AB0412 CYCLING OF JAK-INHIBITORS IN PATIENTS WITH RHEUMATOID ARTHRITIS: A SINGLE-CENTRE EXPERIENCE

Background

Despite the availability of multiple effective disease-modifying antirheumatic drugs (DMARDs), discontinuation/switching of treatment is common for many patients with rheumatoid arthritis (RA). Janus kinase (JAK) inhibitors or JAKi, are the latest class of DMARDs approved for RA. Data on the outcomes of cycling JAKi in RA patients is still limited to this day.

Objectives

To assess the outcomes of switching between JAKi baricitinib, tofacitinib and upadacitinib in a real-world cohort of RA patients.

Methods

This was a hospital-based, retrospective observational study of all RA patients treated in a single-centre. Data was collected between 2016 and 2021 for all patients who failed JAKi and were treated with another JAKi. Demographic data, antibody status, history of DMARD use and clinical outcomes were assessed according to change in disease activity scores, time to JAKi discontinuation and reason for switching based on DAS 28-CRP scores.

Results

We identified 26 RA patients, 23 (88%) of which were RhF and/or anti-CCP positive, that failed JAKi and were cycled to another JAKi. 23 (88%) patients had failed treatment with one or more biological therapies prior to initiating JAKi. 13 (50%) patients were prescribed baricitinib and the other 13 patients Tofacitinib as their initial JAKi. During their RA treatment pathway, 9 (35%) of the patients on tofacitinib switched to baricitinib, and 4 (15%) switched to upadacitinib. 7 (27%) patients who started on baricitinib were switched to upadacitinib, and 6 (23%) were switched to tofacitinib. 3 (12%) patients cycled between all 3 JAKi. Reasons for switching first JAKi included primary treatment failure at initial 3-month rescore due to lack of efficacy (7/26; 27%), secondary failure (9/26; 35%), adverse drug reactions (ADR) (2/26; 8%) and others (1/26; 4%). Additionally, 7 (27%) patients on tofacitinib were switched following a drug safety update published by the Medicines and Healthcare products Regulatory Agency (MHRA), in an effort to minimize risk of major adverse cardiovascular events and malignancies. The median time to switching first JAKi was 11.5 months (range 3-23 months). After switching JAKi, 17 (65%) patients were found to have improved DAS 28-CRPs at their 3-month rescore and continued treatment with their second JAKi. Following their switch, a total of 8 (31%) patients stopped their second JAKi due to inefficacy, 3 (12%) due to ADRs and 2 (8%) for other reasons. Of the 3 patients that went on to receive treatment with a 3rd JAKi (2/3 for primary failure; 1/3 for secondary failure), 2 patients were found to improve at their 3-month rescore.

Conclusion

Cycling through JAKi is an appropriate and safe treatment strategy in RA patients that discontinue first JAKi therapy due to lack of efficacy or ADR.

References

NA

Disclosure of Interests

None declared

Lithium monitoring in clinical practice

Introduction

Lithium is widely used for the treatment of bipolar disorder. Owing to its narrow therapeutic index and side-effect profile, regular monitoring is recommended by all major guidelines on lithium use.

Objectives

The aim of this study was to determine whether routine lithium monitoring practice at the local mental hospital in Malta reaches the standard set by the most recent NICE guidelines (NICE, 2014a).

Methods

All patients on lithium maintenance treatment for bipolar disorder at the local Mental Hospital were included. Blood tests within the last one year were collected using iSOFT clinical manager (iCM). After the first audit cycle, a lithium monitoring sheet was created in accordance with the NICE guideline and after 6 months of implementation, the second audit cycle was conducuted.

Results

In the first cycle, 28 patients met the NICE criteria for increased risk of toxicity and have a recommended testing frequency for lithium levels of every 3 months. However, only 1 patient was observed to meet this criteria. When assessing the last lithium level only 35.7% were within 0.4-0.8 mmol/L. In the second audit cycle, 28 patients met the NICE criteria for increased risk of toxicity and have a recommended testing frequency for lithium levels of every 3 months. Almost half of the patients (12 patients, 42%) were to observed to meet this criteria. When assessing the last lithium level, 50% were within 0.4-0.8 mmol/L

Conclusions

After the introduction of the lithium monitoring sheet, monitoring improved substantially especially in high risk patients. Moreover, the majority of test results for lithium levels were within the therapeutic range.

Effectiveness of surgical treatment of severe macrocheilia in a patient with orofacial granulomatosis

Orofacial granulomatosis (OFG) is the term given to a group of diseases characterized by the presence of non-necrotizing granulomatous inflammation affecting the soft tissues of the orofacial region. Treatment of OFG is often challenging and unsatisfactory. We report on a 32-year-old man with a 2-year history of oedema and swelling of the upper lip without systemic symptoms. The history, clinical features and histopathological findings led to the diagnosis of cheilitis granulomatosa (CG), a disease included in the spectrum of OFG. The patient was treated with oral diaminodiphenyl sulfone (DDS) and clofazimine without success. Oral doxycycline led to a slight improvement of the disease. Because the volume of the upper lip was twice normal size, surgical reduction was performed, followed by administration of oral doxycycline for 3 months. This therapeutic approach led to complete remission, with no recurrence after 3 years.

