In vitro pharmacological characterization of standard and new lysophosphatidic acid receptor antagonists using dynamic mass redistribution assay

Lysophosphatidic acid (LPA) is a bioactive phospholipid that acts as an agonist of six G protein-coupled receptors named LPA receptors (LPA1-6). LPA elicits diverse intracellular events and modulates several biological functions, including cell proliferation, migration, and invasion. Overactivation of the LPA-LPA receptor system is reported to be involved in several pathologies, including cancer, neuropathic pain, fibrotic diseases, atherosclerosis, and type 2 diabetes. Thus, LPA receptor modulators may be clinically relevant in numerous diseases, making the identification and pharmacodynamic characterization of new LPA receptor ligands of strong interest. In the present work, label-free dynamic mass redistribution (DMR) assay has been used to evaluate the pharmacological activity of some LPA1 and LPA2 standard antagonists at the recombinant human LPA1 and LPA2 receptors. These results are compared to those obtained in parallel experiments with the calcium mobilization assay. Additionally, the same experimental protocol has been used for the pharmacological characterization of the new compound CHI. KI 16425, RO 6842262, and BMS-986020 behaved as LPA1 inverse agonists in DMR experiments and as LPA1 antagonists in calcium mobilization assays. Amgen compound 35 behaved as an LPA2 antagonist, while Merck compound 20 from WO2012028243 was detected as an LPA2 inverse agonist using the DMR test. Of note, for all the compounds, similar potency values were estimated by DMR and calcium assay. The new compound CHI was found to be an LPA1 inverse agonist, but with potency lower than that of the standard compounds. In conclusion, we have demonstrated that DMR assay can be successfully used to characterize LPA1 and LPA2 ligands. Compared to the classical calcium mobilization assay, DMR offers some advantages, in particular allowing the identification of inverse agonists. Finally, in the frame of this study, a new LPA1 inverse agonist has been identified.

Optimization of M3 Antagonist-PDE4 Inhibitor (MAPI) Dual Pharmacology Molecules for the Treatment of COPD

Aiming at the inhaled treatment of pulmonary diseases, the optimization process of the previously reported MAPI compound 92a is herein described. The project was focused on overcoming the chemical stability issue and achieving a balanced bronchodilator/anti-inflammatory profile in rats in order to be confident in a clinical effect without having to overdose at one of the biological targets. The chemical strategy was based on fine-tuning of the substitution pattern in the muscarinic and PDE4 structural portions of the dual pharmacology compounds, also making use of the analysis of a proprietary crystal structure in the PDE4 catalytic site. Compound 10f was identified as a chemically stable, potent, and in vivo balanced MAPI lead compound, as assessed in bronchoconstriction and inflammation assays in rats after intratracheal administration. After the in-depth investigation of the pharmacological and solid-state profile, 10f proved to be safe and suitable for development.

Discovery of a Potent, Selective, and Orally Bioavailable Tool Compound for Probing the Role of Lysophosphatidic Acid Type 2 Receptor Antagonists in Fibrotic Disorders

Idiopathic pulmonary fibrosis (IPF) is a progressive and fatal disease characterized by lung fibrosis leading to an irreversible decline of lung function. Current antifibrotic drugs on the market slow down but do not prevent the progression of the disease and are associated with tolerability issues. The involvement of lysophosphatidic acid receptor 2 (LPA₂) in IPF is supported by LPA₂ knockdown studies. To further validate the role of LPA₂ receptors in modulating IPF and potentially other fibrotic processes, a potent and selective LPA₂ receptor antagonist with a good pharmacokinetic (PK) profile is needed. Herein, we report the medicinal chemistry exploration that led to the discovery of a new class of highly potent and selective LPA₂ antagonists. Among them, compound 58 exhibits excellent potency, selectivity, and oral PK profile, making it a suitable tool for probing the involvement of LPA₂ receptors in IPF and other fibrotic processes.

Discovery of M3 Antagonist-PDE4 Inhibitor Dual Pharmacology Molecules for the Treatment of Chronic Obstructive Pulmonary Disease

In this paper, we report the discovery of dual M₃ antagonist-PDE4 inhibitor (MAPI) compounds for the inhaled treatment of pulmonary diseases. The identification of dual compounds was enabled by the intuition that the fusion of a PDE4 scaffold derived from our CHF-6001 series with a muscarinic scaffold through a common linking ring could generate compounds active versus both the transmembrane M₃ receptor and the intracellular PDE4 enzyme. Two chemical series characterized by two different muscarinic scaffolds were investigated. SAR optimization was aimed at obtaining M₃ nanomolar affinity coupled with nanomolar PDE4 inhibition, which translated into anti-bronchospastic efficacy ex vivo (inhibition of rat trachea contraction) and into anti-inflammatory efficacy in vitro (inhibition of TNFα release). Among the best compounds, compound 92a achieved the goal of demonstrating in vivo efficacy and duration of action in both the bronchoconstriction and inflammation assays in rat after intratracheal administration.

Novel Pyrrolidine Derivatives of Budesonide as Long Acting Inhaled Corticosteroids for the Treatment of Pulmonary Inflammatory Diseases

Inhaled corticosteroids (ICSs) represent the first line therapy for the treatment of asthma and are also extensively utilized in chronic obstructive pulmonary disease. Our goal was to develop a new ICS with a basic group, which can allow solid state feature modulation, achieving at the same time high local anti-inflammatory effect and low systemic exposure. Through a rational drug design approach, a new series of pyrrolidine derivatives of budesonide was identified. Within the series, several compounds showed nanomolar binding affinity ( K_i) with GR that mostly correlated with the effect in inducing GR nuclear translocation in CHO cells and anti-inflammatory effects in macrophagic cell lines. Binding and functional cell-based assays allowed identifying compound 17 as a potent ICS agonist with a PK profile showing an adequate lung retention and low systemic exposure in vivo. Finally, compound 17 proved to be more potent than budesonide in a rat model of acute pulmonary inflammation.

