Investigating coping and stigma in people living with HIV through narrative medicine in the Italian multicentre non-interventional study DIAMANTE

Antiretroviral therapy (ART) significantly reduced Human Immunodeficiency Virus (HIV) morbidity and mortality; nevertheless, stigma still characterises the living with this condition. This study explored patients' coping experience by integrating narrative medicine (NM) in a non-interventional clinical trial. From June 2018 to September 2020 the study involved 18 centres across Italy; enrolled patients were both D/C/F/TAF naïve and previously ART-treated. Narratives were collected at enrolment (V1) and last visit (V4) and then independently analysed by three NM specialist researchers through content analysis. One-hundred and fourteen patients completed both V1 and V4 narratives. Supportive relationships with clinicians and undetectable viral load facilitated coping. Conversely, lack of disclosure of HIV-positive status, HIV metaphors, and unwillingness to narrate the life before the diagnosis indicated internalised stigma. This is the first non-interventional study to include narratives as patient reported outcomes (PROs). Improving HIV awareness and reducing the sense of guilt experienced by patients helps to overcome stigma and foster coping.

Epileptologists telling their experiences caring for patients with epilepsy

OBJECTIVE

This research was focused on expert professionals in epilepsy care to understand their points of view on the care pathway and their living relationships with patients.

METHODS

Researchers prepared a semi-structured parallel chart and distributed it online among 21 Italian centres of care. Each health professional was prompted to write five narratives on cases of patients with epilepsy, subsequently analysed through narrative medicine methods. Next, a consensus meeting was held, to individualise an action plan based on the narratives.

RESULTS

Ninety-one parallel charts were collected from 25 epileptologists, who had a mean age of 50 years; their narratives concerned patients with a mean age of 37 years, with different types of epilepsy (53 % drug-resistant; 31 % unemployed). The limitations in the daily life of people with epilepsy (57 %), employment (42 %), caregiver burden (51 %), and the universal prevalence of fear were the primary topics that emerged. Attentive and reassuring care relationships were found to be the main element of coping (21 %). A new multi-factorial classification of epilepsies, integrating clinical with social and legal risk factors, was the main agreed action to face the issues identified.

CONCLUSIONS

The narrative medicine approach supplied a broader scenario of living with epilepsy, including the family and social impact and possible effects on the choices for care pathways. The epileptologists showed a strong motivation to care for patients with epilepsy and deep involvement in the care relationships; the use of parallel chart demonstrated to be an effective tool to preserve their wellbeing.

Minimal impact of lenvatinib (Lenvima®) on muscle mass in advanced hepatocellular carcinoma and implications for treatment duration. Two cases from the REFLECT study

OBJECTIVE

Two case reports of advanced unresectable hepatocellular carcinoma (HCC) treated with lenvatinib (Lenvima®) are presented; the drug's effect on muscle loss and duration of treatment are discussed.

PATIENTS AND METHODS

Between November 2014 and December 2017, at the Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy, two male patients with advanced HCC enrolled in the lenvatinib arm of the REFLECT trial received the drug over 24 cycles (almost 2 years). We reviewed the clinical charts from baseline, when lenvatinib was started, through 24 months of treatment. The changes in the skeletal mass area (SMA), as assessed by computed tomography (CT) at the third lumbar level (L3), between baseline and month 24 into treatment were recorded.

RESULTS

Case 1: SMA decreased by 2.8 cm2 between baseline and month 24 (134 cm2 vs. 131.2 cm2), with a muscle loss of 2.13%. Case 2: SMA decreased by 13 cm2 between baseline and month 24 (133 cm2 vs. 120 cm2), with a muscle loss of 10.83%.

CONCLUSIONS

The disease remained stable for over 2.5 years in both patients. A minimal loss of muscle mass was noted at 24 months of treatment. The minimum effect on muscle loss may be correlated with the positive clinical response and the drug's low toxicity. Our findings may help to elucidate the effect of lenvatinib on muscle mass and inform the development of the targeted nutritional support for HCC patients.

