Favorable experience of transplant strategy including liver grafts from COVID-19 donors: One-year follow-up results

BACKGROUND

Since November 2020, Italy was the first country to carry out a protocol and use liver from COVID-19 donors. We aimed to evaluate the medium-term outcome of patients who underwent liver transplant (LT) with those grafts.

METHODS

We consecutively enrolled 283 patients who underwent first LT from November 2020 to December 2022 in our Center (follow-up 468 days). Twenty-five of 283 (8.8%, study population) received a graft from donors with previous (4%) or active (96%) SARS-CoV-2 infection, and 258/283 (91.2%, control group) received a graft from COVID-19-negative donors. SARS-CoV-2-RNA was tested on graft tissue of COVID-19 donors and their recipients underwent weekly evaluation of SARS-CoV-2-RNA in nasal swabs for the first month after LT.

RESULTS

One-year and 2-year patient survival was 88.5% and 88.5% in study group versus 94.5% and 93.5% in control group, respectively (p = .531). In study population there was no evidence of donor-recipient virus transmission, but three (12%) patients (vs. 7 [2.7%] of control group, p = .048) developed hepatic artery thrombosis (HAT): they were SARS-CoV-2-RNA negative at LT and 1/3 grafts tested SARS-CoV-2-RNA positive on liver tissue. COVID-19 donor was independently associated with HAT (odds ratio (OR) = 4.85, 95% confidence interval (CI) 1.10-19.15; p = .037). By comparing study population with control group, acute rejection and biliary complication rates were not significantly different (16% vs. 8.1%, p = .26; 16% vs. 16.3% p = .99, respectively).

CONCLUSIONS

Our 1-year results of transplant strategy including liver grafts from COVID-19 donors were favorable. HAT was the only complication with significantly higher rate in patients transplanted with COVID-19 donors compared with control group.

Early post-liver transplant use of direct-acting antivirals in naive and NS5A inhibitor-experienced HCV patients

Direct-acting antiviral drugs (DAA) are safe and effective in the HCV population. However, in patients with decompensated cirrhosis and/or active hepatocellular carcinoma or relapse to NS5A inhibitors, response rates are lower and DAA therapy must be postponed until after liver transplant in an era of organ shortage and suboptimal donors. We aimed to assess the prevalence of patients still HCV infected at time of transplantation over the last 3 years in our Center and describe the safety and efficacy of DAA therapy started as soon as possible after surgery. We enrolled all HCV viraemic patients transplanted in our Centre from January 2019 to March 2022. The follow-up was closed in July 2022. Among 490 liver transplants, 49 (10%) patients were still HCV viraemic at operation, 43 naive to DAA and 6 were NS5A-experienced. Median donor age was 64 years; donor risk index was 1.8. In naive patients, sofosbuvir/velpatasvir was started after a median time of 1 day from surgery, while in NS5A-experienced sofosbuvir/velpatasvir/voxilaprevir after 14.5 days (p = .001). Response rate was 98%. 1 NS5A-experienced patient experienced acute cholestatic hepatitis which promptly reverted after permanent DAA discontinuation. Hence, very early post-liver transplant HCV eradication was safe and effective thanks to a close teamwork which involved anaesthesiologists, transplant surgeons and hepatologists.

Medium-term outcome of liver recipients from COVID-19 donors

Background

COVID-19 is associated with thrombotic complications and can result in hepatobiliary injury. Excellent early outcomes have been reported in recipients of solid non-lungs organs from SARS-CoV-2-infected donors, however longer follow-up data are lacking. We aimed to describe the medium-term outcome of our liver transplants (LT) from COVID-19 donors.

Methods

From 11/2020 to 03/2022, we consecutively enrolled all patients who received a graft from COVID-19 donor in our Centre. Protocol liver biopsy and magnetic resonance cholangiopancreatography (MRCP) after 1-year from LT were reported.

Results

In the study period 12/213 (5.6%) adult LT patients received a COVID-19 donor (11 active, 1 resolved COVID-19)¹. Eleven patients underwent end-to-end biliary anastomosis and 1 biliodigestive anastomosis. Recipients’ and donors’ characteristics are reported in table 1. Two recipients tested SARS-CoV-2 RNA positive on nasopharyngeal swab at LT and one was treated with sotrovimab on day-1 after LT. None of the patients developed COVID-19 after LT. One patient underwent hepatic artery thrombectomy at day-1 and died after 320 days for HCC recurrence. Until now: -10 patients underwent protocol MRCP (median time from LT 562 days, IQR 245-614), which showed: 7 no visible abnormalities, 1 donor-recipient's bile duct size discrepancy, 2 caliber changes <50% at the anastomotic level (untreated for the absence of cholestasis); -7 patients underwent protocol liver biopsy (median time from LT 553 days, IQR 311-557) which showed 1 acute cellular rejection (RAI 4/9) successfully treated with steroids; no signs of fibrosis, rejection or biliopathy in the other 6 patients.