Chronic localized leukocytoclastic vasculitis: clinicopathological spectrum of granuloma faciale with and without extrafacial and mucosal involvement

Granuloma faciale (GF) is a rare cutaneous condition of unknown origin, that usually presents as one or more brown-purple papules, plaques and/or nodules, localized mostly on the face, although extrafacial lesions can also occur. Eosinophilic angiocentric fibrosis (EAF) is regarded as the mucosal counterpart of GF. Histologically, it has been described as a persistent leukocytoclastic vasculitis, with a dense polymorphous inflammatory infiltrate in the superficial and mid dermis, typically sparing the subpapillary dermis, the so called grenz zone. The presence of eosinophils is considered a characteristic feature of the disease. All the cases of GF seen at the Dermatology Unit from 2002 to 2013 were considered and reviewed, both clinically and histopathologically. Only cases with consistent clinical findings of GF, and accurate patient's history were considered. Ten cases of GF were reviewed for both histological specificity and clinico-pathological correlation. Two patients presented extrafacial lesions. One patient had involvement of nasal mucosa. Two patients suffered from associated rheumatological diseases. The most frequent histopathologic features were the presence of a grenz zone and eosinophils in the infiltrate, but also adnexal involvement was often present; vascular changes were constant, yet leukocytoclastic vasculitis could be recorded only in four cases. Fibrosis or sclerosis were always absent. Clinical pictures of the patients treated demonstrated a complete remission of the lesions, without scarring. However, a complete enduring healing was observed only in two patients, and relapse or incomplete remission of the disease was the rule. In conclusion a review of clinicopathological findings of ten patients affected by GF was made and new details of the disease presented.

Acute generalized exanthematous pustulosis: report of five cases and systematic review of clinical and histopathological findings

Acute generalized exanthematous pustulosis (AGEP) is a rare, drug-related pustular eruption usually starting from folds with edema and erythema and with subsequent spreading. Clinically AGEP is characterized by the sudden appearance of dozen of sterile, non follicular, small pustules on erythematous and edematous skin. Mild non erosive mucosal involvement, mostly oral, may sometimes occur. Fever, neutrophilia and peripheral blood eosinophilia (in a third of patients) are present. Other skin signs such as facial edema, purpura, target-like lesions and blisters have been described but are not typical for AGEP. Diagnostic criteria for AGEP were established by an international committee of experts, the European Study of Severe Cutaneous Adverse Reactions (EuroSCAR). The most relevant histopathological feature is represented by the detection of non-follicular subcorneal and/or intracorneal spongiform pustules that are usually large, contiguous and tend to coalesce. After elimination of the causative drug, pustules usually spontaneously disappear in a few days with desquamation and the reaction fully resolves within 15 days. Internal organs are not usually involved and no systemic treatment is required. Withdrawal of the culprit drug is mandatory. Although AGEP is a self-limiting disease with a favourable prognosis, secondary infections are a not infrequent complication in patients in poor general medical conditions. The reported mortality is about 5%. The most severe cases are associated with drug rechallenge.

Acute generalized exanthematous pustulosis: report of five cases and systematic review of clinical and histopathological findings

Acute generalized exanthematous pustulosis (AGEP) is a rare, drug-related pustular eruption usually starting from folds with edema and erythema and with subsequent spreading. Clinically AGEP is characterized by the sudden appearance of dozen of sterile, non follicular, small pustules on erythematous and edematous skin. Mild non erosive mucosal involvement, mostly oral, may sometimes occur. Fever, neutrophilia and peripheral blood eosinophilia (in a third of patients) are present. Other skin signs such as facial edema, purpura, target-like lesions and blisters have been described but are not typical for AGEP. Diagnostic criteria for AGEP were established by an international committee of experts, the European Study of Severe Cutaneous Adverse Reactions (EuroSCAR). The most relevant histopathological feature is represented by the detection of non-follicular subcorneal and/or intracorneal spongiform pustules that are usually large, contiguous and tend to coalesce. After elimination of the causative drug, pustules usually spontaneously disappear in a few days with desquamation and the reaction fully resolves within 15 days. Internal organs are not usually involved and no systemic treatment is required. Withdrawal of the culprit drug is mandatory. Although AGEP is a self-limiting disease with a favourable prognosis, secondary infections are a not infrequent complication in patients in poor general medical conditions. The reported mortality is about 5%. The most severe cases are associated with drug rechallenge.

