POS0660 CONCOMITANT USE OF STATINS IN FILGOTINIB-TREATED PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

The Janus kinase-1 preferential inhibitor filgotinib (FIL) improved rheumatoid arthritis (RA) signs and symptoms in phase (P)3 trials.1–3 RA elevates cardiovascular disease risk; statins are used to reduce risk.

Objectives:

To assess safety of statin and filgotinib coadministration across the clinical program.

Methods:

Patients (pts) meeting 2010 ACR/EULAR RA criteria in P2 DARWIN 1–2 (D1–2; NCT01888874, NCT01894516), P3 FINCH 1–3 (F1–3; NCT02889796, NCT02873936, NCT02886728), and long-term extensions DARWIN 3 and FINCH 4 (D3, F4; NCT02065700, NCT03025308) receiving FIL 100 mg (FIL100) QD, FIL 200 mg QD (FIL200), adalimumab (ADA), methotrexate (MTX), or placebo (PBO) were included. Events related to statin use were analysed as exposed by treatment received. N and % were provided.

Week (W)12 PBO-controlled safety analysis included pts receiving FIL100, FIL200, or PBO for ≤12W (D1–2, F1–2); as-treated safety analysis included pts receiving long-term FIL100 QD (n=1647), FIL200 QD (n=2267), ADA (n=325), MTX (n=416), or PBO (n=781) (D1–3, F1–4); P3 as-randomised analysis included data up to W52 (F1–3) per assigned treatment.

Results:

In each arm, similar proportions of pts took statins at baseline (9.4%–11.9%); initiation during study was low (1.2%–6.8%). Through W12 in PBO-controlled analysis, mean creatine phosphokinase (CPK; Figure 1), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) levels were similar regardless of statin use and remained within normal levels across all arms.

Mean baseline ALT and AST levels were 20–23 and 20–22 U/L, respectively; at W12, ALT and AST ranged from 22–24 and 20–25 U/L, respectively. Graded CPK, ALT, and AST elevations are in Table 1.

Table 1.

Graded laboratory abnormalities at week 12 by baseline statin use in PBO-controlled analysis

ConcomitantNoneFIL200(n=68)FIL100(n=95)PBO(n=93)FIL200 (n=709)FIL100(n=693)PBO(n=688)CPK increased*598281562549537G1 (≤2.5×ULN)10 (16.9)13 (15.9)6 (7.4)71 (12.6)47 (8.6)18 (3.4)G2 (>2.5 to 5×ULN)3 (5.1)006 (1.1)2 (0.4)3 (0.6)G3 (>5 to 10×ULN)0001 (0.2)03 (0.6)G4 (>10×ULN)0001 (0.2)2 (0.4)0AST increased**689492708692684G1 (≤3.0×ULN)9 (13.2)11 (11.7)7 (7.6)97 (13.7)79 (11.4)60 (8.8)G2 (>3.0 to 5.0×ULN)0003 (0.4)2 (0.3)3 (0.4)G3 (>5.0 to 20.0×ULN)01 (1.1)02 (0.3)00G4 (>20.0×ULN)000000ALT increased**689492708692684G1 (≤3.0×ULN)13 (19.1)14 (14.9)13 (14.1)98 (13.8)92 (13.3)72 (10.5)G2 (>3.0 to 5.0×ULN)02 (2.1)010 (1.4)5 (0.7)6 (0.9)G3 (>5.0 to 20.0×ULN)0001 (0.1)01 (0.1)G4 (>20.0×ULN)000000

Data are n (%). Grading per Common Terminology Criteria for Adverse Events v4.03

*FINCH 1–2

**DARWIN 1–2, FINCH 1–2

ALT, alanine aminotransferase; AST, aspartate aminotransferase; CPK, creatine phosphokinase; csDMARD, conventional synthetic disease-modifying antirheumatic drug; FIL200/100, filgotinib 200/100 mg + csDMARDs; Grade, G; PBO, placebo; ULN, upper limit of normal.

In the long-term as-treated analysis, 1 (0.5%)/6 (3.2%)/0/0/0 treatment-emergent adverse events (AE) of myalgia occurred in pts on statins at baseline receiving FIL200/FIL100/ADA/MTX/PBO and in 12 (0.6%)/8 (0.5%)/3 (1.0%)/2 (0.5%)/1 (0.1%) pts not on statins. Muscle spasms occurred in 2 (0.9%)/3 (1.6%)/1 (3.2%)/0/1 (1.1%) pts on statins at baseline receiving FIL200/FIL100/ADA/MTX/PBO and 21 (1.0%)/8 (0.5%)/0/3 (0.8%)/1 (0.1%) pts not on statins at baseline. One patient not on statins receiving FIL200 reported rhabdomyolysis. For all treatment arms in P3 as-randomised analysis, mean LDL and HDL increased similarly from baseline (108–110 and 56–59 mg/dL, respectively) to W52 (119–130 and 59–71 mg/dL, respectively).

Conclusion:

No increases in statin-induced AEs such as muscle or liver toxicities occurred with statins and filgotinib coadministration; results are supported by a drug-drug interaction study.4 Mean LDL and HDL increased at W52 in all treatment arms.