Conclusions

11/12 patients who received a LT from COVID-19 donors are alive, without evidence of SARS-CoV-2 transmission. At a median follow-up of 1.5 years, protocol liver biopsy and MRCP did not show biliopathy, supporting the utilization of COVID-19 donors to expand the donor pool and reduce the waiting list mortality.

Seroconversion After Coronavirus Disease 2019 Vaccination in Patients Awaiting Liver Transplantation: Fact or Fancy?

Chronic liver disease increased the risk of severe coronavirus disease 2019 (COVID-19). Trials to assess efficacy/safety of COVID-19 vaccines in liver disease are underway. We evaluated the humoral immune response and safety of anti-COVID-19 vaccination among patients waiting liver transplantation (LT). We enrolled all pre-LT adults who completed anti-COVID-19 vaccination between January 2021-August 2021 as study group. Patients with histories of COVID-19 received 1 vaccine dose, and all others received 2 doses. Patients were tested for COVID-19 immunoglobulin G (IgG) within 1 and 2 months after vaccination. Safety was evaluated with telephone interviews/outpatient visits. A control group of 30 healthcare workers who underwent vaccination in January 2021 and tested for IgG after 4 months was included. In the 89 pre-LT patients, at T1 (23 days after vaccination), seroconversion rate was 94.4%, and median IgG value was 1980 binding antibody units/mL (interquartile range 646-2080), and at T2 (68 days after vaccination) was 92.0%, with IgG value of 1450 (577-2080); (T1 versus T2, P = 0.38). In the 10/89 patients who received 1 vaccine dose, the median IgG value was 274 (68-548) before vaccine (T0), 2080 (1165-2080) at T1, and 2030 (964-2080) at T2 (T0 versus T1, P = 0.03; T1 versus T2, P = 0.99). All controls tested positive at 4 months after vaccination, with a median value of 847 (509-1165; P < 0.001 versus T1 and P = 0.04 versus T2 in the study group). No serious adverse event was reported in both groups. Our data from 89 pre-LT patients suggest a high rate of immunization (94.4%) after a median time of 23 days from safe COVID-19 vaccine. None of the patients developed COVID-19.

Liver transplantation from active COVID-19 donors: A lifesaving opportunity worth grasping?

COVID-19 pandemic dramatically impacted transplantation landscape. Scientific societies recommend against the use of donors with active SARS-CoV-2 infection. Italian Transplant Authority recommended to test recipients/donors for SARS-CoV-2-RNA immediately before liver transplant (LT) and, starting from November 2020, grafts from deceased donors with active SARS-CoV-2 infection were allowed to be considered for urgent-need transplant candidates with active/resolved COVID-19. We present the results of the first 10 LTs with active COVID-19 donors within an Italian multicenter series. Only two recipients had a positive molecular test at LT and one of them remained positive up to 21 days post-LT. None of the other eight recipients was found to be SARS-CoV-2 positive during follow-up. IgG against SARS-CoV-2 at LT were positive in 80% (8/10) of recipients, and 71% (5/7) showed neutralizing antibodies, expression of protective immunity related to recent COVID-19. In addition, testing for SARS-CoV-2 RNA on donors' liver biopsy at transplantation was negative in 100% (9/9), suggesting a very low risk of transmission with LT. Immunosuppression regimen remained unchanged, according to standard protocol. Despite the small number of cases, these data suggest that transplanting livers from donors with active COVID-19 in informed candidates with SARS-CoV-2 immunity, might contribute to safely increase the donor pool.

Gastroesophageal reflux disease: key messages for clinicians

Gastroesophageal reflux disease (GERD) is a chronic common disorder for which patients often refer to specialists. In the last decades, numerous studies helped to clarify the pathophysiology and the natural history of this disease. Currently, in the clinical setting, GERD is defined by the presence of symptoms that, when endoscopic investigation is required, permit to distinguish between cases with or without associated esophageal mucosal injuries. These conditions are called erosive reflux disease and non-erosive reflux disease (NERD), respectively. The latter is the most common manifestation of GERD. Symptoms are defined typical, as heartburn and regurgitation, and atypical (also called extra-esophageal), as coughing and/or wheezing, hoarseness, sore throat, otitis media, and dental manifestations. In this context, it is crucial for clinicians to investigate the presence of features of suspected malignancy, as unexplained weight loss, anemia, dysphagia, persistent vomiting, familiar history of cancer, long history of GERD, and beginning of GERD symptoms after the age of 50 years. The presence of these risk factors should induce to perform an endoscopic examination. Particular attention should be given to functional conditions that can mimic GERD, such as functional heartburn and hypersensitive esophagus as well as, more rarely, eosinophilic esophagitis. The former ones have different pathophysiology and this explains the frequent non-response to proton pump inhibitor drugs. This narrative review provides to clinicians a useful and practical overview of the state-of-the-art on advancements in the knowledge of GERD.