Histopathologic spectrum of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): a diagnosis that needs clinico-pathological correlation

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is characterized by an heterogeneous group of severe dermatologic manifestations and systemic involvement, due to several groups of medicaments. A series of 9 consecutive cases, observed from 2008 to 2013 in the Department of Dermatology, University of Pavia, is reported, all satisfying the clinical, hematological and systemic diagnostic criteria of DRESS. Clinically, 4 out of 9 patients had an urticarial and papular eruption, 2 an erythema-multiforme-like (EM-like) pattern, 2 erythroderma and 1 had an erythematous and macular reaction. Aim of the study was to describe the histopathologic features of DRESS and to trace a possible correlation between the four clinical recognized types of the syndrome and the histopathological patterns. Predominantly, a superficial perivascular lymphocytic infiltrate, extravasation of erythrocytes, and focal interface changes characterized DRESS cases. Less frequently, histopathology revealed the presence of necrotic keratinocytes; surprisingly, only in 2 cases the presence of rare dermal eosinophils was detected, even if all the patients had significant peripheral eosinophilia. A histopathological diagnosis of DRESS seems per se, according to our data, not feasible, since the main histopathological changes (interface changes, superficial perivascular dermatitis, focal spongiosis, lichenoid infiltrate, rare presence of necrotic keratinocytes) can be interpreted generically as a drug induced dermatitis. The above mentioned histopathological changes, however, when associated with clinical information on cutaneous and systemic involvement of the patient, allow the pathologist or the dermatopathologist to make a diagnosis of DRESS with a reliable margin of certainty.

Tyrosine kinase inhibitors: muco-cutaneous side effects at the microscope

In the past recent years, treatments that target receptors with kinase activity, involved in the transmission of neoplastic proliferation signals, had revolutionized cancer therapy. Imatinib mesylate has been the first of this novel family of drugs approved for the treatment of hematologic malignancies. Afterwards, other second-generation kinase inhibitors, such as dasatinib and nilotinib, have been introduced to circumvent resistance to imatinib. These target therapies have a better tolerability profile than standard chemotherapy, but their range of activity is not simply directed at tumor cells, and a wide spectrum of systemic side effects is now recognized. In particular, muco-cutaneous side effects represent the most frequent non-hematological adverse events. Due to the need of a prompt recognition of these toxicities, diagnosis is usually made on clinical grounds, and an accurate histological characterization is generally lacking. The aim of this paper was to focus on the histopathological findings of cutaneous reactions related to tyrosine kinase inhibitors use. We propose a differentiation between specific and non-specific cutaneous side effects, through an analysis of the possible etiopathogenetic mechanisms of actions of the drug, clinical aspects and major histological features. A review of the literature has been integrated by our personal experience, highlighting the importance of clinico-histological correlation, necessary to make a proper diagnosis.

Erroneously low continuous ScvO2 reading due to red blood cells transfusion

Hemoglobin oxygen saturation in superior vena cava (ScvO(2)) is used as a parameter to guide hemodynamic management in shock patients and it can be continuously read through a central venous catheter equipped with a fiberoptic spectrophotometric probe (Edwards PreSep catheter) connected to a specific monitor (Edwards Vigileo). We report of an episode of erroneous ScvO(2) reading by this technology in a patient with septic shock who was receiving an erythrocytes transfusion through the PreSep catheter main lumen. We think this artifact should be known by intensivists since it can lead to ScvO(2) misinterpretation and subsequent erroneous therapeutic decisions.

Isomorphic cutaneous graft-versus-host disease reaction after ultraviolet exposure: clinical, histological and direct immunofluorescence studies of four allo-transplanted patients

BACKGROUND

Acute and chronic graft-versus-host disease (GVHD) continues to be a major limitation to successful haematopoietic stem cell transplantation. If experimental studies and clinical observations could partially elucidate the pathophysiology of acute GVHD, the biology of chronic GVHD is still much less well understood.

OBJECTIVES

The aim of this study is to describe a peculiar photoinduced rash which triggered acute and then chronic lesions of GVHD in four allogenic haematopoietic-transplanted patients and discuss the possible aetiology and treatment.

PATIENTS/METHODS

Four patients, two children and two adults affected by either mild or severe chronic GVHD, developed an erythematous rash on sun- or narrow-band ultraviolet B-exposed area, which triggered the onset of acute lesions of GVHD. Any of the patients presented neither a history of photosensitivity nor circulating autoantibodies nor urinary/fecal porphyrine.

RESULTS

The histopathologic findings were characterized by an interface dermatitis with sparse perivascular infiltrate of lymphocytes and scattered necrotic keratinocytes, especially in the upper part of epidermis. Direct immunofluorescence studies excluded lupus-like pattern, revealing nests of fluorescent bodies at the dermal-epidermal junction and in papillary dermis.

CONCLUSIONS

This peculiar isomorphic reaction of cutaneous GVHD after sun or narrow-band ultraviolet B exposures is described, and the possible mechanism involved is discussed. It may represent an interesting model of progression of chronic GVHD, starting with an acute stage and ending up with chronic clinical and histological findings, especially considering that there is no animal model that fully replicates all of the features of chronic GVHD in humans.