Response of central serous chorioretinopathy evaluated by multimodal retinal imaging

PurposeTo identify predictive biomarkers of treatment outcomes by multimodal retinal imaging in patients affected by central serous chorioretinopathy (CSC).Patients and methodsIn this interventional non-randomized clinical study, 27 treatment-naive CSC patients were prospectively enrolled and treated with oral eplerenone for 5-13 weeks. Primary outcomes included presence of pathological findings on indocyaine green angiography (ICGA), structural optical coherence tomography (OCT) and OCT-angiography (OCT-A) at baseline associated with different response to the treatment.ResultsA total of 29 eyes of 27 patients (2 females, 25 males) met the inclusion criteria and were included in the study (mean age was 45±7 years). Mean CSC duration at baseline was 13.5±4.4 weeks. After a mean of 10.5 weeks of treatment, mean central macular thickness significantly reduced (P<0.001), and mean best-corrected visual acuity improved (P<0.001). Seventeen eyes (61%) demonstrated total reabsorption of subretinal fluid on structural OCT, five eyes (18%) presented a partial response to eplerenone therapy and six eyes (21%) showed no response. The complete response to the treatment was associated with absence of CNV at OCT-A and the presence of hotspot at ICGA (P<0.001 and P=0.002, respectively). None of eight eyes with CNV in OCT-A imaging had a complete response to eplerenone and none of three eyes without hotspot at ICGA showed a complete response to the treatment.ConclusionsMultimodal retinal imaging allowed us to propose predictive biomarkers (ie, absence of CNV on OCT-A and presence of hotspot on ICGA) for treatment outcomes.

Discovery and Optimization of Thiazolidinyl and Pyrrolidinyl Derivatives as Inhaled PDE4 Inhibitors for Respiratory Diseases

Phosphodiesterase 4 (PDE4) is a key cAMP-metabolizing enzyme involved in the pathogenesis of inflammatory disease, and its pharmacological inhibition has been shown to exert therapeutic efficacy in chronic obstructive pulmonary disease (COPD). Herein, we describe a drug discovery program aiming at the identification of novel classes of potent PDE4 inhibitors suitable for pulmonary administration. Starting from a previous series of benzoic acid esters, we explored the chemical space in the solvent-exposed region of the enzyme catalytic binding pocket. Extensive structural modifications led to the discovery of a number of heterocycloalkyl esters as potent in vitro PDE4 inhibitors. (S*,S**)-18e and (S*,S**)-22e, in particular, exhibited optimal in vitro ADME and pharmacokinetics properties and dose-dependently counteracted acute lung eosinophilia in an experimental animal model. The optimal biological profile as well as the excellent solid-state properties suggest that both compounds have the potential to be effective topical agents for treating respiratory inflammatory diseases.

Discovery of a novel isoxazoline derivative of prednisolone endowed with a robust anti-inflammatory profile and suitable for topical pulmonary administration

A novel glucocorticoids series of (GCs), 6α,9α-di-Fluoro 3-substituted C-16,17-isoxazolines was designed, synthesised and their structure-activity relationship was evaluated with glucocorticoid receptor (GR) binding studies together with GR nuclear translocation cell-based assays. This strategy, coupled with in silico modelling analysis, allowed for the identification of Cpd #15, an isoxazoline showing a sub-nanomolar inhibitory potency (IC50=0.84 nM) against TNFα-evoked IL-8 release in primary human airways smooth muscle cells. In Raw264.7 mouse macrophages, Cpd #15 inhibited LPS-induced NO release with a potency (IC50=6 nM)>10-fold higher with respect to Dexamethasone. Upon intratracheal (i.t.) administration, Cpd #15, at 0.1 μmol/kg significantly inhibited and at 1 μmol/kg fully counteracted eosinophilic infiltration in a model of allergen-induced pulmonary inflammation in rats. Moreover, Cpd #15 proved to be suitable for pulmonary topical administration given its sustained lung retention (t1/2=6.5h) and high pulmonary levels (>100-fold higher than plasma levels) upon intratracheal administration in rats. In summary, Cpd #15 displays a pharmacokinetic and pharmacodynamic profile suitable for topical treatment of conditions associated with pulmonary inflammation such as asthma and COPD.

CHF6001 I: a novel highly potent and selective phosphodiesterase 4 inhibitor with robust anti-inflammatory activity and suitable for topical pulmonary administration

This study examined the pharmacologic characterization of CHF6001 [(S)-3,5-dichloro-4-(2-(3-(cyclopropylmethoxy)-4-(difluoromethoxy)phenyl)-2-(3-(cyclopropylmethoxy)-4-(methylsulfonamido)benzoyloxy)ethyl)pyridine 1-oxide], a novel phosphodiesterase (PDE)4 inhibitor designed for treating pulmonary inflammatory diseases via inhaled administration. CHF6001 was 7- and 923-fold more potent than roflumilast and cilomilast, respectively, in inhibiting PDE4 enzymatic activity (IC50 = 0.026 ± 0.006 nM). CHF6001 inhibited PDE4 isoforms A-D with equal potency, showed an elevated ratio of high-affinity rolipram binding site versus low-affinity rolipram binding site (i.e., >40) and displayed >20,000-fold selectivity versus PDE4 compared with a panel of PDEs. CHF6001 effectively inhibited (subnanomolar IC50 values) the release of tumor necrosis factor-α from human peripheral blood mononuclear cells, human acute monocytic leukemia cell line macrophages (THP-1), and rodent macrophages (RAW264.7 and NR8383). Moreover, CHF6001 potently inhibited the activation of oxidative burst in neutrophils and eosinophils, neutrophil chemotaxis, and the release of interferon-γ from CD4(+) T cells. In all these functional assays, CHF6001 was more potent than previously described PDE4 inhibitors, including roflumilast, UK-500,001 [2-(3,4-difluorophenoxy)-5-fluoro-N-((1S,4S)-4-(2-hydroxy-5-methylbenzamido)cyclohexyl)nicotinamide], and cilomilast, and it was comparable to GSK256066 [6-((3-(dimethylcarbamoyl)phenyl)sulfonyl)-4-((3-methoxyphenyl)amino)-8-methylquinoline-3-carboxamide]. When administered intratracheally to rats as a micronized dry powder, CHF6001 inhibited liposaccharide-induced pulmonary neutrophilia (ED50 = 0.205 μmol/kg) and leukocyte infiltration (ED50 = 0.188 μmol/kg) with an efficacy comparable to a high dose of budesonide (1 μmol/kg i.p.). In sum, CHF6001 has the potential to be an effective topical treatment of conditions associated with pulmonary inflammation, including asthma and chronic obstructive pulmonary disease.