Gastro-esophageal reflux disease: Key messages for clinicians

Gastroesophageal reflux disease (GERD) is a chronic common disorder for which patients often refer to specialists. In the last decades, numerous studies helped to clarify the pathophysiology and the natural history of this disease. Currently, in the clinical setting, GERD is defined by the presence of symptoms that, when endoscopic investigation is required, permit to distinguish between cases with or without associated esophageal mucosal injuries. These conditions are called erosive reflux disease and non-erosive reflux disease (NERD), respectively. The latter is the most common manifestation of GERD. Symptoms are defined typical, as heartburn and regurgitation, and atypical (also called extra-esophageal), as coughing and/or wheezing, hoarseness, sore throat, otitis media, and dental manifestations. In this context, it is crucial for clinicians to investigate the presence of features of suspected malignancy, as unexplained weight loss, anemia, dysphagia, persistent vomiting, familiar history of cancer, long history of GERD, and beginning of GERD symptoms after the age of 50 years. The presence of these risk factors should induce to perform an endoscopic examination. Particular attention should be given to functional conditions that can mimic GERD, such as functional heartburn and hypersensitive esophagus as well as, more rarely, eosinophilic esophagitis. The former ones have different pathophysiology and this explains the frequent non-response to proton pump inhibitor drugs. This narrative review provides to clinicians a useful and practical overview of the state-of-the-art on advancements in the knowledge of GERD.

Innovations in prevention of infections in oncological megaprostheses: a narrative review

Infection is a significant complication in oncological megaprostheses. The purpose of our study is to indagate the innovations and new trend about the prevention of infection in this kind of surgery. The research focused on the use of antimicrobic prophylaxis, the defensive antibacterial coating and the use of silver coated.

The effects of collagenase of Clostridium Histolitycum (CCH) in Dupuytren's disease: a histological study on cell mediated mechanisms that allow enzymatic fasciotomy

Dupuytren Disease is a benign fibromatosis of palmar fascia of the hand, whose pathophysiology is not completely understood. The present study is intended to provide a description of the effects of Collagenase of Clostridium Hystoliticum (CCH) into an injected cord of Dupuytren. Our experimental study wanted to evaluate the histological effects of injection of CCH in the first 24 hours, without manipulating the specimens.

MATERIALS AND METHODS

Surgical specimens were injected with CCH, and then fixed in formalin every six hours, up to 24 hours. Those specimens were compared to control specimen (non-injected), fixed and analyzed at the same times.

RESULTS

In the injected specimens, the number of CD68 positive cells increased into and outside the cords compared to non injected specimens, within the same time from the surgical removal.

CONCLUSION

CCH has a proinflammatory activity and provokes a short ray chemotactic action on white blood cells. The lysis of the cord induced by CCH stimulates the inflammatory response. The role of the inflammatory infiltration deserves to be investigated in a more accurate way, preferably by using in vivo studies.

Use of ceramic bearings in hip arthroplasty: correct implantation and review of clinical and radiographic results

Ceramic materials are widely used in hip prosthetic surgery. Faced with important developments in the design and characteristics of the materials, ceramic-on-ceramic (CoC) are today the bearings in Total Hip Replacement (THR) showing the minimal wear rate. Moreover, ceramic wear debris demonstrated the absence of local and systemic toxicity. This makes ceramic bearing particularly suitable for active patients, whatever their age. The results show excellent survival rates of THRs with ceramic components and excellent clinical and radiographic scores with follow-up close to 20 years. However, the excellent outcomes of THRs with ceramic bearings are depending on appropriate and correctly performed surgical technique.

AB0241 PREVALENCE OF ANXIOUS SYMPTOMS AND DEPRESSION IN A SAMPLE OF PATIENTS WITH RHEUMATOID ARTHRITIS (RA) AND OTHER CHRONIC RHEUMATIC DISEASES

Background:

Clinical practice with patients suffering from chronic diseases highlights the presence of psychological symptoms of discomfort fed by biological and non-biological mechanisms linked to disease and treatment. In rheumatic diseases, literature detects the presence of anxious symptoms and depressed mood of clinical and sub-clinical importance with a multifactorial genesis1.

