surprisingly, no endothelial cells were found in the defective cusps, and the surface of the structure is covered by a fibro-reticular lamina.

CONCLUSIONS

Although the lack of endothelial cells in the internal jugular vein intraluminal obstacles is a further abnormality found in course of chronic cerebrospinal venous insufficiency, our investigation cannot clarify whether this finding is primary or caused by progressive loss of endothelium in relation to altered haemodynamic forces and/or to a past post-thrombotic/inflammatory remodelling.

CHIVA strategy in chronic venous disease treatment: instructions for users

Along the years, scientific clinical data have been collected concerning the possible saphenous flow restoration without any ablation and according with the CHIVA strategy. Moreover, in 2013 a Cochrane review highlighted the smaller recurrence risk following a CHIVA strategy rather than a saphenous stripping. Nevertheless, the saphenous sparing strategy surely remains a not-so-worldwide-spread and accepted therapeutic option, also because considered not so immediate and easy to perform. Aim of this paper is to provide an easily accessible guide to an everyday use of a saphenous sparing strategy for chronic venous disease, highlighting how even apparently too complicated reflux patterns classifications can be fastly and successfully managed and exploited for a hemodynamic correction.

Colloidal dispersions for the delivery of acyclovir: a comparative study

This paper describes a comparative study on the performances of ethosomes and solid lipid nanoparticle as delivery systems for acyclovir. Ethosomes were spontaneously produced by dissolution of phosphatidylcholine and acyclovir in ethanol followed by addition of an aqueous buffer while solid lipid nanoparticle were produced by homogenization and ultrasonication. Both colloidal systems were morphologically characterized by cryo-transmission electron microscopy. The encapsulation efficiency was 94.2±2.8% for ethosomes and 53.2±0.2% for solid lipid nanoparticle. Concerning Z potential, both formulations are close to neutrality. The diffusion coefficients of the drug from ethosomes and solid lipid nanoparticle, determined by a Franz cell method, were 9.4 and 1.2-fold lower as compared to the free acyclovir in solution, thus evidencing the ability of both colloidal systems in enhancing the diffusion of the drug. The antiviral activity against HSV-1 of both systems was tested by plaque reduction assay in monolayer cultures of Vero cells. Data showed that no significant differences in the antiviral activity were observed by acyclovir in the free or loaded forms. Taken together these results, colloidal systems could be interesting to mediate the penetration of acyclovir within Vero cells.

Clotrimazole nanoparticle gel for mucosal administration

In this study a formulation suitable to be applied on oral and/or vaginal mucosa has been developed for the treatment of fungal infections. The aim of the research is a comparison between clotrimazole (CLO) containing semisolid formulations based on monoolein aqueous dispersion (MAD) or nanostructured lipid carrier (NLC). MAD and NLC have been characterized in terms of morphology and dimensional distribution by cryogenic Transmission Electron Microscopy (cryo-TEM) and Photon Correlation Spectroscopy (PCS). CLO was encapsulated with high entrapment efficiency both in MAD and in NLC, according to Sedimentation Field Flow Fractionation (SdFFF) combined with HPLC. CLO recovery in MAD and NLC has been investigated by time. In order to obtain formulations with suitable viscosity for mucosal application, MAD was diluted with a carbomer gel, while NLC was directly viscosized by the addition of poloxamer 407 in the dispersion. The rheological properties of MAD and NLC after viscosizing have been investigated. Franz cell has been employed to study CLO diffusion from the different vehicles, evidencing diffusion rates from MAD and NLC superimposable to that obtained using Canesten(®). An anticandidal activity study demonstrated that both CLO-MAD and CLO-NLC were more active against Candida albicans with respect to the pure drug.

Eudragit(®) microparticles for the release of budesonide: a comparative study

This study compares the behaviour of budesonide-containing microparticles made of Eudragit(®)RS or Eudragit(®)RS/Eudragit(®)RL 70:30 (w/w) prepared either by solvent evaporation or spray-drying technique. The loading efficiency of budesonide within microparticles was about 72% for microparticles prepared by solvent evaporation and around 78% for spray-dried microparticles. Thermal analyses were assessed to collect information about the structural stability of budesonide within the polymeric microspheres. The in vitro release was performed using simulating gastric (fasted state simulated gastric fluid) and intestinal (fasted state simulated intestinal fluid) fluids as the receiving solutions. After 3 h the drug release from Eudragit(®)RS/Eudragit(®)RL microparticles was about 6-fold higher than that obtained in the case of monopolymer microparticles. Using fasted state simulated intestinal fluid the drug was released between 4 and 30% in both types of preparations. Eudragit(®)RS microparticles showed a better protection of the drug from gastric acidity than those of Eudragit(®)RS/Eudragit(®)RL allowing us to propose Eudragit(®)RS microparticles as a hypothetical system of colon specific controlled delivery.