A case of Beauveria bassiana keratitis confirmed by internal transcribed spacer and LSU rDNA D1-D2 sequencing

We describe a case of fungal keratitis due to Beauveria bassiana in a farmer with Fuchs' dystrophy, treated with amphotericin B. Surgery with penetrating keratoplasty was necessary to resolve the lesions. Susceptibility testing and molecular sequencing permitted the identification and treatment of this rare aetiological agent of invasive fungal disease.

Cigarette smoke and its component acrolein augment IL-8/CXCL8 mRNA stability via p38 MAPK/MK2 signaling in human pulmonary cells

Interleukin-8 (IL-8/CXCL8) is an important neutrophil chemoattractant known to be elevated in the airways of cigarette smokers and in patients with chronic obstructive pulmonary disease (COPD). We examined the acute effect of aqueous cigarette smoke extract (CSE) on IL-8 expression in primary human pulmonary cells, in particular in normal human bronchial smooth muscle cells (HBSMCs). IL-8 mRNA levels increased upon CSE exposure in a concentration- and time-dependent manner, and such an effect was accompanied by IL-8 secretion. CSE-evoked elevation of IL-8 mRNA was mimicked by its component acrolein. Both CSE and acrolein induced p38 mitogen-activated protein kinase (MAPK) phosphorylation, accompanied by the phosphorylation of MAPK-activated kinase 2 (MK2), a known downstream substrate of the p38 MAPK, both in HBSMCs and in human airway epithelial cells. Furthermore, pharmacological inhibition of p38 MAPK or MK2 strongly accelerated the decay of IL-8 mRNA levels upon stimulation with CSE or acrolein and subsequent blockade of mRNA neosynthesis with actinomycin D in pulmonary structural cells (HBSMCs and airways epithelial cells) as well as in human alveolar macrophages. Conversely, pharmacological inhibition of ERK1/2 signaling inhibited CSE-induced steady-state levels of IL-8 mRNA without affecting mRNA stability, thus suggesting inhibition at the transcriptional level. In sum, p38 MAPK/MK2 signaling is an important posttranscriptional mechanism underlying upregulation of IL-8 mRNA levels elicited by CSE and acrolein. Given the pivotal role of IL-8 in neutrophil chemotaxis and activation, our results shed light on the mechanisms through which cigarette smoke can initiate inflammation in the lung.

Genome-wide inventory of metal homeostasis-related gene products including a functional phytochelatin synthase in the hypogeous mycorrhizal fungus Tuber melanosporum

Ectomycorrhizal fungi are thought to enhance mineral nutrition of their host plants and to confer increased tolerance toward toxic metals. However, a global view of metal homeostasis-related genes and pathways in these organisms is still lacking. Building upon the genome sequence of Tuber melanosporum and on transcriptome analyses, we set out to systematically identify metal homeostasis-related genes in this plant-symbiotic ascomycete. Candidate gene products (101) were subdivided into three major functional classes: (i) metal transport (58); (ii) oxidative stress defence (32); (iii) metal detoxification (11). The latter class includes a small-size metallothionein (TmelMT) that was functionally validated in yeast, and phytochelatin synthase (TmelPCS), the first enzyme of this kind to be described in filamentous ascomycetes. Recombinant TmelPCS was shown to support GSH-dependent, metal-activated phytochelatin synthesis in vitro and to afford increased Cd/Cu tolerance to metal hypersensitive yeast strains. Metal transporters, especially those related to Cu and Zn trafficking, displayed the highest expression levels in mycorrhizae, suggesting extensive translocation of both metals to root cells as well as to fungal metalloenzymes (e.g., laccase) that are strongly upregulated in symbiotic hyphae.

Maternal plasma level of antimicrobial peptide LL37 is a major determinant factor of neonatal plasma LL37 level

AIM

To determine cathelicidin antimicrobial peptide LL37subcellular distribution in cord neutrophils and normal plasma LL37 levels in mothers and neonates, relate them to delivery mode and relevant biochemical markers, including 25-OHvitamin D [25(OH)D] as this molecules increases cathelicidin gene expression.

METHODS

A total of 115 infants were included, n = 68 with normal delivery and n = 47 with elective Caesarean section (C-section), a subset of these being 50 mother-infant pairs. Biomarkers were determined in maternal and cord blood. Subcellular peptide LL37 distribution was analysed with immunoelectron microscopy.

RESULTS

Cord plasma LL37 levels were three-times higher after normal delivery compared with C-section. A highly significant correlation was observed between maternal and cord plasma LL37 levels, regardless of delivery mode. No relationship was found between LL37 and 25(OH)D levels. Neutrophils from cord blood after normal delivery contained 10-times more cytoplasmatic cathelicidin peptide compared with corresponding cells after C-section where a strict granular localization was found.

CONCLUSION

These data are consistent with a placental transfer of LL37 and identifies maternal stores as the critical factor determining neonatal plasma LL37 level. An additional enhancement of neonatal cathelicidin mobilization and release is connected to normal delivery stress.

[Nuchal translucency and combined test: what are the implications in clinical practice?]

AIM

The aim of this study was to evaluate the performance of the combined test (nuchal translucency, NT) and maternal serum free-beta human chorionic gonadotropin (free beta-hCG) and pregnancy-associated plasma protein-A (PAPP-A), compared to the NT measurement alone, in fetal aneuploidy screening in the general population and in pregnant women aged 35 years and over. In addition, the association between increased NT and presence of cardiac defects in fetuses with normal karyotype was evaluated.

METHODS

Screening at 11-14 weeks of gestation by NT measurement and combined test was carried out in 1521 pregnant women. The estimated risk for trisomy 21 and trisomy 13+18 was calculated (risk cut-off 1/300 and 1/750 respectively) and the outcomes was evaluated.

RESULTS

Ten cases of trisomies (21 and 18) occurred, seven of which among the older group of pregnant women. The detection rate (DR) for the combined test was 80% in the general population and 85.7% in older pregnant women, which resulted higher rate than NT measurements alone. Detection rate of cardiac defects using NT measurements was 66.6%.

CONCLUSION

The combined test is an effective screening for aneuploidies and reduces at 14% the need of invasive testing in the older obstetric population, detecting all the trisomies occurred in this group. The association between increased NT and cardiac defects is confirmed but it seems too weak to consider NT as a single screening strategy for these abnormalities.