Objectives:

To detect the impact on the state of health of anxious symptoms and depressed mood in a population suffering from RA and other rheumatic diseases in order to implement the effectiveness of psychological intervention through the selection of patients who present critical levels of discomfort.

Methods:

Patients afferent to the Rheumatology outpatient clinic of Mauriziano Hospital have been screened from May 2018 to July 2018 with two self-administered questionnaires: HADS-A and HADS-D (Hospital Anxiety and Depression Scale), specifically developed for the evaluation of anxious and depressive symptoms in medical pathologies, and HAQ (Health Assessment Questionnaire) to explore functional disability. Data about rheumatic diagnosis and socio-demographic characteristics were also collected. Data were analyzed with descriptive statistics; the Student Test and the ANOVA test were used to evaluate prevalence and to compare the presentation of symptoms in the different diseases and the Pearson correlation coefficient was used to evaluate the relationship between symptoms and disability.

Results:

A total of 427 subjects were screened (317 females and 110 males), aged between 19 and 90 years (mean 60 ± 14 yrs). 156 subjects (36.5%) had a diagnosis of RA, 76 (17.8%) of psoriatic arthritis, 42 (9.8%) of ankylosing spondylitis, 14 (3.3%) of systemic lupus erythematosus and 139 (32.6%) of other rheumatic diseases (including Sjogren, osteoarthritis, fibromyalgia).

A high prevalence of anxious symptoms and depressed mood has been found and the number of subjects reporting scores indicating a clinically relevant uncomfortable situation (HADS ≥ 11) was also relevant (Table 1); an increased prevalence in female patients was observed. There were no differences in the presentation of symptoms between RA and the other included pathologies (Table 2).

Table 1.

Prevalence of anxiety and depression according to the HADS questionnaire in rheumatic diseases

MeanSDHADS-A7.564.63HADS-D7.124.59HADS-A ScoreN%0-722452.47-108419.711-2111927.9HADS-D ScoreN%0-723154.17-109221.511-2110424.4Table 2.

Comparison between RA and other rheumatic diseases in anxiety and depression symptoms presentation (ANOVA test).

NMeanSDSECIHADS-ARA1562.345.200.411.52PsA762.304.470.511.28AS421.513.190.490.51SLE141.773.741.00-0.38other1392.465.080.431.61HADS-DRA1561.743.510.281.19PsA762.034.210.481.07AS420.690.540.080.52SLE140.930.680.180.54other1391.683.790.321.04

There was a positive and significant correlation between anxious symptoms or depressed mood and functional disability (0.49 and 0.60 respectively, p<0,01).

Conclusion:

The results show a significant presence of uncomfortable situations that could evolve in a psychopathological sense. The discomfort expressed through anxious and depressive symptoms is related to the level of functional disability. Recognizing the presence of psychological distress allows to orient the treatment plan and facilitate the patient’s adaptation to the disease condition.

References:

[1]Geenen R. et al. Best Pract Res Clin Rheumatol. 2012;26(3):305-19.

Disclosure of Interests:

Gloria Crepaldi Consultant of: Advisory board for Sanofi and Celgene, Speakers bureau: BMS, MSD, Mariarosaria Voci: None declared, Marta Saracco: None declared, Antonella Laezza: None declared, Paolo Santino: None declared, Maddalena Marcato: None declared, Guido Rovera: None declared, Claudia Lomater Consultant of: Advisory board for Sanofi, Novartis, Abbvie

OP0063 QUANTITATIVE COMPUTED TOMOGRAPHY PREDICTS 10-YEAR MORTALITY IN INTERSTITIAL LUNG DISEASE RELATED TO SYSTEMIC SCLEROSIS

Background:

Interstitial lung disease (ILD) is the main cause of death in Systemic Sclerosis (SSc). Chest CT is the gold standard in detecting ILD although it is not easy to understand its prognostic value. ILD qualitative assessment is almost worthless. Goh et al. semi quantitative score of ILD extent is related to mortality risk but it is burdened by relevant inter/intra-readers variability. An operator independent algorithm based on voxel-wise analysis proved to identify SSc patients with an increased risk of mortality according to prediction models.

Objectives:

To verify if quantitative analysis of chest CT (QCT) predict 10 years-mortality in SSc patients.

Methods:

SSc patients with availability of a chest CT were enrolled in 13 different centers. The CT voxel-wise analysis with a free software (www.horosproject.com) provided QCT indexes: kurtosis, skewness, mean lung attenuation and standard deviation. Patients characteristics, autoimmune profile and pulmonary function test were collected. The follow-up interval lasted from the date of chest CT to the one of the last visit or death. Each QCT index cutoff, established in a previous study (1), clustered patients in two groups. Kaplan-Meier analysis estimated and compared survival in the above mentioned groups. p < 0.05 was considered statistically significant.

