Acute care related to cannabis use during pregnancy after the legalization of nonmedical cannabis in Ontario

BACKGROUND

Cannabis use during pregnancy is increasing, but the contribution of cannabis legalization to these trends is unclear. We sought to determine whether health service utilization related to cannabis use during pregnancy increased after the legalization of nonmedical cannabis in October 2018 in Ontario, Canada.

METHODS

In this population-based, repeated cross-sectional study, we evaluated changes in the number of pregnant people who received acute care (emergency department visit or admission to hospital) between January 2015 and July 2021 among all people eligible for the province's public health coverage. We used segmented regression to compare changes in the quarterly rate of pregnant people with acute care related to cannabis use (primary outcome) with the quarterly rates of acute care for mental health conditions or for noncannabis substance use (control conditions). We identified risk factors associated with acute care for cannabis use and the risk of adverse neonatal outcomes using multivariable logistic regression models.

RESULTS

The mean quarterly rate of acute care for cannabis use during pregnancy increased from 11.0 per 100 000 pregnancies before legalization to 20.0 per 100 000 pregnancies after legalization (incidence rate ratio [IRR] 1.82, 95% confidence interval [CI] 1.44-2.31), while acute care for mental health conditions decreased (IRR 0.86, 95% CI 0.78-0.95) and acute care for noncannabis substance use did not change (IRR 1.03, 95% CI 0.91-1.17). Legalization was not associated with an immediate change, but the quarterly change in rates of pregnancies with acute care for cannabis use increased by 1.13 (95% CI 0.46-1.79) per 100 000 pregnancies after legalization. Pregnant people with acute care for cannabis use had greater odds of having received acute care for hyperemesis gravidarum during their pregnancy than those without acute care for cannabis use (30.9% v. 2.5%, adjusted odds ratio [OR] 9.73, 95% CI 8.01-11.82). Pregnancies with acute care for cannabis use had greater odds of newborns being born preterm (16.9% v. 7.2%, adjusted OR 1.93, 95% CI 1.45-2.56) and of requiring care in the neonatal intensive care unit (31.5% v. 13.0%, adjusted OR 1.94 95% CI 1.54-2.44) than those without acute care for cannabis use.

INTERPRETATION

The rate of acute care related to cannabis use during pregnancy almost doubled after legalization of nonmedical cannabis, although absolute increases were small. These findings highlight the need to consider interventions to reduce cannabis use during pregnancy in jurisdictions pursuing legalization.

The BEACON study: an update to the protocol for a cohort study as part of an evaluation of the effectiveness of smartphone-assisted problem-solving therapy in men who present with intentional self-harm to emergency departments in Ontario

BACKGROUND

Men who present to the emergency department (ED) with self-harm are at high risk of dying by suicide, with 2.7% of men dying in the year following their presentation, more than double the rate for women (1.2%). Despite this, care received after an ED visit is highly variable and many are not assessed for psychological needs. Furthermore, the limited psychological care that is available is often not covered by provincial health insurance. Even when referrals for follow-up care are made, engagement rates are low. Previous recommendations to improve engagement include written discharge plans, caring contacts, and focused interventions targeting middle-aged men at elevated risk of dying by suicide. Blended care, the incorporation of technology into traditional care, has also been proposed as a method to increase engagement in and clinical benefits from psychotherapy. This project aims to determine whether the delivery of an evidence based treatment (problem-solving therapy (PST)) is enhanced by the addition of a custom smartphone application (BEACON) compared to usual care. Due to the impact of the COVID-19 pandemic on site participation and the planned implementation, we have made several changes to the study design, primary outcome, and implementation.

METHOD

We originally proposed a cohort study nested within a larger cluster randomized trial wherein intervention sites would deliver the blended care, and control sites, whose personnel were not aware of their participation, would continue delivering usual care. The cohort study evaluated participant level outcomes as previously described by Hatcher et al. (2020). Due to pandemic-related constraints, our number of participating sites dropped to five potential sites which left the cohort study underpowered. As such, we changed the study design to a multi-site, individual randomized controlled trial (RCT) among the five remaining sites. Participants will be randomized to six sessions of therapy (PST) alone, or to the therapy plus BEACON, and followed up for 6 months. Our primary outcome was changed to evaluate feasibility and acceptability with the aim of designing a definitive RCT. Study implementation was reimagined to allow for completely virtual/online conduct to comply with local COVID-19 and institutional restrictions on in-person activities.

CONCLUSION

This updated protocol will provide strong results for the planning of a definitive RCT of the blended care intervention in the future, addressing areas of difficulty and concern prior to its implementation. We will evaluate the feasibility of the study intervention, assess recruitment and retention of participants, and address challenges with implementing the protocol. Lastly, we will evaluate the appropriateness of our primary outcome measure and accurately determine a sample size for a definitive RCT.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03473535 . Registered on March 22, 2018.