The effect of pneumatic trabeculoplasty on intraocular pressure: the results of a 6-month, open-label, multicenter study

PURPOSE

To evaluate the effects of pneumatic trabeculoplasty (PNT) in ocular hypertension and glaucoma subjects.

METHODS

A total of 63 consecutive subjects, either treated (79%) or untreated (21%), with intraocular pressure (IOP) between 20 and 25 mmHg were enrolled; the eye with higher IOP (or, in case of identical IOP, worse visual field) was treated with PNT, with the fellow eye used as control. Subjects underwent a baseline evaluation the day before treatment, two PNT treatments at day 0 and 7, visits at day 1, 8, 14, and at each month until the end of the study, which lasted 6 months. Safety was addressed at all visits; an IOP curve (at 8 and 10 AM, 2 and 4 PM) was obtained at baseline and during monthly visits.

RESULTS

In PNT eyes, baseline IOP was 22.2-/+1.6 mmHg. Following PNT a statistically significant reduction of IOP occurred at all visits (p<0.0001), with a mean decrease ranging from -2.7-/+2.5 (-11.9-/+10.8%) to -3.6-/+2.6 mmHg (-16.0-/+11.6%); mean reduction was 12.8-/+11.5%. Although IOP diminished also in the control eyes after baseline (p<0.05), the change in IOP was significantly higher in PNT group at each visit (p<0.05). Mild side effects were experienced by 76% of subjects and they all resolved without sequelae.

CONCLUSIONS

The results suggest the effect of this procedure in reducing IOP in glaucoma and ocular hypertensive subjects.

Membrane transporters and protein traffic networks differentially affecting metal tolerance: a genomic phenotyping study in yeast

Genomic phenotyping was used to assess the role of all non-essential S. cerevisiae proteins in modulating cell viability after exposure to cadmium, nickel and other metals.

Background

The cellular mechanisms that underlie metal toxicity and detoxification are rather variegated and incompletely understood. Genomic phenotyping was used to assess the roles played by all nonessential Saccharomyces cerevisiae proteins in modulating cell viability after exposure to cadmium, nickel, and other metals.

Results

A number of novel genes and pathways that affect multimetal as well as metal-specific tolerance were discovered. Although the vacuole emerged as a major hot spot for metal detoxification, we also identified a number of pathways that play a more general, less direct role in promoting cell survival under stress conditions (for example, mRNA decay, nucleocytoplasmic transport, and iron acquisition) as well as proteins that are more proximally related to metal damage prevention or repair. Most prominent among the latter are various nutrient transporters previously not associated with metal toxicity. A strikingly differential effect was observed for a large set of deletions, the majority of which centered on the ESCRT (endosomal sorting complexes required for transport) and retromer complexes, which - by affecting transporter downregulation and intracellular protein traffic - cause cadmium sensitivity but nickel resistance.

Conclusion

The data show that a previously underestimated variety of pathways are involved in cadmium and nickel tolerance in eukaryotic cells. As revealed by comparison with five additional metals, there is a good correlation between the chemical properties and the cellular toxicity signatures of various metals. However, many conserved pathways centered on membrane transporters and protein traffic affect cell viability with a surprisingly high degree of metal specificity.

Efficacy of the symmetric, patient-oriented, rigid, three-dimensional, active (SPoRT) concept of bracing for scoliosis: a prospective study of the Sforzesco versus Lyon brace

AIM

Bracing is considered to be effective in the treatment of adolescent idiopathic scoliosis. The concept prevailing today includes an asymmetrical construction, mainly using a mechanical three-point system. We developed the new Sforzesco brace, based on the SPoRT concept (Symmetric, Patient-oriented, Rigid, Three-dimensional, active). The aim of this study is to verify the results of this concept and brace, compared to three-point classical systems.

METHODS

We performed a prospective, pair-controlled study. It was possible to match 15 patients, out of the first 18 consecutively treated with the Sforzesco brace (Group SPoRT), with previous patients treated with the Lyon brace (Group LY). SPoRT included 14.2+/-1.7 year old patients, with 47+/-7 degrees Cobb worst curves, and 11+/-4 degrees Bunnell; LY included 13.6+/-1.6 year old patients, with 43+/-7 degrees Cobb and 12+/-5 degrees Bunnell. The brace had to be worn 23 h per day and patients were evaluated after 6 months both clinically and radiographically (without the brace). Appropriate statistics were used.

RESULTS

At the baseline there were slight differences between the groups, with SPoRT worse than LY. All radiographic and clinical parameters decreased significantly with treatment in both groups, apart from thoracic Cobb degrees in LY. SPoRT had better results than LY (P<0.05) radiographically (worst curve -10+/-5 degrees vs -5+/-7 degrees, all curves -8+/-7 degrees vs -6+/-7 degrees), for sagittal profile (distance from plumbline: T12 -6+/-9 mm vs +2+/-8 and L3 -7+/-12 vs 0+/-10) and aesthetics of the shoulders (9 improved and 6 unchanged vs 5 and 8) and waists (10 improved and 5 unchanged vs 5 and 8). Finally, clinical results in terms of patient recovery were better in SPoRT than LY (12 improved and 3 unchanged vs 8 and 5).

CONCLUSION

When a new treatment is introduced, it is not possible to wait years (end of therapy) before verifying its utility, and in scoliosis bracing a short term study already gives very important clues. This study confirms the immediate efficacy of brace treatment (even in such high degree cases) whatever the brace concept used, with only 2 (out of 30) progressed curves. In SPoRT we had no progressions, and obtained a statistically significant 80% better radiographic results than LY in the worst scoliosis curve, and 40% in the average of all curves, as well as improved aesthetics and sagittal profile (that is crucial in scoliosis bracing). The Sforzesco brace should be used, and the SPoRT concept explored in the long term to verify if the classical three-point system should be totally (or partially) abandoned.

The newborn infant is protected by an innate antimicrobial barrier: peptide antibiotics are present in the skin and vernix caseosa

BACKGROUND

Peptide antibiotics are part of the surface defences against microbial intruders. However, the presence and significance of these innate immune effectors in the skin barrier of the newborn infant have not yet been appreciated. Erythema toxicum neonatorum is an inflammatory skin reaction of unknown aetiology and significance, commonly present in the healthy newborn infant.

OBJECTIVES

As peptide antibiotics are upregulated in inflammatory skin disorders, we hypothesized that this also could be the case in erythema toxicum. We also investigated if the vernix caseosa, a cream-like white substance present on the skin of the infant at birth, might contribute to host defences.

