Cardio-Oncology: a medical specialty in constant growth and evolution. the 10-year experience of the first cardio-oncology service in the United Kingdom

Introduction

Survivorship has increased significantly in cancer patients with the advent of novel therapies. However, this improvement has been at the cost of higher rates of cardiotoxicity. Cardiovascular disease has become the main cause of death or cancer therapy interruption in many of these patients. The need for specialist services to deal with these emerging problems has led to global development of many Cardio-Oncology services.

Objectives

To describe how a Cardio-Oncology service has grown and evolved over a 10 year period in response to the constantly changing oncological landscape.

Methods and results

Prospective, single center, study of cancer patients referred to our service from February 2011 to December 2021. 1499 patients were referred to the service. Mean age was 60 years (SD: 15) and 60% were female. CV risk factors including hypertension (32%), dyslipidaemia (12%) and diabetes (6%) were common.

The most frequent primary tumour location was breast (427 patients, 28%), followed by haematological (151, 10%) and gastrointestinal tract (114, 8%). The average number of referrals per month increased 6 fold from 2011, from 3.3 patients per month to 21 patients in 2021. In the last 5 years there was a 10 fold increase in the number of outpatient consultations from 189 consultations in 2016 to 1988 consultations in 2021.

The most frequent reason for referral was pre-treatment assessment (39%), followed by cancer therapy related cardiac dysfunction (CTRCD) (33%) and other acute cancer therapy related CV diseases (CTR-CVDs) (22%). From 2011 to 2017 CTRCD was the main CTR-CVD due to anthracycline and trastuzumab. This ratio changed in 2018 when other CTR-CVDs became the most frequent referral reason following pre-treatment assessment. Patients referred to our service were or had been, mostly under medical therapy alone or in combination with surgery or radiotherapy (1058 patients, 70%), anthracyclines being the predominant treatment (435 patients, 40%). Targeted therapies and immune check point inhibitors became more popular in the last two years (2020–2021). A multivariable logistic regression model was built to assess the relation between the medical treatment and the prevalence of CTRCD vs other CTR-CVDs. Anthracyclines and HER2 therapy are independently associated with a higher prevalence of CTRCD while tyrosine kinase inhibitors and immune checkpoint inhibitors increase the risk of other CTR-CVDs e.g. hypertension, arrhythmias and myocarditis.

Conclusions

Cardio-Oncology has rapidly evolved from its origin as a subspecialty of heart failure medicine, to a diverse medical specialty that encompasses many different domains of cardiology. Future cardio-oncology services should reflect this and be dynamic, collaborating with cardiac sub-specialities as necessary. Provision of cardio-oncology services requires a considerable knowledge and understanding of the ever growing and changing oncology therapies.

Funding Acknowledgement

Type of funding sources: None.

THU0354 CHARACTERIZATION OF ANTI-MYOSITIS ANTIBODY RELATED MYOPATHIES. DESCRIPTIVE STUDY IN A MULTICENTRIC COHORT

Background:

Idiopathic inflammatory myopathies (IIM) are a group of rare diseases consisting on immune-mediated muscle damage. About 40 to 60% show specific-myositis antibodies; aditionally, 20-40% can show myositis-related (non-specific) antibodies. The profile of antibodies can help to divide patients into subgroups with more homogeneous clinical characteristics and prognosis.

Objectives:

This study characterizes patients with IIM with specific or related anti-myositis antibodies, in five hospitals in the Alicante health area.

Methods:

This is an observational study, carried out in five hospitals with a reference population of 1.083.463 people. Patients with positive anti-myositis antibodies between October 2015 and May 2018 were selected from the database of the Clinical Laboratory of the University Hospital of Alicante. We considered the following antiboides: anti-myositis specific antibodies (anti-TIF1y, anti-MDA5, anti-Mi-2, anti-PmScl75, anti-PMScl100, anti-NXP2, anti-SRP), anti-synthetase antibodies (anti-PL7, anti-PL12, anti-Jo1, anti-OJ), myositis-related antibodies (anti-Ro52, anti-Ku). Clinical records were examined, identifying those patients with a diagnosis of IIM acording to their clinician, rheumatologist. Epidemiological and clinical data were obtained.

Results:

291 patients with positive anti-myositis antibodies were identified. Among them, 40 patients had a diagnosis of IIM. Median age was 59.5 (IQR 41.5, 70) years and 68% were women. Within the subgroups, the most frequent diagnosis were dermatomyositis (n=22; 55%) and polimyositis (n=9; 22%). The most common antibody detected was anti-TIF-y among specific antibodies, and anti-Jo-1 among the anti-synthetase antibodies. The most common extramuscular feature was skin involvement. The presence of interstitial lung disease was reported in about one third of patients, being UIP the most commong pattern. Regarding treatment, the use of steroids was generalized; methotrexate was the most used inmunosupresant agent. Eight patients had a cancer related myopathy.