Critical analysis of major and ancillary features of LI-RADS v2018 in the differentiation of small (≤ 2 cm) hepatocellular carcinoma from dysplastic nodules with gadobenate dimeglumine-enhanced magnetic resonance imaging

OBJECTIVE

To evaluate the performance of major features, ancillary features, and categories of Liver Imaging Reporting and Data System (LI-RADS) version 2018 at magnetic resonance (MR) imaging in the differentiation of small hepatocellular carcinoma (HCC) from dysplastic nodules (DNs).

PATIENTS AND METHODS

This retrospective study included cirrhotic patients with pathologically proven untreated HCCs and DNs (≤ 2 cm) and liver MR imaging performed with gadobenate dimeglumine contrast agent within 3 months before pathological analysis, between 2015 and 2018. 37 patients with 43 observations (17 HCCs and 26 DNs) met the inclusion criteria. Two radiologists assessed major and ancillary imaging features for each liver observation and assigned a LI-RADS v2018 category in consensus. Estimates of diagnostic performance of major features, ancillary features, and LI-RADS categories were assessed based on their sensitivity, specificity, positive (PPV), and negative predictive values (NPV).

RESULTS

Major features (nonrim arterial phase hyperenhancement, nonperipheral "washout", and enhancing "capsule") had a sensitivity of 94.1%, 88.2%, and 41.2%, and a specificity of 57.7%, 42.3%, and 88.5% for HCC, respectively. Ancillary features (hepatobiliary phase hypointensity, mild-moderate T2 hyperintensity, restricted diffusion, and fat in the lesion more than adjacent liver) had a sensitivity of 94.1%, 64.7%, 58.8%, and 11.8%, and a specificity of 26.9%, 61.5%, 65.4%, and 76.9% for HCC, respectively. The LR-5 category (determined by using major features only vs. the combination of major and ancillary features) had a sensitivity of 88.2% at both evaluations and a specificity of 76.9% and 80.8% for HCC, respectively. The combination of LR-4, LR-5 categories (determined by using major features only vs. the combination of major and ancillary features) had a sensitivity of 94.1% at both interpretations and a specificity of 65.4% and 26.9% for HCC, respectively. The use of ancillary features modified LI-RADS category in 25.6% of observations (11/43), predominantly upgraded from LR-3 to LR4 (10/11), increasing the proportion of low-grade DNs and high-grade DNs categorized as LR-4 (from 15.4% to 61.5% and from 7.7% to 46.1%, respectively).

CONCLUSIONS

The added value of ancillary features in combination with major features is limited for the non-invasive diagnosis of small HCC; however, their use modifies the final category in a substantial proportion of observations from LR-3 to LR-4, thus allowing possible changes in the management of patients at risk for HCC.

Imaging assessment of portal venous system: pictorial essay of normal anatomy, anatomic variants and congenital anomalies

The purpose of this pictorial essay is to describe anatomic variants and congenital anomalies of portal venous system and related liver parenchymal alterations. The imaging findings of some of these entities have been previously described in other articles, however this work encompasses all congenital anomalies of portal venous system with attention to their features on various imaging modalities; in particular we illustrated with detailed pictures all the main portal vein variants, congenital extra- and intra-hepatic porto-systemic venous shunts and portal vein aneurysm. Variants of portal branches and intrahepatic portosystemic shunts are quite uncommon, however, when present, they should be recognized before performing surgery or interventional procedures. Congenital absence of the portal vein is an important finding as the complete loss of portal perfusion predisposes the liver to focal or diffuse hyperplastic or dysplastic changes. Portal vein aneurysm is a rare clinical entity that can affect intra- and extra-hepatic portal branches; although usually asymptomatic, thrombosis can occur. Awareness of congenital variants of portal venous system among radiologists should allow a more confident diagnosis and permit an accurate planning of surgical procedures and percutaneous interventions; identification of portal system anomalies also suggest an accurate evaluation of associated hepatic parenchymal anomalies such as nodular regenerative hyperplasia, focal nodular hyperplasia (FNH), and adenomas with high risk of malignant transformation.