METHODS

The presence of the human antibacterial peptide LL-37 was investigated by immunohistochemistry and confocal imaging of skin biopsies from four 1-day-old infants with an erythema toxicum rash and four matched newborns without the rash. In addition, we analysed the expression of LL-37 and human beta defensin-1, an antibacterial peptide of epithelial origin, by reverse transcriptase-polymerase chain reaction. Finally, we screened for antibacterial components in vernix material obtained from six healthy newborns by inhibition zone assays.

RESULTS

All biopsies from the lesions of erythema toxicum showed a dense, nodular infiltrate with numerous LL-37-expressing cells located in the dermal layer and a clear localization of the peptide within CD15-expressing neutrophils, EG2-expressing eosinophils and CD1a-expressing dendritic cells. LL-37 was also found to be located in CD1a-expressing Langerhans cells and a positive staining for the peptide was seen throughout the whole epidermal layer, both in infants with and without the rash. Skin samples from infants with the rash of erythema toxicum showed a constitutive expression of human beta defensin-1, while the expression of LL-37 seemed to be induced. Furthermore, LL-37 and lysozyme were detected in the protein fractions derived from the vernix caseosa, and these fractions exhibited a clear antibacterial activity.

CONCLUSIONS

Peptide antibiotics are present in the vernix caseosa and in the skin of the healthy newborn infant, indicating effective innate immune protection already during fetal and neonatal life.

Transscleral diode laser photocoagulation in refractory glaucoma

BACKGROUND AND OBJECTIVE

Patients with glaucoma refractory to medical or surgical treatment are difficult to treat. The aim of this study was to evaluate the effect of contact transscleral diode laser cyclophotocoagulation (DLPC) on these patients' intra-ocular pressure (IOP) and visual acuity.

PATIENTS AND METHODS

37 eyes of 36 patients who suffered from refractory glaucoma and who had undergone DLPC, were followed at the Eye Clinic of Verona University for an average of 14 +/- 4 months. The average age was 54 +/- 26 years. IOP, visual acuity and ocular complications were analysed.

RESULTS

A total of 71 treatments were given. More than 1 treatment was given in 22 eyes (59%). The mean pretreatment IOP was 33.1 +/- 3.3 mm Hg. At the last follow-up, the mean IOP was 21 +/- 1.6 mm Hg. Mean total medications were reduced from 4.4 +/- 0.5 to 2.4 +/- 0.3. No serious complications occurred in 71 treatments. Visual acuity remained stable in 25 eyes (67.5%), improved in 6 eyes (16.2%) and decreased in 6 eyes (16.2%).

CONCLUSIONS

DLPC is effective in lowering IOP in eyes with refractory glaucoma. It also serves to reduce the number of antiglaucoma medications. This procedure is relatively safe. Nevertheless, multiple DLPC applications may be needed.

Effects of 2% ibopamine on pupil, refraction, anterior segment anatomy and intraocular pressure

The aim of the study was to determine the effects of a dopaminergic drug, 2% ibopamine, on the pupil, intraocular pressure and other ocular and ultrasound biometric variables. Thirty healthy subjects and 15 patients with primary open-angle glaucoma, aged from 40 to 78 years (mean age: 59.2 +/- 11), were included in two prospective open controlled trials. In the first, the mydriatic effect of 2% ibopamine and its inhibition and reversibility were evaluated in 15 healthy subjects using the alpha1-adrenergic drug, 0.5% dapiprazole. In the second, refraction, visual acuity, pupil diameter, intraocular pressure and 5 A-scan ultrasound biometric variables were evaluated in 15 healthy subjects and in 15 glaucoma patients. As early as forty min after administration of 2% ibopamine, a marked mydriatic effect (7.3 vs 3.9 mm; P < 0.0001), which was completely inhibited or reversed by 0.5% dapiprazole, was detected. The drug induced no changes in refraction, visual acuity or A-scan ultrasound biometric variables in any of the subjects examined. In healthy subjects, the intraocular pressure values were not changed to a statistically significant extent (13.8 vs 14.8 mm Hg; P = 0.668), whereas a slight, though significant, hypertensive effect (24 vs 22.2 mm Hg; P = 0.002) was observed in the glaucoma patients. The study confirms the intense mydriatic effect of 2% ibopamine with no changes in refraction, visual acuity or A-scan ultrasound biometric variables. The drug has no effect on intraocular pressure in healthy subjects, but induces a significant hypertensive effect in patients with initial glaucoma. This characteristic could be used for early diagnosis of primary open-angle glaucoma.

Erythema toxicum neonatorum: an immunohistochemical analysis

Erythema toxicum neonatorum is a benign rash of unknown etiology, present to various degrees in most term newborns and characterized by an accumulation of eosinophils in dermal lesions. The recruitment of leukocytes to tissues implicates the involvement of adhesion molecules, cytokines, and chemokines. We therefore performed immunohistochemistry on punch biopsy specimens from cutaneous lesions of ten 1-day-old infants with erythema toxicum using specific monoclonal antibodies directed against a variety of adhesion molecules, cytokines, chemokines, and cell type-specific membrane markers. Biopsy specimens of noninflamed skin from four matched newborns and four adults served as controls. The immunohistologic features of erythema toxicum in all 10 infants included a strong staining of the adhesion molecule E-selectin in the vessel wall and the presence of numerous inflammatory cells that were identified as dendritic cells (CD1a, CD83, HLA-DR, CD40, and ICAM-1 positive), eosinophils (EG2 positive), neutrophils (CD15 positive), macrophages (CD14, CD68, and Mac387 positive), and E-selectin-expressing cells. Furthermore, the lesions showed a high incidence of the proinflammatory cytokines interleukin (IL)-1alpha and IL-1beta and of the chemokines IL-8 and eotaxin. This immunologic activity was reduced or absent in noninflamed skin from newborn controls and adults. We conclude that there is an accumulation and activation of immune cells in the lesions of erythema toxicum, also present in noninflamed skin of 1-day-old infants, but to a lower level. The physiologic significance of the rash remains to be elucidated.

Ultrasound biomicroscopy and intraocular-pressure-lowering mechanisms of deep sclerectomy with reticulated hyaluronic acid implant

PURPOSE

To evaluate the anatomic characteristics and intraocular pressure (IOP) lowering mechanisms of deep sclerectomy with reticulated hyaluronic acid implant (DS with RHAI) using ultrasound biomicroscopy (UBM).