DM (N=22)PM (n=9)DMJ (N=3)IMNM (n=1)AS (n=5)Age, median (IQR)65,5(46, 76)57(34, 66)15,7 (14, 18)83 (-)61(56, 64)Femalen(%)15(68,2)6(66,6)2(66,6)1(100)3(60)Muscular feat. n(%)16(77,7)9(100)1(33,3)1(100)5(100)ILD n(%)1(4,5)3(33,3)005(100)Disfagia n(%)3(13,6)1(11,1)000Skin feat n(%)17(77,3)02(66,6)01(20)arthritis n(%)1(4,5)02(66,6)04(80)Raynaud n(%)4(19)1(11,1)001(20)Calcinosis n(%)1(4,5)1(11,1)(66,6)00Puffy hands n (%)2(9)0002(40)Sicca synd n(%)3(13,6)1(11,1)000Cáncer n(%)7(31,8)1(11,1)000Ck máx(UI/l), median (IQR)432(171, 706)809(350, 1653)--665(396, 2300)

Conclusion:

This register allows us to characterise patients with inflammatory myositis in our area. It is important to make multicentric and prospective registers in infrequent diseases such as IIM in order to have more detailed and representative information about clinical and socio-demographic characteristic as well as prognostic data from these patients.

References:

[1]Dalakas M. Inflammatory Muscle Diseasees. N Engl J Med 2015;372:1734-47.

[2]Lündberg IE, Tjärnlund A, Bottai M, et al. 2017 Ann Rheum Dis2017;76:1955–1964.

[3]Betteridge Z, McHugh N. J. Intern Med, 2016 Jul;280(1):8-23.

[4]Nuño L et al. Reumatol Clin. 2017;13(6):331-337

[5]Lilleker JB, Vencovsky J, Wang G, et al.. Ann Rheum Dis 2018;77:30-39

Disclosure of Interests:

None declared

THU0414 ORDINARY LIGHT MICROSCOPY IS ABLE TO IDENTIFY MOST CRYSTAL-CONTAINING SYNOVIAL FLUIDS

Background:

Optical microscopy remains the gold standard for the diagnosis of crystal arthropathies. The complete protocol consists of three phases. In the first stage, microscopy with simple light provides information on the morphology of the crystal. The second stage, polarized light, allows detecting the intensity of the birefringence. Finally, with the first-order red compensator, the type of elongation is detected, positive for calcium pyrophosphate (CPP) crystals and negative for monosodium urate (MSU) crystals. Finally, with the obtained data, the presence and type of crystals is concluded.

Objectives:

Analyze the validity and agreement of each stage of microscopy regarding the conclusion, emphasizing ordinary light microscopy.

Methods:

Fifty consecutive samples of synovial fluid obtained in routine clinical practice were independently analyzed under the compensated polarized microscope by 5 observers blinded to clinical data (250 observations in total). Each observer recorded the presence and type of crystals at each stage and reached a conclusion after gathering all the information. To estimate the diagnostic yield of each microscope stage, sensitivity, specificity and positive and negative predictive values, as well as the accuracy (number of correct observations/number of total observations), were calculated; also, the total weighted kappa was used to assess the degree of agreement with the complete protocol.

Results:

Main results of the study are shown in Table 1. Regarding diagnostic yield, ordinary light microscopy showed excellent sensitivity, specificity and predictive values, similar to the results noted with simple and compensated polarized microscopy.

Table 1.

In parentheses, 95% confidence intervals.

AccuracySensitivitySpecificityPositive predictive valueNegative predictive valueKappaOrdinary light96.8%(93.8-98.4)97.2%(93.1-98.9)96.2%(90.7-98.5)97.2%(93.1-98.9)96.2%(90.7-98.5)0.954(0.919-0.989)Simple polarized light92.0%(88.0-94.8)84.1%(76.8-89.5)100%(97.0-100)100%(96.5-100)86.1%(79.5-90.8)0.874(0.821-0.927)Compensated polarized light97.6 %(94.9-98.9)95.5%(89.8-98.0)99.3%(96.1-99.9)99.1%(94.8-99.8)96.5%(92.1-98.5)0.962(0.933-0.992)

Diagnoses established by ordinary light microscopy matched conclusions (accuracy) in 242/250 (96.8%) observations. Discrepant cases were crystals missed under ordinary light in 4 cases (3 MSU, 1 CPP), and 4 samples with CPP crystals initially seen but later concluded their absence. Interestingly, lowest accuracy was seen with simple polarization; CPP crystals were not detected in 20 out of 93 observations with CPP (21.5%). The accuracy of compensated polarized light was similar to ordinary light. On 5 occasions no crystals were seen but finally they were present (1 MSU, 4 CPP); on the contrary, CPP was registered in one observation but the conclusion indicated no crystals.