Intranasal immunization in mice with non-ionic surfactants vesicles containing HSV immunogens: a preliminary study as possible vaccine against genital herpes

The purpose of this study was to investigate the potential of intranasal immunization with non-ionic surfactant vesicles (NISV) containing either the secretory recombinant form of glycoprotein B (gBs) of herpes simplex virus type 1 or a related polylysine reach peptides (DTK) for induction of protective immunity against genital herpes infection in mice. NISV were prepared by lipid film hydration method. The mean diameter of vesicles was around 390 nm for DTK-containing NISV (DTK-NISV) and 320 nm for gB1s-containing NISV (gB1s-NISV). The encapsulation efficiency of the molecules was comprised between 57% and 70%. After 7-14 day NISV maintained stable dimensions and a drug encapsulation higher than 48%. We showed that intranasal immunization with gB1s-NISV induces gB-specific IgG antibody and lymphoproliferative responses, whereas vaccination with DTK-NISV was not able to generate a gB-specific immune response. Our results indicate that vaccination of BALB/c mice with gB1s-NISV induced Th1 responses, as characterized by increased titre of IG2a in plasma and IFN-production in CD4+ splenic cells. Intranasal immunization with gB1s-NISV could elicit 90% (almost complete) protection against a heterologous lethal vaginal challenge with herpes simplex virus type 2. These data may have implications for the development of a mucosal vaccine against genital herpes.

Fusion imaging technology of the intracranial veins

Objectives

Fusion imaging technology (FIT) combines different imaging techniques by means of properly designed software. The aim of this study was to validate the ultrasonographic representation of intracranial vein anatomy by combining transcranial echo-colour Doppler (TECD) with conventional magnetic resonance imaging (MRI). In addition, we investigated the possibility of insonating the veins of the base of the skull through the novel condylar window.

Methods

We examined venous brain circulation in five healthy subjects by means of FIT, using a 1.5 T MR scanner and an ultrasound TECD equipped with Virtual Navigator technology.

Results and conclusions

Insonation of the Rosenthal and other intracranial veins through the classical transtemporal window, based on anatomical assumption, but never before validated by means of FIT study, was confirmed. Moreover, in all five subjects, FIT demonstrated the possibility of insonating the petrosal sinuses and the cavernous sinus area through the novel transcondylar approach. In conclusion, the feasibility of FIT of the intracranial veins potentially permits to study subjects in different postures and/or at the bed of non-transportable patients, after the initial MRI acquisition. Finally, the novel transcondylar approach allows obtaining haemodynamic information from the cavernous and the petrosal sinuses usually not investigated by TECD alone.

Screening for chronic cerebrospinal venous insufficiency (CCSVI) using ultrasound--recommendations for a protocol

Chronic cerebrospinal venous insufficiency (CCSVI) is a syndrome characterized by stenoses or obstructions of the internal jugular and/or azygos veins with disturbed flow and formation of collateral venous channels. Studies using ultrasound in patients with multiple sclerosis (MS) have demonstrated a high prevalence of CCSVI (mean 70%; range 0-100%; N.=1496), whereas, in normal controls and patients without MS the prevalence was much lower (mean 10%; range 0-36%; N.=635). Ultrasound uses a combination of physiological measurements as well as anatomical imaging and has been used for the detection of CCSVI by different centers with variable results. A high prevalence ranging from 62% to 100% of obstructive lesions has been found by some teams in patients with MS compared with a lower prevalence of 0-25% in controls. However, absence of such lesions or a lower prevalence (16-52%) has been reported by others. This variability could be the result of differences in technique, training, experience or criteria used. The current lack of a methodology shared among experts is a confounding element in epidemiologic studies, and does not permit further Bayesan or other kind of analysis. In order to ensure a high reproducibility of Duplex scanning with comparable accuracy between centers, a detailed protocol with standard methodology and criteria is proposed. This is also necessary for training. It has been shown that inter-rater variability increases post-training (from k=0.47 to k=0.80), while within-rater reproducibility in trained operators was k=0.75. Finally, the consensus document proposes a reporting standard of Duplex measurements, and future research to answer areas of uncertainty.

