The management of endoscopic retrograde cholangio- pancreatography-related infections risk: results of an italian survey at regional level

BACKGROUND AND AIM

Among the Endoscopic retrograde cholangiopancreatography (ERCP) adverse events, an increasingly arising problem is the transmission of Multi Drug Resistant (MDR) Bacteria through duodenoscopes. The aim of this survey was to evaluate the current clinical practice of management of ERCP associated infections in Emilia-Romagna, Italy.

METHODS

An online survey was developed including 12 questions on management of ERCP associated infections risk. The survey was proposed to all 12 endoscopy centers in Emilia Romagna that perform at least > 200 ERCPs per year.

RESULTS

11 centers completed the survey (92%). Among all risk factors of ERCP infections, hospitalization in intensive care units, immunosuppressant therapies, and previous MDR infections have achieved a 80 % minimum of concurrence by our respondents. The majority of them did not have a formalized document in their hospital describing categories and risk factors helpful in the detection of patients undergoing ERCP with an high-level infective risk (9/11, 82%). Most centers (8/11, 72%) do not perform screening in patients at risk of ERCP infections. Post procedural monitoring is performed by 6 of 11 centers (55%).

CONCLUSION

Our survey showed that, at least at regional level, there is a lack of procedures and protocols related to the management of patients at risk of ERCP infections.

C34 INDIRECT MITRAL ANNULOPLASTY USING THE CARILLON CONTOUR SYSTEM, SINGLE CENTER EXPERIENCE

Mitral Regurgitation (MR) is both the most common and the most underdiagnosed valvulopathy in Western countries. When MR’s entity is moderate to severe it is highly burdened by incident heart failure causing an important impact on prognosis, in terms of mortality and re–hospitalization. Unfortunately a lot of symptomatic patients are not elegible to reparative or replacement surgery also due to the high procedural risks. Hence, the need for a less invasive treatment has grown, so endovascular repair techniques have been developed such as the CARILLON Mitral Contour System, a percutaneous procedure for reshape the mitral annulus reducing its dilation and mitral regurgitation. This technique is indicated for patients with secondary mitral regurgitation. The CARILLON is a simple and fast procedure with a right jugular approach that requires neither general anesthesia nor anticoagulant/antiplatelet therapy. Four patients including 3 men, aged 37–64 years, suffering from heart failure and moderate to severe secondary mitral regurgitation who were symptomatic in optimal medical therapy, NYHA II – III class, were admitted to our Cardiological Intensive Care Unit from April to September 2021. All patients underwent coronary angiography and three patients had no obstructive coronary artery disease (CAD). All patients underwent transthoracic and transesophageal echocardiography showing severely dilated left ventricles (DTD 70 ± 10mm, DTS 46 ± 21mm, VTD 264 ± 6ml, VTS 204 ± 6ml), severe reduction in ejection fraction (mean EF 24 ± 5%), severely dilated left atrium, mean volume values 47 ± 13ml/m2, moderate to severe mitral regurgitation (vena contracta 6 ± 2mm, EROA 34 ± 9mm2, regurgitation volume 37 ± 12 ml, regurgitation fraction mean 54 ± 4%). After implantation of the Carillon no complications were observed. In the 3–month follow–up, patients reported improvement in symptoms, exercise capacity and NYHA class. At the echocardiographic evaluation we saw improvement in contractile function and left ventricular size, reduction in the degree of mitral regurgitation to mild–moderate. There were no further hospitalizations for heart failure during the follow–up. The data, albeit limited to our little experience, show how the Carillon reduces mitral regurgitation and improves clinical outcomes in terms of exercise tolerance, quality of life and reduction of hospital admissions, which have social and economic relevance.

P310 CARDIAC AMYLOIDOSIS: INITIAL MONOCENTRIC EXPERIENCE

 

Cardiac amyloidosis is a group of diseases characterized by the accumulation in the interstitial space of amorphous material consisting of amyloid fibrils and, until recently, considered rare, with poor therapeutic prospects and burdened by a poor prognosis. However, both for amyloidosis from immunoglobulin light chains (AL) and for transthyretin amyloidosis in its wild type and mutated forms, there has been a significant increase in diagnostic capabilities. The aim of this work is to show the characteristics found in our population affected by cardiac amyloidosis.

Materials and Methods

We enrolled 18 patients observed over 12 months. The mean age was 63 ± 5, 14 patients were male. 8 patients in NYHA Class I – II, 10 patients in NYHA Class II – III. On the ECG in 88% of cases low QRS voltages in the peripheral leads. Among the conduction disturbances: 1st degree AV block in 45%, EAS in 33%, BBSn in 17%, occurrence of isolated BEV and BESV in 90%; 1 patient presented with AF. Defibrillator was implanted in 3 patients for detection of TVS and TNnS. In the whole population, the echocardiogram showed concentric parietal hypertrophy with a granular sparkling appearance; the mean FE was 55 ± 3%, the diastolic filling pattern was altered in type I in 42%, type II in 33% and type III in 25% of patients, respectively. In 92% of cases the left atrium was dilated. In 87% of cases there was an involvement of the valves in particular in 64% of cases we found calcifications of the aortic valve and in 66% mitral insufficiency. In 42% of patients there was an increase in the thickness of the atrial septum as well as the free wall of the right ventricle. Finally, signs of non–buffering pericardial effusion were found in 33% of patients.

Results

In our study population, 15 patients had multiple myeloma and presented with cardiac AL–type amyloidosis; among these 3 also presented renal involvement. In 3 patients, on the other hand, after positive bone scan and genetic screening, we diagnosed cardiac amyloidosis due to transthyretin mutation for which therapy with Tafamidis was undertaken. 3 patients died.

Conclusions

Our population presented echographic and echocardiographic characteristics comparable to those reported in the literature.