Regarding agreement with the complete protocol, the kappa with simple light is 0.954, similar to compensated polarized light (0.962), while simple polarized light showed the lowest agreement (0.874).

Conclusion:

Ordinary light microscopy is enough to correctly reach the majority of diagnoses, with a very high degree of agreement with the complete protocol. Results were comparable to using a compensated polarized microscopy. Thus, if a microscope with polarizer and first-order compensator was not available, using ordinary light would be enough on most occasions. Polarized light microscopy better identifies MSU crystals, but over 20% of CPP crystals were missed at this stage, reinforcing the value of the ordinary light microscopy.

Acknowledgments:

Thanks to Loreto Carmona for the help with the statistical aspects.

Disclosure of Interests: :

None declared

AB0174 T REGULATORY CELLS LEVEL IN PERIPHERAL BLOOD OF PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS AND ITS RELATION WITH DISEASE ACTIVITY

Background:

The most important T-cell subtype in maintenance of immune tolerance is T regulatory cells (Treg). These are characterized by CD4 and CD25 receptors on surface, and by showing FoxP3 regulatory factor, which is necessary for maintaining the suppressive activity of Treg cells in peripheral blood (PB). Previous studies have studied Treg cells in PB and synovial fluid in patients with Juvenile Idiopathic Arthritis (JIA). However, there was insufficient evidence to draw robust conclusions about Treg implication in JIA, due to small simple size and variable results across studies. A deeper understanding of regulatory mechanism in JIA may increase comprehension on variability among JIA subtypes and may help to stablish prognosis on the follow up.

Objectives:

To analyze Treg cells level in PB of JIA patients and its relation with disease activity.

Methods:

Descriptive, cross-sectional, observational study conducted in a regional reference centre for Pediatric Rheumatology. We included consecutive patients with JIA diagnosed by ILAR criteria. The primary variable was the Treg percentage in PB measured by flow cytometry. To assess JIA activity, we used disease activity indexes (JADAS10, 27, 71 – CRP/ESR and cJADAS), Wallace remission criteria, VAS disease activity by patient/parents and physicians, morning stiffness, multidimensional evaluation (JAMAR) and acute phase reactants (CRP and ESR). Assessment of long-term damage was evaluated with JADI. Association analyses among study variables and Treg levels were performed by Pearson’s correlation coefficient and Mann Whitney’s U test.

Results:

Ongoing study, we present a preliminary analysis with first 50 JIA patients. Mean age (SD) was 11.3 yr (4.6), being females 60%. Most common JIA subtype was persistent oligoarticular (42%) followed by RFneg polyarticular (24%). 42% patients were treated by csDMARD and 46% by biological agents. Mean levels of CRP and ESR were 0.18 mg/dl (0.3) and 6.3 mm/hr (5.4), respectively. At the time of the study, 84% of patients were in remission (Wallace criteria). Mean of JADAS 27-VSG, JADAS 27-PCR and cJADAS were 3.6 (5.1), 3.7 (5.1), and 3.7 (5.5), respectively. Mean long-term damage scores were 0.48 (1.1) for JADI-A and 0 for JADI-E. Mean levels of Treg cells in PB were 2.11% (1.1). The table shows the association between clinical variables and % of Treg. We can observe a significant, inverse and moderate correlation between Treg levels and disease activity by patient/parents, disability and quality of life (global and the physical component). Close to statistical significance, we found inverse and moderate correlation between Treg cells and all JADAS scores, cJADAS, disease activity by physician and morning stiffness. There was no association between Treg and acute phase reactants. Furthermore, there were no differences in Treg cells in Wallace remission (p=0.692) and regarding use of conventional or biological DMARD (p=0.984 and p=0.386, respectively).

Conclusion:

According to our preliminary data, higher levels of Treg cells in PB of patients with JIA could be related with lesser disease activity and better quality of life. Larger studies are needed to confirm whether this Treg-mediated regulatory mechanism can have prognostic implication JIA.