Panbacterial real-time PCR to evaluate bacterial burden in chronic wounds treated with Cutimed™ Sorbact™

The impact of polymicrobial bacterial infection on chronic wounds has been studied extensively, but standard bacteriological analysis is not always sensitive enough. Molecular approaches represent a promising alternative to the standard bacteriological analysis. This work aimed to assess the usefulness of a panbacterial quantitative real-time PCR reaction to quantitate the total bacterial load in chronic wounds treated with Cutimed™ Sorbact™, a novel therapeutic approach based on hydrophobic binding of bacteria to a membrane. The results obtained by panbacterial real-time PCR on conserved sequences of the bacterial 16S gene show that the bacterial burden significantly decreased in 10 out of 15 healing chronic wounds, and did not change in 5 out of 5 non-healing chronic wounds. On the contrary, classical culture for S. aureus and P. aeruginosa, and real-time PCR for Bacteroides and Fusobacterium did not show any correlation with the clinical outcome. Our study also shows that quantification of chronic wounds by panbacterial real-time PCR is to be performed on biopsies and not on swabs. These results show that panbacterial real-time PCR is a promising and quick method of determining the total bacterial load in chronic wounds, and suggest that it might be an important biomarker for the prognosis of chronic wounds under treatment.

Genotype, phenotype and hormonal levels correlation in non-classical congenital adrenal hyperplasia

Non-classical congenital adrenal hyperplasia (NCAH) is a morbid condition sustained by the reduced function of one of the enzymes involved in the adrenal steroid biosynthesis pathway, mainly the 21-hydroxylase. Different degrees of enzyme activity impairment determine different clinical pictures, with childhood or post-pubertal onset. The aim of this study was to evaluate the relationship between genotype, phenotype, and adrenal hormonal levels in a group of 66 patients affected by NCAH attending outpatient pediatric or endocrinological Clinics. Our findings show that age at pubarche/menarche was significantly younger, height SD score) and Δ bone age-chronological age were significantly higher in patients with a more severe enzyme activity impairment, while cutaneous androgenization and menstrual irregularities in post-pubertal girls were not related to the grading of genotype.

Correlation between genotype and hormonal levels in heterozygous mutation carriers and non-carriers of 21-hydroxylase deficiency

Congenital adrenal hyperplasia, both in its classic (CCAH) and non-classic form (NCAH), is a morbid condition sustained by the absent or reduced function of one of the enzymes involved in cortisol biosynthesis - mainly 21 hydroxylase - associated with different levels of clinical androgenization. In a wide group of relatives of patients affected by CCAH and NCAH (no.=222) and healthy volunteers (no.=30), a clinical, hormonal and genetic evaluation was performed in order to differentiate between the condition of heterozygous mutation carrier and non-carrier of any among 21-hydroxylase gene (CYP21) mutations. This study shows that clinical presentation and basal 17α-hydroxyprogesterone (17α-OHP) are not able to differentiate between heterozygous carriers and non-carriers, whereas 17α-OHP value after ACTH bolus is significantly different between heterozygous carriers and non-carriers: p<0.001 with a cut-off value of 3 ng/ml (90% sensitivity and 74,3% specificity). Moreover, our data indicate that 17α-OHP response to ACTH may be a useful tool to select subjects for genetic analysis.

The recurrent cervical swelling syndrome

The objective of this study is to report an overlooked cause of cervical swelling linked to a thoracic duct (TD) intraluminal obstruction. Four consecutive patients underwent supraclavicular fossa echo-colour-Doppler assessment (ECD) because of recurrent spontaneous cervical swelling. In all patients, during the swelling period we documented a TD dilation with hyperechogenic content, resulting undetectable during asymptomatic periods; ECD also allowed an effective differential diagnosis with TD cysts, obstructive malignancy or other causes of cervical swelling. In conclusion, ECD is to be considered an effective tool in cervical swelling and TD anomalies investigation.

Value of MR venography for detection of internal jugular vein anomalies in multiple sclerosis: a pilot longitudinal study

BACKGROUND AND PURPOSE

CCSVI was recently described in patients with MS. CCSVI is diagnosed noninvasively by Doppler sonography and invasively by catheter venography. We assessed the role of conventional MRV for the detection of IJV anomalies in patients with MS diagnosed with CCSVI and in healthy controls who underwent MRV and Doppler sonography examinations during 6 months.

MATERIALS AND METHODS

Ten patients with MS underwent TOF, TRICKS, Doppler sonography, and catheter venography at baseline. They were treated at baseline with percutaneous angioplasty and re-evaluated 6 months' posttreatment with MRV and Doppler sonography. In addition, 6 healthy controls underwent a baseline and a 6-month follow-up evaluation by Doppler sonography and MRV.