P78 AN ANTEGRADE RECANALIZATION OF LEFT ANTERIOR DESCENDING CHRONIC TOTAL OCCLUSION WITH ORBITAL ATHERECTOMY IN PATIENT WITH SEVER LEFT VENTRICULAR DISFUNCTION

We share the case of a 71–year old man, affected by hypertension, presented in Emergency Room (ER) with chest pain. No clinical evidence of heart failure. EKG showed fast atrial fibrillation with QS complex and ST elevation in precordial leads. Echocardiogram confirmed sept and apex akinesia. Troponin I peak was 72pg/ml. In ER electrical cardioversion was efficacy performed. He was referred for invasive coronary angiography, that showed a left anterior descending (LAD) chronic total occlusion (CTO), with Rentrop grade 2 collaterals providing retrograde flow from the right coronary artery (RCA), a severe stenosis of ramus intermedius (RI) and a moderate stenosis of circumflex. A stress–echocardiogram demonstrated vitality of medio–basal anterior wall. Subsequent, recanalization procedure of LAD CTO was planned. J–CTO score was 1 (tapered calcific, lesion, <20mm). double radial access and ante grade approach was chosen. An EBU3.5 guiding catheter was engaged in the left coronary artery, and 8000 units of heparin administered. The iFR of Cx was 0.99, indicative of non significant myocardial ischemia. During hemodynamic evaluation of RI, a ventricular fibrillation occurred, treated by DC–SHOCK and PCI with stenting with no polymer, eluted with Biolimus A9 (3.0x24mm) with good result. The occlusion was crossed via an antegrade approach with an Asahi Gaia II wire and with microcatheter support. Gaia II was changed in favor of Asai Sion blu, and the IVUS catheter was enable of cross the lesion. Efficacy orbital atherectomy with Diamondback 260 was performed (5 ante and retro grade run at 80Krpm and a retro grade run at 120 Krpm. Ivus was able to cross the lesion. Efficacy pre–dilatation with semi and non compliant balloon (2.5–3.5mm) was performed and then stented with a 3.0 × 36 mm Bioloimu A9–eluting stent. Finally, IVUS confirmed correct stent expansion, achieving an excellent angiographic result. Patient was discharged with triple anti–thrombotic therapy, with indication to “life jacket” till the assessment at 1 month.

P163 BOTALLO ARTERIAL DUCT SURGICALLY TREATED IN URGENCY

The Botallo arterial duct connects the pulmonary artery and the aorta during fetal life; after birth there is a progressive fall in pulmonary resistance mediated by the increase in oxygen concentration and the decrease in prostaglandins with a vasodilating action. In these physiological conditions, spontaneous closure of the duct is observed within the first 48–72 hours of life. In the preterm infant the patency of the Botallo duct is very frequent due to the peculiar anatomical and physiological characteristics of the preterm infant. The incidence of PDA is higher the lower the birth weight and gestational age are.

We report a case of Manuel, a baby born at 32 weeks of gestational age from elective CT due to transverse presentation with difficulty in extraction and anhydrosis. 37–year–old mother hospitalized for reduction of amniotic fluid (AFI 85 index) with no apparent rupture of the membranes, for which she began a cycle of glucocorticoids 12mg twice a day. At birth, the weight of the child was 1,780 g, length 42 cm, skull circumference 28 cm, absence of valid respiratory activity, bradycardia (78 bpm) APGAR index of 4. At 5 ‘of life he was intubated with a 3 Fi rush tube fixed to 8 cm from the buccal rim with neopuff with PIP 20 cmH2O, PEEP 5 cmH2O, FiO2 0.40, transferred to the NICU, placed in the incubator, connected to the ventilator and ventilated with A/C mode with PIP 23 cmH2O, PEEP 5 cmH2O, FiO2 0, 40 –> 0.60, given surfactant alfa 200 mg/kg. Anemic, plasma and red blood cells were administered multiple times; infectious disease tests (aerobic–anaerobic haemocolutre, umbilical culture, culture of OT tubes, BAL, ear and throat swabs) were negative. After 3 days, systolic heart murmur appeared 2–3/6 radiated to the axilla. The echocardium showed the persistence of the Duct of Botallo, with a mosaic jet in the pulmonary artery and a “growing” ductal flow pattern. He started treatment with indomethacin 0.2 mg/kg every 12 hours x 3 doses, but on echocardiographic control the picture remained unchanged. At 16 days of age, the newborn was transferred to the Bambin Gesù in Rome and underwent cardiac surgery via the left posterolateral thoracotomy to close the arterial duct with a Weck clip. The post–operative course was regular. Manuel was discharged 2.5 months after birth in good general conditions, good growth–weight, with a weight of 2460 g.

P62 LEFT ANTERIOR DESCENDING CACIFIED LESION IN A PATIENT WITH RECENT INFERIOR STEMI SUPPORTED WITH VENTRICULAR ASSISTANCE FROM IMPELLA 2.5, TREATED WITH ORBITAL ATHERECTOMY AND DRUG ELUTING STENT AND OPTIMIZED WITH IVUS CO–REGISTRATION

We present a case of a 65 years old patient with hypertension.He comes to our cath lab with an inferior STEMI treated with primary PCI of right coronary artery and we found a sub–occlusive and severly calcified lesion on proximal left anterior descending artery (LAD) and a diffused disease of its middle and distal portion (Fig 2). After collegial discussion on Heart Team we decided to proceed with a staged percutaneous revascularization on LAD. After an accurate planning we decided to proceed with a single femoral access a 14f femoral sheat was positioned on femorl artery, so we put the ventricular assistance catheter and then on the same sheat we put our 7 f guiding catheter to use only a single access for IMPELLA and for the guiding catheter (Fig. 1).The IVUS catheter doesn’t be able to cross the calcified lesion on LAD so we go on with a debulking using the orbital atherectomy of Diamond Back, with several passages antegrade and retrograde.At this point we are able to perform an IVUS Co–registration that demostrated also a critical lesion on ostial LAD.After multiple pre–dilatation to prepare the lesion we put three big drug eluting stent till 5 mm of diameter.The IVUS shows us a little malapposition so we proceed with a big non compliant balloon of 6mm with optimal result (Fig 3).In conclusion we go on with a reduction of ventricular assistance and final removal of IMPELLA catheter and closure of 14f vascular access with a single Pro–glide previously implanted.This procedure has some discussion points, first of all the possibility to treat a sub–occlusive lesion of an important non culprit artery after a few days of an acute coronary syndrome in safe mode with a ventricular assistance, that allowed us to work peacefully, being able to carry out all the maneuvers we considered appropriate (multiple balloon dilatations, IVUS evaluations, orbital atherectomy).An other point of discussion is the use of this new orbital atherectomy easy to use because with a single device,6f guiding catheter compatible, we are able to treat artery from 2.5 till 4mm only setting the rotational speed and removing not only the intraluminal calcium but also the deeper one and this allows a better stent expansion.The procedure is IVUS guided associated with angiographic images on Co–registration that allow us to obtain even more informations.The last comment is for the new stent Megatron, the only stent that are able to treat coronary artery till 6 mm.