Variablesrp valueCRP (mg/dl)-0.240.099ESR (mm/hour)-0.150.314VAS-disease activity (patient / parents)-0.280.049VAS-disease activity (physician)-0.250.081JADAS10 (VSG)-0.270.064JADAS27 (VSG)-0.270.064JADAS71 (VSG)-0.270.064JADAS10 (PCR)-0.280.054JADAS27 (PCR)-0.280.054JADAS71 (PCR)-0.280.054c JADAS10-0.260.065Disability (JAFS – JAMAR)-0.340.021Quality of lyfe (PRQL – JAMAR)-0.390.007Quality of life physical (PRQLPh – JAMAR)-0.460.001Quality of life psychosocial (PRQLPs-JAMAR)-0.210.156Morning Stiffness-0.270.066

Disclosure of Interests:

None declared

A Randomized Study of Low-Dose Interleukin-2 Subcutaneous Immunotherapy versus Interleukin-2 plus Interferon-Alpha as First Line Therapy for Metastatic Renal Cell Carcinoma

Aims and Background

IL-2 given subcutaneously in combination with interferon-alpha 2b (IFN) appears to induce a response rate comparable to that obtained with IL-2 intravenous injection in patients with metastatic renal cell carcinoma (RCC) but with lower toxicity. The role of IFN when combined with IL-2 has however still to be defined. The present study was performed to draw some preliminary conclusions about the effect of IFN in combination with IL-2 in metastatic RCC.

Methods

The study included 30 consecutive patients with metastatic RCC who were randomized to treatment with IL-2 subcutaneous therapy (3 million IU twice/daily for 5 days/week for 6 weeks) or with IL-2 plus IFN (5 million U/m2 subcutaneously thrice weekly). In patients without progressive disease, a second cycle was repeated after a 28-day rest period.

Results

No significant difference in partial response rate was found between patients treated with IL-2 alone and those given IL-2 plus IFN (5/15 vs 4/15). Similarly, no difference was seen in the percentage of stable disease (7/15 vs 7/15). Toxicity was higher in patients who received IL-2 plus IFN. Lymphocyte and eosinophil mean increase was higher in patients treated with IL-2 alone than in those treated with IL-2 plus IFN, without however any significant difference.

Conclusions

The present results, which require confirmation in a larger series, indicate that combination with IFN does not increase the efficacy of IL-2 subcutaneous immunotherapy in metastatic RCC but only the toxicity of treatment.

Second-Line Therapy with Interferon-Alpha plus Vinblastine in Metastatic Renal Cell Cancer Patients Progressed under Interleukin-2 Subcutaneous Immunotherapy

Aims and background

Interferon (IFN) ± vinblastine (VNB) has appeared to be effective as first–line therapy of metastatic renal cell cancer. This study was performed to establish the efficacy of IFN plus VNB in metastatic RCC previously treated with interleukin-2 (IL-2).

Methods

The study included 14 metastatic renal cell cancer patients who did not respond to IL-2 subcutaneous therapy or who relapsed after initial response or stable disease. IFN-alpha 2a was given subcutaneously at 3 million U thrice a week in association with VNB (0.1 mg/kg i.v. every 21 days) until progression or toxicity. Patients were considered as evaluable when they were treated for at least 1 month.

Results

Evaluable patients were 13/14. No patient had a complete response. Partial response was achieved in 2/13 (15%) patients. Stable disease was seen in 5/13 patients, and the last 6 progressed.

Conclusions

This study, by showing a tumor response rate comparable to that reported with first-line therapy, suggests that previous IL-2 immunotherapy does not influence negatively the efficacy of IFN + VNB in metastatic renal cell cancer.

The EULAR Outcome Measures Library: development and an example from a systematic review for systemic lupus erythematous instruments

OBJECTIVES

Patient reported outcomes (PROs) are relevant in rheumatology. Variable accessibility and validity of commonly used PROs are obstacles to homogeneity in evidence synthesis. The objective of this project was to provide a comprehensive library of "validated PROs".

METHODS

A launch meeting with rheumatologists, PROs methodological experts, and patients, was held to define the library's aims and scope, and basic requirements. To feed the library we performed systematic reviews on selected diseases and domains. Relevant information on PROs was collected using standardised data collection forms based on the COSMIN checklist.

RESULTS

The EULAR Outcomes Measures Library (OML), whose aims are to provide and to advise on PROs on a user-friendly manner albeit based on scientific grounds, has been launched and made accessible to all. PROs currently included cover any domain and, are generic or specifically target to the following diseases: rheumatoid arthritis, osteoarthritis, spondyloarthritis, low back pain, systemic lupus erythematosus, gout, osteoporosis, juvenile idiopathic arthritis, and fibromyalgia. Up to 236 instruments (106 generic and 130 specific) have been identified, evaluated, and included. The systematic review for SLE, which yielded 10 specific instruments, is presented here as an example. The OML website includes, for each PRO, information on the construct being measured and the extent of validation, recommendations for use, and available versions; it also contains a glossary on common validation terms.

CONCLUSIONS

The OML is an in progress library led by rheumatologists, related professionals and patients, that will help to better understand and apply PROs in rheumatic and musculoskeletal diseases.

Lupus nephritis: a 15-year multi-centre experience in the UK

OBJECTIVES

Our aim was to audit the outcome of lupus nephritis (LN) at three East Midlands centres.

METHODS

We undertook a retrospective review of all biopsy-proven LN types III-V 1995-2010.