RESULTS

At baseline, the sensitivity, specificity, PPV, and NPV of Doppler sonography for detecting IJV abnormalities relative to catheter venography in patients with MS were calculated, respectively, at 82%, 100%, 99%, and 95%. The figures were 99%, 33%, 33%, 99% for TOF and 99%, 39%, 35%, and 99% for TRICKS. Venous anomalies included the annulus, septum, membrane, and malformed valve. No agreement was found between TOF and catheter venography in 70% of patients with MS and between TRICKS and catheter venography in 60% of patients with MS. At follow-up, 50% of the patients with MS presented with abnormalities on Doppler sonography but only 30% were diagnosed with restenosis.

CONCLUSIONS

Conventional MRV has limited value for assessing IJV anomalies for both diagnostic and posttreatment purposes.

Vascular endothelial growth factor genetic polymorphisms and haplotypes in female patients with bisphosphonate-related osteonecrosis of the jaws

OBJECTIVE

To investigate the polymorphisms of the vascular endothelial growth factor (VEGF) gene in relation to female patients who developed bisphosphonate-related osteonecrosis of the jaws (BRONJ).

METHODS

Test subjects were 30 Italian female patients with BRONJ (Group A). Control subjects were 30 female patients with a history of intravenous bisphosphonate use without any evidence of osteonecrosis (Group B) and 125 unrelated healthy volunteers (Group C). Three single-nucleotide polymorphisms were investigated: -634 G>C, occurring in 5' untranslated region (UTR); +936 C>T, occurring in 3' UTR; and -2578 C>A of the promoter region.

RESULTS

The frequency of the VEGF CAC (+936/-2578/-634) haplotype was increased in patients with BRONJ, compared with female disease-negative controls [odds ratio (OR) = 2.76, 95% CI = 1.09-4.94, P = 0.039; corrected P value: P(c) = 0.117], and was also increased compared with female healthy controls (OR = 2.11, 95% CI = 1.14-3.89, P = 0.024; corrected P value: P(c) = 0.072). The CC homozygotes of -634G>C of VEGF gene and AA homozygotes of -2578C>A have also been significantly correlated in female patients who developed BRONJ compared with healthy controls (OR = 2.04, 95% CI = 1.12-3.70, P = 0.008; corrected P value: P(c) = 0.024).

CONCLUSIONS

These results suggest a possible haplotype effect of VEGF polymorphisms expression in BRONJ Italian female patients. Studies with different and larger populations possibly using TagSNP to represent all haplotypes within the VEGF gene are needed to further delineate the genetic contribution of this gene to BRONJ.

Ethosomes for the delivery of anti-HSV-1 molecules: preparation, characterization and in vitro activity

This paper describes the production, characterization and in vitro activity of ethosomes containing two molecules with antiviral activity, such as acyclovir (ACY) and N1-beta-D-ribofuranosyl-pyrazole [3,4d]pyridazin-7(6p-chlorine-phenyl)-one nucleoside (N1CP). Ethosomes were prepared and morphologically characterized by Cryo-TEM. The encapsulation efficiency was 92.3 +/- 2.5% for ACY and 94.2 +/- 2.8% for N1CP. The release of the drug from vesicles, determined by a Franz cell method, indicated that both drugs were released in a controlled manner. In order to possibly guarantee the stability during long-term storage ethosome suspensions was freeze-dried. It was found that the freeze-dried ethosomes' cakes were compact, glassy characterized by low density and quick re-hydration. However, the storage time slightly influences the percentage of drug encapsulation within ethosomes showing a drug leakage after re-hydration around 10%. The antiviral activity against HSV-1 of both drugs was tested by plaque reduction assay in monolayer cultures of Vero cells. Data showed that ethosomes allowed a reduction of the ED50 of N1CP evidencing an increase of its antiviral activity. However, ACY remains more active than N1CP. No differences are appreciable between drug-containing ethosomes before and after freeze-drying. Taken together these results, ethosomal formulation could be possibly proposed as mean for topical administration of anti-herpetic molecules.

Nanosystems for skin hydration: a comparative study

The present investigation describes a comparative study for the design of innovative topical formulation for skin hydration. In particular, different colloidal forms based on lipidic components have been produced and characterized. Morphology and dimensional distribution have been investigated by means of electron microscopy and photon correlation spectroscopy. Nanoparticulate systems characterized by different morphology and dimensions depending on production procedures have been obtained, namely cubosomes, nanovesicles, solid lipid nanoparticles and liposomes. Hydration power has been studied by means of a corneometer, measuring the skin electrical capacitance before and after the application of opportunely viscosized nanoparticulate systems. It has been demonstrated that nanovesicle gel displayed a pronounced hydration power with respect to the other nanostructured forms, its hydration effect on skin was 3.5-fold higher, with respect to the untreated area, after 5 min from the application and 1.5-fold higher after 2 h.