226 EFFECTS OF MICROVESICLES SECRETED FROM EQUINE AMNIOTIC-DERIVED PROGENITOR CELLS ON IN VITRO LIPOPOLYSACCHARIDE-TREATED TENDON AND ENDOMETRIAL CELLS

Administration of horse amniotic mesenchymal cell conditioned medium (AMC-CM) improves the in vivo recovery of spontaneous equine tendon lesions. This effect may involve paracrine mechanisms whose nature remains unknown. It has recently been demonstrated that microvesicles (MV) released from cells are an integral component of cell-to-cell communication during tissue regeneration. Aims of this study were to investigate the presence and type of MV secreted by AMC using Nanosight instrument (Malvern Instruments, Malvern, UK) and transmission electron microscopy (TEM) and the incorporation of MV in equine tendon and endometrial cells by fluorescence semiquantitative analysis. Tendon cells were used to understand the in vitro role of MV on stressed cells compared with the in vivo results previously obtained, while the endometrial cells were investigated in view of the prospective use of AMC-CM or MV in in vivo inflammatory endometrial diseases. Moreover, the ability of MV to counteract in vitro inflammation of tendon and endometrial cells induced by lipopolysaccharide (LPS) was also evaluated. The MV were obtained by ultracentrifugation at 100 000 × g for 1 h at 4°C of the media obtained by culturing AMC isolated from 3 different placentas. Tendon and endometrial cells were obtained from collagenase digestion for 17 and 3 h, respectively and cultured in HG-DMEM with 10% fetal calf serum. To study the ability of tendon and endometrial cells to incorporate MV, a dose-response curve was performed adding 10, 20, 30, 40, and 50 × 106 MV mL–1 labelled with PKH-26 for 24, 48, and 72 h. The uptake of MV was evaluated by an Olympus BX51 microscope (Olympus, Tokyo, Japan) equipped with software for image acquisition. A dose-response curve of LPS was also investigated by apoptotic and MTT tests showing that 100 ng mL–1 at 48 h on tendon cells and 10 ng at 24 h on endometrial cells were the doses and times most effective in inducing cellular stress. RT-qPCR expression of pro-inflammatory genes such as metallopeptidase (MMP) 1 and 13 was evaluated in the in vitro LPS stress by Mann-Whitney U-test. Results by Nanosight Instrument showed that AMC secrete MV in the range of 100 to 200 nm; TEM showed budding of the AMC membrane, proving that these MV fall within the shedding vesicles category. The same semiquantitative fluorescence uptake signal was obtained when 50 × 106 MV were incorporated at 24 h, or 40 × 106 MV at 48 h, and 30 × 106 MV at 72 h, suggesting that an inverse correlation between concentration and time was found in MV uptake equally by tendon and endometrial cells. The MV induced a significant (P < 0.05) down-regulation of MMP1 and MMP13 expression in both cell lines after in vitro LPS stress. Our data suggest that these MV can be incorporated in tendon and endometrial cells and have a role in modulating inflammatory genes in vitro.