Bartonella-related pseudomembranous angiomatous papillomatosis of the oral cavity associated with allogeneic bone marrow transplantation and oral graft-versus-host disease

Patients undergoing allogeneic stem cell transplantation are at high risk for infection with a variety of pathogens during different phases of the procedure. Human infections due to Bartonella spp. are viewed as emerging diseases typical in, although not exclusive to, immunosuppressed patients, in particular those with AIDS, organ transplants and haematological malignancies. We describe four patients, three children and one adult, who developed vegetating papillomatous lesions exclusively on the oral mucosae. They shared a history of haematological malignancy and allogeneic bone marrow/stem cell transplantation, and later developed chronic graft-versus-host disease, also involving the oral mucosae. Histopathologically, the vegetating lesions were characterized by a diffuse neoangiogenesis, granulation-like tissue, and a mixed cell infiltrate predominantly composed of neutrophils. Gram-negative bacteria were found in the endothelial cells of the vessels in the deeper portion of the corium by electron microscopy. In three cases, DNA of B. henselae was detected by polymerase chain reaction (PCR), and confirmed by sequencing of the PCR products. All the lesions healed after systemic antibiotic therapy, although some recurred after months, and regressed again after systemic antibiotic treatment associated with conservative surgical excision.

Keratoacanthoma in vitiligo lesion after UVB narrowband phototherapy

The treatment of vitiligo is still a challenge. Among various therapeutic modalities, phototherapy with UVB narrowband (UVB-NB) is presently considered a treatment of choice for this skin disease. The exact skin cancer risk deriving from UVB-NB is a serious concern to be determined. We report a case of keratoacanthoma developed in the vitiligo area during a prolonged course of UVB-NB therapy.

Bilateral inguinal hernia with dislocation of great saphenous vein as complication of long-standing granulomatous slack skin: a case report

Granulomatous slack skin (GSS) represents a rare variant of mycosis fungoides, histologically characterized by a variably deep T helper lymphocytes infiltrate with alteration of the dermal elastic tissue and consequent elastolysis, elastophagocytosis and numerous giant cells. Clinically, a development of unelastic, slack skin, especially on flexural areas, is observed. Hereby, we describe a man with a 12-year history of GSS. In 2002, for practical (limitation of movement, deambulation) and cosmetic reasons, he underwent the surgical excision of loose and sagging skinfold over inguinal area, and, afterwards, of the opposite affected inguinal skin. The surgical treatment of bilateral inguinal hernia with reposition of inguinal dislocated vasculature is also reported. In both cases the excised material confirmed the former diagnosis of GSS and revealed a very deep, muscular infiltrate of neoplastic lymphocytes. One year later, a new excision of GSS on the axillae was made. Now, after 2 years, deambulation keeps improving, although an initial relapse of the inguinal slack skin has been observed.

Normal-looking skin in oncohaematological patients after allogenic bone marrow transplantation is not normal

BACKGROUND

Graft-versus-host-disease (GvHD) occurs in one-third or even half of bone marrow transplant (BMT) patients, involving three major target organs: gut, liver and skin.

OBJECTIVES

The histopathological and immunohistochemical features of normal-looking skin in oncohaematological patients on day 100 after BMT were studied to find a possible relationship between the histopathological findings and clinical variables (history or clinical evidence of GvHD, previous therapeutic regimens or infections).

METHODS

Fifty-one Caucasian oncohaematological patients, who had had an allogenic BMT, had a biopsy taken from normal-looking skin in nonsun-exposed areas (buttocks or the lumbar region), around the 100th day after BMT. The histology was studied, and the influence of clinical variables on the development of every different histopathological pattern was evaluated through statistical analysis.

RESULTS

Histopathological analysis based on morphological criteria revealed the presence of three different patterns: a postinflammatory pattern (45%), changes similar to grade I and II of GvHD (31%) and no significant changes (24%). Statistical analysis revealed that only the presence of peaks of cytomegalovirus (CMV) antigen in the blood within 100 days from BMT was significantly associated with the pattern of GvHD-like changes.

CONCLUSIONS

Normal-looking skin in 76% of BMT patients is not necessarily histologically normal. The pattern with more prominent changes, the GvHD-like pattern, has been found to be associated with a more frequent history of CMV antigen in the blood within 100 days from BMT.

HIV seronegative eosinophilic pustular folliculitis successfully treated with doxicycline

Eosinophilic pustular folliculitis (EPF) is an unusual disease, first described in adult East Asians in 1970 by Ofuji. It is characterized by follicular papules and pustules tending to coalesce and form plaques involving the trunk, face and extremities. In recent years, it has been often associated with human immunodeficiency virus (HIV) infection or with immunosuppressed and/or oncohaematological patients. EPF has been described in immunocompetent adult caucasian patients only occasionally. The diagnosis requires clinical and microbiological features such as sterile folliculitis and histopathological findings characterized by folliculitis and perifolliculitis with eosinophilic infiltrate. We describe an HIV seronegative caucasian male with EPF, allergic to non-steroidal anti-inflammatory drugs and indomethacin, treated with oral doxicycline. The treatment led to the complete remission of the lesions within 2 months.

Biliopancreatic Diversion with Transitory Gastric Restriction and Duodenal Bulb Preservation: 88 Patients since 1992

BACKGROUND

Over 10 years, 88 patients underwent biliopancreatic diversion with transitory gastric restriction (BPD-TGR) as a first choice operation or after gastric restrictive procedures.