Results:

Five hundred sixty three SSc patients were enrolled (35938 patient-months); 52.4% had ILD detectable at CT scan. For each QCT index cutoff the cohort was split in two subgroups without differences in terms of sex, age, disease duration, autoimmune profile. All QCT indexes’ cutoff selected subgroups with statistically different survival rate (e.g in Figure 1).

Figure 1

Conclusion:

QCT can arise as the new gold standard in identifying SSc patients with poor prognosis. The real possibility to stratify SSc subjects according mortality risk will have a pivotal role in ILD treatment decisional process with the incoming anti-fibrotic drugs.

References:

[1]Ariani A et al. Rheumatology 2017

Disclosure of Interests:

Alarico Ariani: None declared, Elena Bravi: None declared, Maria De Santis: None declared, Vanessa Hax: None declared, Simone Parisi: None declared, Federica Lumetti: None declared, Francesco Girelli: None declared, Marta Saracco: None declared, Fabio De Gennaro: None declared, Alessandro Giollo: None declared, Masen Abdel Jaber: None declared, Francesco Bozzao: None declared, Mario Silva: None declared, Maria Chiara Ditto: None declared, Claudia Lomater: None declared, Flavio Mozzani: None declared, Daniele Santilli: None declared, eleonora Di Donato: None declared, Andrea Becciolini Speakers bureau: Sanofi-Genzyme, UCB and AbbVie, Francesco Pucciarini: None declared, Lorenzo Canziani: None declared, Flavio Cesare Bodini: None declared, eugenio arrigoni: None declared, M Bredemeier: None declared, Rafael Mendonça da Silva Chakr: None declared, Amelia Spinella: None declared, Luca Idolazzi: None declared, Roberto Bortolotti: None declared, Paola Tomietto: None declared, Elisa Baratella: None declared, Saverio Tollot: None declared, Dilia Giuggioli: None declared, Fabio Fischetti: None declared, Enrico Fusaro: None declared, Nicola Sverzellati: None declared, Carlo Alberto Scirè: None declared

High anti-TNF alfa drugs trough levels are not associated with the occurrence of adverse events in patients with inflammatory bowel disease

Objectives: Up to 40% of inflammatory bowel disease (IBD) patients treated with anti-TNF drugs lose response within 1 year of treatment, therefore requiring drug optimization. Although higher drug trough levels (TLs) are associated with sustained clinical outcomes, there are concerns that they may be associated with a higher risk of adverse events (AEs). The aim was to evaluate the presence of a possible association between drug TLs and the occurrence of AEs in IBD patients treated with anti-TNF drugs.Methods: We retrospectively studied a cohort of 113 IBD patients treated with adalimumab or infliximab, of whom 27 were in combination therapy with immunosuppressants. TLs were measured using a homogeneous mobility shift assay.Results: During a median follow-up of 16 months (range 1-144), we observed 103 AEs occurring in 58 patients. We found no statistically significant difference (p = .21) in median TLs between patients who did 6.7 mcg/mL; range 0.0-36.2) or did not (7.7 mcg/mL; range 0.0-20.7) experience an AE. No difference was observed in the rate of AEs between patients in mono- or combination therapy (p = .38), as well as between elderly (i.e., >65 years) and younger patients (p = .32). Considering a TL cutoff of 7 mcg/mL for infliximab and 12 mcg/mL for adalimumab, or even double these TL values, we observed no statistically significant difference in the rate of AEs occurrence.Conclusion: Our study suggests that, when clinically required, anti-TNF drug dosage may be increased without particular concerns regarding the risk of AEs occurrence in IBD patients, even in patients on combination therapy and elderly ones.

Risk factors for failure of two-stage revision arthroplasty for infected hip prosthesis: review of the literature and single centre cohort analysis

OBJECTIVE

Periprosthetic joint infections (PJI) are one of the most dangerous complications in hip surgery. "Two-stage" revision surgery is the treatment of choice. Nevertheless, 5-10% of failures are reported. The aim of this study is to evaluate which factors determine the failure of the two-stage revision in patients affected by hip PJI.

PATIENTS AND METHODS

We retrospectively enrolled 21 patients treated for hip PJI who had undergone two-stage revision surgery. The diagnosis had been made using criteria established by the Musculoskeletal Infection Society (MSIS) and readapted by the Philadelphia Consensus Conference group. The patients underwent periodic clinical and laboratory controls after the surgical procedure. The two-stage revision treatment was considered unsuccessful in the event of re-infection or in case of severe complications occurring within one year from the treatment.