References:

[1]Genovese et al. JAMA. 2019;322:315–25.

[2]Westhovens et al. Ann Rheum Dis. 2021; online first.

[3]Combe et al. Ann Rheum Dis. 2021; online first.

[4]Anderson et al. EULAR 2021 abstract.

Disclosure of Interests:

Peter C. Taylor Consultant of: AbbVie, Biogen, Eli Lilly, Fresenius, Galapagos, Gilead, GlaxoSmithKline, Janssen, Nordic Pharma, Pfizer, Roche, BMS, Sanofi, Celltrion, and UCB, Grant/research support from: Celgene, Eli Lilly, Galapagos, and Gilead, Christina Charles-Schoeman Consultant of: Gilead, Pfizer, and Regeneron-Sanofi, Grant/research support from: AbbVie, Bristol-Myers Squibb and Pfizer Inc, Muhsen Alani Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Mona Trivedi Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Vanessa Castellano Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Iyabode Tiamiyu Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Deyuan Jiang Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Lei Ye Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Sander Strengholt Shareholder of: Galapagos BV, Employee of: Galapagos BV, Michael Nurmohamed Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, Roche, and Sanofi, Consultant of: AbbVie, Celgene, Celltrion, Eli Lilly, Janssen, and Sanofi, Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, MSD, Mundipharma, Novartis, Pfizer, Roche, and Sanofi, Gerd Rüdiger Burmester Speakers bureau: AbbVie, Eli Lilly, Pfizer, and Gilead Sciences, Inc., Consultant of: AbbVie, Eli Lilly, Pfizer, and Gilead Sciences, Inc.

Pyrethroid insecticide lambda-cyhalothrin induces hepatic cytochrome P450 enzymes, oxidative stress and apoptosis in rats

This study aimed to examine in rats the effects of the Type II pyrethroid lambda-cyhalothrin on hepatic microsomal cytochrome P450 (CYP) isoform activities, oxidative stress markers, gene expression of proinflammatory, oxidative stress and apoptosis mediators, and CYP isoform gene expression and metabolism phase I enzyme PCR array analysis. Lambda-cyhalothrin, at oral doses of 1, 2, 4 and 8mg/kg bw for 6days, increased, in a dose-dependent manner, hepatic activities of ethoxyresorufin O-deethylase (CYP1A1), methoxyresorufin O-demethylase (CYP1A2), pentoxyresorufin O-depentylase (CYP2B1/2), testosterone 7α- (CYP2A1), 16β- (CYP2B1), and 6β-hydroxylase (CYP3A1/2), and lauric acid 11- and 12-hydroxylase (CYP4A1/2). Similarly, lambda-cyhalothrin (4 and 8mg/kg bw, for 6days), in a dose-dependent manner, increased significantly hepatic CYP1A1, 1A2, 2A1, 2B1, 2B2, 2E1, 3A1, 3A2 and 4A1 mRNA levels and IL-1β, NFκB, Nrf2, p53, caspase-3 and Bax gene expressions. PCR array analysis showed from 84 genes examined (P<0.05; fold change>1.5), changes in mRNA levels in 18 genes: 13 up-regulated and 5 down-regulated. A greater fold change reversion than 3-fold was observed on the up-regulated ALDH1A1, CYP2B2, CYP2C80 and CYP2D4 genes. Ingenuity Pathway Analysis (IPA) groups the expressed genes into biological mechanisms that are mainly related to drug metabolism. In the top canonical pathways, Oxidative ethanol degradation III together with Fatty Acid α-oxidation may be significant pathways for lambda-cyhalothrin. Our results may provide further understanding of molecular aspects involved in lambda-cyhalothrin-induced liver injury.

1-Octadecene as a Solvent for Ferrofluids for Intraocular use

Purpose.

1-Octadecene is a hydrocarbon with one double bond in its structure that could serve as a solvent for ferrofluids. The aim of this pilot study was to obtain preliminary information on intraocular tolerance to 1-octadecene.

Methods.

Vitreous compression with perfluoropropane gas was achieved in 20 eyes of albino rabbits. Four days after gas injection a fluid-gas exchange was undertaken. Sixteen eyes received 1-octadecene. Four eyes received balanced salt solution. Eyes were obtained at 3, 7, 14 and 30 days. The samples were fixed in 10% buffered formalin, processed in paraffin and sections were stained with hematoxylin and eosin.

Results.

Emulsification of the oil bubble was observed in 31.25% of the cases by the fifth day; light microscopy showed normal retinal architecture in all the eyes and epiretinal and vitreous macrophages in 50% of the eyes.

Conclusions.

1-Octadecene does not appear to have any retinal cytotoxic effect but elicits an inflammatory response in the vitreous activity.