METHODS

From 1992 to 1999, BPD-TGR was performed on 71 patients as a first choice operation (Group 1 - BMI 41.9 +/- 6.5). The TGR was achieved by a polydioxanone (PDS) band. The duodenal bulb was maintained to 5 cm distal to the pylorus, constructing an end-to-side antecolic isoperistaltic duodeno-ileal anastomosis. Since 1993, a further 17 patients underwent BPD-TGR as a correction for restrictive procedures (Group 2 - BMI 37.4, range 27.2-61.0).

RESULTS

Results in weight loss in Group 1 were similar to those in our previous classical BPD. Percent excess weight loss (%EWL) was 68.0 +/- 18.4, 75.9 +/- 12.3, and 75.4 +/- 12.0 at 1,5 and 10 years respectively. No patient had severe dysproteinemia (only 3% of patients had hypoalbuminemia of 3.0-3.4 g/dl). There was no case of diarrhea or halitosis. Anastomotic ulcers occurred in 2% of the patients. In Group 2, the patients had weight loss already present from the first operation, which continued after BPD-TGR with great variability from patient to patient. %EWL was 35.1 (range 0 to 72.5) and 35.2 (range 18.4 to 43.2) at 1 and 5 years.

CONCLUSIONS

BPD-TGR appears to be an effective operation with few complications and also a satisfactory correction for failed gastric restrictive procedures, or even a sequential operation in the super-obese.

60 reoperations on 890 patients after gastric restrictive surgery

BACKGROUND

Since 1988 we performed gastric restriction operations on 890 patients; 60 required subsequent re-operation.

METHODS

The Molina non-adjustable band was discontinued early because of a high percentage of re-operations. Between 1992 and 1995, we performed the Mason vertical banded gastroplasty (VBG) using a 9-cm long vertical staple-line, with a re-operation rate of 15%. Since 1996, we have been performing a 6-cm long vertical staple-line, with a re-operation rate of 0.7%. The MacLean VBG also had a low re-operation rate (0.9%), but the seriousness of its most dangerous complication, perioperative cardia fistula, limited our use of this method to specifically selected cases. With adjustable banding, we have used the Swedish band which produced a low re-operation rate (2.1%), consisting of relatively simple corrective procedures.

RESULTS

The re-operations produced results similar to those of first-time operations in terms of weight loss and nutritional status. In particular, after 3 years, re-operated patients had similar weight to those who had been operated upon with the same method initially.

CONCLUSIONS

When the surgical procedure was selected with greater astuteness and modified appropriately, the re-operation rate decreased from 17% in the period 1992 to 1995, to 1% in the period 1996 to 2000.

Flexural erythematous eruption following autologous peripheral blood stem cell transplantation: a study of four cases

Autologous bone marrow transplantation and autologous peripheral blood stem cell transplantation (APBSCT) are alternative therapeutic options in the treatment of various malignancies. We describe four patients undergoing APBSCT for malignancies; they developed a cutaneous eruption characterized by confluent erythematous and hyperpigmented patches within the flexural areas during the first month after transplantation. The lesions were poorly circumscribed without epidermal changes such as scaling, xerosis, erosions or atrophy. The skin patches were treated with topical corticosteroids and resolved within a few days with discoloration. Histopathological findings were characterized by focal vacuolar degeneration of the basal layer with epidermal dysmaturation. We believe that these cutaneous eruptions are consistent with an interplay of high-dose chemotherapy and local factors such as friction, local skin temperature and eccrine gland distribution, which could explain the constant location of this eruption in the axillae and genital area.

Adaptability and compliance of the obese patient to restrictive gastric surgery in the short term

BACKGROUND

Low compliance, as well as recurrent vomiting, are often pointed out as the main causes of both postoperative technical complications and poor weight loss.

METHODS

50 patients were examined. All underwent preoperative psychological assessment through an intensive clinical interview. Between October 1999 and January 2000, all the patients underwent vertical banded gastroplasty (VBG). Excess Weight Loss (EWL) was followed, and the number of vomiting episodes was recorded at 1, 3 and 6 months after surgery.

RESULTS

3 different groups of patients could be distinguished: 1) those with no vomiting and good weight loss; 2) those with sporadic vomiting and fairly good weight loss; and 3) those with frequent vomiting and poorer weight loss. However, this last group of patients was not homogeneous and should be divided into 2 subgroups: 1) patients who lose weight, while vomiting; 2) patients who do not lose weight, while vomiting.

CONCLUSIONS

The experience of vomiting is a crucial cross-roads. The influence of psychosocial factors was noticed in all patients. The absence of psychosocial stressors, together with realistic expectations and a strong motivation to change, should be considered as reliable and replicable predictors of success. However, even those patients with accentuated psychological difficulties were able to succeed in coping with them, and achieved a good weight outcome, with good effects on the psychic side. Therefore, the evidence of psychological disorders cannot be taken as an absolute criterion of selection/exclusion of candidates for the operation. Accurate presurgical education and postoperative psychological support are likely to increase the patient's compliance and the percentage of successful cases.