RESULTS

At a mean follow-up of 23.8 months 57% healed with no complications. The reinfection rate was 19% and, after the 3rd stage, the final failure rate was 9.5%. The study has shown, with statistical significance, that a greater number of previous surgical procedures (p<0.05, OR=22) and BMI>25 (p<0.05, OR=4) represent increased risk factors in predicting the failure of two-stage revision surgery. Age, CRP, ESR and a shorter lapse (<60 days) between 1st and 2nd stage were recorded in the failure cases, and have to be considered, even if not statistically significant.

CONCLUSIONS

Knowing the factors responsible for the increased failure of two-stage revision could lead to closer monitoring and more aggressive management in those patients expected to be at greater risk of reinfection. Obesity and multiple surgeries are risk factors for failure.

Arthroscopy in osteochondral pathology of the elbow: indications, treatment and complications

The arthroscopic technique has revolutionized orthopaedic surgery in the last forty years, due to the improvement in surgical technique and innovations in technologies. Actually, knee and shoulder arthroscopy are commonly used to treat the most frequent pathologies with mini-invasive approaches demonstrate recovery of function and outcomes. Not the same thing can be said for other joints such as ankle, elbow and hip, where the narrowness of the space makes the technique more challenging. In this study, a brief review of the literature and the history of elbow arthroscopy are described. Indications, surgical technique, risks and complication, tip and tricks, advices and notes to avoid complications are reported. Elbow arthroscopic surgery is a difficult technique that requires a long learning curve, but in an experienced surgeon's hands, it is a safe and successful methodology when applied with correct indications and cautions.

Study on the possible role of the -174G>C IL-6 promoter polymorphism in predicting response to rituximab in rheumatoid arthritis

OBJECTIVE

Identification of genetic biomarkers of response to biologics in rheumatoid arthritis (RA) is a relevant issue. The -174G>C interleukin-6 (IL-6) promoter polymorphism was investigated in RA patients treated with rituximab (RTX), being IL-6 a key cytokine for B cell survival and proliferation, thus possibly implicated in rituximab efficacy.

METHODS

The study was conducted in a real-life retrospective cohort of 142 unselected RA patients (120F/22M) treated with RTX and referred to 7 rheumatologic centres in the north of Italy. One hundred and thirteen (79.6%) patients were rheumatoid factor (RF)-positive and 112 (78.9%) were anti-CCP antibodies positive. The response to therapy was evaluated at the end of the sixth month after the first RTX infusion, by using both the EULAR criteria (DAS28) and the ACR criteria. The IL-6 -174G>C promoter polymorphism was analyzed by RFLP following previously reported methods.

RESULTS

Lack of response to RTX at month +6 by EULAR criteria was more prevalent in RA patients with the IL-6 -174 CC genotypes (9/21, 42.8%), than in the GC/GG patients (23/121, 19.0%) (OR 3.196, 95% CI=1.204-8.485; p=0.0234). Similar results were found when evaluating the response by ACR criteria. No differences were found in RA duration, baseline DAS28, baseline HAQ, RF status, anti-CCP status according to the different IL-6 -174 genotypes.

CONCLUSION

IL-6 promoter genotyping may be useful to better plan treatment with RTX in RA. Larger replication studies are in course to confirm these preliminary results.

[Rheumatoid factor positivity rather than anti-CCP positivity, a lower disability and a lower number of anti-TNFalpha agents failed are associated with response to rituximab in rheumatoid arthritis]

OBJECTIVE

Predictors of response to biologics in rheumatoid arthritis (RA) is an important issue in the current era. Rituximab (RTX) has been demonstrated effective and safe in active RA, resistant to traditional or biologic DMARDs.

METHODS

Fifty-seven patients with active longstanding RA were treated with RTX after traditional DMARD or anti-TNF alpha therapy failure.

RESULTS

Number of anti-TNF treatment previously failed (p=0.005), HAQ (p=0.013), rheumatoid factor (RF) (p=0.0002) and anti-CCP (p=0.006) were associated with an ACR response > or =50 at the end of 6th month by univariate analysis. Multivariate analysis confirmed that the number of anti-TNF previously failed, baseline HAQ and RF, but not anti-CCP were associated with an ACR response > or =50. EULAR moderate/good response was associated with ESR value (p=0.036), HAQ (p=0.032), and RF (p=0.01) by univariate analysis, while only RF positivity was associated with EULAR moderate/good response by multivariate analysis.

CONCLUSIONS

RF positivity rather than anti-CCP positivity is a predictor of response to RTX, suggesting that RF-positive patients with low disability may obtain a clinical response when treated to RTX after the first anti-TNF agent failure or after traditional DMARD therapies. Larger studies are required to confirm these results.