SETTING

Eye Clinic, Department of Neurological and Vision Sciences, University of Verona, Verona, Italy.

METHODS

Thirty patients with primary open-angle glaucoma not controlled by medical therapy had DS with RHAI in 1 eye. A complete ocular examination and UBM study were performed 1, 3, 6, and 12 months postoperatively and thereafter at 6 month intervals. Eleven parameters were evaluated, the most important of which were IOP, surgical success in lowering IOP to 21 mm Hg or less with or without additional medical therapy, UBM appearance of the site of DS with RHAI, size of the decompression space, presence of a filtering bleb and supraciliary hypoechoic area, and scleral reflectivity around the decompression space.

RESULTS

After a mean follow-up of 11.4 months +/- 4.7 (SD), the mean percentage reduction in IOP compared to preoperatively was 38% (from 26 +/- 4.5 mm Hg to 16.2 +/- 3.8 mm Hg; P =.0001). Twenty-four patients (80%) had an IOP less than 21 mm Hg; however, 7 of these eyes (23%) required additional IOP-lowering medical therapy. The operation failed in 6 patients (20%) despite additional therapy. Ultrasound biomicroscopy revealed a reduction in the size of the decompression space from 6 months postoperatively and its disappearance in 2 cases. The difference in size at the last follow-up and at 1 month postoperatively (maximum length 2.41 +/- 1.02 mm versus 3.53 +/- 0.51 mm) was significant (P =.0001). At the last examination, a filtering bleb was present in 18 patients (60%), a supraciliary hypoechoic area in 18 (60%), and hyporeflectivity of the scleral tissue around the decompression space in 14 (47%). These 3 UBM characteristics were detected singly and in various combinations. The simultaneous presence of all 3 characteristics in the same eye correlated significantly with a higher surgical success rate (P =.004).

CONCLUSIONS

Ultrasound biomicroscopy showed that filtering bleb formation was frequent in eyes having DS with RHAI but that it was not the only surgically induced IOP-lowering mechanism. Increased uveoscleral and transscleral filtration may be equally important.

The relationship between intraocular pressure and glaucoma in a defined population. Data from the Egna-Neumarkt Glaucoma Study

PURPOSE

To provide data on the prevalence of ocular hypertension and glaucoma and on the diagnostic validity of tonometry.

METHODS

In this cross-sectional, population-based study, 4,927 subjects over 40 years of age were examined. Each subject underwent a complete ocular examination as part of the Egna-Neumarkt Glaucoma Study. These examinations were carried out by trained, quality-controlled ophthalmologists, according to a predetermined standard protocol that included a medical interview, applanation tonometry, computerized perimetry, optic nerve head examination and other ocular measurements. The following data were recorded: mean IOP, prevalence of ocular hypertension, primary open-angle glaucoma and normal tension glaucoma. Sensitivity, specificity and the predictive value of the tonometric test, as well as the distribution of IOP in the different groups were also determined.

RESULTS

The overall prevalence of ocular hypertension, hypertensive primary open-angle glaucoma and normal tension glaucoma corresponded to 2.1, 1.4 and 0.6%, respectively. Other types of glaucoma accounted for a further 0.9%. The sensitivity and specificity of the tonometric test in recognizing glaucoma (cut-off between 21 and 22 mm Hg) were, respectively, 80.1 and 97.8%. The predictive values of the positivity and negativity of the test were 52.1 and 99.4%, respectively.

CONCLUSIONS

The prevalence of ocular hypertension and glaucoma was similar to that found in several recent epidemiological studies. Tonometry alone is obviously not sufficient to ascertain or to exclude the presence of glaucoma; its diagnostic validity however is high and should never be underestimated. An elevated IOP is the main risk factor for glaucoma, with the degree of risk increasing as the level of IOP increases.

The birth process initiates an acute phase reaction in the fetus-newborn infant

Our goal was to investigate whether the normal birth process stimulated an acute phase response in healthy infants with physiological changes in the circulating levels of acute phase cytokines and acute phase proteins. We also monitored body temperature, body weight and behavioural state in order to investigate if clinical signs of acute phase reaction were present. We made cross-sectional measurements of interleukin-1beta, interleukin-6, C-reactive protein, serum amyloid A, procalcitonin, prealbumin, body weight, body temperature and the duration of the sleeping period during the first four postnatal days. We found an increase in interleukin-6 (p < 0.001) during the first day, followed by an increase in C-reactive protein, serum amyloid A and procalcitonin on the second postnatal day (p < 0.01). The level of prealbumin fell after birth and reached its lowest value at 3 d of age (p < 0.001). Interleukin-1beta remained unchanged. The duration of the sleeping period was longer during the first day (p < 0.01). There was an increase in body temperature during the first day (p < 0.01). Maximal weight loss was during the first 2 d.

CONCLUSIONS

The normal birth process and extra-uterine adaptation stimulates an acute phase reaction in the newborn infant with a release of interleukin-6 and acute phase proteins and a depression of prealbumin. This reaction, as the body's first line inflammatory defence system, probably affects the infant's behaviour, nutritional state as well as the regulation of body temperature.

Vascular risk factors for primary open angle glaucoma: the Egna-Neumarkt Study

OBJECTIVE

To assess the impact of vascular risk factors on the prevalence of primary open angle glaucoma.

DESIGN

Population-based cross-sectional study.

PARTICIPANTS

Four thousand two hundred ninety-seven patients more than 40 years of age underwent a complete ocular examination in the context of the Egna-Neumarkt Glaucoma Study.

INTERVENTION

Ocular examinations were performed by trained, quality-controlled ophthalmologists according to a predefined standardized protocol including medical interview, blood pressure reading, applanation tonometry, computerized perimetry, and optic nerve head examination.

MAIN OUTCOME MEASURES

Prevalences of ocular hypertension, primary open-angle glaucoma, normal-tension glaucoma, and other types of glaucoma were determined. Correlation coefficients were calculated for the association between systemic blood pressure and age-adjusted intraocular pressure (IOP) and between age and both intraocular and systemic blood pressures. Odds ratios were computed to assess the risk of primary open-angle glaucoma and normal-tension glaucoma in relation to systemic hypertension or antihypertensive medication, blood pressure levels, diastolic perfusion pressure, and a number of other cardiovascular risk factors.