Enhancing COVID Rehabilitation with Technology (ECORT): protocol for an open-label, single-site randomized controlled trial evaluating the effectiveness of electronic case management for individuals with persistent COVID-19 symptoms

BACKGROUND

As of May 2022, Ontario has seen more than 1.3 million cases of COVID-19. While the majority of individuals will recover from infection within 4 weeks, a significant subset experience persistent and often debilitating symptoms, known as "post-COVID syndrome" or "Long COVID." Those with Long COVID experience a wide array of symptoms, with variable severity, including fatigue, cognitive impairment, and shortness of breath. Further, the prevalence and duration of Long COVID is not clear, nor is there evidence on the best course of rehabilitation for individuals to return to their desired level of function. Previous work with chronic conditions has suggested that the addition of electronic case management (ECM) may help to improve outcomes. These platforms provide enhanced connection with care providers, detailed symptom tracking and goal setting, and access to relevant resources. In this study, our primary aim is to determine if the addition of ECM with health coaching improves Long COVID outcomes at 3 months compared to health coaching alone.

METHODS

The trial is an open-label, single-site, randomized controlled trial of ECM with health coaching (ECM+) compared to health coaching alone (HC). Both groups will continue to receive usual care. Participants will be randomized equally to receive health coaching (± ECM) for a period of 8 weeks and a 12-week follow-up. Our primary outcome is the WHO Disability Assessment Scale (WHODAS), 36-item self-report total score. Participants will also complete measures of cognition, fatigue, breathlessness, and mental health. Participants and care providers will be asked to complete a brief qualitative interview at the end of the study to evaluate acceptability and implementation of the intervention.

DISCUSSION

There is currently little evidence about the optimal treatment of Long COVID patients or the use of digital health platforms in this population. The results of this trial could result in rapid, scalable, and personalized care for people with Long COVID which will decrease morbidity after an acute infection. Results from this study will also inform decision making in Long COVID and treatment guidelines at provincial and national levels.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05019963. Registered on 25 August 2021.

Is the hospital Safety Walkround effective to control the risk of contagion during COVID-19 pandemic?

Background

The Safety Walk Round (SWR) is a risk assessment technique designed to decrease adverse events and improve workers attitudes about safety culture through visits and interviews about safety of care. A new field of application could be the safety requirements that hospitals have to guarantee during the Covid-19 pandemic. Our study aimed to investigate the efficacy of SWR on identifying and solving the critical issues that can increase the risk of SARS-CoV-2 infection in three Italian hospitals.

Materials and Methods

The project was developed during the first wave of SARS-Cov-2 pandemic, from May to July 2020, it involved 3 hospitals in Turin: Traumatology and Orthopaedic Centre, Paediatric Hospital Regina Margherita and Sant'Anna Hospital (obstetric and gynaecological hospital). Pre-triage services and outpatient waiting rooms were identified as areas at higher risk of crowding and potential non-compliance with anti-contagion rules. The first round consisted of observations focused on hands sanitation, safety social distance, PPE correct use. Than the workers of the observed areas were interviewed. Thanks their participation, the critical issues about patient safety and the potential resolutions were identified. A second round was realized to verify the implementation of the planned actions and their effectiveness in solving the issues.

Results

A total of 4907 moments were observed and the 9,1% of them was at risk of contagion. During the interviews 23 critical issues and their possible resolutions were identified. A total of 14 critical issues were solved, 4 partially solved and 5 were build environmental problems and cannot be solved. The 77% of total were completely solved, excluding built environment issues.

Conclusions

SWR project was effective in involving health workers in safety promotion activities, sharing informations and improving trust between hospital managers and operators and spreading new skills about safety culture in Covid-19 pandemic contest.

Key messages

SWR was effective in a pandemic context. During the emergency, the front line staff were enthusiastic about the method and felt listened and guided.This has contributed to achieving the aim of safety.

The study showed that SWR is a useful tool for hospital infection control. It also showed that the SWR method can be used in a time of constant change that requires adaptability like a pandemic.

Postpartum mental illness during the COVID-19 pandemic: a population-based, repeated cross-sectional study

BACKGROUND:

It is unclear whether the clinical burden of postpartum mental illness has increased during the COVID-19 pandemic. We sought to compare physician visit rates for postpartum mental illness in Ontario, Canada, during the pandemic with rates expected based on prepandemic patterns.

METHODS:

In this population-based, repeated cross-sectional study using linked health administrative databases in Ontario, Canada, we used negative binomial regression to model expected visit rates per 1000 postpartum people for March–November 2020 based on prepandemic data (January 2016–February 2020). We compared observed visit rates to expected visit rates for each month of the pandemic period, generating absolute rate differences, incidence rate ratios (IRRs) and their 95% confidence intervals (CIs). The primary outcome was a visit to a primary care physician or a psychiatrist for any mental disorder. We stratified analyses by maternal sociodemographic characteristics.