P238 CARDIAC CONTRACTILITY MODULATION THERAPY: INITIAL MONOCENTRIC EXPERIENCE

 

Cardiac contractility modulation therapy consists in the delivery, by a device implanted in the patient at the level of the subclavicular region and connected to the heart through leads that send high intensity electrical impulses within the absolute refractory period of the potential of myocardial action. These pulses are delivered in cycles of 1 hour 7 times a day, each interspersed with pauses of 2–3 hours. CCM has been shown to be able to improve myocardial contractility through better management of intracellular calcium by the cardiomyocyte, exerting short and long–term effects, even managing to induce a positive remodulation of the gene expression of cardiac cells. The recent ESC 2021 guidelines indicate that cardiac contractility modulation therapy (CCM) was evaluated in patients with heart failure, FE 25%–45% and normal QRS duration (<130 ms) considering pVO2, QoL, 6MWT. The modulation of cardiac contractility improves symptoms and exercise tolerance and reduces re–hospitalization for heart failure (HF).

The purpose of this work is to show our little experience on the use of CCM in patients suffering from heart failure.

Materials and methods

4 male patients, aged 38–75 years, with heart failure, on optimal medical therapy, NYHA class III – IV, QRS <130 msec, FE 25–45%, hospitalized for implantation by CCM. NYHA, FE and BNP rated. The device was implanted in 4 patients without significant complications.

Results

In the 3 and 6 month follow–up, patients reported an improvement in symptoms, better exercise capacity and consequently a transition to a lower NYHA class (II – III). BNP values were lower than baseline. Upon checking the defibrillator, the trend of fluid accumulation using the optivol algorithm did not show significant levels of accumulation. No further hospitalizations for heart failure exacerbation.

Conclusion

The data limited to our little experience show how CCM produces similar results to those demonstrated in previous studies in subjects with 25% ≤LVEF≤45% and QRS <130 ms; CCM therapy improves clinical outcomes in terms of exercise tolerance and quality of life, long–term survival and reduces hospitalizations.

P57 SPONTANEOUS DISSECTION OF THE DISTAL MARGINAL BRANCH IN A YOUNG WOMAN IN THE PERIPARTUM WITH NO FLOW LIMITATION AT THE PRESENTATION EVOLVED INTO SEVERE DISSECTION OF THE ANTERIOR CIRCUMFLEX AND DESCENDING ARTERY COMPLICATED BY CARDIOGENIC SHOCK

We describe the case of a 39–year–old woman with a history of recent natural birth, who came to our observation for an episode of oppressive chest pain while breastfeeding her baby at night. At the entrance, the electrocardiographic and echocardiographic findings and myocardiocitonecrosis enzymes were normal; after three hours the second enzymatic determination was clearly increased, so the patient was admitted to our ICU with a diagnosis of SCA / NSTEMI. She was therefore subjected to coronary angiography with a small hematoma in the distal tract of the marginal branch without flow limitation; it was therefore decided, in accordance with the AHA and ESC guidelines, for a conservative medical therapy. On the third day of hospitalization, the patient presented recurrence of chest pain with electrocardiographic evidence of ST segment elevation in the anterolateral site. A new angiographic evaluation was therefore performed urgently, showing a complete retrograde dissection from the marginal branch to the circumflex branch and to the anterior descending branch with TIMI 0–1 flow. During the procedure the patient underwent a prolonged hypotensive episode associated with frequent polymorphic ventricular ectopic beats, with rapid evolution towards a picture of overt cardiogenic shock. Therefore we proceeded quickly to perform PTCA with placement of medicated stents on all branches involved in the dissection, with rapid improvement of the haemodynamic picture. Spontaneous coronary dissections represent for a hemodynamist a condition of great technical difficulty where the margins of error are very high. Thanks to the technological evolution of materials, an experienced hemodynamist is able, more and more easily, to be successful in the revascularization procedure and to resolve extremely serious clinical pictures. This case report describes a spontaneous coronary dissection that most often occurs in young women in good health and without risk factors for coronary heart disease, particularly in the peripartum period. The presentation was similar to an acute coronary syndrome. According to AHA and ESC guidelines, therapy was conservative if dissection / hematoma is not a flow restriction with coronary angiography after a few days to demonstrate vessel restoration.

P63 OPTICAL COHERENCE TOMOGRAPHY–ANGIO CO–REGISTRATION (OCT–ACR) OF LEFT ANTERIOR DESCENDING IN PATIENT WITH ONGOING ANIGNA

We share the case of a 50–year old man, with no cardiovascular risk factor, presented in ER with ongoing angina and positive exercise stress testing. No clinical evidence of heart failure. EKG and echocardiogram was negative. He was referred for invasive coronary angiography, that showed severe stenosis of mid–LAD and moderate ostial LAD stenosis. Subsequent Optical Coherence Tomography–Angio Co–Registration (OCT–ACR) of Left Anterior Descending was performed. An EBU3.5 guiding catheter was engaged in the left coronary artery, and 8000 units of heparin administered. After a pre–dilatation with a semi–compliant balloon of mid LAD, a plaque rupture with thrombus was documented at mid–LAD and a fibro–lipidic plaque with a severe flow limitation (MLA<4mm2) at the ostium, with no involvement of left main (Fig. 1b). Pre–dilatation with SC and NC balloon (2.5–3.5mm) was performed and then stented with a 4.0 × 26 mm DES. Finally, OCT confirmed correct stent expansion, achieving an excellent angiographic result, without carina shifting and compromise of the circ. Patient was discharged, asymptomatic. OCT–ACR guided PCI, taking advantage of its high spatial resolution, permits to plain better the PCI, establish correct stent size, evaluate early complications especially if left main or bifurcation are involved and thanks to co–registration also measurement of long axis of the vessel are facilitated.