Permethrin-induced oxidative stress and toxicity and metabolism. A review

Permethrin (PER), the most frequently used synthetic Type I pyrethroid insecticide, is widely used in the world because of its high activity as an insecticide and its low mammalian toxicity. It was originally believed that PER exhibited low toxicity on untargeted animals. However, as its use became more extensive worldwide, increasing evidence suggested that PER might have a variety of toxic effects on animals and humans alike, such as neurotoxicity, immunotoxicity, cardiotoxicity, hepatotoxicity, reproductive, genotoxic, and haematotoxic effects, digestive system toxicity, and cytotoxicity. A growing number of studies indicate that oxidative stress played critical roles in the various toxicities associated with PER. To date, almost no review has addressed the toxicity of PER correlated with oxidative stress. The focus of this article is primarily to summarise advances in the research associated with oxidative stress as a potential mechanism for PER-induced toxicity as well as its metabolism. This review summarises the research conducted over the past decade into the reactive oxygen species (ROS) generation and oxidative stress as a consequence of PER treatments, and ultimately their correlation with the toxicity and the metabolism of PER. The metabolism of PER involves various CYP450 enzymes, alcohol or aldehyde dehydrogenases for oxidation and the carboxylesterases for hydrolysis, through which oxidative stress might occur, and such metabolic factors are also reviewed. The protection of a variety of antioxidants against PER-induced toxicity is also discussed, in order to further understand the role of oxidative stress in PER-induced toxicity. This review will throw new light on the critical roles of oxidative stress in PER-induced toxicity, as well as on the blind spots that still exist in the understanding of PER metabolism, the cellular effects in terms of apoptosis and cell signaling pathways, and finally strategies to help to protect against its oxidative damage.

Resistance training improves strength and functional capacity in persons with multiple sclerosis

The purpose of this study was to evaluate the effect of an eight-week progressive resistance training programme on lower extremity strength, ambulatory function, fatigue and self-reported disability in multiple sclerosis (MS) patients (mean disability score 3.79-0.8). Eight MS subjects volunteered for twice weekly training sessions. During the first two weeks, subjects completed one set of 8 -10 reps at 50% of maximal voluntary contraction (MVC) of knee flexion, knee extension and plantarflexion exercises. In subsequent sessions, the subjects completed one set of 10 -15 repetitions at 70% of MVC. The resistance was increased by 2 -5% when subjects completed 15 repetitions in consecutive sessions. Isometric strength of the quadriceps, hamstring, plantarflexor and dorsiflexor muscle groups was assessed before and after the training programme using an isokinetic dynamometer. Magnetic resonance images of the thigh were acquired before and after the exercise programme as were walking speed (25-ft), number of steps in 3 min, and self-reported fatigue and disability. Knee extension (7.4%), plantarflexion (52%) and stepping performance (8.7%) increased significantly (PB-0.05). Self-reported fatigue decreased (PB-0.05) and disability tended to decrease (P -0.07) following the training programme. MS patients are capable of making positive adaptations to resistance training that are associated with improved ambulation and decreased fatigue.

Fipronil sulfone induced higher cytotoxicity than fipronil in SH-SY5Y cells: Protection by antioxidants

Fipronil is a broad spectrum insecticide from the phenyl pyrazole family, which targets GABA receptor. Limited information is available about the metabolite fipronil sulfone cytotoxic actions. This study examined in vitro neurotoxicity of fipronil and fipronil sulfone and evaluated Trolox (vitamin E analog) (0.3, 1μM), N-acetyl-cysteine (0.5, 1mM), melatonin (0.1, 1μM) and Tempol (superoxide dismutase analog) (0.3, 0.5mM) protective role in SH-SY5Y cells. MTT and LDH assays were carried out to assess the cytotoxicity of fipronil and fipronil sulfone at 3-100μM concentrations. Fipronil sulfone was more toxic than fipronil. Tempol showed the best neuroprotectant profile against fipronil (50 and 150μM) and fipronil sulfone (3 and 10μM) reaching control levels. Fipronil (100μM) and fipronil sulfone (3μM) treatments induced a 4.7- and 5-fold increases in lipid peroxides measured as malondialdehyde (MDA) and a 2.2- and 2.0-fold increases in the levels of nitric oxide (NO). These results suggest that oxidative stress observed may be one of the major mechanisms of fipronil-induced neurotoxicity and it may be attributed in part to fipronil disposition and metabolism. Our results led us postulate that metabolite fipronil sulfone might be responsible for the fipronil-induced toxicity rather than fipronil itself.

Effects of exposure to pyrethroid cyfluthrin on serotonin and dopamine levels in brain regions of male rats

The effects of cyfluthrin oral exposure (1, 5, 10 and 20mg/kg bw, 6 days) on brain region monoamine levels of male rats were examined. Cyfluthrin-treated rats (1, 5 and 10mg/kg bw, orally 6 days), had no visible injury, i.e., no clinical signs of dysfunction were observed. However, rats treated with cyfluthrin at the highest dose (20mg/kg bw, orally 6 days) showed skeletal muscle contraction in the hind limbs, slight movement incoordination without any signs of dyskinesia and tremor after 1-2h of treatment. These signs were reversible at 6h after dose. After last dose of cyfluthrin, dopamine (DA) and serotonin (5-HT) and its metabolites levels were determined in brain regions hypothalamus, midbrain, hippocampus, striatum and prefrontal cortex by HPLC. Cyfluthrin (1mg/kg bw, orally 6 days) did not affect the DA, 5-HT and metabolites levels in the brain regions studied. Cyfluthrin (5, 10 and 20mg/kg bw, orally 6 days) caused a statistically significant decrease in DA and its metabolites DOPAC and HVA levels and in 5-HT and its metabolite 5-HIAA levels in a brain region- and dose-related manner. Moreover, cyfluthrin (20mg/kg bw, orally 6 days) evoked a statistically significant increase in 5-HT turnover in striatum and midbrain, and in DA turnover in striatum and prefrontal cortex. These findings indicate that serotoninergic and dopaminergic neurotransmission is affected by exposure to cyfluthrin and may contribute to the overall spectrum of neurotoxicity caused by this pyrethroid.