RESULTS

In total, 61 patients with LN were identified, with a median follow-up of 68 months. LN was present at the time of systemic lupus erythematosus (SLE) diagnosis in 20 patients. The median time from SLE diagnosis to the first LN episode was 5.3 years. Some 35 patients received IV cyclophosphamide and 17 received mycophenolate mofetil (MMF) as induction therapy; 81.8% of those treated with cyclophosphamide and 81.3% with MMF had at least 'improved' according to the ACR-response criteria 6 months from induction; 33.3% and 37.5%, respectively, had a 'complete' response. MMF and azathioprine were the most frequently used maintenance therapy. We found that 32.8% experienced a flare after a mean post-induction time of 3.5 years, irrespective of the maintenance therapy used, and 43.8% of partial responders flared compared with 4.8% of complete responders. End-stage renal failure developed in 8.2%.

CONCLUSIONS

Overall, outcomes (response, flare-rate, end-stage renal failure) were comparable with European clinical studies. Partial responders are more likely to flare compared with complete responders. The results highlight that LN can occur, and flare, after many years of SLE, emphasizing the importance of continued vigilance for LN in all patients.

Pilot study of cytokine profiles in prostate cancer patients undergoing proton or conventional radiotherapy

The mechanisms responsible for normal tissue late effects following radiotherapy are largely unknown and currently no method for predicting such risks is available. Abnormal levels of cytokine production induced by radiation has been suggested as a contributing factor by multiple investigators. The purpose of the present study was to evaluate plasma levels of transforming growth factor-beta 1 (TGF-beta 1), basic fibroblast growth factor (bFGF), tumor necrosis factor-alpha (TNF-alpha), and interleukin-1 beta (IL-1 beta) in patients with prostate cancer scheduled for radiotherapy (protons, photons, or combination of both). It has been recently shown that ionizing radiation can increase expression of these cytokines and there are indications that they may be associated with morbidity. Blood samples were obtained from 20 subjects (age 51-80) before, during the first week, and immediately after the end of therapy; 3 healthy volunteers served as controls. Significant positive correlations (p<0.05) were obtained between bFGF, IL-1 beta, and TNF-alpha and the integral dose of radiation during the first week of treatment. Correlations approaching significance (p<0.1) were obtained with bFGF and acute treatment-related morbidity. A higher integral dose (due to larger irradiated volumes) was delivered with conventional photon compared to proton irradiation. No significance was obtained with any of the cytokines and pretreatment prostate specific antigen (PSA) levels, patient age, grade or stage of disease, or the integral dose by the end of radiation treatment. These results show that large changes occur in the plasma levels of certain cytokines early after initiation of radiotherapy and that treatment of larger volumes is more likely to induce these changes. Our data support further investigation of the role of cytokines during radiotherapy.

Impact of apolipoprotein E ε4 and HIV on cognition and brain atrophy: antagonistic pleiotropy and premature brain aging

OBJECTIVE

The apolipoprotein E (APOE) ε4 allele may accelerate the progression of HIV disease, and increase the risk for developing HIV-associated neurocognitive disorder (HAND). Whether APOEε4 allele(s) and age may influence brain atrophy in HIV patients is unknown and was evaluated.

METHODS

Automated morphometry on magnetic resonance images, using FreeSurfer analyses, neuropsychological testing and APOE genotyping were performed in 139 subjects [70 seronegative controls (SN); 69 clinically-stable HIV subjects].

RESULTS

Compared to SN, HIV subjects had smaller volumes throughout the brain regardless of their HAND status. Compared to APOEε4- subjects, SN controls with APOEε4 had better memory and larger global brain volumes (cerebral white matter and cortex) while HIV subjects with the APOEε4 allele(s) had poorer cognition (verbal fluency, learning, executive function and memory) and smaller cerebral and cerebellar white matter and subcortical structures. Further stratification of age showed that younger (<50 years) APOEε4+SN subjects had larger putamen and cerebral white matter, while younger APOEε4+HIV subjects had poorer performance on verbal fluency and smaller brain volumes [3-way (HIV-status×APOEε4×Age) interaction-p-values=0.005 to 0.03].

INTERPRETATION

These findings suggest that APOEε4 allele(s) may show antagonistic pleiotropy on cognition and brain atrophy in SN controls, but may lead to premature aging with neurodegeneration in younger HIV patients prior to the development of HAND. Potential mechanisms for such interactions may include stronger neuro-inflammation or greater amyloid deposition in younger HIV subjects with APOEε4 allele(s). Early screening for the APOEε4 allele and brain atrophy with morphometry may guide neuroprotective intervention of cognitively normal HIV subjects prior to the development of HAND. Longitudinal follow-up studies and larger sample sizes are needed to validate these cross-sectional results.