P334 RARE CASE OF PAPILLIFEROUS FIBROELASTOMA ON AORTIC VALVE

Cardiac tumors are rare neoplastic processes that can arise from any tissue in the heart. They are divided into primitive (benign or malignant) and metastatic (always malignant). The prevalence of cardiac tumors ranges from 0.002% to 0.28%, of which most are benign. Papillary fibroelastoma is the third most common heart cancer and the most frequent heart valve cancer. We describe the case of a 50–year–old ex–smoker patient with a recent history of recurrent right popliteal – tibial femoral thrombectomy and subsequent percutaneous angioplasty. He arrived in the emergency room for ischemic ulcers and fistulization of the right lower limb, for which he was admitted to the Vascular Surgery Department. The patient came to our observation for appearance during the hospitalization of episodes of chest pain at rest with irradiation to the left upper limb and spontaneous regression. The physical examination, blood pressure, blood chemistry tests, chest X–ray and ECG were normal. Transthoracic and transesophageal echocardiography showed a left ventricle with good contractile function, a tricuspid aortic valve with cusp movement preserved with an oval mass, hypoechoic, with well–defined margins, adhering to the ventricular surface of the right coronary cusp, conditioning insufficiency of mild degree. This image was suggestive for papillary fibroelastoma. In addition, in anticipation of cardiac surgery, a coronary CT was performed which confirmed the presence of an oval, hypodense mass and the absence of significant coronary lesions. The absence of fever, increased inflammation and leukocytosis indices made it possible to exclude an endocarditic origin of the lesion, just as the echocardiographic and radiological characteristics eliminated the suspicion of thrombosis. The patient underwent cardiac surgery via longitudinal median sternotomy, in normothermic extracorporeal circulation (CEC). The mass was then excised, preserving the native aortic valve. Postoperative follow–up with transesophageal echocardiography showed no signs of aortic insufficiency. The postoperative course was uneventful. The histological examination of the lesion confirmed the diagnosis of papillary fibroelastoma. At the follow–up after about 3 years the patient was asymptomatic and without echocardiographic signs of local recurrence.

P198 ACUTE CORONARY SYNDROME COMPLICATED BY LEFT VENTRICULAR THROMBOSIS AND ISCHEMIC STROKE IN YOUNG WOMAN WITH ACUTE LYMPHOBLASTIC LEUKEMIA IN CHEMOTHERAPY TREATMENT

Acute lymphoblastic leukemia (ALL) is the most common cancer in children and accounts for 75% of all leukemias. In ALL, very immature leukemia cells build up in the bone marrow, destroying and replacing normal cells. Thrombotic events are a complication of acute leukemia induction therapy, particularly acute lymphoblastic leukemia (ALL) treated with L – asparaginase. We present the case of a 23–year–old girl suffering from acute lymphoblastic leukemia from pediatric age, undergoing chemotherapy treatment. In August 2021 she was admitted to ICU for acute myocarditis in shock which resolved after specific therapy. In September 2021 he came to our observation again for chest pain, fever, pulmonary thickening, but with normal echocardiography and echocardiography. The next day, the patient presented a worsening of symptoms, with the appearance of an elevated ST in the anterior to the ecg trace and apical, SIV and anterior wall akinesia with severely reduced FE on the echocardiogram. After collegial discussion also with fellow haematologists for the presence of thrombocytopenia, antithrombotic therapy was administered and an urgent coronary examination was carried out. The examination showed acute thrombotic occlusion of the middle–distal VAT. In the same session we proceeded to thrombus aspiration and implantation of medicated stents, procedure concluded in the absence of complications. The following morning the patient complained of paresthesia and weakness in the right side. On the echocardiogram, the presence of a thrombus in the apical area of about 2 cm. Skull CT was performed in urgency which showed cortical–subcortical hypodensity area in the left frontal–parietal site, referring to a recent ischemic lesion. In agreement with colleagues from Stroke Unite and hematology, heparin was infused intravenously in an attempt to dissolve the thrombus, but three episodes of VF were treated with effective DC shock during the hospital stay. On the same day, the girl was transferred intubated to resuscitation for respiratory arrest; in the following hours we witnessed the exitus. Our patient presented acute thrombosis both in the heart and in the brain, although she was being treated with antiplatelet and antithrombotic drugs and in the presence of thrombocytopenia. This case highlights the strong procoagulative role of haematological disease and of the chemotherapy indicated for it.

P224 PRIMITIVE DILATED CARDIOMYOPATHY IN YOUNG MAN NOT ELIGIBLE FOR CARDIAC TRANSPLANTATION: COMBINED USE OF DEFIBRILLATOR, CARDIAC CONTRACTILITY MODULATION (CCM) AND CARILLON

Acute heart failure refers to rapid or gradual onset of symptoms and/or signs of chronic heart failure due to precipitating factors. Many patients with heart failure progress into a phase of advanced heart failure, characterized by persistent symptoms despite maximal therapy. Prognosis remains poor, with high 1–year mortality. Prognostic stratification is important to identify the ideal time for referral to an appropriate center capable of providing advanced therapies. We present the case of a 36–year–old black homeless man was admitted to Cardiological intensive care unit for acute heart failure complicated by intermediate–high risk bilateral subsegmentary pulmonary embolism, left endoventricular thrombosis, severe biventricular systolic dysfunction and secondary severe mitral insufficiency. After infusional diuretic and anticoagulant therapy, coronary angiography was performed documenting non–obstructive epicardial coronary arteries. Thereafter the therapy with sacubitril/Valsartan was falled, due to marked hypotension. Due to the high risk of sudden cardiac death, a single–chamber ICD was implanted in primary prevention. He was not eligible for long–term mechanical assistance (VAD) implantation and/or heart transplantation from referral centers, because of the patient‘s precarious psychosocial background. Furthermore, in the fullness of his faculties, the patient refused this possibility for religious reasons. Discharged in fair compensation, after resolution of pulmonary embolism and intracavitary thrombosis, he was again hospitalized for an exacerbation of chronic heart failure. Once labile hemodynamic compensation was reached, a cardiac contractility modulation device (CCM) was positioned, with the aim of improving symptoms. After optimization of therapy, with persistence of severe symptoms despite optimal medical and device therapy, options for intervention on the mitral valve were evaluated before further deterioration of the clinical conditions. Since this is a highly symptomatic patient at high risk for surgery, we opted for a coronary sinus mitral annuloplasty repair with Carillon, performed in the absence of complications. At the follow–up there was a mitral regurgitant volume reduction, improvement symptoms, in the absence of further hospitalizations.

Chemotherapy toxicity and activity in patients with pancreatic ductal adenocarcinoma and germline BRCA1-2 pathogenic variants (gBRCA1-2pv): a multicenter survey

BACKGROUND

Germline BRCA1-2 pathogenic variants (gBRCA1-2pv)-related pancreatic ductal adenocarcinoma (PDAC) showed increased sensitivity to DNA cross-linking agents. This study aimed at exploring safety profile, dose intensity, and activity of different chemotherapy regimens in this setting.

PATIENTS AND METHODS

gBRCA1-2pv PDAC patients of any age and clinical tumor stage who completed a first course of chemotherapy were eligible. A descriptive analysis of chemotherapy toxicity, dose intensity, response, and survival outcomes was performed.