Muco-cutaneous changes during long-term therapy with hydroxyurea in chronic myeloid leukaemia

Hydroxyurea is an antimetabolite agent used in the treatment of myeloproliferative disorders and sickle cell anaemia. Although hydroxyurea is relatively well tolerated, adverse effects often involve skin and mucous membrane during long-term therapy. A group of 510 patients affected by chronic myeloid leukaemia from 1977 to 1998 has been considered. Only 158 patients were treated with hydroxyurea and fulfilled inclusion/exclusion criteria of this study. A spectrum of severe cutaneous and mucosal changes (inflammatory and neoplastic) was seen in about 13% of patients (21 patients out of 158) and was studied in detail. Cutaneous and mucosal atrophy were observed in all 21 patients. Skin atrophy was often characterized by numerous telangiectases, especially on legs and on sun-exposed sites (16/21). Cutaneous, mucosal and nail hyperpigmentation was evident, albeit with variable extent, in 10 of the 21 patients. Severe stomatitis and glossitis with flattening of papillae were another common finding. Five patients, who received a particularly long treatment with hydroxyurea, developed squamous-cell neoplasms on sun-exposed sites (both squamous-cell carcinomas and keratoacanthomas). Acral changes were characteristic and constant, including acral erythema (21/21), dermatomyositis-like changes on the dorsa of hands (7/21), ulcers localized on acral areas of legs, on genitalia and oral mucosae (20/21). The frequency and the variety of these muco-cutaneous changes are reported and the mechanisms by which hydroxyurea may induce this muco-cutaneous syndrome-like group of changes, are proposed.

Wegener granulomatosis in a child: cutaneous findings as the presenting signs

Wegener granulomatosis (WG) is a systemic disease that is particularly unusual in children. A limited form has been described without renal involvement. We report a 14-year-old girl in whom the disease started with acneiform nodular and papular lesions on the forehead. Later necrotic ulcers developed on her forehead, arms, and buttocks. The cutaneous lesions were associated with upper and lower respiratory tract involvement, low-grade fever and arthralgias. Subsequently clinical and laboratory evaluations (increased ESR; leukocytosis and presence of serum IgG antibodies cANCA = 1:160), with chest roentgenograms revealing pulmonary densities and parenchymal infiltration, suggested the diagnosis of WG. The histologic findings of a cutaneous biopsy specimen were ulceration of the epidermis with diffuse neutrophilic inflammatory infiltrate and a late-stage small vessel vasculitis in the dermis. Histopathology of the nasal mucosa was characterized by a granulomatous process with a dense lymphohistiocytic infiltrate with few giant cells, a finding that confirmed the diagnosis of WG. No renal involvement was present. One month of cyclophosphamide (125 mg/day) and prednisone (70 mg/day) therapy markedly improved the patient's clinical condition. At present, 1 year later, she is free from any signs of the disease. According to the literature, the frequency of cutaneous lesions in WG ranges from 16% to 46%. They are the presenting sign only in 6% of patients. Cutaneous lesions are even more uncommon in children. In particular, an "acneiform" presentation is a rare finding in WG.

Divided vertical banded gastroplasty either for correction or as a first-choice operation

BACKGROUND

Staple-line disruption may occur after vertical banded gastroplasty (VBG).

METHODS

Since May 1996, the authors have performed the gastric restrictive procedure divided VBG, as described by MacLean, as a first-choice operation and not only as correction for staple-line breakdown. Divided VBG was done in 111 patients, 32 as correction after staple-line disruption and 79 as a first choice, 29 of them by hand-assisted laparoscopy with the dexterity pneumosleeve.

RESULTS

Weight loss and nutritional status have been very satisfactory. Operating time for the standardized operation has been no longer than 60 minutes.

CONCLUSION

Divided VBG, especially if done by hand-assisted laparoscopy using the dexterity pneumosleeve, is a valid restrictive procedure.

Anesthesia with sevoflurane in bariatric surgery

BACKGROUND

Sevoflurane is a good halogen agent for bariatric surgery anesthesia because of its physical and chemical characteristics and its repartition coefficient (blood/gas = 0.65).

METHOD

From November 1997 to April 1998, 98 bariatric surgery procedures with sevoflurane anesthesia were done: 17 lipectomies, 71 vertical gastroplasties, and 10 biliopancreatic diversions in 71 women and 27 men, average age 30.3+/-8.3 years, with body mass index 43.9+/-5.7. The average operating time was 50+/-15 minutes for vertical gastroplasty, 160+/-20 minutes for biliopancreatic diversion, and 80+/-12 minutes for lipectomy. The technique of anesthesia was as follows: preanesthesia with atropine sulfate 0.01 mg/kg (dosage refers to ideal weight), ranitidine 50 mg, fentanyl 0.1 mg, ketorolac 60 mg; induction with propofol 0.5-1 mg/kg, succinylcholine 1 mg/kg; orotracheal intubation; maintenance with O2-N2O 50%, sevoflurane 1% to 1.5%, actracurium 0.5 mg/kg (dosage refers to ideal weight); awakening and decurarization with atropine sulfate 1 mg and prostigmine 2 mg.

