Very Rapid Improvement in Extended Nitric Oxide Parameters Is Associated With Clinical and Functional Improvement in Patients With Chronic Rhinosinusitis With Nasal Polyps Treated With Dupilumab

BACKGROUND AND OBJECTIVE

Dupilumab, an anti-IL-4 receptor a monoclonal antibody, was recently approved for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) and moderate-to-severe asthma. Onset of its clinical effects is rapid. CRSwNP is characterized by extended type 2 inflammatory involvement that can be assessed using extended nitric oxide analysis. We investigated whether dupilumab was associated with a rapid improvement in extended nitric oxide parameters, lung function, and clinical outcomes in patients with CRSwNP.

METHODS

Consecutive patients with CRSwNP and an indication for dupilumab were evaluated for extended nitric oxide analysis (exhaled, FeNO; bronchial, JawNO; alveolar, CalvNO; nasal, nNO) and lung function 15 and 30 days after initiation of treatment and for clinical outcomes (nasal polyps score [NPS], quality of life questionnaires, visual analog scale [VAS] for the main symptoms, and the Asthma Control Test [ACT]) 30 days after initiation of treatment.

RESULTS

We enrolled 33 patients. All extended nitric oxide and lung function parameters improved significantly after 15 days of treatment, remaining stable at 30 days. Scores on the NPS, VAS for the main RSwNP symptoms, quality of life questionnaires, and the ACT improved significantly 30 days after initiation of treatment.

CONCLUSION

Dupilumab is associated with very rapid improvement in type 2 inflammation in all airway areas. This is associated with improved lung function and clinical parameters in patients with CRSwNP.

Modeling vitamin B1 transfer to consumers in the aquatic food web

Vitamin B1 is an essential exogenous micronutrient for animals. Mass death and reproductive failure in top aquatic consumers caused by vitamin B1 deficiency is an emerging conservation issue in Northern hemisphere aquatic ecosystems. We present for the first time a model that identifies conditions responsible for the constrained flow of vitamin B1 from unicellular organisms to planktivorous fishes. The flow of vitamin B1 through the food web is constrained under anthropogenic pressures of increased nutrient input and, driven by climatic change, increased light attenuation by dissolved substances transported to marine coastal systems. Fishing pressure on piscivorous fish, through increased abundance of planktivorous fish that overexploit mesozooplankton, may further constrain vitamin B1 flow from producers to consumers. We also found that key ecological contributors to the constrained flow of vitamin B1 are a low mesozooplankton biomass, picoalgae prevailing among primary producers and low fluctuations of population numbers of planktonic organisms.

Effect of fish length and nutritional condition on the fecundity of distressed Atlantic cod Gadus morhua from the Baltic Sea

The disappearance of larger individuals and the decrease in individual body condition suffered by Atlantic cod Gadus morhua in the eastern Baltic during the past two decades can be expected to affect the stock reproductive output. To investigate this, female G. morhua were collected during the spawning and pre-spawning period in 2015-2016. The current individual potential fecundity (F_P ) of eastern Baltic G. morhua was estimated and analysed in relation to total length (L_T ) and indices of nutritional status such as body condition (K) and hepato-somatic index (I_H ) using generalized linear models. In addition, the current prevalence of atresia and its potential relation to K were investigated. Moreover, a calibration curve to estimate F_P from oocyte diameter, based on the autodiametric oocyte counting method, was established for the first time for eastern Baltic G. morhua and can be used for future fecundity studies on this stock. The results showed that F_P was mainly positively related to fish length, but K and I_H also contributed significantly to the variation in F_P . The model predicted that fish with K = 1·2 have a F_P 51% higher than fish of the same L_T with K = 0·8. The prevalence of fecundity regulation by atresia was 5·8%, but it was found only in fish in the pre-spawning maturity stage and with low K. Temporal changes in biological features such as the length composition and individual body condition of eastern Baltic G. morhua, should be accounted for when estimating stock reproductive potential.