Q-switching of an all-fiber laser by acousto-optic modulation of a fiber Bragg grating

We report active Q-switching of an all-fiber laser using a Bragg grating based acousto-optic modulator. Q-switching is performed by modulating a fiber Bragg grating with an extensional acoustic wave. The acoustic wave modulates periodically the effective index profile of the FBG and changes its reflection features. This allows controlling the Q-factor of the cavity. Using 1 m of 300 ppm erbium-doped fiber and a maximum pump power of 180 mW, Q-switch pulses of 10 W of peak power and 82 ns wide were generated. The pulse repetition rate of the laser can be continuously varied from few Hz up to 62.5 kHz.

Rolle der Gesundheitsbehörden der Länder bei der Verhütung und Bekämpfung von Infektionskrankheiten

The goal is to describe the structure of administration for the control of infectious diseases in the German states. Internationally there is an increasing risk of potentially global transmission of infectious diseases and therefore increasing need for improved control mechanisms which are viable locally, regionally and internationally. The international public health community must ensure that responses to infectious disease with a potential impact on more than one county entail concerted action, clear communication and decision making by diverse administration agencies. Given Germany's federal structure, the 16 states have differing protocols delineating responsibilities for infection control systems. This paper provides an overview, going into detail only with regard to the administration structure in Hesse. In 2001, the German law governing infectious disease control was amended and significantly expanded. With regard to protection of humans from infectious disease, each state must define its schedule of responsibilities on the resulting scope of duties. Each state in Germany has entrusted the local public health service at the county level with the responsibility for infection prevention and control. As a rule, at the state level both an expert agency and one or more district administration agencies have been installed; these work directly with the Ministry of Health at the state level. In addition to this, Hesse has established a "centre of competence for highly contagious diseases." In the event of an infectious emergency, this network provides special treatment of highly infectious patients and expertise for public health services and the Ministry of Health on a 24-h shift basis. In times of ongoing structural transformation, it is important to emphasize that expertise at the state level is not an alternative to maintaining enough specialised personnel in the public health services themselves. Specialized practitioners are needed to ensure professional and fast-acting responses, both for the prevention and control of infectious diseases.

[1-deamino-4-cyclohexylalanine] arginine vasopressin: a potent and specific agonist for vasopressin V1b receptors

To date, there are no vasopressin (VP) agonists that exhibit a high affinity and selectivity for the VP V1b receptor with respect to the V1a, V2, and oxytocin receptors. In this study, we describe the synthesis and pharmacological properties of [1-deamino-4-cyclohexylalanine] arginine vasopressin (d[Cha4]AVP). Binding experiments performed on various membrane preparations revealed that d[Cha(4)]AVP exhibits a nanomolar affinity for V1b receptors from various mammalian species (rat, bovine, human). It exhibits high V1b/V1a and V1b/oxytocin selectivity for rat, human, and bovine receptors. Furthermore, it exhibits high V1b/V2 specificity for both bovine and human vasopressin receptors. Functional studies performed on biological models that naturally express V1b receptors indicate that d[Cha4]AVP is an agonist. Like VP, it stimulated basal and corticotropin-releasing factor-stimulated ACTH secretion and basal catecholamine release from rat anterior pituitary and bovine chromaffin cells, respectively. In vivo experiments performed in rat revealed that d[Cha4]AVP was able to stimulate both ACTH and corticosterone secretion and exhibits negligible vasopressor activity. It retains about 30% of the antidiuretic activity of VP. This long-sought selective VP V1b receptor ligand with nanomolar affinity will allow a better understanding of V1b-mediated VP physiological effects and is a promising new tool for V1b receptor structure-function studies.

Automatic tunable and reconfigurable fiberoptic microwave filters based on a broadband optical source sliced by uniform fiber Bragg gratings

We demonstrate an automatic tunable transversal notch filter based on uniform fiber Bragg gratings and a broadband optical source. High tunability can be performed by stretching the fiber with the gratings written in series. Also, high sidelobe supression can be achieved by introducing tunable attenuators in a parallel configuration of the gratings.

Designing the properties of dispersion-flattened photonic crystal fibers

We present a systematic study of group-velocity-dispersion properties in photonic crystal fibers (PCF's). This analysis includes a thorough description of the dependence of the fiber geometrical dispersion on the structural parameters of a PCF. The interplay between material dispersion and geometrical dispersion allows us to established a well-defined procedure to design specific predetermined dispersion profiles. We focus on flattened, or even ultraflattened, dispersion behaviors both in the telecommunication window (around 1.55 microm) and in the Ti-Za laser wavelength range (around 0.8 microm}. We show the different possibilities of obtaining normal, anomalous, and zero dispersion curves in the above frequency domains and discuss the limits for the existence of the above dispersion profiles.