327 PORCINE AMNION: A SOURCE OF EPITHELIAL STEM CELLS

The use of pig models for preclinical testing is well established, and the availability of stem cells from this species would open the way to preclinical studies for application of cell therapy. According to the developmental stage from which they are obtained, stem cells are classified as being embryonic, fetal, or adult. Embryonic stem cells have unlimited self-renewing capacity and multilineage differentiation potential, but their clinical application seems to be hindered by the high tumorigenic rate after transplantation. Mesenchymal stem cells (MSC) derived from adult tissues are considered to be more limited in their potential and the risk of the immunological rejection of the transplanted stem cells by the recipient is an important limiting factor. The MSC derived from extra-fetal tissues could overcome many of these restrictions. Indeed, in veterinary medicine, MSC isolated from equine term placenta were the ideal candidates for tendon disease treatment, specifically for their plasticity and their reduced immunogenicity compared to bone marrow-derived cells. Extra-fetal derived MSC in porcine have been isolated from the umbilical cord matrix and amniotic fluid. The aim of this work was to provide, for the first time, an isolation protocol and the characterisation of stem cells from porcine amniotic membrane, which could hold potential uses in regenerative medicine. The amnion is a thin, avascular membrane made of an epithelial layer and an outer layer of connective tissue. From 3 samples of allanto-amnion retrieved at delivery, each amniotic membrane was stripped from the overlying allantois and, for isolation of the epithelial cells, it was digested with trypsin. After removal of epithelial cells, the stromal layer was digested with collagenase to obtain amniotic mesenchymal cells. The cellular yield from term amnion resulted only in epithelial cells (AEC) at a concentration of 10 × 106 for 1 g of digested tissue while no MSC were obtained. Histology, indeed, revealed very few cells in the stromal layer. The AEC readily attached to plastic culture dishes. Culture was established in DMEM-HG medium, supplemented with 10% serum and 10 ng mL–1 of EGF where the cells proliferated robustly. The AEC displayed typical cuboidal morphology. These cells showed a mean of 31 ± 0.24 cell population doublings after 31 days. The mean frequency of colony-forming unit fibroblasts was 1 for each of the 75 plated cells. The AEC expressed MSC mRNA markers (CD29, CD166, CD90, CD73, CD117) and pluripotent markers (Nanog and Oct4), while were negative for CD34 and MHC-II. Osteogenic, adipogenic, and neurogenic differentiations were confirmed by von Kossa, Red Oil, and Nissle stains, respectively, and by expression of specific markers (osteocalcin and osteopontin for osteogenic differentiation, adiponectin and leptin for adipogenic differentiation, and glial fibrillary acid protein and nestin for neurogenic differentiation). We conclude that porcine amnion contain unique and primitive cells whose potential is as yet undefined. Ease of collection and propagation of AEC make this tissue an attractive candidate as a resource for stem cell biotechnology and biomedical research.

A novel missense mutation (C84R) in a patient with type II vitamin d-dependent rickets

A 7-year-old boy with severe rickets that by clinical analysis was diagnosed as affected by type II vitamin D-dependent rickets, was evaluated for mutations in the vitamin D receptor gene (VDR). The molecular analysis showed a homozygous state for a novel missense mutation (C84R) in a highly conserved nucleotide in the second Zn finger of the DNA binding domain.

Nuclear factor-erythroid 2 (NF-E2) expression in normal and malignant megakaryocytopoiesis

Although the transcription factor nuclear factor-erythroid 2 (NF-E2) is known to be functionally linked to the megakaryocytic lineage, little is known about its role in malignant megakaryocytes. We used real-time RT-PCR and Western blotting to investigate expression of NF-E2 and its partner, MafG, in CD34-derived normal (five cases) and malignant megakaryocytes from essential thrombocythemia (ET) patients (eight cases) and in megakaryoblastic cell lines. We also quantitated the mRNA of the thromboxane synthase (TXS) gene, which is directly regulated by NF-E2. Although real-time RT-PCR showed that both a and f NF-E2 isoforms were significantly reduced with respect to the normal counterpart both in ET megakaryocytes and in cell lines (P < or = 0.01), western blotting revealed decreased NF-E2 protein expression only in the latter. However, both the NF-E2a/MafG mRNA ratio (P < or = 0.01) and TXS (P< or = 0.01) mRNA expression were significantly reduced in megakaryocytes from ET patients and cell lines with respect to healthy subjects. These two findings provide strong indirect evidence of altered activity of the a isoform of NF-E2 in malignant megakaryocytes, raising the possibility that NF-E2 could play a role in megakaryocyte transformation.