A proposal for limited criminal liability in high-accuracy endoscopic sinus surgery

The aim of the present study is to propose legal reform limiting surgeons' criminal liability in high-accuracy and high-risk surgery such as endoscopic sinus surgery (ESS). The study includes a review of the medical literature, focusing on identifying and examining reasons why ESS carries a very high risk of serious complications related to inaccurate surgical manoeuvers and reviewing British and Italian legal theory and case-law on medical negligence, especially with regard to Italian Law 189/2012 (so called "Balduzzi" Law). It was found that serious complications due to inaccurate surgical manoeuvers may occur in ESS regardless of the skill, experience and prudence/diligence of the surgeon. Subjectivity should be essential to medical negligence, especially regarding high-accuracy surgery. Italian Law 189/2012 represents a good basis for the limitation of criminal liability resulting from inaccurate manoeuvres in high-accuracy surgery such as ESS. It is concluded that ESS surgeons should be relieved of criminal liability in cases of simple/ordinary negligence where guidelines have been observed.

Health Technology Assessment of pathogen reduction technologies applied to plasma for clinical use

Although existing clinical evidence shows that the transfusion of blood components is becoming increasingly safe, the risk of transmission of known and unknown pathogens, new pathogens or re-emerging pathogens still persists. Pathogen reduction technologies may offer a new approach to increase blood safety. The study is the output of collaboration between the Italian National Blood Centre and the Post-Graduate School of Health Economics and Management, Catholic University of the Sacred Heart, Rome, Italy. A large, multidisciplinary team was created and divided into six groups, each of which addressed one or more HTA domains.Plasma treated with amotosalen + UV light, riboflavin + UV light, methylene blue or a solvent/detergent process was compared to fresh-frozen plasma with regards to current use, technical features, effectiveness, safety, economic and organisational impact, and ethical, social and legal implications. The available evidence is not sufficient to state which of the techniques compared is superior in terms of efficacy, safety and cost-effectiveness. Evidence on efficacy is only available for the solvent/detergent method, which proved to be non-inferior to untreated fresh-frozen plasma in the treatment of a wide range of congenital and acquired bleeding disorders. With regards to safety, the solvent/detergent technique apparently has the most favourable risk-benefit profile. Further research is needed to provide a comprehensive overview of the cost-effectiveness profile of the different pathogen-reduction techniques. The wide heterogeneity of results and the lack of comparative evidence are reasons why more comparative studies need to be performed.

The importance of within-system spatial variation in drivers of marine ecosystem regime shifts

Comparative analyses of the dynamics of exploited marine ecosystems have led to differing hypotheses regarding the primary causes of observed regime shifts, while many ecosystems have apparently not undergone regime shifts. These varied responses may be partly explained by the decade-old recognition that within-system spatial heterogeneity in key climate and anthropogenic drivers may be important, as recent theoretical examinations have concluded that spatial heterogeneity in environmental characteristics may diminish the tendency for regime shifts. Here, we synthesize recent, empirical within-system spatio-temporal analyses of some temperate and subarctic large marine ecosystems in which regime shifts have (and have not) occurred. Examples from the Baltic Sea, Black Sea, Bengula Current, North Sea, Barents Sea and Eastern Scotian Shelf reveal the largely neglected importance of considering spatial variability in key biotic and abiotic influences and species movements in the context of evaluating and predicting regime shifts. We highlight both the importance of understanding the scale-dependent spatial dynamics of climate influences and key predator–prey interactions to unravel the dynamics of regime shifts, and the utility of spatial downscaling of proposed mechanisms (as evident in the North Sea and Barents Sea) as a means of evaluating hypotheses originally derived from among-system comparisons.

[Documentation and biolaw: achievements and perspectives]

Law is more and more implicated in bioethical issues, as demonstrated by the creation of the word "biolaw". One of the most evident aspects of this discipline lies in the extensive production of documents of different kind and provenance (national laws, EU and international regulations). Hence the necessity and interest of collecting this material, for the purpose of facilitating researches on one or more biolaw issues. For this reason a Centre of Biolaw Documentation has been created by the Catholic University of the Holy Hearth, Institute of Bioethics, Rome, Italy. It has the purpose of collecting and cataloguing legal documents, of every kind and geographical provenance, concerning various bioethical issues.