Detection of bovine viral diarrhea virus (BVDV) in seropositive cattle

Detection of bovine virus diarrhoea virus (BVDV) in one vaccinated beef cattle and three non-vaccinated dairy herds was investigated on peripheral blood leukocytes (PBL) with or without previous treatment followed by a capture ELISA (cELISA). Using the combination of PHA and polycation treatment, PBL from 229 seropositive cattle were studied and could be classified in four different states of BVDV infection. Lysed PBL from four animals were directly positive in cELISA (Category I), PBL of 17 animals were positive after PHA stimulation (Category II), 15 animals were positive only after PHA stimulation plus polycation treatment (Category III), while virus could not be detected in 193 seropositive cattle. Wild-type BVDV strains were isolated by co-culture on polycation-treated MDBK cells from 11 of these seropositive animals. BVDV antibodies of these same animals were able to neutralize their own virus, indicating that virus persists in PBL in spite of strain-specific antibodies. No apparent change of leukocyte subpopulations could be detected in any category of virus-positive animals. Thus, BVDV may be present in the PBL of some cattle, even in the presence of a specific active immune response.

A randomized, controlled, phase II trial comparing escalating doses of subcutaneous interleukin-2 plus antiretrovirals versus antiretrovirals alone in human immunodeficiency virus-infected patients with CD4+ cell counts >/=350/mm3

A total of 73 patients with baseline CD4+ cell counts >/=350 cells/mm3 who were receiving combination antiretroviral therapy (ART) were randomized to receive subcutaneous interleukin-2 (IL-2; n=36) in addition to ART or to continue ART alone (n=37). Subcutaneous IL-2 was delivered at 1 of 3 doses (1.5 million international units ¿MIU, 4.5 MIU, and 7.5 MIU per dose) by twice-daily injection for 5 consecutive days every 8 weeks. After 24 weeks, the time-weighted mean change from baseline CD4+ cell count was 210 cells/mm3 for recipients of subcutaneous IL-2, compared with 29 cells/mm3 for recipients of ART alone (P<.001). There were no significant differences between treatment groups for measures of plasma human immunodeficiency virus RNA (P=.851). Subcutaneous IL-2 delivered at doses of 4.5 MIU and 7.5 MIU resulted in significant increases in CD4+ cell count (P=.006 and P<.001, respectively), compared with that seen in control patients. These changes were not significant in the 1.5 MIU dose group compared with that in the control patients (P=.105). Side effects that occurred from subcutaneous IL-2 administration were generally low grade, of short duration, and readily managed in an outpatient environment.

Interactions of dendritic cells with fibronectin and endothelial cells

We studied the phenotypic characteristics of spontaneously migrated skin dendritic cells (sDC) and monocyte-derived dendritic cells (moDC), generated under different culture conditions, and their interactions with fibronectin (FN) and endothelial cells. Monocyte-derived dendritic cells were obtained after culturing monocytes with granulocyte-macrophage colony-stimulating factor (GM-CSF) (800 U/ml) and interleukin-4 (IL-4) (500 U/ml) with either 10% fetal bovine serum (FBS) or 10% allogeneic human serum (HS). Regardless of the type of serum used, the majority of moDC expressed human leucocyte antigen-DR (HLA-DR) and CD86. On day 5 of incubation, 20-67% of moDC cultured in the presence of HS (HS-moDC) expressed CD1a, b and c versus 94-97% when cultured in the presence of FBS (FBS-moDC). DC showed a differential gradient of adhesion to FN: FBS-moDC>HS-moDC>sDC approximately monocytes. Both FBS-moDC and HS-moDC were strongly positive for CD49e (alpha5-integrin) and CD29 (beta1-integrin) but negative for CD49d (alpha4-integrin). A monoclonal antibody (mAb) against CD49e blocked the adhesion of both types of moDC to FN. Although both FBS-moDC and HS-moDC attached to endothelium (a 76% and 63% increase, respectively), only HS-moDC were able to migrate through non-activated endothelium. Overall, these results suggest that spontaneously migrated sDC are less adherent to FN than moDC, that HS and FBS induce differences in CD1 expression, that HS-moDC are less adhesive to FN and endothelial cells but more motile than FBS-moDC, and that alpha5beta1-integrin is the molecule involved in moDC adhesion to FN.

Psychiatric symptoms in male cannabis users not using other illicit drugs

AIM

To assess the prevalence of DSM-III-R axes I and II disorders and the severity of psychiatric symptoms in cannabis users who did not use other illicit drugs.

DESIGN

Cross-sectional psychiatric examination of subjects with different patterns of cannabis use: cannabis dependence, abuse and occasional use.