Great saphenous varicose vein surgery without saphenofemoral junction disconnection

Background

The aim of this case–control study was to determine whether preoperative duplex imaging could predict the outcome of varicose vein surgery without saphenofemoral junction (SFJ) disconnection. The duplex protocol included a reflux elimination test (RET) and assessment of the competence of the terminal valve of the femoral vein.

Methods

One hundred patients with chronic venous disease who had a positive RET result and an incompetent terminal valve were compared with 100 patients matched for age, sex, clinical class (Clinical Etiologic Anatomic Pathophysiologic (CEAP) class C2–C6) and disease duration, but who had a positive RET result and a competent terminal valve. All patients underwent ligation and proximal avulsion of the incompetent tributaries from the great saphenous vein trunk without SFJ disconnection. Clinical and duplex follow-up lasted for 3 years, and included Hobbs' clinical score.

Results

Of legs with a competent terminal valve, 100 per cent were rated as cured (Hobbs' class A or B) and 14·0 per cent developed recurrent varices. Patients with an incompetent terminal valve had significantly worse results: 29·0 per cent had Hobbs' class A or B and 82·0 per cent developed recurrence (P &lt; 0·001).

Conclusion

Preoperative duplex assessment of the terminal valve could be used to identify patients suitable for varicose vein surgery without the need for SFJ disconnection.

The reproducibility of colour Doppler in chronic cerebrospinal venous insufficiency associated with multiple sclerosis

AIM

Chronic cerebrospinal venous insufficiency (CCSVI) is a syndrome described in multiple sclerosis (MS) patients, characterized by stenosis of the main extracranial veins with hampered cerebral venous outflow. In the original description echo-colour Doppler demonstrated to be an ideal non invasive tool for screening CCSVI patients, but the reproducibility was not assessed. Aim of this study is to assess the variability coefficient between trained and in not trained echo-colour Doppler operators.

METHODS

Thirty-six (36) subjects, matched for age and gender, were subset in 3 groups (group A, 12 healthy controls, HC; group B, 12 multiple sclerosis patients, MS; group C, 12 patients with other neurological disease, OND) underwent echo-colour Doppler screening for CCSVI according to an original protocol previously described. The inter observer variability rate was assessed by comparing respectively trained vs not trained operators, and trained vs trained operators, by using the same echo-colour Doppler equipment. In addition, by scanning 15 subjects after one month from the first session, intra observer coefficient was also assessed in trained operator.

RESULTS

The inter observer variability rate between trained and not trained echo-colour Doppler operators, were not completely satisfactory (K coefficient 0.47 95% CI 0.27-0.68). To the contrary the inter observer agreement between trained operators was much more reliable (K coefficient 0.80 95% CI 0.59-1.01). Finally, the intra observer variability rate in trained operators was 0.93, (95% CI 0.80-1.06) confirming a highly satisfactory agreement.

CONCLUSION

Echo-colour Doppler is a powerful, non-invasive and reproducible tool for screening CCSVI-MS but it needs special training.

Chronic cerebrospinal venous insufficiency and iron deposition on susceptibility-weighted imaging in patients with multiple sclerosis: a pilot case-control study

AIM

Chronic cerebrospinal venous insufficiency (CCSVI) is a vascular phenomenon recently described in multiple sclerosis (MS) that is characterized by stenoses affecting the main extracranial venous outflow pathways and by a high rate of cerebral venous reflux that may lead to increased iron deposition in the brain. Aim of this study was to investigate the relationship between CCSVI and iron deposition in the brain of MS patients by correlating venous hemodynamic (VH) parameters and iron concentration in deep-gray matter structures and lesions, as measured by susceptibility-weighted imaging (SWI), and to preliminarily define the relationship between iron measures and clinical and other magnetic resonance imaging (MRI) outcomes.

METHODS

Sixteen (16) consecutive relapsing-remitting MS patients and 8 age- and sex-matched healthy controls (HC) were scanned on a GE 3T scanner, using SWI.

RESULTS

All 16 MS patients fulfilled the diagnosis of CCSVI (median VH=4), compared to none of the HC. In MS patients, the higher iron concentration in the pulvinar nucleus of the thalamus, thalamus, globus pallidus, and hippocampus was related to a higher number of VH criteria (P<0.05). There was also a significant association between a higher number of VH criteria and higher iron concentration of overlapping T2 (r=-0.64, P=0.007) and T1 (r=-0.56, P=0.023) phase lesions. Iron concentration measures were related to longer disease duration and increased disability as measured by EDSS and MSFC, and to increased MRI lesion burden and decreased brain volume.