Evidence for dose-additive effects of a type II pyrethroid mixture. In vitro assessment

Despite the widespread use of pyrethroid insecticides that led to common exposure in the population, few studies have been conducted to quantitatively assess dose-additive effects of pyrethroids using a funcional measure involved in the common toxic mode of action. The aim of this study was to evaluate the potency and efficacy of 6 Type II pyretroids (α-cypermethrin, cyfluthrin, λ-cyhalothrin, deltamethrin, cyphenothrin and esfenvalerate) to evoke induction of both nitric oxide and lipid peroxides levels measured as malondialdehyde in three in vitro models (SH-SY5Y, HepG2 and Caco-2 human cells) as well as to test the hypothesis of dose additivity for mixtures of these same 6 pyrethroids. Concentration-responses for 6 pyrethroids were determined as well as the response to mixtures of all 6 pyrethroids. Additivity was tested assuming a dose-additive model. The human neuroblastoma SH-SY5Y cell line was the most sensitive in vitro model. The rank order of potency for cell SH-SY5Y viability MTT assay was deltamethrin>cyphenothrin>λ-cyhalothrin>cyfluthrin>esfenvalerate>α-cypermethrin. When 6 pyrethroids were present in the mixture at an equitoxic mixing ratio, the action on nitric oxide (NO) and lipid peroxides measured as malondialdehyde (MDA) production was consistent with a dose-additive model. The results of the present study are consistent with previous reports of additivity of pyrethroids in vivo e in vitro.

Acute oral safety study of sodium caseinate glycosylated via maillard reaction with galactose in rats

In order to potentially use sodium caseinate (SC) glycated with galactose (Gal) in the food industry as a new functional ingredient with proved technological and biological properties, an evaluation of oral acute toxicity has been carried out. An acute safety study with SC-Gal glycoconjugates in the Wistar rat with a single oral gavage dose of 2,000 mg/kg of body weight was conducted. The SC-Gal glycoconjugates were well tolerated; no adverse effects or mortality was observed during the 2-week observation period. No abnormal signs, behavioral changes, body weight changes, or alterations in food and water consumption occurred. After this period, no changes in hematological and serum chemistry parameters, organ weights, or gross pathology or histopathology were detected. It was concluded that SC-Gal glycoconjugates obtained via the Maillard reaction were well tolerated in rats at an acute oral dose of 2,000 mg/kg of body weight. The SC-Gal glycoconjugates have a low order of acute toxicity, and the oral 50 % lethal dose for male and female rats is in excess of 2,000 mg/kg of body weight.

Acute and repeated dose (28 days) oral safety studies of ALIBIRD in rats

ALIBIRD, a test substance composed of oligosaccharides derived from lactulose, a hydrolysate of a whey protein concentrate, and a supercritical extract of rosemary (1:0.5:0.05), was prepared in the laboratory and evaluated for its safety as a multifunctional food additive. In oral toxicity studies (acute and 28 days repeated dose) using Wistar rats, ALIBIRD was administered in a single oral gavage dose of 2,000 mg/kg of body weight and resulted in no adverse events or mortality; a daily dose of 2,000 mg/kg of body weight for 28 days by gavage also resulted in no adverse effects or mortality. No abnormal clinical signs, behavioral changes, body weight changes, or changes in food and water consumption occurred in either study. There were no changes in hematological and serum chemistry values, organ weights, or gross or histological characteristics. Based on test results, it is concluded that ALIBIRD is well tolerated in rats at an acute and subchronic (28 days) dose of 2,000 mg/kg of body weight.

Effect of resistance training on risk of coronary artery disease in women with multiple sclerosis

The effects of a lower-extremity progressive resistance-training program (PRT) on risk factors for coronary artery disease (CAD) were determined in patients with multiple sclerosis (MS). Twelve ambulatory women with MS (47.3+/-4.7 years; Expanded Disability Status Score (EDSS), 4.00+/-1.37) completed twice weekly lower-body PRT for 8 weeks. Knee extensor and ankle flexor strength improved significantly (p<0.05) after training, and self-reported fatigue decreased (p<0.05). Serum triglyceride concentrations decreased (p<0.05) but body-weight and fatness, blood pressure, and serum glucose, total cholesterol and high-density lipoprotein cholesterol were unchanged. However, the number of CAD risk factors that reached the clinical threshold for each subject declined after PRT, suggesting that resistance training can promote CAD risk reduction in ambulatory female MS subjects.