RESULTS:

In March 2020, the visit rate was 43.5/1000, with a rate difference of 3.11/1000 (95% CI 1.25–4.89) and an IRR of 1.08 (95% CI 1.03–1.13) compared with the expected rate. In April, the rate difference (10.9/1000, 95% CI 9.14–12.6) and IRR (1.30, 95% CI 1.24–1.36) were higher; this level was generally sustained through November 2020. From April–November, we observed elevated visit rates across provider types and for diagnoses of anxiety, depressive and alcohol or substance use disorders. Observed increases from expected visit rates were greater for people 0–90 days postpartum compared with 91–365 days postpartum; increases were small among people living in low-income neighbourhoods. Public health units in the northern areas of the province did not see sustained elevations in visit rates after July; southern health units had elevated rates through to November.

INTERPRETATION:

Increased visits for mental health conditions among postpartum people during the first 9 months of the COVID-19 pandemic suggest an increased need for effective and accessible mental health care for this population as the pandemic progresses.

Examining the effects of pre-pregnancy weight and gestational weight gain on allergic disease development in offspring: a protocol for a population-based study using health administrative databases in Ontario, Canada

INTRODUCTION

Over the last 20 years, excess maternal pre-pregnancy weight (overweight and obesity) and gestational weight gain have become the most common morbidities in pregnancy. These morbidities may pose a threat to fetal immunological development through associated metabolic dysfunction and inflammation and, as such, may partly explain the concurrent rise of paediatric allergic disease. We will examine the effect of maternal pre-pregnancy weight and gestational weight gain during pregnancy on the incidence of allergic diseases among offspring in Canada's most populous province.

METHODS AND ANALYSIS

We will conduct a retrospective, population-based cohort study of all singleton live births to residents of Ontario, Canada in 2012-2013 and 2013-2014. The study population will be defined using maternal-newborn records from the provincial birth registry, which captures information on maternal pre-pregnancy weight and gestational weight gain. The cohort will be linked with provincial health administrative databases, allowing for follow-up of neonates through early childhood until 2019 (5-7 years of age). Allergic disease development (asthma, rhinitis, atopic dermatitis and anaphylaxis) will be ascertained using diagnostic codes from healthcare encounters. Potential confounders have been identified a priori through a directed acyclic graph. Cox proportional hazards regression models will be employed to assess the associations between maternal pre-pregnancy weight, gestational weight gain and incident paediatric allergic disease. Several preplanned sensitivity analyses will be conducted, including a probabilistic bias analysis of outcome misclassification.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Research Ethics Board of the Children's Hospital of Eastern Ontario and the ICES Privacy Office. Findings will be disseminated in scientific conference presentations and peer-reviewed publications.

[Organization and management of clinical-care pathways at the Regina Margherita Hospital in Turin during Covid-19 emergency]

The Covid-19 pandemic significantly increased the workload for the Italian Health Service. There is few information in the literature on the pediatric population and on the management of pediatric hospitals. The aim of this article is to describe the management of healthcare services during Covid-19 emergency in Regina Margherita Children's Hospital. The Regina Margherita Children's Hospital is specialized in the prevention, diagnosis and treatment of pediatric diseases. About 1000 health worker work in this Hospital and 278 hospitalization places are available.

Predicting difficult discharge from surgical wards: a cohort study in an Italian sample

Background

Poor discharge planning (DP) can increase costs for European hospitals and worsen patient's experience. Validated scores are used in internal medicine to identify clinical or social difficulties in discharges upon admission but there is a lack of such a tool in the surgical context. This study aims to detect early predictors of difficult discharge.

Methods

Socio-demographic and clinical data from 15,165 surgical Hospital Discharge Records (SDOs) of the Molinette hospital of Turin, including an additional pre-surgery evaluation of social vulnerabilites from a subgroup of 388 patients, were collected between 2017 and 2019. Outcomes were length of stay (LOS), discharge destination (home, Long Term Care - LTC). Descriptive analysis and multivariable regressions were performed.

Results

52.3% of patients were male and the median age was 61 (IQR 22). Median LOS was 6 days (IQR 6) but 15 (IQR 30) for patients discharged to LTC. 18.7% were admitted through the Emergency Department (ED) with a median LOS of 7 (IQR 10). 17.6% of the subsample declared living alone. Linear regression showed associations between discharge to LTC, admission through ED, diagnosis of neoplasia and a longer LOS (Bs 10.76, 5.21 and 2.57 respectively, p < 0.001). Logistic regression showed associations between admission by ED, age and discharge to LTC (OR 1.77 and 1.02 respectively, p < 0.001). Preliminary analysis of the subsample did not show any new association with social vulnerabilities, but 98.2% attended elective surgery and thus probably had time to prepare for discharge.

Conclusions

Surgery LOSs are extremely diversified among patients. This study identified several predictors of difficult discharge, mainly admission through ED, discharge to LTC and diagnosis of neoplasia, suggesting difficulties handling an unexpected event by patients' relatives. Further studies gathering patients' data at admission are required in order to develop a predictive tool useful for European hospitals.