RESULTS

This method permitted correct control of the anesthesia, a quick awakening with a low incidence of nausea and vomiting, a prompt regain of physical and psychological functioning, an early discharge from the hospital, and a larger turnover of patients with lower costs.

CONCLUSION

Sevoflurane balanced anesthesia seems to be the best anesthesiologic method for bariatric surgery.

Reactive angioendotheliomatosis in an infant

Reactive cutaneous angioendotheliomatosis (RCA) is an uncommon benign disease characterized by intravascular proliferation of endothelial cells. The observation of RCA in infants is exceedingly rare. We describe a case of RCA in a 3-month-old infant. The lesions were characterized by six small purpuric papules (1-2 mm in diameter), distributed on the thighs and neck. The general condition of the patient was good, with no lymphadenopathy, systemic involvement, or fever. The histopathologic features of a papule were characterized by the presence of cohesive aggregates of large mononucleated cells protruding into the lumina of dilated vessels and filling some of them completely. Neither an inflammatory infiltrate nor a proliferation of pericytes were present around blood vessels. Intravascular proliferating cells demonstrated positive staining for Ulex europaeus agglutinin 1 (UEA-1) and for Factor VIII-RA and CD34 antigens. The course of the disease was unremarkable with persistence of the lesions for 8 months; no treatment was started.

Biliopancreatic diversion with transitory gastroplasty preserving duodenal bulb: 3 years experience

BACKGROUND

The authors have performed 521 bariatric surgery operations (319 restrictive procedures and 202 malabsorptive procedures).

METHODS

During the last few years we have introduced an evolution of biliopancreatic diversion (BPD): BPD with transitory gastroplasty, preserving the duodenal bulb (53 cases). From a technical point of view, the operation consists of a BPD, coupled with a gastroplasty which is transitory due to the use of a polydioxanone (PDS) band. In the last few cases, instead of a VBG (with PDS band) in order to make the operation completely reversible without any suture on the stomach, we made a gastric pouch by banding with PDS calibrated with the same tube as for the Lap-band (20 cc). We maintained completely the duodenal bulb (5 cm from the pylorus), making an end-to-side duodeno-ileal isoperistaltic anastomosis.

RESULTS

With this anastomosis, only 2% of patients developed an anastomotic ulcer. With this new procedure, results have been good in terms of weight loss (similar to that of BPD-AHS) and in nutritional complications. No patient has had hypoalbuminemia, diarrhea or halitosis.

CONCLUSION

BPD with temporary gastric restriction has provided satisfactory results.

Arrangement of domains, and amino acid residues required for binding of vascular cell adhesion molecule-1 to its counter-receptor VLA-4 (alpha 4 beta 1)

Interaction of the vascular cell adhesion molecule (VCAM-1) with its counter-receptor very late antigen-4 (VLA-4) (integrin alpha 4 beta 1) is important for a number of developmental pathways and inflammatory functions. We are investigating the molecular mechanism of this binding, in the interest of developing new anti-inflammatory drugs that block it. In a previous report, we showed that the predominant form of VCAM-1 on stimulated endothelial cells, seven-domain VCAM (VCAM-7D), is a functionally bivalent molecule. One binding site requires the first and the other requires the homologous immunoglobulin-like domain. Rotary shadowing and electron microscopy of recombinant soluble VCAM-7D molecules suggests that the seven Ig-like domains are extended in a slightly bent linear array, rather than compactly folded together. We have systematically mutagenized the first domain of VCAM-6D (a monovalent, alternately spliced version mission domain 4) by replacing 3-4 amino acids of the VCAM sequence with corresponding portions of the related ICAM-1 molecule. Specific amino acids, important for binding VLA-4 include aspartate 40 (D40), which corresponds to the acidic ICAM-1 residue glutamate 34 (E34) previously reported to be essential for binding of ICAM-1 to its integrin counter-receptor LFA-1. A small region of VCAM including D40, QIDS, can be replaced by the similar ICAM-1 sequence, GIET, without affecting function or epitopes, indicating that this region is part of a general integrin-binding structure rather than a determinant of binding specificity for a particular integrin. The VCAM-1 sequence G65NEH also appears to be involved in binding VLA-4.

Activated endothelium binds lymphocytes through a novel binding site in the alternately spliced domain of vascular cell adhesion molecule-1