RESULTS

A positive correlation was found between systemic blood pressure and IOP, and an association was found between diagnosis of primary open-angle glaucoma and systemic hypertension. Lower diastolic perfusion pressure is associated with a marked, progressive increase in the frequency of hypertensive glaucoma. No relationship was found between systemic diseases of vascular origin and glaucoma.

CONCLUSIONS

Our data are in line with those reported in other recent epidemiologic studies and show that reduced diastolic perfusion pressure is an important risk factor for primary open-angle glaucoma.

Epidemiology of angle-closure glaucoma: prevalence, clinical types, and association with peripheral anterior chamber depth in the Egna-Neumarket Glaucoma Study

OBJECTIVE

To assess the prevalence of primary angle-closure glaucoma (PACG), the frequency of its different clinical presentations, and its association with peripheral anterior chamber depth in a defined population in Northern Italy.

DESIGN

Cross-sectional epidemiologic study in a defined population.

PARTICIPANTS

All subjects resident in the Egna-Neumarkt area of the South Tyrol Region (Northern Italy) and more than 40 years of age were invited to undergo an ophthalmologic examination.

INTERVENTION

After the screening examination, subjects with suspected glaucoma were re-examined at the screening center to confirm the diagnosis. All cases that still proved suspect after the second examination underwent a third phase of investigations and were classified as healthy or as definitely glaucomatous. Each subject was examined according to a standard protocol, including medical history interview, refraction and visual acuity determination, ocular biomicroscopy, evaluation of peripheral anterior chamber depth by means of the Van Herick method, applanation tonometry, optic disc evaluation, and computerized perimetry. Gonioscopy was not performed during initial screening but only in all selected patients in the second and third phases of investigations. The diagnosis of PACG was made on the basis of the concomitant presence of at least two of the following criteria: intraocular pressure > or = 22 mmHg, glaucomatous optic disc abnormalities, glaucomatous visual field defects. In addition, biomicroscopic or gonioscopic evidence of angle closure was also necessary.

MAIN OUTCOME MEASURES

Percentage distribution of peripheral anterior chamber depths, prevalence of angle-closure glaucoma, and frequency of the different PACG clinical presentations.

RESULTS

Four thousand two hundred ninety-seven subjects were examined (73.9% overall participation rate). The peripheral depth of the anterior chamber according to the Van Herick method was grade 2 in 14.7%, grade 1 in 2.5%, and grade 0 in 0.3% of the population. The overall prevalence of angle-closure glaucoma was 0.6% (26 cases). Five of these were cases of previous acute attacks resolved by therapy, three were cases of chronic angle-closure after acute attacks, three were intermittent angle-closure glaucomas, and 15 were chronic angle-closure cases.

CONCLUSIONS

Occludable angles were more frequent than in other white populations previously studied. The prevalence of PACG is not as low as is usually believed; this type of glaucoma accounts for more than a quarter of all glaucomas found in the Egna-Neumarkt population. The most frequent clinical presentation is chronic angle-closure glaucoma.

Perimetric defects after a single acute angle-closure glaucoma attack

BACKGROUND

This study was carried out to determine the effect of an acute attack of angle-closure glaucoma on the visual field.

METHODS

A total of 53 eyes were examined 36-48 h after remission of an acute glaucoma attack by means of computerised perimetry (Humphrey 630 perimeter, 30-2 program). Perimetry was repeated after at least 1 month in 22 eyes.

RESULTS

Perimetric defects, varying greatly in severity and primarily of the generalised type or concerning at least wide sectors of the field, were detected in 45 (85%) of 53 cases. The visual field was normal in the remaining 8 patients (15%). The upper nasal quadrants were the most frequently affected and the degree of eccentricity was most frequently involved within the 9 degrees -21 degrees area. In 7 of the 22 cases in which perimetry was repeated after 1 month, complete normalisation was noted in the visual field.

CONCLUSIONS

An isolated attack of acute glaucoma produces in most cases a perimetric defect of generalised or mixed type. This may be reversible. The most affected zones were the upper half of the visual field and the 9 degrees -21 degrees area.

Effects of 0.2% brimonidine on ocular anterior structures

The aim of the study was to evaluate the effect of an alpha2-adrenergic agonist, 0.2% brimonidine, on a number of echobiometry and ultrasound biomicroscopy ocular parameters. Ten healthy subjects ranging in age from 20 to 40 years (mean age 29+/-3.39) were recruited into this prospective open-label trial. After instillation of 0.2% brimonidine eye drops, the following parameters were assessed: refraction, visual acuity, pupil diameter, intraocular pressure, five A-scan echobiometric parameters and 15 ultrasound biomicroscopy parameters. As early as the first hour after administration of the drug, a marked ocular hypotensive effect was detected associated with a miotic effect, without any refractive or visual acuity alterations. The A-scan echobiometry parameters were unchanged, while, as far as the ultrasound biomicroscopy variables were concerned, we observed an increase in iris-lens contact distance and a reduction in iris root thickness with a resulting increase in posterior chamber depth and in iris-ciliary process distances. No changes were observed in either the anterior chamber or the anterior iris profile. Brimonidine 0.2% proved to be an ocular hypotensive agent which is also endowed with a mild miotic effect, without giving rise to refractive or visual acuity alterations. The drug does not alter the thickness and position of the lens and does not facilitate pupil block; it reduces the iris thickness with an increase in posterior chamber depth and in iris-ciliary process distance but with no changes in anterior chamber depth or chamber angle width.

Choroidal calcification in Bartter syndrome

PURPOSE

Bartter syndrome is characterized by hyperplasia of the renal juxtaglomerular apparatus, hyperaldosteronism, and hypokalemic alkalosis. We report a case of Bartter syndrome associated with normal serum calcium levels and posterior choroidal calcification.

METHODS

Case report. A 59-year-old man with bilateral cataract and Bartter syndrome underwent a complete ophthalmic examination, including standardized echography before and after cataract surgery.

RESULTS

Before cataract surgery, echography identified small, hyperreflective, multifocal, bilateral choroidal lesions with posterior shadowing. After surgery, these lesions appeared as yellow-white, barely elevated plaques with smooth edges and were diagnosed as choroidal calcification.

CONCLUSIONS

Choroidal calcification may occur in patients with Bartter syndrome. This condition should be added to the differential diagnosis of posterior segment calcification.