CONCLUSION

The findings from this pilot study suggest that CCSVI may be an important mechanism related to iron deposition in the brain parenchyma of MS patients. In turn, iron deposition, as measured by SWI, is a modest-to-strong predictor of disability progression, lesion volume accumulation and atrophy development in patients with MS.

Is chronic fatigue the symptom of venous insufficiency associated with multiple sclerosis? A longitudinal pilot study

AIM

Chronic fatigue (CF) severely affects patients with multiple sclerosis (MS), but its pathogenesis remains elusive and the effectiveness of available treatments is modest. We aimed to evaluate the effect on CF of the balloon dilatation of stenosing lesions affecting the main extracranial veins configuring the chronic cerebrospinal venous insufficiency (CCSVI), a condition strongly associated with MS.

METHODS

Thirty-one MS consecutive patients (16 males, age 46.2+/-9.4 years) with associated CCSVI and CF underwent the endovascular procedure. Fatigue was assessed using the Fatigue Severity Scale (FSS) and Modified Fatigue Impact Scale (MFIS) at baseline (T0) and one (T1), six (T6) and twelve (T12) months after the procedure. In ambulatory patients (N.=28), mobility was evaluated using the 6-min walking test at T0 and T1.

RESULTS

and MFIS scores significantly improved from preoperative values, and the positive trend was maintained at one year (FSS: T0=5.1+/-1.0 to T12=3.5+/-1.8, P<0.001; MFIS-total score: T0=34.9+/-14.8 to T12=22.5+/-13.7, P<0.001; MFIS-Physical subscale: T0=21.2+/-8.0 to T12=13.5+/-9.7 P<0.001; MFIS-Cognitive subscale: T0=9.2+/-9.5 to T12=6.0+/-6.3, P=0.03; MFIS-Psychosocial subscale: T0=4.5+/-2.1 to T12=2.5+/-2.1, P<0.001). Six-min walking distance (6MWD) at T1 improved significantly (332+/-190m to 378+/-200m, P=0.0002). In addition, an inverted correlation between 6MWD and MFIS-physical subscale variations was found in the subgroup of patients (N.=8) with no lower limb motor impairment (r=-0.74, P=0.035).

CONCLUSION

The reestablishment of cerebral venous return dramatically reduced CF perception in a group of MS patients with associated CCSVI, suggesting that CF is likely the symptom of CCSVI.

Use of neck magnetic resonance venography, Doppler sonography and selective venography for diagnosis of chronic cerebrospinal venous insufficiency: a pilot study in multiple sclerosis patients and healthy controls

AIM

Chronic cerebrospinal venous insufficiency (CCSVI) is a vascular condition characterized by anomalies of primary veins outside the skull that restrict normal outflow of blood from the brain. CCSVI was recently described as highly prevalent in patients with multiple sclerosis (MS), and can be non-invasively diagnosed by Doppler sonography (DS) and invasively by selective venography (SV). The aim of this paper was to investigate the value of neck magnetic resonance venography (MRV) for the diagnosis of CCSVI compared to DS and SV in patients with MS and in healthy controls (HC).

METHODS

Ten MS patients and 7 HC underwent DS, 2D-Time-Of-Flight venography (TOF) and 3D-Time Resolved Imaging of Contrast Kinetics angiography (TRICKS). MS patients also underwent SV. The internal jugular veins (IJVs) and the vertebral veins (VVs) were assessed by both MRV sequences, and the findings were validated against SV and DS. SV has been considered the diagnostic gold standard for MS patients.

RESULTS

All MS patients and none of the HC presented CCSVI, according to the DS criteria. This was confirmed by SV. For CCSVI diagnosis, DS showed sensitivity, specificity, accuracy, PPV and NPV of 100%, whereas the figures were 40%, 85%, 58%, 80% and 50% for 3D-TRICKS, and 30%, 85%, 52%, 75% and 46% for 2D-TOF in the IJVs. In MS patients, compared to SV, DS showed sensitivity, specificity, accuracy, PPV and NPV of 100%, 75%, 95%, 94% and 100%, whereas the figures were 31%, 100%, 45%, 100% and 26% for 3D-TRICKS and 25%, 100%, 40%, 100% and 25% for 2D-TOF in the IJVs.

CONCLUSION

The use of MRV for diagnosis of CCSVI in MS patients has limited value, and the findings should be interpreted with caution and confirmed by other imaging techniques such as DS and SV.