[Therapy of dyslipidemia in post-infarction: state of the art]

Between the risks factors involved in the atherogenesis LDL-cholesterol is determinant because highly associated to cardiovascular events. The primary target for the prevention of coronary diseases is a reduction of LDL-cholesterol because that reduces the cardiovascular mortality and the total mortality. The NCEP ATP III 2004 guide-lines propose as therapeutic target for the high-risk patients the reduction of plasma levels of LDL-cholesterol under 100 mg/dl and according to new trials under 70 mg/dl. The dyslipidaemia treatments are based on two approaches, i.e., the therapeutic lifestyle change and the pharmacological therapy. The available drugs are statins, fibrates, anion exchange resins, nicotinic acid. In the acute coronary syndrome patients is desirable to start immediately a therapy with statins since the hospital phase and direct the treatment to aggressive therapy. Unfortunately, the statin doses used in the most secondary prevention trials allow to get LDL-cholesterol under 100 mg/dl in the only half high-risk patients. The innovative therapeutic approach to hypercholesterolemia today is based on a double inhibition of cholesterol synthesis and absorption combining a statin with ezetimibe.

[Hereditary hemorragic telangiectasia: the state of art]

Hereditary Hemorrhagic Telangiectasia (HHT) or Rendu-Osler-Weber syndrome, is a multisystemic vascular dysplasia. The disease is transmitted as a dominant autosomic character. The Hereditary Hemorrhagic Telangiectasia is differentiated in two subclasses: (1) HHT1, which is caused by mutation of ENG gene. This gene is localized on long arm of chromosome 9: (2) HHT2, which is caused by mutation of ALK-1 gene. This gene is located on long arm of chromosome 12. These two genes codify for two receptorial proteins: the endoglin and the activin-like protein 1; these proteins belong to receptorial superfamily of TGF-beta, which is involved in vascular remodelling and angiogenesis. Clinically, the consequences of these mutations are represented by the formation of cutaneous and/or mucous telangiectases and artero-venous fistulas. In both cases histological alteration is the same: extremely ectatic venules with numerous layers of myocytes around them. Arterioles communicate with venules directly without a capillary filter. Essentially, telangiectases manifest themselves with hemorrhages, while more common consequences of fistulas are secondary to formation of shunts with a possible thromboembolism; that is particularly serious in case of pulmonary artero-venous malformations. In 2000. Shovlin published 4 diagnostic criteria (criteria of Curaçao): (1) spontaneous and recurrent epistaxis; (2) multiple telangiectases; (3) visceral artero-venous malformations; (4) familiarity for HHT. Actually there is no possibility for a genetic therapy of HHT. Therefore, the therapeutic efforts are turned to control of symptoms and to the prevention of complications.

Psychological impact of sports activity in spinal cord injury patients

OBJECTIVE

To investigate whether sports activity is associated with better psychological profiles in patients with spinal cord injury (SCI) and to evaluate the effect of demographic factors on psychological benefits.

METHODS

The State-Trait Anxiety Inventory, Form X2 (STAI-X2), the Eysenck Personality Questionnaire for extraversion (EPQ-R (E)) and the questionnaire for depression (QD) were administered in a cross-sectional study of 137 males with spinal cord injury including 52 tetraplegics and 85 paraplegics. The subjects were divided into two groups according to sports activity participation (high frequency vs no sports participation). Moreover, multiple regression analysis was adopted to investigate the influence of demographic variables, such as age, educational level, occupational status and marital status, on psychological variables.

RESULTS

Analysis of variance revealed significant differences among the groups for anxiety (STAI-X2), extraversion (EPQ-R (E)) and depression (QD). In particular, SCI patients who did not practice sports showed higher anxiety and depression scores and lower extraversion scores than sports participants. In addition, with respect to the paraplegics, the tetraplegic group showed the lowest depression scores. Following multiple regression analysis, only the sports activity factor remained as an independent factor of anxiety scores.

CONCLUSION

These findings demonstrate that sports activity is associated with better psychological status in SCI patients, irrespective of tetraplegia and paraplegia, and that psychological benefits are not emphasized by demographic factors.

Determinants of sit-to-stand capability in the motor impaired elderly

Among the healthy elderly, sit-to-stand (STS) movement largely depends on: (a) trunk bending momentum, (b) centre of gravity (CG) position before the body rises and (c) lower limb extensor muscle strength. Because determining whether (c) improvement would affect STS capability in the motor impaired elderly (MIE) has been recommended, we studied the relative importance of (a), (b) and (c) in determining a successful fast STS movement comparing the healthy elderly with MIE with orthopaedic disorders studied before and after a rehabilitation program. Force platform was used to measure body's posture and kinematics during a STS test and therefore to assess (a), (b) and maximum vertical velocity (VVpeak), assumed as outcome measurement. Knee extensor maximal isometric voluntary contraction normalized by body mass (nMVC) was an indicator of (c). A multiple regression model was built to predict VVpeak from the three determinants of STS movement. In both groups, the model significantly determined VVpeak, with (a) and (c) being significant predictors of VVpeak and (a) being the major predictor. Rehabilitation was effective in improving nMVC. This process resulted in a change of the relative importance of (a) and (c), strength becoming the major predictor of VVpeak. In conclusion the present study demonstrates that a rehabilitative intervention aimed at increasing strength is effective in improving STS capability in MIE.