Ultrasound biomicroscopic and conventional ultrasonographic study of ocular dimensions in primary angle-closure glaucoma

OBJECTIVE

To determine the biometric findings of ocular structures in primary angle-closure glaucoma (PACG).

DESIGN

An observational case series with comparisons among three groups (patients with acute/intermittent PACG [A/I-PACG], patients with chronic PACG [C-PACG], and normal subjects [N]).

PARTICIPANTS

A total of 54 white patients with PACG (13 male, 41 female) were studied: 10 with acute, 22 with intermittent, and 22 with chronic types of PACG. Forty-two normal white subjects (11 male, 31 female) were studied as control subjects. Only one eye was considered in each patient or subject.

TESTING

Ultrasound biomicroscopy (UBM) and standardized A-scan ultrasonography (immersion technique) were performed in each patient during the same session or within 1 to 3 days.

MAIN OUTCOME MEASURES

The following A-scan parameters were measured: anterior chamber depth (ACD), lens thickness (LT), axial length (AL), lens/axial length factor (LAF), and relative lens position (RLP). Ten UBM parameters were measured, the most important of which were anterior chamber angle, trabecular-ciliary process distance (TCPD), angle opening distance at 500 microm from the scleral spur (AOD 500), and scleral-ciliary process angle (SCPA).

RESULTS

Compared to normal subjects, the patients with PACG presented a shorter AL (A/I-PACG = 22.31 +/- 0.83 mm, C-PACG = 22.27 +/- 0.94 mm, N = 23.38 +/- 1.23 mm), a shallower ACD (A/I-PACG = 2.41 +/- 0.25 mm, C-PACG = 2.77 +/- 0.31 mm, N = 3.33 +/- 0.31 mm), a thicker lens (A/I-PACG = 5.10 +/- 0.33 mm, C-PACG = 4.92 +/- 0.27 mm, N = 4.60 +/- 0.53 mm), and a more anteriorly located lens (RLP values, A/I-PACG = 2.22 +/- 0.12, C-PACG = 2.34 +/- 0.16, N = 2.41 +/- 0.15). The LAF values in A/I-PACG, C-PACG, and N were 2.28 +/- 012, 2.20 +/- 0.11, and 1.97 +/- 0.12, respectively. Anterior chamber angle (A/I-PACG = 11.72 +/- 8.84, C-PACG = 19.87 +/- 9.83, N = 31.29 +/- 9.18 degrees) and SCPA (A/I-PACG = 28.71 +/- 4.02, C-PACG = 30.87 +/- 6.04, N = 53.13 +/- 9.58 degrees) were narrower, TCPD (A/I-PACG = 0.61 +/- 0.12 mm, C-PACG = 0.71 +/- 0.14 mm, N = 1.08 +/- 0.22 mm) and AOD 500 shorter (A/I-PACG = 0.13 +/- 0.09 mm, C-PACG = 0.21 +/- 0.10 mm, N = 0.36 +/- 0.11 mm) in patients with PACG. All the biometric differences proved statistically significant using the one-way analysis-of-variance test.

CONCLUSIONS

In patients with PACG, the anterior segment is more crowded because of the presence of a thicker, more anteriorly located lens. The UBM confirms this crowding of the anterior segment, showing the forward rotation of the ciliary processes. A gradual progressive shift in anatomic characteristics is discernible on passing from normal to chronic PACG and then to acute/intermittent PACG eyes.

Hunger behaviour contributes to early nutritional homeostasis

OBJECTIVES AND METHODS

Our goal was to describe nutritional homeostasis in healthy exclusively breastfed infants (n = 175) during their first 5 d, by cross-sectional measurements of body weight, blood glucose, plasma insulin, insulin-like growth factor-I (IGF-I), insulin-like growth factor binding-protein-1 (IGFBP-1), free fatty acids (FFA), glycerol, ketone (3-OH-butyric acid) and lactate. We also investigated whether nutrition affected feeding behaviour by timing the interval between feedings.

RESULTS

A progressive loss of body weight, as percentage of birthweight, occurred up to 2 d of age, with a maximal decrease of 5.8 +/- 2.1% (mean +/- SD); this was accompanied by inhibition of anabolic hormone and metabolic pathways and an increased mobilization of stored fat and ketogenesis. The interval between feedings decreased between d 1 and 2. Weight gain occurred at 3 d and the following re-feeding phase returned fuel stores to their previous levels and established an anabolic hormonal and metabolic situation. Infants with weight loss exceeding 10% had a further accentuation in their peripheral picture of starvation and a further 7% shortening of the interval between feedings.

CONCLUSIONS

breastfeeding on demand is accompanied by a balanced nutritional situation and an increased drive to eat when weight reduction is <6%. However, a weight loss of > or = 10%, probably elicits hunger sensations in response to decreased fuel availability.

Plasma leptin in infants: relations to birth weight and weight loss

BACKGROUND

The hormone leptin, produced in the adipose tissue, is involved in the regulation of body weight. The release of the hormone is increased in obese adults and decreased after fasting in human adults. This study investigated whether the plasma leptin level was related to the infant's birth weight and whether the level was reduced in connection with the physiological weight loss during the neonatal period.

METHODS

We measured the plasma leptin level in cord blood from infants who were large for gestational age (LGA) (n = 15), small for gestational age (SGA) (n = 16), and appropriate for gestational age (AGA) (n = 38). AGA infants (n = 120), who were exclusively breastfed, were also studied during their first 4 postnatal days in a cross-sectional method. One blood sample was collected before breastfeeding from each infant. Plasma leptin concentrations were determined by radioimmunoassay.

RESULTS

The median (range) concentration of leptin from cord blood was increased in LGA infants and decreased in SGA infants compared with the level in AGA infants. There was a positive correlation between the log of the plasma leptin level in cord blood and both the infant's birth weight (r = 0.76; n = 69) and the body mass index (r = 0.63; n = 69). The normal 3% to 6% weight reduction that occurs during the first 4 postnatal days was associated with a 26% decrease in the plasma leptin level in healthy breastfed infants.

CONCLUSIONS

The plasma leptin level is highly correlated to the size of adipose tissue mass and decreases in connection with the initial physiological weight loss in newborn infants. These data provide evidence that leptin is highly related to the nutritional status already during the fetal and neonatal periods.