Hemodynamic patterns of chronic cerebrospinal venous insufficiency in multiple sclerosis. Correlation with symptoms at onset and clinical course

AIM

Chronic cerebrospinal venous insufficiency (CCSVI) is associated with multiple sclerosis (MS). CCSVI is detected by transcranial and extracranial color-Doppler high-resolution examination (TCCS-ECD) and venography that permit to identify five types of venous malformations and four major (A-D) hemodynamic patterns of anomalous extracranial-extravertebral venous outflow. We investigated possible correlation between such hemodynamic patterns and both the symptoms at onset and clinical course in patients with MS and CCSVI.

METHODS

TCCS-ECD, selective venography and clinical records of 65 patients affected by definite MS and CCSVI were reviewed.

RESULTS

The four hemodynamic patterns of CCSVI were unevenly (P<0.0001) distributed with respect to the types of clinical presentation and course. In particular the Type A or B patterns were common in patients with onset of optic neuritis, but rare in patients presenting with spinal cord symptoms who typically showed a type D pattern. As well, the type A or type B hemodynamic were more common in patients with relapsing remitting course than in patients with secondary progressive course and rare in patients with primary progressive course. The C hemodynamic pattern was not observed in patients with primary progressive course who showed a remarkable prevalence of the type D pattern.

CONCLUSION

The distribution of venous malformations and the resulting hemodynamic pattern show correlation with symptoms at onset and clinical course in patients with MS and CCSVI.

CSF dynamics and brain volume in multiple sclerosis are associated with extracranial venous flow anomalies: a pilot study

AIM

We previously reported unexpectedly robust associations between vascular haemodynamic (VH) anomalies in the principal extracranial cerebral veins, causing chronic cerebrospinal venous insufficiency (CCSVI), and multiple sclerosis (MS). Aim of this study was to investigate the relationship between the VH changes and MRI measures of MS disease severity in a cross sectional survey.

METHODS

The number of anomalous VH criteria were measured using an echo-color Doppler, whereas CSF flow, atrophy and lesion measures were obtained from quantitative magnetic resonance imaging (MRI) analysis in sixteen consecutive relapsing-remitting MS patients, (mean age: 36.1+/-SD 7.3 years, disease duration: 7.5+/-1.9 years and median EDSS: 2.5) and in 8 healthy controls (HC) with similar age and sex distributions.

RESULTS

All 16 MS patients investigated and none of the HCs met the VH criteria for CCSVI (P<0.0001). MS patients showed significantly lower net CSF flow compared to the HC (P=0.038) that was associated with number of anomalous VH criteria present (r=0.79, P<0.001). Moreover, increases in the number of anomalous VH criteria present were negatively associated with lower whole brain volume (Spearman R=-0.5, P=0.05).

CONCLUSION

VH changes occur more frequently in MS patients than controls. Altered VH is associated with abnormal CSF flow dynamics and decreased brain volume.

Effect of charge and lipid concentration on in-vivo percutaneous absorption of methyl nicotinate from liposomal vesicles

We have investigated the influence of charge and lipid concentration on the in-vivo percutaneous absorption of a model compound, methyl nicotinate (MN), from liposomal vesicles. MN-loaded liposomes were produced by the reverse-phase evaporation method (REV) using different concentrations of phosphatidyl choline (PC), in association with surfactants such as dioctadecyl dimethyl ammonium bromide (DDAB18) and dicetyl phosphate (DCP), which impart a positive or negative charge to the systems, respectively. The liposomal suspensions were then processed to hydrogels and used to study in-vivo the MN permeation profile. MN was chosen as the model compound since it was capable of causing cutaneous erythema, the intensity and duration of which was proportional to the amount entering the living epidermis over time. The extent of the erythema was monitored by reflectance spectrophotometry, a non-invasive technique. In-vivo findings showed an interesting MN delayed release, which was proportional to the amount of phospholipids in each liposomal formulation. Furthermore, it could be noted that the erythematous effect was more prolonged when MN was delivered from neutral or negatively-charged liposomal forms.

Liposomes- and ethosomes-associated distamycins: a comparative study

The present article describes a comparative study of the performances of liposomes and ethosomes as specialized delivery systems for distamycin A (DA) and two of its derivatives. Liposomes and ethosomes were prepared by classical methods, extruded through polycarbonate filters, and characterized in terms of dimensions, morphology, and encapsulation efficiency. It was found that DA was associated with vesicles (either liposomes or ethosomes) by around 16.0%, while both derivatives of DA showed a percentage of association around 80% in the case of liposomes and around 50% in the case of ethosomes. In vitro antiproliferative activity experiments performed on cultured human and mouse leukemic cells demonstrated that vesicles were able to increase the activity of both derivatives of DA. In addition, it was demonstrated that the aging of both liposomes- and ethosomes-associated distamycin suspensions did not heavily influence the vesicle size, while all samples showed a relevant drug leakage with time. Moreover, according to the different physicochemical characteristics of DA and its derivatives (i.e., log P), vesicle-associated DA showed the highest loss of drug with respect to both its derivatives. In conclusion, the enhancement of drug activity expressed by these specialized delivery systems-associated DD could be interesting to obtain an efficient therapeutic effect aimed at reducing or minimizing toxic effects occurring with distamycins administration.