Effect of antiretroviral drugs on liver fibrosis in HIV-infected patients with chronic hepatitis C: harmful impact of nevirapine

BACKGROUND

The hepatotoxicity of highly active antiretroviral therapy (HAART) could enhance liver fibrosis in HIV/Hepatitis C virus (HCV)-coinfected patients. Moreover, HAART-related immune restoration could lessen HCV-associated liver damage. The data on the effect of protease inhibitors (PI) on liver fibrosis are scant and contradictory. No information is available on the relationship between non-nucleoside analogue therapy and liver fibrosis in co-infected patients.

OBJECTIVE

To investigate the associations between the use of different antiretroviral drugs and the liver fibrosis in patients with HIV and HCV infections.

DESIGN

Cross-sectional study.

METHODS

All HIV/HCV co-infected patients with an available liver biopsy and known or estimated duration of HCV infection seen at a Infectious Diseases Unit were included in the study. The fibrosis stage and the fibrosis progression rate were evaluated.

RESULTS

The inclusion criteria were fulfilled by 152 patients. Age at HCV infection < 20 years [adjusted odds ratio (AOR), 0.39; 95% confidence interval (CI), 0.19-0.82], PI-based HAART (AOR, 0.39; 95% CI, 0.19-0.78) and nevirapine-based HAART (AOR, 2.56; 95% CI, 1.02-6.58) were associated with fibrosis stage >or= F3. The variables associated with fibrosis progression rate > 0.2 units/year were age at HCV infection < 20 years (AOR, 0.23; 95% CI, 0.1-0.52), CD4 cell counts < or = 250 x 10/l at liver biopsy (AOR, 2.8; 95% CI, 1.1-7.1), PI-based HAART (AOR, 0.39; 95% CI, 0.2-0.8) and nevirapine-based HAART (AOR, 3.82; 95% CI, 1.9-7.6).

CONCLUSIONS

HAART regimens including nevirapine are associated with faster liver fibrosis progression in HIV-infected patients with chronic hepatitis C. In contrast, patients on PI as the backbone of potent antiretroviral therapy are more likely to show less liver fibrosis.

[Endotrachael aspiration protocol in patients with serious cranial trauma. study of neurophysiological variables]

Aspiration of tracheobronchial secretions can cause noxious effects on neurophysiological variables. Different studies that refer to aspiration of secretions in Serious Cranial Trauma use hyperinsuflation and hyperoxygenation to minimize its repercussion on Intracranial Pressure and thus try to not contribute to the secondary lesion. After reviewing these studies, a protocol of tracheobronchial secretion aspiration was performed in our ICU in patients with serious cranial trauma subjected to mechanical ventilation in order to assess the effect of the aspiration of secretions in the neurophysiological variables following homogeneous and standardized guidelines. Neurological, hemodynamic, oxygenation and ventilation variables were analyzed before, during and after aspiration of secretions. When the results were compared before and during this, we observed a decrease in the Intracranial Pressure with increase of Cerebral Perfusion Pressure (due to increase of Mean Blood Pressure), maintaining the levels of PaCO2 and jugular saturation of O2, with an increase in the airway pressures. After finishing the aspiration process, all the affected values recovered. It is concluded that the aspiration of tracheobronchial secretions in patients with Severe Cranial Trauma, after standardized hyperinsuflation and hyperoxygenation, does not alter the hydrodynamics or brain use of O2.

Exercise induced muscle damage and recovery assessed by means of linear and non-linear sEMG analysis and ultrasonography

This study was aimed at investigating the time-course and recovery from eccentric (EC) exercise induced muscle damage by means of surface electromyography (sEMG), ultrasonography (US), and blood enzymes. Five subjects (EC Group) performed two bouts of 35 EC maximum contractions with the biceps brachii of their non dominant arm, five subjects were tested without performing EC (Control Group: CNT). The maximal isometric force (MVC) was measured. Force and sEMG signals were recorded during 80% MVC isometric contractions. In EC and CNT subjects US assessment on non-dominant biceps brachii was performed; creatin kinase (CK) and lactic dehydrogenasis (LDH) plasma levels were also assessed. Force, sEMG and CK-LDH measurements were performed before EC and after it periodically for 4 weeks. The sEMG was analysed in time and frequency domains; a non-linear analysis (Lyapunov 1st exponent, L1) of sEMG was also performed. After EC, the MVC was reduced by 40% on average with respect to the pre-EC values. A significant decrease in the initial frequency content, and in the MDF and L1 decay (13-42% less than the pre-EC values, respectively) was also observed. The sEMG amplitude (Root Mean Square, RMS) was unchanged after EC. The US revealed an increase in muscle belly thickness and in local muscle blood flow after EC. A complete recovery of all the considered parameters was achieved in two weeks. In conclusion sEMG analysis was confirmed as an early indicator of muscle damage. Muscle recovery from damage is followed by both sEMG and US and this may have useful clinical implications. Non linear analysis (L1) was revealed to be sensitive to early sEMG modifications induced by EC as well as able to follow the post EC changes in the sEMG.