RESULTS

A total of 85 gBRCA1-2pv PDAC patients treated in 21 Italian centers between December 2008 and March 2021were enrolled. Seventy-four patients were assessable for toxicity and dose intensity, 83 for outcome. Dose intensity was as follows: nab-paclitaxel 72%, gemcitabine 76% (AG); cisplatin 75%, nab-paclitaxel 73%, capecitabine 73%, and gemcitabine 65% (PAXG); fluorouracil 35%, irinotecan 58%, and oxaliplatin 64% (FOLFIRINOX). When compared with the literature, grade 3-4 neutropenia, thrombocytopenia, and diarrhea were increased with PAXG, and unmodified with AG and FOLFIRINOX. RECIST responses were numerically higher with the three- (81%) or four-drug (73%) platinum-containing regimens that outperformed AG (41%) and oxaliplatin-based doublets (56%). Carbohydrate antigen 19.9 (CA19.9) reduction >89% at nadir was reported in two-third of metastatic patients treated with triplets and quadruplets, as opposed to 33% and 45% of patients receiving oxaliplatin-based doublets or AG, respectively. All patients receiving AG experienced disease progression, with a median progression-free survival (mPFS) of 6.4 months, while patients treated with platinum-containing triplets or quadruplets had an mPFS >10.8 months. Albeit still immature, data on overall survival seemed to parallel those on PFS.

CONCLUSIONS

Our data, as opposed to figures expected from the literature, highlighted that platinum-based regimens provoked an increased toxicity on proliferating cells, when dose intensity was maintained, or an as-expected toxicity, when dose intensity was reduced, while no change in toxicity and dose intensity was evident with AG. Furthermore, an apparently improved outcome of platinum-based triplets or quadruplets over other regimens was observed.

Multiparametric MR imaging of the prostate at 1.5-T without endorectal coil using an 8 channel pelvic phased array: Is it still a viable option?

INTRODUCTION

The purpose of our work was to evaluate the feasibility of prostate multiparametric MR imaging at 1.5-T without endorectal coil using an 8 channel pelvic phased array coil.

MATERIAL AND METHODS

A total of 154 patients who underwent mp-MRI were retrospectively included. Patients received a standardized mp-MRI, compliant with 2012 European Society of Uro-Radiology guidelines, with 1·5 T magnetic field strength and an 8 channel pelvic phased-array coil. Two blinded readers graded the image quality of mp-MRI on a three-point scale and they scored the prostate lesions according to PI-RADS v2. All PI-RADS of 4 or 5 underwent biopsy. A third radiologist and a pathologist verified the correspondence between the MRI images and the results of the biopsy.

RESULTS

64 (41.6%) patients showed a Pi-rads of 4 or 5. At biopsy, 79.7% showed a Gleason score ≥7, 12.5% showed a Gleason score of 6 and 7.8% showed a negative biopsy. In the group of Pi-rads ≤ 3, 12 patients underwent a biopsy with the following results: negative biopsy in 33.3%, atypical Small Acinar Proliferation in 16.7%, prostatic intraepithelial neoplasia in 25% and indolent PCa 25%. Mp-MRI in the identification of clinically significant cancer provided a low percentage of false positive (7.8%) while in 79.7% of cases it was capable to detect clinically significant prostate cancer. In 92.2% of patients mp-MRI identified a prostate cancer with a Gleason score ≥6. The inter-reader agreement was excellent in defining both the quality of the examination and the PI-RADS category (k = 0.83 and k = 0.70, respectively).

CONCLUSIONS

mp-MRI at 1.5-T without endorectal coil using an 8 channel phased array is an appropriate tool for early detection of clinically significant prostate cancer.

IMPLICATIONS FOR PRACTICE

8 channel pelvic phased array is still an appropriate tool for early detection of clinically significant prostate cancer and for obtaining a reduction in overdiagnosis of indolent PCa.

Searching for novel multimodal treatments in oligometastatic pancreatic cancer

BACKGROUND

Metastatic pancreatic cancer has a median overall survival of less than 12 months, even if treated with chemotherapy. Selected patients with oligometastatic disease could benefit from multimodal treatments connecting chemotherapy and surgical treatment or radiofrequency ablation (RFA) of metastases.

CASE PRESENTATION

We present a patient with oligometastatic pancreatic cancer recurrence who was successfully treated with a multimodal therapeutic approach. A 57-year-old male initially presenting with resectable pancreatic cancer underwent pancreatoduodenectomy. The histopathological diagnosis revealed ductal pancreatic adenocarcinoma with positive surgical resection margins and negative lymph nodes. He completed six cycles of adjuvant therapy with gemcitabine (1000 mg/mq 1,8,15q 28), followed by external radiotherapy (54 Gy in 25 fractions) associated with gemcitabine 50 mg/mq twice weekly. Three years later, the patient developed multiple liver metastases, and he started FOLFIRINOX (oxaliplatin 85 mg/mq, irinotecan 180 mg/mq, leucovorin 400 mg/mq and fluorouracil 400 mg/mq given as a bolus followed by 2400 mg/mq as a 46 h continuous infusion,1q 14) as a first-line treatment. The CT scan showed a partial response after 6 cycles. After multidisciplinary discussion, the patient underwent a laparotomic metastasectomy of the three hepatic lesions. After additional postsurgical chemotherapy with 4 cycles of the FOLFIRINOX schedule, the patient remained free of recurrence for 12 months. A CT scan showed a new single liver metastasis, which was treated with radiofrequency ablation (RFA). A second radiofrequency ablation was performed when the patient developed another single liver lesion 12 months after the first RFA; currently, the patient is free from recurrence with an overall survival of 6 years from the diagnosis.

CONCLUSIONS

Our case has benefited from successful multimodal treatment, including surgical and local ablative techniques and systemic chemotherapy. A multimodal approach may be warranted in selected patients with oligometastatic pancreatic cancer and could improve overall survival. Further research is needed to investigate this approach.

Hepatocellular carcinoma recurrence in patients with curative resection or ablation: impact of HCV eradication does not depend on the use of interferon

BACKGROUND

In HCV-infected cirrhotic patients with successfully treated early hepatocellular carcinoma (HCC), the time to HCC recurrence and the effects of sustained viral eradication (SVR) by interferon (IFN)-based or IFN-free regimens on HCC recurrence remain unclear.

AIM

To perform an indirect comparison of time to recurrence (TTR) in patients with successfully treated early HCC and active HCV infection with those of patients with SVR by IFN-based and by IFN-free regimens.

METHODS

We evaluated 443 patients with HCV-related cirrhosis and Barcelona Clinic Liver Cancer Stage A/0 HCC who had a complete radiological response after curative resection or ablation. Active HCV infection was present in 328, selected from the Italian Liver Cancer group cohort; 58 patients had SVR achieved by IFN-free regimens after HCC cure, and 57 patients had SVR achieved by IFN-based regimens after HCC cure. Individual data of patients in the last two groups were extracted from available publications.