The severity of chronic cerebrospinal venous insufficiency in patients with multiple sclerosis is related to altered cerebrospinal fluid dynamics

Chronic cerebrospinal venous insufficiency (CCSVI) is a vascular picture that shows a strong association with multiple sclerosis (MS). The aim of this study was to investigate the relationship between a Doppler cerebral venous hemodynamic insufficiency severity score (VHISS) and cerebrospinal fluid (CSF) flow dynamics in 16 patients presenting with CCSVI and relapsing-remitting MS (CCSVI-MS) and in eight healthy controls (HCs). The two groups (patients and controls) were evaluated using validated echo-Doppler and advanced 3T-MRI CSF flow measures. Compared with the HCs, the CCSVI-MS patients showed a significantly lower net CSF flow (p=0.027) which was highly associated with the VHISS (r=0.8280, r2=0.6855; p=0.0001). This study demonstrates that venous outflow disturbances in the form of CCSVI significantly impact on CSF pathophysiology in patients with MS.

Chronic cerebrospinal venous insufficiency in patients with multiple sclerosis

BACKGROUND

The extracranial venous outflow routes in clinically defined multiple sclerosis (CDMS) have not previously been investigated.

METHODS

Sixty-five patients affected by CDMS, and 235 controls composed, respectively, of healthy subjects, healthy subjects older than CDMS patients, patients affected by other neurological diseases and older controls not affected by neurological diseases but scheduled for venography (HAV-C) blindly underwent a combined transcranial and extracranial colour-Doppler high-resolution examination (TCCS-ECD) aimed at detecting at least two of five parameters of anomalous venous outflow. According to the TCCS-ECD screening, patients and HAV-C further underwent selective venography of the azygous and jugular venous system with venous pressure measurement.

RESULTS

CDMS and TCCS-ECD venous outflow anomalies were dramatically associated (OR 43, 95% CI 29 to 65, p<0.0001). Subsequently, venography demonstrated in CDMS, and not in controls, the presence of multiple severe extracranial stenosis, affecting the principal cerebrospinal venous segments; this provides a picture of chronic cerebrospinal venous insufficiency (CCSVI) with four different patterns of distribution of stenosis and substitute circle. Moreover, relapsing-remitting and secondary progressive courses were associated with CCSVI patterns significantly different from those of primary progressive (p<0.0001). Finally, the pressure gradient measured across the venous stenosies was slightly but significantly higher.

CONCLUSION

CDMS is strongly associated with CCSVI, a scenario that has not previously been described, characterised by abnormal venous haemodynamics determined by extracranial multiple venous strictures of unknown origin. The location of venous obstructions plays a key role in determining the clinical course of the disease.

Echo-guided foam sclerotherapy treatment of venous malformation involving the sciatic nerve

Primary sciatic nerve varices (SNV) lie within the sciatic nerve possibly causing chronic venous disease and sciatic pain as well. We report a series of 12 consecutive patients affected by symptomatic SNV. All of them were treated by echo-guided Tessari foam sclerotherapy (EGFSCL). Mean follow up lasted two years. Reflux through the sciatic veins, as the connected superficial varicose veins, disappeared in the entire cohort and only minor complications have emerged. EGFSCL seems to be both safe and effective, so representing a reliable and minimally invasive treatment.

Arginine modification in Kunitz bovine trypsin inhibitor through 1, 2-cyclohexanedione

Arginine residues (5.5 out of 6) of the trypsin-kallikrein inhibitor from bovine organs (Kunitz inhibitor) were selectively modified by reaction with 1, 2-cyclohexanedione in sodium borate buffer, pH 9.0. The modified inhibitor is still highly active in inhibiting trypsin and chymotrypsin at 1:1 inhibitor: enzyme molar ratio and full inhibition was achieved at slightly higher molar ratio. The extent of correct refolding, upon reoxidation, of the reduced, arginine-modified inhibitor is diminished and regeneration of two arginines occurred under the reduction conditions. The stability constants and the standard-free energies of binding of the complexes between trypsin, or chymotrypsin, and the native, the arginine-modified and the reduced and reoxidized arginine-modified inhibitor have been determined from inhibitory assays.