Vasopressin receptors in human adrenal medulla and pheochromocytoma

The nature of vasopressin (VP) receptors present in normal and tumoral human adrenal was investigated using various experimental approaches. Specific VP-binding sites were detected by autoradiography using [3H]arginine VP as a radioligand in adrenal cortex and medulla. The V1a receptor subtype was expressed in the two parts of the gland, as shown by pharmacological studies and RT-PCR experiments. By contrast, the V1b receptor subtype was only expressed in medullary chromaffin cells. This was confirmed by the characterization of V1b transcripts detected in adrenal medulla tissues. In pheochromocytoma, we also detected functional V1b receptors. These receptors triggered intracellular calcium mobilization from intracellular pools and were involved in catecholamine secretion. Binding experiments performed on pheochromocytoma plasma membrane preparations also revealed V1a vasopressin-binding sites, whose roles and cellular localization have not yet been determined. RT-PCR experiments confirmed these data; 100% and 80% of the five tumors tested exhibited V1a and V1b transcripts, respectively. Perifusion experiments also demonstrated that some pheochromocytomas may secrete large amounts of VP. Our findings imply that VP locally secreted by human adrenal medulla may regulate adrenal function by acting on V1a or V1b receptors. More interestingly, we demonstrate that one pheochromocytoma oversecretes VP. In this particular case, this may contribute to the increase in blood pressure observed.

Improved removal of white cells with minimal platelet loss by filtration of apheresis platelets during collection

BACKGROUND

Filtration of apheresis platelets to remove white cells (WBCs) requires operator intervention after the collection procedure (postcollection filtration), which may cause variable and unsatisfactory filter performance (WBC removal and platelet loss). The MCS+ LN9000 apheresis system filters platelets through a WBC-reduction filter during each collection cycle (continuous filtration) at a flow rate of 15 to 25 mL per minute. Apheresis platelets obtained by continuous filtration were evaluated in terms of platelet loss, WBC removal, and platelet storage properties and then were compared to unfiltered apheresis platelets and to apheresis platelets that underwent postcollection filtration. Two WBC-reduction filters were tested (LRF6 and LRFXL).

STUDY DESIGN AND METHODS

In 70 apheresis platelets, postcollection filtration was performed by using the LRF6 at flow rates of 80 mL per minute (n = 30) and 50 mL per minute (n = 30) and the LRFXL at 50 mL per minute (n = 10). One hundred fifty-eight apheresis platelets underwent continuous filtration through the LRF6 (n = 58) or the LRFXL (n = 100). Unfiltered apheresis platelets (controls) (n = 30) were obtained by the same collection protocol.

RESULTS

Estimated platelet loss with continuous filtration was 7 percent for the LRFXL and 3 percent for the LRF6. A reduction in the filtration flow rate from 80 to 50 mL per minute with postcollection filtration through the LRF6 resulted in markedly lower WBC levels, with 10 percent versus 57 percent of the apheresis platelets having WBC counts <1 x 10(5), respectively. Additional improvements in WBC removal were found with continuous filtration; 85 percent of the apheresis platelets filtered with the LRF6 and 100 percent of the apheresis platelets filtered with the LRFXL had WBC counts <1 x 10(5).

CONCLUSIONS

Continuous or postcollection filtration of freshly collected apheresis platelets resulted in minimal platelet loss. Better WBC removal from apheresis platelets was obtained with continuous filtration than with postcollection filtration, likely because of the slower flow rate. Platelet storage quality was not affected by filtration.

[Immunotherapy for metastatic renal carcinoma with interleukin-2 in a subcutanous administration schedule of short duration. Subcutaneous IL-2 in renal carcinoma]

It has been shown that low-dose subcutaneous (SC)IL-2 exerts an efficacy similar to that described for the intravenous high-doses in the immunotherapy of metastatic renal cell cancer (RCC). However, it remains to be established which could be the optimal duration of treatment. The most common schedules with subcutaneous IL-2 are generally consisting of 6 weeks of therapy, with an IL-2 dose of about 6 million IU/day. This study was performed to evaluate the efficacy of IL-2 subcutaneous immunotherapy with a duration of 4 weeks only. The study included 13 evaluable metastatic RCC patients. IL-2 has been injected subcutaneously at 6 million IU/day for 6 days/week for 4 weeks, by repeating a second cycle in nonprogressing patients after a 21-day rest period. Objective tumor regressions were achieved in 3/13 (23%) patients consisting of CR in 1 and PR in the other 2. Stable disease was obtained in other 6 patients. This preliminary study would suggest that a shorter dose-matched S.C.IL-2 immunotherapy may have a similar therapeutic efficacy in metastatic RCC. Therefore, the 4-week IL-2 S.C. immunotherapy, instead of the 6-week schedule could become the standard immunotherapeutic schedule, with following decreased cost and toxicity.