Key messages

Clinical (cancer) and social (sudden event, no housing solutions) factors can determine a difficult discharge for European patients and should be investigated to anticipate discharge planning. Elective surgery patients seem less prone to social vulnerabilities (e.g. living alone), probably because relatives have time to prepare, while ED patients often need help in the discharge process.

Transition of care from paediatric to adult age for rare chronic disorders: an Italian experience

Background

Transition of care represents the transfer from child to adult care. An effective transition maintains continuity of care and presents better clinical outcomes. Thanks to improved survivorship of chronic paediatric patients to adulthood, this process has assumed growing relevance. Aim of the study was to evaluate quality and effectiveness of transition of care model of one of the biggest Hospitals of Northern Italy, that has organised a common structured model, differentiated according to patients' clinical and social complexity.

Methods

The sample consisted of patients with chronic rare diseases transited within the Hospital in the years 2016-2019. To analyse the evolution of all pathologies, for each patient the medical record was consulted; questionnaires were then administered to patients to investigate their illness perception and quality of life.

Results

The average age at transition of the retrospective study patients was 19.8±4.7 years. For most disorders, 100% of patients made the first post-transition visit. More than 90% of patients who did not make further post-transition visits were patients with Neurofibromatosis 1. Only 7 out of 18 patients with NF1 continued their treatment to the indicated specialist. One-year drop-out was 13%. Regarding the perception of one's own illness, 78% of respondents consider their health status from good to excellent, but more than 30% of respondents believe not to have currently adequate psychological and social support.

Conclusions

Transition of care represents an important phase in chronic diseases management. The proposed model assures a multidisciplinary approach, involving all specialists of both paediatric and adult teams. Preliminary data were positive and showed how this model could be an example for other institutions in Europe. Anyway, the transition model might be still be improved. Our data underlined the importance of a complete taking charge, with peculiar attention to psychological and social support.

Key messages

The study shows to the European Healthcare Providers the importance of a personalized planning of transition of care, that considers the complexity of clinical situation and concomitant social issues. A successful strategy of transition of care requires a multidisciplinary approach, that guarantees a complete taking charge, with peculiar attention to psychological and social support.

Abstract P4-13-07: SEQUERPLUS: A multicenter real practice observational study investigating the endocrine-based (E) therapies sequential approach in hormonal receptor positive (HR+) HER2 negative (-) metastatic breast cancer (MBC)

Background: Despite the sequential E therapy is recognized as the preferred approach for HR+/HER2- MBC, no data from clinical trials support the choice between the different sequential strategies.

Methods: In this retrospective study descriptive statistics are reported using the median (Interquartile range, IQR) or frequency. Progression Free Survival (PFS) curves were estimated with the Kaplan-Meier method and compared with the log-rank test. Analysis were performed by SPSS version 21.0 (SPSS Inc., Chicago, IL).

Results: From January 2006 to December 2017, 240 patients (pts) with HR+/HER2- MBC receiving at least two consecutive E therapies as first approach were selected from 12 italian cancer centers. The median age at the time of metastasis onset was 63.5 (IQR: 55-72.5) years; 184 (76.7%) pts were in menopausal status; 38 (16%) had de novo stage IV disease and the remaining 202 (84%) had recurrent BC with a median time of 78 months (5-396 months). At the beginning of MBC diagnosis, 148 (62%) pts had a single site of distant disease, 108 (45%) of whom had bone only disease and 45 (18.8%) presented visceral involvement too. The aromatase inhibitor (AI) was chosen as I-line therapy in 146 (60.9%) pts, followed by Fulvestrant (F) in 62 (25.8%) pts; the alternative I-line options were everolimus-exemestane (Eve-Exe), tamoxifene (T), Palbociclib (P)+AI and F+AI in 13 (5.4%), 14 (5.8%), 1 (0.4%) and 4 (1.7%) pts, respectively. The most favourite II-line option resulted F for 111 (46.2%) pts while the Eve-Exe combination was chosen in 70 (29.2%) pts, AI in 30 (12.5%) pts; T, AI+F, P+F and antiprogestincwere administered in 4 (1.7%), 4 (1.7%), 19 (7.9%) and 2 (0.8%) pts, respectively. For I and II-line, the AI followed by F (40%) and F followed by Eve-Exe (18%) were the most common sequential therapeutic approaches; the several alternative options were scanty used (in less than 10%). The median Progression-Free Survival (PFS) from first and second-line E therapies resulted 15.7 (95% CI 13.3-18.1) and 10.3 months (95% CI 8.7-11.9), respectively. Among 194 pts with disease progression after second-line E therapy, 87 (44.8%) received further E therapies with a median PFS 9.4 months (95% CI 7.9-10.9). The remaining 70 (29.2%) pts was treated with palliative chemotherapy. Interestingly, the median Overall Survival (OS) was even longer for pts receiving more lines of E therapies compared to the group with earlier introduction of chemotherapy (204.3 vs 92.8; p=0.007).