Factors predicting response and graft-versus-host disease after donor lymphocyte infusions: a study on 593 infusions

In the present study, we analyze factors predicting graft-versus-host disease (GvHD) and response after donor lymphocyte infusions (DLI). A total of 100 patients received 593 DLI between June 1990 and December 2000 in a bulk dose (n=14) or in escalating dose infusions (n=86). Patients were analyzed after stratification for type of relapse: (1). molecular relapse (n=6), (2). cytogenetic relapse (n=20), (3). chronic phase of chronic myeloid leukemia (CML) or complete remission of other disease post chemotherapy (n=24), (4). CML in accelerated/blastic phase (n=14), (5). resistant disease not responding to chemotherapy (n=36). The proportion of responders to DLI in these five groups was 100, 90, 75, 36 and 0% (P<0.0001). Factors predicting response by multivariate analysis were type of relapse (P<0.0001), post-DLI GvHD (P=0.005), pancytopenia (P=0.008), and a diagnosis of CML (P=0.04). Acute GvHD (grades II-IV) occurred in 21 patients (21%), and correlated in multivariate analysis with pancytopenia and less than four DLI. Other predictors of GvHD were the number of CD3+cells/infusion and serum levels of gamma-glutamyl transferase (gammaGT). The actuarial probability of treatment-related mortality was 9% for HLA identical siblings and 44% for alternative donor transplants (P=0.006). Response to DLI is predicted by tumor burden and is associated with GvHD and pancytopenia.

[Management of chronic heart failure: clinical features and resource utilization among patients managed by the general practitioner. Pilot project in the province of Udine (Italy)]

RATIONALE

In the management of heart failure the general practitioner (GP) plays an important role. However, international studies proved that the GP differs in the management of these patients from the cardiologist. This pilot study aims at investigating if such differences persist in the Italian community.

MATERIALS AND METHODS

Seventy patients with heart failure have been enrolled prospectively by 10 GPs in the Udine district (ASL 4). All of them have been evaluated at the first and subsequent visits, both with respect to clinical and instrumental parameters, overall resource consumption and quality of life.

RESULTS

We observed a high degree of heterogeneity in the follow up patterns; a low coordination between GP and cardiologists in managing patients; several co-morbidities; high social burden; a good adherence to treatment guidelines; a moderate workload, subjectively evaluated from the GP.

CONCLUSIONS

This experience motivated the need of further research in the field, and, from the point of view of the daily practice, the need of integrating hospital and community management of patients with heart failure.

Comparison of antimicrobial use and resistance of bacterial isolates in a haematology ward and an intensive care unit

The objective of the study presented here was to compare antimicrobial use and resistance of bacterial isolates in the haematology ward and the intensive care unit of Bolzano General Hospital. The bacterial organisms isolated most frequently from patients in the two wards (coagulase-negative staphylococci, Enterococcus spp., and Pseudomonas aeruginosa) were investigated for antimicrobial resistance. Isolates obtained from patients in the haematology ward were more often resistant to antimicrobial agents than isolates obtained from patients in the intensive care unit, and the agents against which the highest rates of resistance were found were third- and fourth-generation cephalosporins, carbapenems and monobactams, quinolones, aminoglycosides, and trimethoprim-sulfamethoxazole. These classes of antimicrobial agents were also used more frequently in the haematology ward than in the intensive care unit. Conversely, penicillinic beta-lactam antibiotics, rifamycins, macrolides and lincosamides were used less frequently in the haematology ward than in the intensive care unit, and the rates of resistance against these classes of antimicrobial agents were significantly lower in the haematology ward than in the intensive care unit. The results support the hypothesis that a causal relationship exists between antimicrobial use and the development of resistance and indicate that careful monitoring of antimicrobial use in hospitals is required to identify situations in which prescription patterns are contributing to the development of resistance.

[Uronephrologic echography: state of the art]

We report the ultrasound usefulness and capacity of them to be explain several disease that find field of uronephrology. We value the improvement make to the system. At the time, in fact, it is the early diagnostic technique to be performed. The AA emphasize the absence of invasiveness, the simplicity and the good compliance. Ultrasonography limit the application of more invasive and complicate procedure as TAC and RM.

[Pathology of the spermatic cord]

The purpose of this study has been to establish the role of spermatic cord in the etiopathogenesis of fertility. We describe herein the anatomy and pathology of the spermatic cord and objective method for diagnosing the disorder and evaluating the therapeutic results. The most pathological conditions affecting the cord there was a complete resolution, this condition it isn't the same for the vas deferens or varicocele. A variety of diagnostic modalities including thermography, Doppler, and particularly ultrasonography may be used to study satisfactorily. Ultrasonography technique may provide a simple but accurate non-invasive method for accurately determined pathological conditions of the scrotum. It has a limited role in the management of the normal vas deferens or in congenital malformations including agenesis of vas deferens.