Distribution of polychlorinated biphenyls in contaminated swine tissue

In 1999 an accidental contamination of feed occurred in Belgium. This incident lead Authorities to increase monitoring levels of polychlorinated biphenyls (PCB) in food of animal origin. In our Department 220 samples of swine tissues, meat and adipose tissue, were analysed. The quantitation of PCB was made from the sum of 7 congeners obtained by gas chromatography with an electron capture detector. Confirmatory analysis was performed by gas chromatography/mass spectrometry. The PCBs in the majority of samples were close to the method limit of detection and only a few samples had PCB concentrations > the limit of quantitation. In those tissues the average concentration of PCBs was 0.035 mg/kg. The legal limit of 0.200 mg PCB/kg established by the European Union was exceeded by only 1 sample, a smoked ham from Belgium. This sample showed the presence of all selected congeners. We report the profile of the PCB congeners in this sample.

Urodynamics in spinal cord injured patients walking with reciprocating gait orthosis

PURPOSE

We evaluated the effects of walking with reciprocating gait orthosis on bladder function and upper urinary tract status in spinal cord injured patients.

MATERIALS AND METHODS

Seven patients using reciprocating gait orthosis underwent urodynamics before and during walking. Abdominal ultrasound was performed before and after urodynamics.

RESULTS

Baseline urodynamics showed detrusor areflexia in 3 patients and hyperreflexia in 4. During walking urodynamics revealed hyperreflexia in 6 patients with worse uninhibited detrusor contraction amplitude (38.2 +/- 41.2 versus 73.7 +/- 44.4 cm. water, p = 0.006) and duration (2.1 +/- 2.1 versus 6.8 +/- 5.3 minutes, p = 0.023). After walking ultrasound demonstrated bilateral pyelectasia in 2 patients.

CONCLUSIONS

Spinal cord injured patients using reciprocating gait orthosis have worse urodynamic measurements and upper urinary tract disorders during walking. They require close urological followup.

Urological dysfunctions and upper urinary tract involvement in multiple sclerosis patients

The goal of the present study was to investigate the involvement of the upper urinary tract (UUT) in patients with multiple sclerosis and its relationship with other neurological and urological features of the disease. One hundred sixteen patients underwent complete neurological and urological assessments, urodynamic investigation, and morphofunctional study of the urinary tract by ultrasonography, voiding cistourethrography, and/or intravenous excretory pyelography. The most remarkable relationships were observed among disease duration, pyramidal system score, amplitude of uninhibited detrusor contractions and the presence of bladder morphological abnormalities (P = 0.03, 0.0008, and 0.018, respectively) and the relationship between pyramidal system score or the presence of bladder pathology and UUT abnormalities (P = 0.03 and 0.0006, respectively). A significant relationship was found between the maximum amplitude of uninhibited contractions and UUT involvement (P = 0.002). No other significant relationship was observed between UUT involvement and any other urodynamic or urological features of the disease (type of progression and progression rate, Expanded Disability Status Scale, and other functional system scores). The relationship among disease duration, high vesical pressures, and the lack of reliable clinical indices of risk to the UUT stress the importance for patients with multiple sclerosis to adhere to a strict follow-up program with urodynamic assessment and urinary tract imaging and to maintain detrusor relaxation with anticholinergic medications.

Walking index for spinal cord injury (WISCI): an international multicenter validity and reliability study

STUDY DESIGN

Construction of an international walking scale by a modified Delphi technique.

OBJECTIVE

The purpose of the study was to develop a more precise walking scale for use in clinical trials of subjects with spinal cord injury (SCI) and to determine its validity and reliability.

SETTING

Eight SCI centers in Australia, Brazil, Canada (2), Korea, Italy, the UK and the US.

METHODS

Original items were constructed by experts at two SCI centers (Italy and the US) and blindly ranked in an hierarchical order (pilot data). These items were compared to the Functional Independence Measure (FIM) for concurrent validity. Subsequent independent blind rank ordering of items was completed at all eight centers (24 individuals and eight teams). Final consensus on rank ordering was reached during an international meeting (face validation). A videotape comprised of 40 clips of patients walking was forwarded to all eight centers and inter-rater reliability data collected.

RESULTS

Kendall coefficient of concordance for the pilot data was significant (W=0. 843, P<0.001) indicating agreement among the experts in rank ordering of original items. FIM comparison (Spearman's rank correlation coefficient=0.765, P<0.001) showed a theoretical relationship, however a practical difference in what is measured by each scale. Kendall coefficient of concordance for the international blind hierarchical ranking showed significance (W=0.860, P<0.001) indicating agreement in rank ordering across all eight centers. Group consensus meeting resulted in a 19 item hierarchical rank ordered 'Walking Index for Spinal Cord Injury (WISCI)'. Inter-rater reliability scoring of the 40 video clips showed 100% agreement.

CONCLUSIONS

This is the first time a walking scale for SCI of this complexity has been developed and judged by an international group of experts. The WISCI showed good validity and reliability, but needs to be assessed in clinical settings for responsiveness.

Ambulation training of neurological patients on the treadmill with a new Walking Assistance and Rehabilitation Device (WARD)

STUDY DESIGN

Patients with neurological walking impairment were rehabilitated with a new system, consisting of an apparatus to constantly relieve the body weight and a treadmill: The Walking Assistance and Rehabilitation Device (WARD). Patients were evaluated before and after rehabilitation with clinical scales and physiological measurements.

OBJECTIVES

To evaluate the effectiveness of the WARD in improving walking capability in these patients.