Finally, in the subgroup analyses a longer PFS benefit was observed in pts with disease recurrence over 12 months from initial diagnosis (38.1 vs 30.3 months p=0.04) and limited sites of disease involvement at the time of MBC diagnosis (37.6 vs 28.3 months, p=0.03)

Conclusions: The sequential use in first and second-line setting of E therapies for HR+/HER2- MBC improves median PFS up to 32.3 months. According to real practice experience the optimal sequences could be AIs followed by F and F followed by Eve-Exe. A role for these compounds should be redefined in the light of recently introduction of CDK 4/6 inhibitors in combination with AIs or F for the first or later lines.

Citation Format: Fabi A, Giannarelli D, Botticelli A, Scagnoli S, Pellegrino A, Fabbri A, Corsi D, Magri V, Pizzuti L, Paris I, Bruni V, Pace R, Lanzetta G, Stani S, Moscetti L, Marchetti P, Piesco G, Cognetti F, Rossi V. SEQUERPLUS: A multicenter real practice observational study investigating the endocrine-based (E) therapies sequential approach in hormonal receptor positive (HR+) HER2 negative (-) metastatic breast cancer (MBC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-13-07.

Availability and affordability of essential medicines for diabetes across high-income, middle-income, and low-income countries: a prospective epidemiological study

BACKGROUND

Data are scarce on the availability and affordability of essential medicines for diabetes. Our aim was to examine the availability and affordability of metformin, sulfonylureas, and insulin across multiple regions of the world and explore the effect of these on medicine use.

METHODS

In the Prospective Urban Rural Epidemiology (PURE) study, participants aged 35-70 years (n=156 625) were recruited from 110 803 households, in 604 communities and 22 countries; availability (presence of any dose of medication in the pharmacy on the day of audit) and medicine cost data were collected from pharmacies with the Environmental Profile of a Community's Health audit tool. Our primary analysis was to describe the availability and affordability of metformin and insulin and also commonly used and prescribed combinations of two medicines for diabetes management (two oral drugs, metformin plus a sulphonylurea [either glibenclamide (also known as glyburide) or gliclazide] and one oral drug plus insulin [metformin plus insulin]). Medicines were defined as affordable if the cost of medicines was less than 20% of capacity-to-pay (the household income minus food expenditure). Our analyses included data collected in pharmacies and data from representative samples of households. Data on availability were ascertained during the pharmacy audit, as were data on cost of medications. These cost data were used to estimate the cost of a month's supply of essential medicines for diabetes. We estimated affordability of medicines using income data from household surveys.

FINDINGS

Metformin was available in 113 (100%) of 113 pharmacies from high-income countries, 112 (88·2%) of 127 pharmacies in upper-middle-income countries, 179 (86·1%) of 208 pharmacies in lower-middle-income countries, 44 (64·7%) of 68 pharmacies in low-income countries (excluding India), and 88 (100%) of 88 pharmacies in India. Insulin was available in 106 (93·8%) pharmacies in high-income countries, 51 (40·2%) pharmacies in upper-middle-income countries, 61 (29·3%) pharmacies in lower-middle-income countries, seven (10·3%) pharmacies in lower-income countries, and 67 (76·1%) of 88 pharmacies in India. We estimated 0·7% of households in high-income countries and 26·9% of households in low-income countries could not afford metformin and 2·8% of households in high-income countries and 63·0% of households in low-income countries could not afford insulin. Among the 13 569 (8·6% of PURE participants) that reported a diagnosis of diabetes, 1222 (74·0%) participants reported diabetes medicine use in high-income countries compared with 143 (29·6%) participants in low-income countries. In multilevel models, availability and affordability were significantly associated with use of diabetes medicines.

INTERPRETATION

Availability and affordability of essential diabetes medicines are poor in low-income and middle-income countries. Awareness of these global differences might importantly drive change in access for patients with diabetes.

FUNDING

Full funding sources listed at the end of the paper (see Acknowledgments).