Proliferation and cell loss of human leukemic cell subpopulations in liquid culture

A kinetic study was performed on leukemic blasts from patients with acute myeloid leukemia, separated into 2 subpopulations by a specific density gradient. The growth curve and the [3H]-thymidine uptake were simultaneously analyzed. While cumulative nucleotide uptake fitted with the growth kinetics in the low-density fraction, such a concordance was not found in the high-density subpopulation. That indicated the occurrence of simultaneous growth and loss in the high density fraction, which could not be evaluated by a simple numerical determination.

Cytoplasmic immunoglobulins in chronic lymphocytic leukemia B cells

It is generally assumed that chronic lymphocytic leukemia of B cell origin (B-CLL) is characterized by the presence of surface membrane immunoglobulins (SmIg) and by the absence of cytoplasmic immunoglobulins (CyIg). In a variable number of cases SmIg are not detectable because of their low density on the cellular surface. Because a constant presence of CyIg in 20 subjects suffering from B-CLL has been reported recently, we reexamined 15 SmIg-negative and 10 SmIg-positive B-CLL patients by SmIg and CyIg determinations. We used a direct immunofluorescence method on peripheral blood mononuclear cells for the detection of SmIg and, after fixation, for CyIg. CyIg were detectable in 24 out of 25 cases, with a fluorescence intensity ranging from weak to moderate. The existence of frequent negative results for CyIg determination in B-CLL reported in the literature probably depends on the low sensitivity of the method used. We conclude that CyIg determination is useful in phenotyping every B-CLL patient, especially SmIg-negative ones.

Successful treatment of a steroid-resistant form of idiopathic thrombocytopenic purpura in pregnancy with high doses of intravenous immunoglobulins

Idiopathic thrombocytopenic purpura (ITP) during pregnancy may cause serious bleeding in the mother and fetus. Therapy with high-dose intravenous immunoglobulins has caused an immediate and predictable rise in platelet count in both adults and children with chronic or acute ITP. We report our experience in managing a woman near term in pregnancy. The patient demonstrated a rapid increase in platelet count, delivered without excessive bleeding and had a normal child with normal platelet count. Intravenous immunoglobulins may offer a new and safe way to control maternal and fetal platelet counts during pregnancy, delivery and neonatal period.

[Digoxin-propafenone interaction: values and limitations of plasma determination of the 2 drugs. Anti-arrhythmia effectiveness of propafenone]

Propafenon's influence on the pharmacokinetic and actions of digitalis and viceversa have been evaluated in 27 patients (25 with ventricular hyperkinetic arrhythmias and 2 with paroxismal atrial fibrillation). Patients were divided in two groups according to whether the drug firstly administered were digoxin or propafenon. Plasmatic digoxin and/or propafenon's concentrations, these last performed only in 12 patients, were determined before and during the association and after propafenon's interruption at 7.55-9-11 and at 3-8 p.m. During drug's association area under the plasmatic digoxin concentration curve (AUC 12h) increased on the average by 13.8% (from 19.27 +/- 6.002 ng hours/ml to 21.94 +/- 6.198 ng hours/ml: P less than 0.05) and by 19% at the first hour. Neverthless individual behaviour was not homogeneous since the plasmatic digoxin concentration (PDC) increased in 22 cases (81.4%) and decreased in 5 (18.6%). In 6 patients mean increase was 38.8% (from 16.72 +/- 3.0 ng hours/ml to 23.21 +/- 5.44 ng hours/ml) without signs of digoxin intoxication. Another patient with congestive heart failure and basal PDC 1.87 ng/ml experienced digoxin poisoning with fatal ventricular fibrillation after propafenon. Digoxin administration in the second group's patients produced a not significant increase of plasmatic propafenon concentration (PPC). There was a good correlation among propafenon's absolute amount and plasmatic concentration and antiarrhythmic effect and no correlation among PPC and body-weight related dose. Propafenon's to digitalis association induced, in propafenon's steady state, significant P-R longation from 170 to 190 ms (P less than 0.01) but HR, QRS and QTc didn't show any important change (P greater than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

A Randomized Trial Comparing Cisplatin Plus Cyclophosphamide Versus Cisplatin, Doxorubicin, and Cyclophosphamide in Advanced Ovarian Cancer

In the article by Conte et al, "A Randomized Trial Comparing Cisplatin Plus Cyclophosphamide Versus Cisplatin, Doxorubicin, and Cyclophosphamide in Advanced Ovarian Cancer" (Journal of Clinical Oncology 4:965–971, 1986), an error was made in the abstract on page 965 that altered the meaning of a sentence. The correct sentence appears below.