RESULTS

TTR by Kaplan-Meier curve was significantly lower in patients with active HCV infection compared with those with SVR both by IFN-free (P = 0.02) and by IFN-based (P < 0.001) treatments. TTR was similar in patients with SVR by IFN-free or by IFN-based (P = 0.49) strategies.

CONCLUSION

In HCV-infected, successfully treated patients with early HCC, SVR obtained by IFN-based or IFN-free regimens significantly reduce tumour recurrence without differences related to the anti-viral strategy used.

Ultrastructural localization and distribution of Nardilysin in mammalian male germ cells

Background

NRD convertase, also termed Nardilysin, is a Zn⁺⁺ metalloendopeptidase that specifically cleaves the N-terminus of arginine and lysine residues into dibasic moieties. Although this enzyme was found located within the testis, its function in male reproduction is largely unknown. In addition, the precise distribution of this enzyme within germ cells remains to be determined.

Methods

To answer these questions, we developed an immuno-gold electron microscopy analysis to detect Nardilysin at ultrastructural level in mice. In addition, we performed a quantitative analysis of these gold particles to statistically estimate the distribution of Nardilysin in the different subcellular compartments of differentiating late spermatids/spermatozoa.

Results

Expression of Nardilysin in wild-type mice was restricted to germ cells and markedly increased during the last steps of spermiogenesis. In elongated spermatids, we found the enzyme mainly localized in the cytoplasm, more precisely associated with two microtubular structures, the manchette and the axoneme. No labelling was detected over the membranous organelles of the spermatids. To test whether this localization is dependent of the functional microtubules organization of the flagella, we analysed the localization into a specific mouse mutant ebo/ebo (ébouriffé) known to be sterile due to an impairment of the final organization of the flagellum. In the ebo/ebo, the enzyme was still localized over the microtubules of the axoneme and over the isolated cytoplasmic microtubules doublets. Quantification of gold particles in wild-type and mutant flagella revealed the specific association of the enzyme within the microtubular area of the axoneme.

Conclusions

The strong and specific accumulation of Nardilysin in the manchette and axoneme suggests that the enzyme probably contributes either to the establishment of these specific microtubular structures and/or to their functional properties.

Years of life that could be saved from prevention of hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) causes premature death and loss of life expectancy worldwide. Its primary and secondary prevention can result in a significant number of years of life saved.

AIM

To assess how many years of life are lost after HCC diagnosis.

METHODS

Data from 5346 patients with first HCC diagnosis were used to estimate lifespan and number of years of life lost after tumour onset, using a semi-parametric extrapolation having as reference an age-, sex- and year-of-onset-matched population derived from national life tables.

RESULTS

Between 1986 and 2014, HCC lead to an average of 11.5 years-of-life lost for each patient. The youngest age-quartile group (18-61 years) had the highest number of years-of-life lost, representing approximately 41% of the overall benefit obtainable from prevention. Advancements in HCC management have progressively reduced the number of years-of-life lost from 12.6 years in 1986-1999, to 10.7 in 2000-2006 and 7.4 years in 2007-2014. Currently, an HCC diagnosis when a single tumour <2 cm results in 3.7 years-of-life lost while the diagnosis when a single tumour ≥ 2 cm or 2/3 nodules still within the Milan criteria, results in 5.0 years-of-life lost, representing the loss of only approximately 5.5% and 7.2%, respectively, of the entire lifespan from birth.

CONCLUSIONS

Hepatocellular carcinoma occurrence results in the loss of a considerable number of years-of-life, especially for younger patients. In recent years, the increased possibility of effectively treating this tumour has improved life expectancy, thus reducing years-of-life lost.

Comparison between alcohol- and hepatitis C virus-related hepatocellular carcinoma: clinical presentation, treatment and outcome

BACKGROUND

Hepatitis C virus (HCV) and alcohol abuse are the main risk factors for hepatocellular carcinoma (HCC) in Western countries.

AIM

To investigate the role of alcoholic aetiology on clinical presentation, treatment and outcome of HCC as well as on each Barcelona Clinic Liver Cancer (BCLC) stage, as compared to HCV-related HCCs.

METHODS

A total of 1642 HCV and 573 alcoholic patients from the Italian Liver Cancer (ITA.LI.CA) database, diagnosed with HCC between January 2000 and December 2012 were compared for age, gender, type of diagnosis, tumour burden, portal vein thrombosis (PVT), oesophageal varices, liver function tests, alpha-fetoprotein, BCLC, treatment and survival. Aetiology was tested as predictor of survival in multivariate Cox regression models and according to HCC stages.

RESULTS

Cirrhosis was present in 96% of cases in both groups. Alcoholic patients were younger, more likely male, with HCC diagnosed outside surveillance, in intermediate/terminal BCLC stage and had worse liver function. After adjustment for the lead-time, median (95% CI) overall survival (OS) was 27.4 months (21.5-33.2) in alcoholic and 33.6 months (30.7-36.5) in HCV patients (P = 0.021). The prognostic role of aetiology disappeared when survival was assessed in each BCLC stage and in the Cox regression multivariate models.

CONCLUSIONS

Alcoholic aetiology affects survival of HCC patients through its negative effects on secondary prevention and cancer presentation but not through a greater cancer aggressiveness or worse treatment result. In fact, survival adjusted for confounding factors was similar in alcoholic and HCV patients.

A retrospective evaluation of the global decline of carnivores and ungulates

Assessing temporal changes in species extinction risk is necessary for measuring conservation success or failure and for directing conservation resources toward species or regions that would benefit most. Yet, there is no long-term picture of genuine change that allows one to associate species extinction risk trends with drivers of change or conservation actions. Through a review of 40 years of IUCN-related literature sources on species conservation status (e.g., action plans, red-data books), we assigned retrospective red-list categories to the world's carnivores and ungulates (2 groups with relatively long generation times) to examine how their extinction risk has changed since the 1970s. We then aggregated species' categories to calculate a global trend in their extinction risk over time. A decline in the conservation status of carnivores and ungulates was underway 40 years ago and has since accelerated. One quarter of all species (n = 498) moved one or more categories closer to extinction globally, while almost half of the species moved closer to extinction in Southeast Asia. The conservation status of some species improved (toward less threatened categories), but for each species that improved in status 8 deteriorated. The status of large-bodied species, particularly those above 100 kg (including many iconic taxa), deteriorated significantly more than small-bodied species (below 10 kg). The trends we found are likely related to geopolitical events (such as the collapse of Soviet Union), international regulations (such as CITES), shifting cultural values, and natural resource exploitation (e.g., in Southeast Asia). Retrospective assessments of global species extinction risk reduce the risk of a shifting baseline syndrome, which can affect decisions on the desirable conservation status of species. Such assessments can help conservationists identify which conservation policies and strategies are or are not helping safeguard biodiversity and thus can improve future strategies.