Local effects of atherosclerotic plaque on arterial distensibility

Hypertension, diabetes, and hypercholesterolemia are characterized by a reduction in arterial distensibility and by accelerated atherosclerosis. Whether arterial stiffening is an inherent feature of these conditions or just the consequence of the atherosclerotic clinical or subclinical lesions is not known, however. Our aim was to obtain information on this issue by directly measuring, in humans, arterial distensibility both at the site of an atherosclerotic lesion and at the proximal normal site. In 10 patients (8 men; mean+/-SEM age, 65.2+/-3.4 years) affected by monolateral hemodynamic significant internal carotid artery stenosis, we measured arterial distensibility (Wall Track System; PIE Medical) bilaterally, both at the internal carotid artery and at the common carotid artery level. In the common carotid artery, measurements were made 3 cm below the bifurcation. In the affected internal carotid artery, measurements were made at the plaque shoulder (wall thickness of 2 mm). Measurements were made in the contralateral internal carotid artery at a symmetrical level. Arterial wall thickness was measured in the same site of arterial distensibility. Arterial distensibility was less in the internal than in the common carotid artery, with a marked reduction at the plaque internal carotid artery level compared with the corresponding contralateral site (-45%, P<0.01). It was also less, however, in the common carotid artery branching into the atherosclerotic internal carotid artery than in the contralateral common carotid artery (-25%, P<0.05). Wall thickness was similar in the 2 common carotid arteries and obviously greater in the affected internal carotid artery than in the contralateral artery. Arterial distensibility was markedly less in the internal carotid artery where there was a plaque compared with the intact contralateral internal carotid artery; it was also less, however, in the common carotid artery of the affected side in comparison with the contralateral common carotid artery. This provides evidence that the effect of a plaque on arterial mechanical properties is not limited to the actual plaque site but rather extends to a considerable degree in a proximal direction.

Identification of Blood Erythroid Markers Useful in Revealing Erythropoietin Abuse in Athletes

Recombinant human erythropoietin (rEpo) is being used with increasing frequency by endurance athletes to improve aerobic potential. Although rEpo administration has been banned by the International Olympic Committee, no methods are available to unequivocally detect its abuse in sports. Prompted by these considerations, we evaluated the main hematological and biochemical modifications measured in the blood of 18 volunteers upon rEpo administration. Different rEpo regimens, iron, folic acid, and vitamin B12 administration did not significantly modify the percentage increase in hematocrit. However, a significant decrease in circulating ferritin (fr) and an increase in the soluble transferrin receptor (sTfr) were not found in athletes receiving low (30 IU/kg) doses of rEpo. Thus, an increase in the sTfr/fr ratio cannot be used as an indicator of rEpo abuse, at least when the hormone is administered at low concentrations. In contrast, the amounts of beta-globin mRNA detected by quantitative competitive (RT)-PCR in whole blood samples significantly increased above the threshold levels in all of the treatments investigated. Taken together, these data suggest that hematocrit value, reticulocyte count, soluble transferrin receptor content, and concentration of beta-globin mRNA, when included in a new multiparametric formula, can detect rEpo abuse in 57.5% of the samples examined with a confidence interval of 99.99%. Thus, the method reported in this paper could significantly improve the tests currently available, which in similar experiments allowed the detection of rEpo abuse in only 7.6% of the samples examined.

Unscheduled cyclin B expression and p34 cdc2 activation in T lymphocytes from HIV-infected patients

OBJECTIVE

To study the role of cell cycle regulation during HIV infection by investigating in vivo and in vitro cyclin B and p34 cdc kinase expression.

METHODS

Cyclin B expression was analysed by Western blot in CD4 and CD8 cells from 25 HIV-infected patients and 24 uninfected individuals. In eight patients, a sequential analysis was performed after initiation of antiretroviral therapy (ART), and correlations with CD4 cell count and HIV viremia were studied. Sequential changes in cyclin B expression and p34 cdc kinase expression and activity were also studied in lymphocytes activated in vitro with phytohaemagglutinin (PHA).

RESULTS

Lymphocytes from untreated HIV-infected patients demonstrate persistent in vivo overexpression of cyclin B in both CD4 and CD8 cell subpopulations. When cells are stimulated to proliferate in vitro, biochemical events that characterize the entrance into the cell cycle [ornithine decarboxylase (ODC) activity, interleukin 2 production, interleukin 2 alpha-chain receptor (IL-2R, CD25) expression, total protein synthesis, total DNA synthesis] show similar timing and sequence in lymphocytes from HIV-infected and uninfected individuals. However, in peripheral blood lymphocytes (PBL) from HIV-infected patients, cyclin B and p34 cdc kinase show premature expression during the cell cycle. Both in vivo cyclin B overexpression and in vitro unscheduled cyclin B expression were almost completely reversed 2-4 weeks after initiation of effective ART.

CONCLUSION

Increased and unscheduled expression of cyclin B and p34 cdc kinase is consistently observed in CD4 and CD8 cells from HIV-infected patients, both in vivo and after in vitro mitogenic stimulation. These alterations correlate with the level of viremia and may provide a link between the perturbation of lymphocyte proliferative homeostasis and the exaggerated propensity towards apoptosis.