PARTICIPANTS

One hundred and thirty-three cannabis users identified through random urine testing of draftees to the Italian army and interviewed after 2-5 days of abstinence from drug use.

MEASUREMENTS

The subjects completed the Beck Depression Inventory, the Spielberger State-Trait Anxiety Index and the 20-item revised Toronto Alexithymia Scale and were then interviewed with the Structured Clinical Interview for DSM-III-R.

FINDINGS

The prevalence of co-morbid psychiatric disorders varied with the pattern of cannabis use: 83% of subjects with DSM-III-R cannabis dependence, 46% of those with DSM-III-R cannabis abuse and 29% of occasional users received at least one DSM-III-R psychiatric diagnosis. The severity of depressive, anxious and alexithymic symptoms increased progressively with the degree of involvement with cannabis.

CONCLUSIONS

In this sample of young men, the risk of associated psychiatric disabilities varied with the pattern of cannabis use. Chronic use of cannabis was associated with a high prevalence of co-morbid psychiatric disorders.

[Diverticular disease and its treatment]

Diverticular disease of the colon is being seen with increasing frequency. Not infrequently, the first attack of diverticulitis may result in serious and potentially fatal complications. A period of observation and conservative management is necessary to determine the outcome of a particular attack. Approximately 30% of symptomatic patients require surgical intervention. Controversy still surrounds the appropriate operative approach to be employed in the management of diverticular disease, moreover when it presents with a complication. In general, resection is the procedure of choice for perforating diverticulitis. There is an emerging role for down-staging interventions in the recent literature; with few exception, there is no role for three-stages procedure for diverticular disease. In the setting of stage I or stage II disease (Hinchey classification) primary resection with anastomosis is safe and should be performed. Proximal colostomy formation may be carried out at the discretion of the surgeon if warranted by such local circumstances as contiguous inflammation or macroscopic contamination. For patients with stage III and stage IV disease endcolostomy with Hartmann closure of the rectum is the procedure of choice, although anastomosis with proximal stoma may prove to be an acceptable alternative. We reviewed the changing patterns in the operative treatment in 46 patients admitted to our Division for perforated diverticulitis. We performed the resection with anastomosis in 39 patients with perforation at the II stage; in 7 patients with generalized peritonitis (stage III-IV by Hinchey) we preferred Hartmann intervention in 4 cases and the three-stages procedure in 3 cases. We had no death at all. From 1979 to 1994 we noticed an increasing use of down-staging procedures.

Symptom profile, Axis II comorbidity and suicidal behaviour in young males with DSM-III-R depressive illnesses

We assessed the descriptive validity of DSM-III-R major depression (MDD), dysthymia (DD) and adjustment disorder with depressed mood (ADDM) by comparing the clinical profiles of 176 young male patients. The severity of depression increased progressively across the three diagnostic groups (ADDM < DD < MDD). Symptom presentation did not distinguish clearly between the diagnostic groups, even though somatic symptoms were more frequent among MDD patients. The prevalence of personality disorders was much higher (43%) among DD patients than among MDD (22%) and ADDM (15%) patients. The lifetime prevalence of suicide attempts differed in the three diagnostic groups (MDD 27%, DD 17%, ADDM 4%). Assessment of Axis II comorbidity and suicidal behavior can improve the diagnostic distinction between these DSM-III-R depressive illnesses.

[Acute biliary pancreatitis. Therapeutic approach]

Those forms of acute pancreatitis with a biliary etiology necessitate the choice of surgical techniques whose main objective is to obviate the cause of lithiasis and remove the necrotic and hemorrhagic areas of the gland. While probably overestimated from an epidemiological point of view, acute biliary pancreatitis still causes an overall mortality rate of 10% and has hardly been affected by the development of intensive care units and the routine use of somatostatin. By comparing the various approaches reported in the literature the Authors attempt to match the surgical concept of "timing" and the type of operation to be performed with the anatomopathological stage of disease. The paper reports the preliminary results of a treatment protocol in use since 1988 in group of 35 patients in whom the preoperative diagnosis of acute biliary pancreatitis was confirmed by computerised tomography.

[Treatment of Crohn's disease in the acute phase]

The authors sent a questionnaire containing a series of questions dealing with acute manifestations of Crohn's disease, to eminent surgeons of different surgical schools. Results are interesting because differences are quite evident. In terminal ileitis mimicking acute appendicitis, 75% of surgeons perform an appendectomy. In the case of on acute intestinal obstruction, resection of the diseased bowel with primary anastomosis is preferred. In case of free perforation of the lesion, abdominal and massive hemorrhage, answers need to be analyzed in details.