Allele-specific loss and transcription of the miR-15a/16-1 cluster in chronic lymphocytic leukemia

Deregulation of the miR-15a/16-1 cluster has a key role in the pathogenesis of chronic lymphocytic leukemia (CLL), a clinically heterogeneous disease with indolent and aggressive forms. The miR-15a/16-1 locus is located at 13q14, the most frequently deleted region in CLL. Starting from functional investigations of a rare SNP upstream the miR cluster, we identified a novel allele-specific mechanism that exploits a cryptic activator region to recruit the RNA polymerase III for miR-15a/16-1 transcription. This regulation of the miR-15a/16- locus is independent of the DLEU2 host gene, which is often transcribed monoallellically by RPII. We found that normally one allele of miR-15a/16-1 is transcribed by RNAPII, the other one by RNAPIII. In our subset of CLL patients harboring 13q14 deletions, exclusive RNA polymerase III (RPIII)-driven transcription of the miR-15a/16-1 was the consequence of loss of the RPII-regulated allele and correlated with high expression of the poor prognostic marker ZAP70 (P=0.019). Thus, our findings point to a novel biological process, characterized by double allele-specific transcriptional regulation of the miR-15a/16-1 locus by alternative mechanisms. Differential usage of these mechanisms may distinguish at onset aggressive from indolent forms of CLL. This provides a basis for the clinical heterogeneity of the CLL patients carrying 13q14 deletions.

Effects of errors and gaps in spatial data sets on assessment of conservation progress

Data on the location and extent of protected areas, ecosystems, and species' distributions are essential for determining gaps in biodiversity protection and identifying future conservation priorities. However, these data sets always come with errors in the maps and associated metadata. Errors are often overlooked in conservation studies, despite their potential negative effects on the reported extent of protection of species and ecosystems. We used 3 case studies to illustrate the implications of 3 sources of errors in reporting progress toward conservation objectives: protected areas with unknown boundaries that are replaced by buffered centroids, propagation of multiple errors in spatial data, and incomplete protected-area data sets. As of 2010, the frequency of protected areas with unknown boundaries in the World Database on Protected Areas (WDPA) caused the estimated extent of protection of 37.1% of the terrestrial Neotropical mammals to be overestimated by an average 402.8% and of 62.6% of species to be underestimated by an average 10.9%. Estimated level of protection of the world's coral reefs was 25% higher when using recent finer-resolution data on coral reefs as opposed to globally available coarse-resolution data. Accounting for additional data sets not yet incorporated into WDPA contributed up to 6.7% of additional protection to marine ecosystems in the Philippines. We suggest ways for data providers to reduce the errors in spatial and ancillary data and ways for data users to mitigate the effects of these errors on biodiversity assessments.

Long-term benefits and adverse effects of intermittent versus daily glucocorticoids in boys with Duchenne muscular dystrophy

OBJECTIVE

To assess the current use of glucocorticoids (GCs) in Duchenne muscular dystrophy in the UK, and compare the benefits and the adverse events of daily versus intermittent prednisolone regimens.

DESIGN

A prospective longitudinal observational study across 17 neuromuscular centres in the UK of 360 boys aged 3-15 years with confirmed Duchenne muscular dystrophy who were treated with daily or intermittent (10 days on/10 days off) prednisolone for a mean duration of treatment of 4 years.

RESULTS

The median loss of ambulation was 12 years in intermittent and 14.5 years in daily treatment; the HR for intermittent treatment was 1.57 (95% CI 0.87 to 2.82). A fitted multilevel model comparing the intermittent and daily regiments for the NorthStar Ambulatory Assessment demonstrated a divergence after 7 years of age, with boys on an intermittent regimen declining faster (p<0.001). Moderate to severe side effects were more commonly reported and observed in the daily regimen, including Cushingoid features, adverse behavioural events and hypertension. Body mass index mean z score was higher in the daily regimen (1.99, 95% CI 1.79 to 2.19) than in the intermittent regimen (1.51, 95% CI 1.27 to 1.75). Height restriction was more severe in the daily regimen (mean z score -1.77, 95% CI -1.79 to -2.19) than in the intermittent regimen (mean z score -0.70, 95% CI -0.90 to -0.49).

CONCLUSIONS

Our study provides a framework for providing information to patients with Duchenne muscular dystrophy and their families when introducing GC therapy. The study also highlights the importance of collecting longitudinal natural history data on patients treated according to standardised protocols, and clearly identifies the benefits and the side-effect profile of two treatment regimens, which will help with informed choices and implementation of targeted surveillance.

Effect of the serine proteases inhibitor gabexate mesylate (GM) on the activity of gemcitabine (G) in cell lines of pancreatic cancer (PC)

e15645

Background: Negligible advances for PC treatment have been done over the last decade and G remains the standard. Proteolitic degradation of extracellular matrix (ECM) is essential for early local invasion, metastasis and desmoplastic reaction characterizing PC. Differently from MMPs, the serine proteases (uPA and TAT) action is earlier and larger, degradating not only ECM, but also basement membrane, and activating trypsin, plasmin, angiogenesis via TGF-β1 and proliferation via PAR-2. GM is an inhibitor of u-PA,TAT, trypsin and plasmin, used in Italy and Japan for prophylaxis of acute pancreatitis after ERCP. In a previous study, GM demonstrated antinvasion and antimetastatic activity. Study aim: to evaluate if GM increases G efficacy on pancreatic cancer cell line. Methods: In vitro study of phenotypic effects of GM and G in poor differentiated PANC-1 PC cell line using:1) Cell vitality test (Trypan blu);2) Invasion test (Matrigel invasion assay);3) Cell cycle analysis (cytofluorimeter);4) Antiangiogenic test (tube formation assay in extracellular matrix using E.A.hy926 endothelial cells with matrigel). Different doses of G and GM (100,200,250,500 μM;1mM) alone or combined (concomitant or sequential) have been tested vs controls (PANC-1 without any treatment). All tests have been done in triplicate. Results: G alone (250 μM) decreases invasion by 40% (±5,6%) and cell vitality by 15% (±1,3%.). GM alone (100 μM) decreases invasion by 30% (±4,6%.) but 1mM is needed for similar vitality decrease. GM+G together are detrimental vs G alone while sequential treatment (GM before G with or without 24 hours of interval) enhances G activity. GM (200 μM) and G (250 μM) in immediate sequence show better results decreasing ability of invasion by 75% (±8,3%). Cell vitality is better inhibited from GM (100)/G (250) 24 h-delayed sequence by 28% (±3,8%). Combined treatment mainly blocks cells in G1 phase of cell cycle (5%±0,5%) vs controls. Concerning antiangiogenic assay, the administration of G alone is ineffective to inhibit angiogenesis, while pre-treatment with GM results in a strong anti-angiogenic effect. Conclusions: Association of GM to G could represent a new effective approach to inhibit invasion, angiogenesis and growth in pancreatic cancer.