Alteration of alpha-spectrin ubiquitination due to age-dependent changes in the erythrocyte membrane

Mammalian red blood cell alpha-spectrin is ubiquitinated in vitro and in vivo [Corsi, D., Galluzzi, L., Crinelli, R., Magnani, M. (1995) J. Biol. Chem. 270, 8928-8935]. This process shows a cell age-dependent decrease, with senescent red blood cells having approximately one third of the amount of ubiquitinated alpha-spectrin found in young cells. In-vitro ubiquitination of alpha-spectrin was dependent on the source of the red cell membranes (those from older cells are less susceptible to ubiquitination than those from younger cells), on the source of ubiquitin-conjugating enzymes (those from older cells catalyze the process at a reduced rate compared to those from younger cells) and on the ubiquitin isopeptidase activity (which decreases during red cell ageing). However, once alpha-spectrin has been extracted from the membranes of young or old red blood cells, it is susceptible to ubiquitination to a similar extent regardless of source. This suggests that it is the membrane architecture, and not spectrin itself, that is responsible for the age-dependent decline in ubiquitination. Furthermore, spectrin oligomers, tetramers and dimers are also equally susceptible to ubiquitination. As spectrin ubiquitination occurs on domains alphaIII and alphaV of alpha-spectrin, and domain alphaV contains the nucleation site for the association of the alpha- and beta-spectrin chains, alterations in ubiquitination during red cell ageing could affect the stability and deformability of the erythrocyte membrane.

Protein degradation and apoptotic death in lymphocytes during Fiv infection: activation of the ubiquitin-proteasome proteolytic system

The movement of a cell through the sequential phases of apoptosis is accompanied by a progressive decrease in cell size with loss in protein mass. In lymphocytes from Hiv-infected persons, protein loss during apoptosis is due to increased protein degradation rather than decreased synthesis. To identify and characterize the proteolytic enzymes or enzyme systems involved in this process, we studied several features of protein turnover in lymphocytes from peripheral blood and lymph nodes during the natural and experimental infection by feline immunodeficiency virus (Fiv). This animal model allowed us to integrate in vivo results with in vitro observations of protein damage. Here we report that protein breakdown in apoptotic cells is concomitant with the activation of the ATP and ubiquitin-dependent multicatalytic system (proteasome). We suggest that proteasome activation is part of the proteolytic cascade in the execution phases of apoptosis in AIDS.

Effects of flow triggering on breathing effort during partial ventilatory support

The effects of flow triggering (FT) as compared with pressure triggering (PT) on breathing effort have been the focus of several studies, and discrepant results have been reported. In the initial part of our study, a lung model was used to quantify triggering effort (airway pressure-time product, PTPaw) for a range of sensitivity settings in nine new-generation ventilators. A ventilator providing both FT and PT was then used to compare these systems during pressure-support (PSV) and volume-targeted assist-control ventilation (ACV) in eight ventilator-dependent patients, using sensitivity settings (2 L/min for FT and -2 cm H2O for PT) that had proven significantly different in the initial bench study. Indexes of effort included the esophageal and transdiaphragmatic pressure-time products and inspiratory work of breathing per minute (PTPes/min, PTPdi/min, and Wi/min, respectively). The experimental study revealed significant differences between ventilators in PTPaw at commonly used settings. In two of three ventilators featuring both systems, PTPaw was significantly lower with FT than PT (p < 0.001). In the clinical study, FT as compared with PT, was associated with reductions in all indexes of breathing effort during PSV: 16 +/- 6% (p < 0.001), 13 +/- 10% (p < 0.01), and 14 +/- 12% (p < 0.05) for PTPdi/min, PTPes/min, and Wi/min, respectively. By contrast, no differences were found when FT was used during ACV. Although FT reduced triggering effort in both modes (p < 0.001), the effects observed during the post-trigger phase differed, and explained the discrepant results between the two modes. We conclude that FT more effectively reduces breathing effort when used in conjunction with a pressure-targeted mode than with a volume-targeted mode, especially when flow delivery is close to or below demand.

Oxidative protein damage and degradation in lymphocytes from patients infected with human immunodeficiency virus

It has been proposed that oxidative stress is the common mediator of apoptotic cell death in AIDS. However, mechanistic relationships between oxidative damage and cell death are far from clear. It is reported here that the mitogenic activation of T lymphocytes from human immunodeficiency virus-positive subjects involves perturbation of redox balance, as indicated by the increase in hydroethydine intracellular oxidation and manganese superoxide dismutase adaptive induction. Principal molecular targets of oxidative injury are cellular proteins whose content in carbonyl groups increases together with a dramatic increase in degradation of newly synthesized proteins catalyzed by the ATP- and ubiquitin-dependent proteolytic system. The major consequence of this metabolic anomaly is the decrease in protein cell mass leading to cells that are smaller than normal at lethal mitosis.