A novel splicing defect (IVS6+1G>T) in a patient with pseudovitamin D deficiency rickets

A 15-month-old boy with severe rickets, that by clinical analysis was diagnosed as affected by hereditary pseudovitamin D deficiency rickets (PDDR), was evaluated for mutations in the 25OHD3 1alpha-hydroxylase gene. Molecular analysis showed a double heterozygous state for a novel splicing mutation in the invariant dinucleotide of the donor site of IVS6 and a 7 nucleotide insertion in the exon 8, which is common in different ethnical backgrounds.

hMAF, a small human transcription factor that heterodimerizes specifically with Nrf1 and Nrf2

A 1.6-kilobase pair full-length cDNA encoding a transcription factor homologous to the Maf family of proteins was isolated by screening a K562 cDNA library with the NFE2 tandem repeat probe derived from the globin locus control region. The protein, which was designated hMAF, contains a basic DNA binding domain and an extended leucine zipper but lacks any recognizable activation domain. Expressed in vitro, the hMAF protein is able to homodimerize in solution and band-shift the NFE2 tandem repeat probe. In addition to homodimers, hMAF can also form high affinity heterodimers with two members of the NFE2/CNC-bZip family (Nrf1 and Nrf2) but not with a third family member, p45-NFE2. Although hMAF/hMAF homodimers and hMAF/Nrf1 and hMAF/Nrf2 heterodimers bind to the same NFE2 site, they exert functionally opposite effects on the activity of a linked gamma-globin gene. In fact, whereas all hMAF/CNC-bZip heterodimers stimulate the activity of a gamma-promoter reporter construct in K562 cells, the association into homodimers that is induced by overexpressing hMAF inhibits the activity of the same construct. Thus variations in the expression of hMAF may account for the modulation in the activity of the genes that bear NFE2 recognition sites.

A 4-week, double-blind, parallel-group study to compare the gastrointestinal effects of meloxicam 7.5 mg, meloxicam 15 mg, piroxicam 20 mg and placebo by means of faecal blood loss, endoscopy and symptom evaluation in healthy volunteers

Meloxicam is a new non-steroidal anti-inflammatory drug (NSAID) which preferentially inhibits cyclooxygenase-2 (COX-2) over cyclooxygenase-1 (COX-1). Gastrointestinal (GI) tolerability of meloxicam 7.5 and 15 mg vs piroxicam 20 mg was evaluated in a 4-week, double-blind, parallel group, placebo-controlled study in 51 healthy male volunteers, using a combination of oesphago-gastro-duodenal endoscopy, faecal blood loss measurement and symptom evaluation. Analysis of covariance found no significant difference in faecal blood loss between the groups. However, significantly higher bleeding was found with piroxicam 20 mg compared with placebo using a Student's t-test on the weighted means. Endoscopy score were significantly higher with piroxicam than with meloxicam 7.5 mg or placebo (P < 0.01). A significant difference from baseline was observed in the meloxicam 15 mg and piroxicam groups (P < 0.05), but not in the meloxicam 7.5 mg and placebo groups. Six piroxicam-treated volunteers were withdrawn following a poor endoscopic score, but no such withdrawals occurred in the meloxicam and placebo groups (P < 0.01). Meloxicam 7.5 mg caused less GI damage compared with piroxicam 20 when administered to healthy young volunteers for 28 days; a possible dose dependency effect in GI tolerability was also suggested for meloxicam 7.5 and 15 mg, in relation to endoscopic findings.

Isolation of a differentially regulated splicing isoform of human NF-E2

The transcription factor NF-E2 (nuclear factor erythroid 2), interacting via DNA motifs within regulatory regions of several hematopoietic genes, is thought to mediate the enhancer activity of the globin locus control regions. By screening a human fetal liver cDNA library with probes derived from mouse NF-E2, we have isolated a splicing variant of the NF-E2 gene (fNF-E2) that differs in the 5' untranslated region from the previously reported cDNA (aNF-E2). The fNF-E2 isoform is transcribed from an alternative promoter located in the 3' end of the first intron and joined by alternative splicing to the second and third exons, which are shared by both RNA isoforms. Although the two forms produce the same protein, they are expressed in different ratios during development. fNF-E2 is more abundant in the fetal liver and less abundant in the adult bone marrow compared to the previously described form. Their distribution apparently follows the differential expression of fetal and adult hemoglobins.