Vascular cell adhesion molecule-1 (VCAM-1) is induced on endothelial cells by inflammatory cytokines, and binds mononuclear leukocytes through the integrin very late antigen-4 (VLA-4) (alpha 4 beta 1). This adhesion pathway has been implicated in a diverse group of physiological and pathological processes, including B cell development, leukocyte activation and recruitment to sites of inflammation, atherosclerosis, and tumor cell metastasis. The major form of VCAM-1 (VCAM-7D) has seven extracellular immunoglobulin (Ig)-like domains, of which the three NH2-terminal domains (domains 1-3) are similar in amino acid sequence to domains 4-6. By functional analysis of VCAM-7D relative to VCAM-6D (a minor 6-domain form of VCAM-1 in which domain 4 is deleted because of alternative splicing), and chimeric constructs between VCAM-1 and its structural relative intercellular adhesion molecule-1 (ICAM-1), we show that either the first or the homologous fourth domain of VCAM-1 is required for VLA-4-dependent adhesion. Either of these binding sites can function in the absence of the other. When both are present, cell binding activity is increased relative to monovalent forms of the molecule. The homologous binding regions appear to have originated by internal duplication of a portion of a monovalent ancestral gene, before the mammalian radiation. Thus VCAM-1 exemplifies evolution of a functionally bivalent cell-cell adhesion molecule by intergenic duplication. We have also produced a new class of anti-VCAM-1 monoclonal antibodies that block domain 4-dependent adhesion, and demonstrate that both binding sites participate in the adhesion function of VCAM-1 on endothelial cells in vitro. Therefore both sites must be blocked in clinical, animal, or in vitro studies depending on the use of anti-VCAM-1 antibodies to inactivate the VCAM-1/VLA-4 adhesion pathway.

Activation of endothelial-leukocyte adhesion molecule 1 (ELAM-1) gene transcription

Leukocyte adherence to endothelium is in part mediated by the transient expression of endothelial-leukocyte adhesion molecule 1 (ELAM-1) on endothelial surfaces stimulated by tumor necrosis factor alpha (TNF), interleukin (IL) 1, or bacterial lipopolysaccharide (LPS). The intracellular factors controlling induction of ELAM-1 mRNA and protein are unknown. In nuclear runoff experiments with cultured human umbilical vein endothelial cells (HUVEC), we demonstrate that transcriptional activation of the ELAM-1 gene occurs following stimulation with TNF. Sequence analysis of the 5' flanking region of the ELAM-1 gene reveals consensus DNA-binding sequences for two known transcription factors, NF-kappa B and AP-1. Gel mobility shift assays demonstrate that TNF, IL-1, or LPS (but not IL-2, IL-4, IL-6, interferon gamma, histamine, or transforming growth factor beta) induces activation of NF-kappa B-like DNA binding activity in HUVEC. In contrast, neither TNF, IL-1, nor LPS activates proteins that bind to an AP-1 consensus sequence under these experimental conditions. Phorbol 12-myristate 13-acetate, a known activator of protein kinase C (PKC), weakly induces NF-kappa B-like activity, ELAM-1 mRNA, and ELAM-1 surface expression in HUVEC. However, TNF, IL-1, and LPS do not activate PKC in HUVEC at doses that strongly induce NF-kappa B-like protein activation and ELAM-1 gene expression. PKC blockade with H7 does not inhibit activation of these NF-kappa B-like proteins but does inhibit ELAM-1 gene transcription. We conclude that PKC-independent activation of NF-kappa B in HUVEC with TNF, IL-1, or LPS is associated with, but not sufficient for, activation of ELAM-1 gene transcription.

Cloning of an alternate form of vascular cell adhesion molecule-1 (VCAM1)

Vascular cell adhesion molecule-1 (VCAM1) of the Ig superfamily is induced by the inflammatory cytokines interleukin-1 and tumor necrosis factor on human umbilical vein endothelial cells (HUVECs). It binds to mononuclear leukocytes via the integrin VLA-4. We have cloned and expressed a cDNA encoding a new form of human VCAM1 containing an additional Ig homologous domain inserted between the third and fourth domains of the original six-domain protein. Characterization of mRNA from HUVECs from three individuals at various time points after induction by tumor necrosis factor indicates that both the long and short VCAM1 mRNAs are made by all three individuals, with the long form predominating quantitatively. Immunoprecipitation of VCAM1 protein from cos7 cells transfected with each cDNA and from cultured endothelial cells followed by deglycosylation suggests that the long form is the major form found on endothelium. The two forms may result from alternate splicing of a precursor mRNA. Both forms support adhesion of VLA-4-expressing cell lines.

A blocking monoclonal antibody to endothelial-leukocyte adhesion molecule-1 (ELAM1)

ELAM1 is a leukocyte adhesion molecule induced on human umbilical vein endothelial cells (HUVECs) by inflammatory cytokines. Balb/C mice were immunized with COS cells transiently expressing cell-surface ELAM1 after transfection with ELAM1 cDNA. After fusion, ELAM1-specific monoclonal antibodies (Mabs) were identified by selective adhesion to ELAM1-expressing, but not control, CHO cells, and to cytokine-treated but not untreated HUVECs. One Mab, designated BB11, binds to and immunoprecipitates ELAM1 expressed on HUVECs, COS and CHO cells. BB11 blocks the interaction of ELAM1 with human PMN, the human myelomonocytic cell line HL60, and the human colon carcinoma line HT29.

[Alloplasts in the therapy of hernias]

With the use of mesh prosthetics, it is now easy to repair most difficult hernias with no suture line tension. The Authors report their experience (1984-1988) of dacron meshes: they performed 63 alloplasties with a total of 665 repairs for hernias (9.5%) and the results were satisfactory. They observed only 2 recurrences. The technique is good and can be done safely on all difficult hernias.