No significant financial relationships to disclose.

[Educational campaign targeting high school smokers]

The problem of smoking among young people continues to be a major health problem. In this study, high school students from the provinces of Rimini and Ravenna were invited to take the carbon monoxide test, in order to investigate the main reasons behind their smoking behaviour and to analyse attitudes towards changing the habit. The initiative involved 288 students: 56% males and 44% females aged between 14 and 20. The average daily consumption of cigarettes was 7.9 for the 14-17 age range, and 8.5 for the older group; the average age of starting smoking was 14.6 years. The consumption was seen to rise in both sexes at the weekend among those who smoked more than 10 cigarettes a day. The main reasons for smoking were relaxation and pleasure; the females were more addicted to cigarettes and to the rituals surrounding the habit. Although the students were aware of the risks involved in smoking, only 15% intended to quit. This confirms that awareness of the dangers alone is not sufficient to break the habit. Once again the school environment appears to be the most suitable place to meet young people in order to establish and assess their needs, and to set up programs of health promotion and education.

GEMOX as first-line chemotherapy in advanced pancreatic cancer (APC): A monoinstitutional experience

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Background: To date, gemcitabine (GEM) remains the cornerstone of chemotherapy (CHT) for APC. According to GERCOR and GISCAD phase III trials the combination of GEM and oxaliplatin (GEMOX) has proven superior to GEM alone in terms of response rate (RR), time to progression (TTP) and clinical benefit rate (CBR). Methods: We conducted a retrospective analysis on 19 patients (pts) affected with histologically-confirmed APC, in order to determine the impact of GEMOX as first-line chemotherapy in terms of objective responses (OR) and TTP, using the Kaplan-Meier method. Among the 19 pts considered there were 15 males and 4 females (median age at diagnosis of 60.84 yrs; ECOG 0–2). The staging, according to AJCC criteria, was: IIB in 1 case, III in 5 cases and IV in the 13 remaning cases. The only metastatic site was the liver (in 13/19 pts). Ten of the 19 pts underwent surgical treatment prior to CHT: 2 radically resected (R0) subsequently treated with GEMOX after recurrence, 4 with positive margins (R1) and 4 surgically palliated. All pts received GEM 1000 mg/m2/d1 + oxaliplatin 100 mg/m2/d2 every 2 weeks. The median number of cycles was 5.89. Results: Among the 19 pts, 3 had a partial response (PR, 15.69%), 6 had stable disease (SD, 31.57%); no complete response was observed and 10 pts had progressive disease (PD, 52.63%). The overall disease control rate (DCR: PR + SD) was 47.37% while the OR were 15.69%. The median survival observed was 9.03 months (95% C.I. 5.15–12.91) and the median TTP was 6.13 months (95% C.I. 2.81–9.46). The main toxicities were: leucopenia, piastrinopenia, diarrhoea, nausea, fever and peripheral neuropathy; 3 pts discontinued the treatment due to grade 3–4 neurotoxicity. Conclusions: In our experience GEMOX gives an improved control of APC in terms of OR and TTP, with acceptable toxicity. The OS is in accordance to literature as well as the other data.

No significant financial relationships to disclose.

Comparative bioavailability of a generic capsule formulation of the reverse transcriptase inhibitor efavirenz and the innovator product

OBJECTIVE

Efavirenz is a non-nucleoside reverse transcriptase inhibitor (NNRTI) that has been used successfully for more than a decade to treat human immunodeficiency virus (HIV) infection. The objective of the current study was to determine the bioequivalence between a generic capsule formulation of efavirenz and the innovator product.

MATERIAL AND METHODS

A total of 41 healthy subjects (34 males and 8 females) received a single 200 mg oral dose of efavirenz as the generic (Ranbaxy-Efavirenz, Ranbaxy Laboratories Ltd.) and innovator (Sustiva, Bristol-Myers Squibb) capsule formulations under fasting conditions in a randomized, 2-way crossover study. Multiple blood samples were collected over 72 hours and plasma concentrations of efavirenz were assayed using an LC/MS/MS method. Pharmacokinetic (PK) parameters were calculated using non-compartmental methods.

RESULTS

Plasma concentrations of efavirenz peaked within 2.5 hours and then declined in a multi-exponential manner for both formulations. At 72 hours post dose, all plasma concentrations of efavirenz were above the LOQ of the assay (10 ng/ml). Mean area under the curve from 0 - 72 hours (AUC0-72) and maximum plasma concentrations (Cmax) of efavirenz for the generic capsule formulation were 22,840 ng x h/ml and 1,199 ng/ml, respectively. Ratios and 90% confidence intervals of PK parameters between the two formulations were within 80.0 - 125.0%, suggesting that the two capsule formulations resulted in similar rate and extent of bioavailability under fasting conditions. Adverse events were similar in nature and frequency for the two formulations.

CONCLUSIONS

Based on the above results, the generic capsule formulation of efavirenz developed by Ranbaxy should be as effective as the innovator product.

Direct dark matter search using large-mass superheated droplet detectors in the PICASSO experiment

The PICASSO experiment investigates the presence and nature of dark matter in the Universe. The experiment is based on the detection of acoustic signals generated in explosive phase transitions induced by dark matter particles. This technique is an alternative more traditional detection technique like scintillation and ionisation, which are largely employed for dark matter search. One of the main advantages of this technique, besides its sensitivity to very low nuclear recoil energies (few keV), is its excellent background suppression features. A pilot experiment consisting of six superheated droplet detectors (40 g of active mass) is presently taking data at the Sudbury Neutrino Observatory (SNO) at a depth of 2000 m. We discuss the operation, calibration and data acquisition of the experiment and also the ongoing work to increase the sensitivity and the active mass of the detectors.