A comparison of the local tolerability, safety and efficacy of meloxicam and piroxicam suppositories in patients with osteoarthritis: a single-blind, randomized, multicentre study

The local tolerability, safety and efficacy of meloxicam 15 mg suppositories were compared with piroxicam 20 mg suppositories over a 3-week period in a single-blind, randomized study in patients with osteoarthritis. Patients were randomized 2:1 to receive meloxicam (n = 216) or piroxicam (n = 109). More than 90% of patients and investigators assessed local tolerability of both treatments as good or very good (primary endpoint). There was no significant difference between the groups. Global efficacy was reported by approximately 80% of patients in both groups to be good or very good. Pain on movement and at rest and joint mobility showed statistically significant improvements compared with baseline with both meloxicam and piroxicam; there were no statistically significant differences between treatment groups. Piroxicam and meloxicam suppositories were equally well tolerated, with no serious adverse events recorded in either treatment group. Local adverse events occurred in 11.9% of patients receiving piroxicam and 6.9% of those receiving meloxicam. Overall, gastrointestinal adverse events were the most frequent of all 11.9% of piroxicam-treated patients). In both groups, about 90% of global tolerability assessments were classified, by the investigator and the patient, as either very good or good. In conclusion, meloxicam 15 mg suppositories showed excellent local tolerability accompanied by good safety and efficacy in osteoarthritis, which was comparable to that of an established non-steroidal anti-inflammatory drug (NSAID) administered by the rectal route, and to that previously observed with oral formulations of meloxicam 15 mg.

A novel pharmacological approach for paraquat poisoning in rat and A549 cell line using ambroxol, a lung surfactant synthesis inducer

Paraquat (PQ) is a widely used herbicide that causes acute adult respiratory distress syndrome (ARDS) and chronic lung damage (diffuse fibrosis). One of the earliest biochemical effects induced by PQ is damage to type II pneumocytes with consequent depletion of surfactant. With the aim of counteracting the toxic effects of PQ, a series of investigations were performed into the possible protective effect of the drug ambroxol, which induces the synthesis of surfactant in lung alveolar type II cells. The number of survivors and survival time of rats treated ip with 35 mg PQ/kg was significantly increased by 3 days of ambroxol pretreatment and by ambroxol treatment 30 min or 2 hr after PQ. Total phospholipid content in lung and bronchoalveolar lavage fluid (BALF) was significantly reduced 30 hr after treatment with PQ alone. The association of ambroxol with PQ significantly antagonized this reduction. In BALF the ratio between palmitic acid and stearic acid concentrations was significantly lower in animals treated with PQ alone but was returned to normal by the association with ambroxol. The cell line A549, exposed in vitro to PQ concentrations from 0.5 x 10(-4) to 2 x 10(-3) M, showed a significant dose-dependent loss of viability. Cells pretreated with ambroxol (10 mg/ml) were more resistant to PQ and their viability started to decrease significantly only from a PQ concentration of 0.8 x 10(-3) M. Membrane microviscosity was measured on the same cells. Cells treated with PQ alone showed a reduction of membrane microviscosity, which was significantly counteracted by ambroxol pretreatment. The curves of modification of membrane microviscosity of cells treated with PQ and with ambroxol plus PQ paralleled those of cell viability, indicating that the stimulation of surfactant synthesis in vitro may be a prerequisite for counteracting some of the early effects of PQ.

Alterations of the endoalveolar surfactant after surgery with extracorporeal circulation

In 10 patients who required extracorporeal circulation (ECC) during surgery, we studied the damage induced by surgery to the pulmonary surfactant and the effectiveness of ambroxol in preventing changes in the phospholipid pool. There were 5 control patients and 5 patients who were given 1 g/day of ambroxol on the 4 days prior to and the 4 days after surgery. To follow changes in phospholipid concentrations, bronchoalveolar lavage (BAL) was performed before surgery and 24 h and 8 days after ECC. Phospholipids were assayed in the BAL liquid by two-dimensional thin-layer chromatography. There were marked decreases in total phosphorus and quantitative alterations of individual phospholipid species in the surfactant of the control group, but not in the patients treated with ambroxol.