Identification of alpha-spectrin domains susceptible to ubiquitination

Previously, we demonstrated that alpha-spectrin is a substrate for the ubiquitin system and that this conjugation is a dynamic process (Corsi, D., Galluzzi, L., Crinelli, R., and Magnani, M. (1995) J. Biol. Chem. 270, 8928-8935). In this study, we mapped the sites of ubiquitination on erythrocyte alpha-spectrin. A peptide map of digested alpha-spectrin, previously submitted to in vitro 125I-ubiquitin conjugation, revealed the presence of four distinct labeled bands with Mr 40,000, 36,000, 29,000, and 25,500. Western blotting experiments using antibodies against each alpha-spectrin domain revealed that only IgG anti-alphaIII domain recognized the 125I-labeled ubiquitin peptide of 29 kDa, whereas the IgG anti-alphaV domain recognized the Mr 40,000 125I-ubiquitin-labeled peptide. The other two labeled bands of Mr 36,000 and Mr 25,500 were identified as tetra and tri multiubiquitin chains. Ubiquitination of the alphaIII and alphaV domains was further confirmed by anti-alpha-spectrin domain immunoaffinity chromatography. Endoprotease Lys C-digested spectrin conjugated previously to 125I-ubiquitin was incubated with antibodies against each trypsin-resistant domain of alpha-spectrin. Gamma counting of the radiolabeled antigen-antibody complexes purified by protein A chromatography showed labeling in the IgG anti-alphaIII and anti-alphaV complexes alone. Domain alphaIII is not associated with any known function, whereas domain alphaV contains the nucleation site for the association of the alpha and beta chains. Ubiquitination of the latter domain suggests a role for ubiquitin in the modulation of the stability, deformability, and viscoelastic properties of the erythrocyte membrane.

High-level expression and purification of a human "mini"-hexokinase

Human hexokinase type I is a 100-kDa enzyme with the catalytic site located in the C-terminal domain. We had previously expressed this domain in Escherichia coli, however only a small amount of the recombinant enzyme was catalytically active. To overcome this problem we have now expressed the "mini"-hexokinase using the pET expression system. An average of 1000 U of enzyme per liter of culture was obtained. The recombinant enzyme was purified to homogeneity by a combination of ion-exchange chromatography, affinity chromatography, and dye-ligand chromatography. The enzyme was unstable under ultrafiltration; thus, a multicolumn purification procedure was developed in order to avoid the ultrafiltration steps. The recombinant "mini"-hexokinase was found to have the same kinetic properties as the entire enzyme. Using the method described, the enzyme can be obtained in sufficient quantities for biophysical and biochemical investigations.

Ubiquitin is conjugated to the cytoskeletal protein alpha-spectrin in mature erythrocytes

Ubiquitination of red blood cell (RBC) proteins was investigated by encapsulation of 125I-ubiquitin into human erythrocytes using a procedure of hypotonic dialysis, isotonic resealing, and reannealing. Incubation (37 degrees C, up to 2 h) of 125I-ubiquitin-loaded cells resulted in the recovery of 125I-ubiquitin with the cytosolic proteins (9.22 +/- 0.4 micrograms/ml RBC) and conjugated to membrane proteins (2.18 +/- 0.05 micrograms/ml RBC). This conjugation was time-dependent, and the predominant membrane protein band that became labeled showed an apparent molecular mass of 240 kDa on SDS-polyacrylamide gel electrophoresis (PAGE). Western blotting experiments with three different anti-ubiquitin antibodies revealed that this protein is also ubiquitinated in vivo. Cell-free experiments have shown that fraction II (a DEAE-bound protein fraction eluted by 0.5 M KCl) prepared from both mature erythrocytes and reticulocytes is able to conjugate ubiquitin to this protein. Ubiquitin conjugation was ATP-dependent (Km 0.09 mM), time-dependent, and fraction II-dependent (8 +/- 0.5 pmol of 125I-ubiquitin/h/mg of fraction II). Isolation of the major RBC membrane protein that is ubiquitinated was obtained by using biotinylated ubiquitin. Membrane proteins, once ubiquitinated with this derivative, were extracted and purified by affinity chromatography on immobilized avidin. The major components retained by the column were two peptides of molecular masses 220 and 240 kDa. Both proteins are recognized by a monoclonal anti-spectrin antibody, but only the 240-kDa component is detected by streptavidin peroxidase conjugate. That indeed the ubiquitinated membrane protein of 240-kDa is alpha-spectrin was confirmed by immunoaffinity chromatography using 125I-ubiquitin and a monoclonal anti-spectrin antibody. Antigen-antibody complexes were purified by protein A chromatography and analyzed by SDS-PAGE and autoradiography. Again two bands of 240 and 220 kDa were eluted (alpha- and beta-spectrin), but only one band corresponding to the electrophoretic mobility of alpha-spectrin was detected by autoradiography. Thus, alpha-spectrin is a substrate for the ATP-dependent ubiquitination system, suggesting that the cytoskeleton is covalently modified by ubiquitination both in reticulocytes and mature RBC.

Polyamines in lymphocytes from patients infected by human immunodeficiency virus

Lymphocytes from patients with antibodies against the AIDS associated human immuno-deficiency virus (HIV-1) have elevated concentrations of polyamines. Spermidine and spermine are similar in amount in patients with Persistent Generalized Lymphadenopathy (PGL) and overt AIDS, while putrescine is much higher in the latter. Spermidine-acetyltransferase activity is also increased in lymphocytes from patients with PGL. Diamine-oxidase activity is decreased in serum of patients with PGL, but not in those with AIDS.