After primary surgery, 125 patients with epithelial ovarian cancer (International Federation of Gynaecology and Obstetrics [FIGO] 1c + IIb + IIc = 22 patients, FIGO III = 82 patients, FIGO IV = 21 patients) were randomly allocated to receive PC (cisplatin 50 mg/m2 + cyclophosphamide 600 mg/m2 on day 1 every 28 days) or PAC (PC + doxorubicin 45 mg/m2).

Platelet-derived growth factor(s) mitogenic activity in patients with myeloproliferative disease

Platelet-derived growth factor has been invoked in the pathogenesis of medullary fibrosis during myeloproliferative disorders. In this study we compared the mitogenic activity of heat-stable platelet-growth factor(s) from 13 patients suffering from myeloproliferative disorders with that of a normal group. The test was carried out on Go growth arrested Balb/c 3T3 fibroblasts incubated with various concentrations of platelet extracts, determining the entrance into the S phase by means of [14C]thymidine uptake. The incorporation curves of [14C]thymidine by the fibroblast culture, under the effect of pathological extracts, were consistently lower than the control curve, indicating a lower level of PDGF(s) in platelets from patients. The greatest depression of this activity was found to be associated with highest degree of medullary fibrosis (agnogenic myeloid metaplasia patient group), in agreement with the hypothesis that fibroblast activation within bone marrow during myeloproliferative disorders might be correlated with a PDGF(s) release in the bone marrow environment.

[Propafenone in refractory supraventricular arrhythmias]

Twelve patients with ventricular arrhythmias were given 300-900 mg oral of propafenon daily. We have obtained VT's suppression in 6 of 8 cases (75%) and "complex" VEB's suppression or significant reduction in 6 of 10 cases (60%). Total VEB have been strongly reduced (-91,2%) in 7 of 12 patients (58,3%). The effects of Propafenon on electrocardiographic intervals have not been significant at lower doses and only with 900 mg we have noted a significant (p less than 0,05) lengthening of the P-R (+27,1%) and QTc (+10,2%) intervals. Propafenon has never caused important negative inotropic effects. These results have been confirmed during a follow-up period of 5-19 months. In conclusion we believe that Propafenon must be considered a highly efficient drug for the treatment and prevention of refractory ventricular arrhythmias.

Modified Shumacker repair of transposition of the great arteries. Surgical and angiocardiographic considerations

Sixteen patients with transposition of the great arteries, 8 days to 2 1/2 years of age, underwent intra-atrial transposition of venous return by the modified Shumacker technique. A bipedicle flap of right atrial wall was used to direct vena caval return to the mitral valve, and a hinged viable flap of pericardium was used to form the lateral wall of the pulmonary venous pathway. Thirteen patients survived operation and are well to date. Two of the three nonsurvivors were less than 1 month of age at operation, and the third had an associated inlet ventricular septal defect and a straddling tricuspid valve. Early postoperative chest radiographs were compared with preoperative films in each patient. Postoperative findings included minor right pleural effusion in four, minor pneumothorax in two, and paralyzed right hemidiaphragm in one. Two patients required a permanent pacemaker because of the development of sick sinus syndrome 2 and 4 years postoperatively. Each preoperative angiocardiogram was reviewed and compared with postoperative studies in nine patients. The latter demonstrated absence of caval gradients in each, trivial baffle leaks in four, a moderate baffle leak in one, small residual ventricular septal defects in two, and mild tricuspid regurgitation in two patients.

Penetrating wounds of the neck: explore or not?

While routine formal exploration for all neck wounds penetrating the platysma remains a safe policy, our experience indicates that it is not necessarily the best policy in large, well-staffed teaching hospitals with extensive trauma services. Careful and repeated physical examinations and observations supplemented by simple radiograph examinations allowed selection of a large group of patients who were satisfactorily treated by simple wound closure and clinical observations. Aggressive emergency room management and adequate exposure and repair of vascular injuries prevented cerebral damage so common in previous reports.