SETTING

The study was carried out in a clinical environment (IRCCS S. Lucia, Rehabilitation Hospital, Rome, Italy).

METHODS

Seven patients (six with spinal cord injuries, one with brain injury) underwent a 1 - 2 month training period with the WARD. During the WARD training the body weight constant unloading (BWCU) applied to the patient through the WARD was regularly evaluated. Oxygen consumption, carbon dioxide production and heart rate were measured in order to obtain energy and cardiac costs of walking. These measurements were carried out while walking with the WARD at an appropriate treadmill speed (ATS) and in the open field at the most comfortable speed (MCS). All measurements, in addition to clinical scores related to the walking capability, were carried out at the beginning of the WARD training period (BWT) and at the end (EWT). At the EWT the patients were tested walking with the WARD observing the same BWT conditions (same ATS and BWCU), referred to as beginning conditions second measurements (BCSM). The relationships between physiological costs and ATS were described through second order polynomial regression curves and studied.

RESULTS

Comparing the data obtained at the BWT and EWT, the following results were found significantly different: (1) Clinical scores improved; (2) All patients increased their ATS; (3) The BWCU was reduced; (4) The Walking Energy Cost (WEC) and the Walking Cardiac Cost (WCC) measured when walking with the WARD at the ATS improved in all patients; and (5) The WEC and WCC measured in the open field improved in all patients. The WEC vs ATS curve found at the EWT in the BCSM was found significantly different from the BWT curve, demonstrating a major improvement due to the WARD training.

CONCLUSION

Despite some limitations due to sample size and functional ambulation scale, this study has demonstrated that the WARD training is effective in improving the walking capability and efficiency of the patients.

Cost of walking and locomotor impairment

The aim of the present study was to evaluate the importance and the necessity of metabolic measurements to quantify locomotor impairment in a clinical context. Oxygen consumption, heart rate, pulmonary ventilation and walking speed were measured during locomotion in 14 normal subjects, used as a control group, and 82 patients with different pathologies [hemiparetic, paraparetic, tetraparetic, orthopaedic and paraplegic patients, who walked using a reciprocating gait orthosis (RGO)]. The subjects were characterized on the basis of a cumulative impairment score (CIS), based on clinical scales commonly used to evaluate impairment and disability in locomotion. Appropriate indices of energy, cardiac and ventilatory costs expressed per metre walked, globally called physiological costs, were obtained. It resulted that the most comfortable speed (MCS) of normal subjects was significantly higher than that of each group of patients. Normal subjects' physiological costs were found to be significantly lower than those of patients who needed either a device or the help of a person to walk. All measured parameters correlated significantly with each other. The MCS was found to be the most correlated parameter with the CIS (r = 0.8), and therefore it must be considered the best single measurement, if only one is to be used. Measurements more precise than MCS, such as the physiological costs, may be necessary in clinical trials.

Immunological and endocrinological disturbances in patients after prolonged coma following head injury

It has been previously reported that following severe brain damage, a deficit of cellular immunity could be detected in the early phase after the occurence of the lesion. We report here the results of a cross-sectional study on long term effects of severe brain damage on immunological and neuro-endocrine changes in patients who recovered from prolonged coma caused by head injury. Results obtained from post-comatose (PC) patients were compared with those obtained from two control groups made up of spinal-cord injury (SCI) patients and healthy subjects, respectively. The following parameters were studied: lymphomonocyte subsets; interleukin 2 (IL-2) production; natural killer (NK) activity and serum levels of adrenocorticotrophic hormone (ACTH), cortisol, follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, tri-iodothyronine (T3) and thyroxine (T4). With respect to healthy controls the PC1 subgroup, i.e. patients examined 3-6 months after injury, showed a statistically significant decrease in IL-2 production, NK activity and CD25+ lymphocytes. Similar immunological disturbances were observed in SCI but not in the PC2 subgroup, i.e. patients examined later than 6 months after injury. The same sub-group of PC1 patients showed high serum levels of cortisol and PRL. These results could be related to the immunological status and may be interpreted as a transient but prolonged condition of chronic stress or "chronic alarm reaction". Copyright Rapid Science Ltd

Clean intermittent catheterization and prevention of renal disease in spinal cord injury patients

Upper urinary tract complications have been reported in about 20-30% of spinal cord injury patients. Their pathogenesis is linked to the presence of high-pressure uninhibited detrusor contractions, high leak point pressure and low bladder compliance. The aim of this study was to evaluate the incidence of upper urinary tract complications in two homogeneous groups of spinal cord injury patients with different bladder emptying modalities (intermittent catheterization vs. tapping, abdominal straining, Crede's manoeuvre) and the relationship with clinic and urodynamic features. A total of 17 patients (22%) had upper urinary tract complications. The incidence of both urinary tract dilatation and vesicoureteral reflux was significantly lower in patients having intermittent catheterization (P = 0.03 and 0.04 respectively). Intermittent catheterization thus seems to be effective in preventing upper urinary tract disease in spinal cord injury patients requiring mechanical bladder emptying modalities. The finding of upper urinary tract complications also in patients having intermittent catheterization showing high intravesical pressures stresses the need of adding anticholinergic medications to the rehabilitation regimen of these patients.