[Clinical response and survival in metastatic renal carcinoma during subcutaneous administration of interleukin-2 alone. Subcutaneous Il-2 in renal carcinoma]

Several clinical studies have demonstrated the efficacy of subcutaneous immunotherapy with Il-2 alone in metastatic renal cell carcinoma (RCC). In an attempt to better define the clinical parameters which may predict the efficacy of treatment, the present study shows the results obtained with subcutaneous Il-2 alone in 91 evaluable metastatic RCC patients. IL-2 was injected subcutaneously at 3 million IU twice/day for 5 days/week for 6 weeks, corresponding to one immunotherapeutic cycle. In nonprogressing patients, a second cycle was given after 28-day rest period. A complete response (CR) was achieved in 2/91 patients. Moreover, 19/91 patients had a partial response (PR). Therefore, objective response (OR) rate was 21/91 (23%) patients. Stable disease (SD) was achieved in 41 patients, while the remaining 29 patients had a progressive disease (PD). OR rate was significantly higher in patients with a long disease-free survival than in patients with synchronous metastases, in nephrectomized patients than in the non-nephrectomized ones, and in patients with high than in those with low PS. The survival obtained in patients with CR or PA was significantly longer with respect to that found in patients with SD or PD. The toxicity was substantially low in all patients. This study confirms that the subcutaneous immunotherapy with IL-2 alone is an effective and well tolerated therapy of metastatic RCC.

[Preoperative subcutaneous immunotherapy with interleukin-2 in renal carcinoma with synchronous metastasis: randomized clinico-biological study. Preoperative use of Il-2 in renal carcinoma]

Despite the efficacy of IL-2 in the treatment of metastatic renal cell carcinoma (RCC), the prognosis of patients with synchronous metastases still remains poor. Nephrectomy itself, as well as other surgical operations, may further suppress the antitumor immune response. Previous studies suggested that the preoperative injection of IL-2 may neutralize surgery-induced lymphocytopenia in advanced colon cancer. On this basis, a pilot randomized study was performed in an attempt to evaluate the effects of a preoperative administration of IL-2 on postoperative lymphocyte numbers and on the survival in advanced RVV patients with more than 3 synchronous metastases. The study included 20 consecutive patients, who were randomized to receive nephrectomy alone or nephrectomy plus preoperative subcutaneous immunotherapy with IL-2 (18 million IU/day for 3 days). Then, all patients underwent postoperative immunotherapy with IL-2 (6 million IU/day for 5 days/week for 6 weeks). Surgery-induced lymphocytopenia was completely abolished by IL-2 preoperative injection. The frequency of postoperative complications was significantly higher in controls than in patients preoperatively treated with IL-2. On the contrary, significant differences between control and patients preoperatively treated with IL-2 were observed neither in the clinical response to IL-2 immunotherapy, nor in the percent of 1-year survival. The results of this preliminary pilot study would suggest that IL-2 preoperative immunotherapy may neutralize surgery-induced lymphocytopenia and reduce the postoperative complications in RCC patients with synchronous metastases, without, however, influencing their prognosis in terms of survival time.

[Radical prostatectomy: comparison of technics]

From 1989 until today 46 patients aged 44-75 years underwent a radical prostatectomy two of whom transperineal and another 44 patients underwent a retropubical prostatectomy (twenty of whom with the nerve sparing technique). Based on our experience, the clinical stages that benefit from a radical prostatectomy as are as followed: T1b, T1c, T2a, T2b; T2c, in patients who present a good A.S.A., a remaining life-span of ten years is expected. Our preference, regarding the best access was clearly the traditional retropubical which allowed us on a preliminary bases a bilateral iliaco-otturatorial lymphoadenectomy with extemporaneus histological exams. Based on our experience we do not see an indication for a radical surgical intervention in the following with: P.S.A. higher than 60 ng./ml in patients with a clinical stage C. Positive abdominal-pelvical computer tomography for macrometastical lymph nodes. Positive bone scintigraphy. Patients over the age of 75 years.

[Terazosin in the treatment of benign prostatic hypertrophy]

Benign prostatic hypertrophy provokes clinical manifestations correlated on one hand to a static obstructive component, due to the increase in glandular size, and on the other hand to a dynamic component, controlled by the alpha adrenergic autonomic system which gives the smooth muscular tonus of the prostatic adenoma. The alpha adrenergic receptor block reduces the dynamic component, improves the clinical and urodynamic parameters determined by the infra-bladder obstruction in patients with BPH. The selective alpha 1, long acting antagonists especially, such as terazosin, offer a safe and efficient therapy for selected patients suffering from BPH. They also have the indisputable benefit of mono-administration. In this study the basic concepts of BPH treatment with terazosin are discussed.