Safety outcomes and patients' preferences for home-based intravenous enzyme replacement therapy (ERT) in pompe disease and mucopolysaccharidosis type I (MPS I) disorder: COVID-19 and beyond

BACKGROUND

The Italian Medicines Agency (AIFA) demands precise information on benefit/risk profile of home-based enzyme replacement therapy (ERT) for the treatment of patients with Pompe disease and Mucopolysaccharidosis type I (MPS I). This passage is necessary to obtain the authorization for ERT home therapy, even after the coronavirus disease-19 (COVID-19) pandemic period. This research intends to evaluate the safety, treatment satisfaction, and compliance of MPS I patients treated with laronidase (Aldurazyme®) and Pompe Disease patients treated with alglucosidase alfa (Myozyme®) in a homecare setting.

RESULTS

We report herein an early interim analysis of the HomERT (Home infusions of ERT) study, a multicenter, non-interventional, double-cohort study that retrospectively analyzed 38 patients from 14 sites in Italy: cohort A (Pompe disease - 32 patients) and cohort B (MPS I - 6 patients). Among the selected patients who started home therapy before enrollment, the average number of missed home-based infusions was 0.7 (1.3) in cohort A and 3.8 (6.4) in cohort B with no return to the hospital setting. Irrespective of the treatment location, 3 prior ADRs per cohort were reported. The majority of patients preferred home-based infusions (cohort A: 96.9%; cohort B: 100%): the main reason was attributed to treatment convenience (cohort A: 81.3%; cohort B: 83.3%). Despite the underlying conditions, most patients self-evaluated their health as "good" (cohort A: 50%; cohort B: 83.3%).

CONCLUSIONS

Evidence of favorable safety profile, improved treatment compliance and personal satisfaction validates the use of ERT with laronidase and alglucosidase alfa as a strong candidate for home therapy.

Continuous atmospheric in-situ measurements of the CH4/CO ratio at the Mt. Cimone station (Italy, 2165 m a.s.l.) and their possible use for estimating regional CH4 emissions

Methane (CH₄) is an important climate forcer, contributing about 17% of the total radiative forcing by long living greenhouse gases. The Po basin is one of the most polluted and densely populated areas in Europe representing an important source region for CH₄. The aim of this work was to test an inter-species correlation approach to derive estimates of anthropogenic CH₄ emissions for the period 2015-2019 from the Po basin by combining CO bottom-up inventory data and continuous CH₄ and CO observations from a mountain site in the northern Italy. The tested methodology suggested lower emissions in respect to EDGAR (-17%) and the Italian National Inventory (-40%) for the Po basin. However, despite the two bottom-up inventories, the emissions derived from the atmospheric observations reported an increasing tendency from 2015 to 2019 for the CH₄ emissions. A sensitivity study revealed that using different subsets of the atmospheric observations implied a difference of 26% in the CH₄ emission estimates. The highest agreement with two bottom-up CH₄ inventories (EDGAR and the Italian national inventory) were obtained when atmospheric data were strictly selected for periods representative of air mass transport from the Po basin. Our study identified various challenges when using this methodology as a benchmark to verify bottom-up CH₄ inventories. Issues could be attributed to the annual aggregation of the proxies used to derive the emission amounts, to the CO bottom-up inventory used as input information and to the relatively high sensitivity of the results to the different subsets of the atmospheric observations. However, the use of different bottom-up inventories as input data for CO emissions can potentially provide information that should be carefully considered for the purpose of integrating CH₄ bottom-up inventories.

Co-benefits of changing diet. A modelling assessment at the regional scale integrating social acceptability, environmental and health impacts

Several commentaries have suggested that the overconsumption of animal foods exerts several detrimental effects on human and environmental health. However, no studies have accurately estimated the impact of a reduction in animal food consumption on mortality due to the direct effects on metabolic health (i.e. animal protein and saturated fat intake as modulators of pathways leading to cardiovascular disease, cancer and accelerated ageing), and indirect effects on health due to excessive exposure to pollutants (i.e. PM₁₀ concentrations originated by livestock ammonia emissions). The proposed modelling approach is innovative since it integrates social acceptability, environmental and health impacts. It is adopted to investigate different scenarios at a regional scale presenting the Lombardy region case study. The work focuses on the impact on the human and environmental health of diets characterized by three different animal protein intake levels. Our integrated assessment modelling approach faces the issue from two points of view. On one side, it estimates the mortality due to the population exposure to PM₁₀ concentrations including the inorganic fraction originated by livestock ammonia emissions, on the other, it evaluates the mortality (i.e. total, cardiovascular and cancer) due to high dietary animal protein and/or saturated fat intake. The impacts of the mentioned animal protein intake levels of diets are also estimated through the people willingness to change their eating behaviour. The importance of putting in place end-of-pipe and energy measures in order to reduce ammonia and methane emissions from the breeding activities, going further the current EU legislation on air quality and climate, is emphasized.

High black carbon and ozone concentrations during pollution transport in the Himalayas: five years of continuous observations at NCO-P global GAW station

To study the influence of polluted air-mass transport carrying ozone (O3) and black carbon (BC) in the high Himalayas, since March 2006 the Nepal Climate Observatory at Pyramid (NCO-P) GAW-WMO global station (Nepal, 5079 m a.s.l.) is operative. During the first 5-year measurements, the O3 and BC concentrations have shown a mean value of 48 +/- 12 ppb (+/- standard deviation) and 208 +/- 374 ng/m3, respectively. Both O3 and BC showed well defined seasonal cycles with maxima during pre-monsoon (O3: 61.3 +/- 7.7 ppbV; BC: 444 +/- 433 ng/m3) and minima during the summer monsoon (O3: 40.1 +/- 12.4 ppbV; BC: 64 +/- 101 ng/m3). The analysis of the days characterised by the presence of a significant BC increase with respect to the typical seasonal cycle identified 156 days affected by "acute" pollution events, corresponding to 9.1% of the entire data-set. Such events mostly occur in the pre-monsoon period, when the O3 diurnal variability is strongly related to the transport of polluted air-mass rich on BC. On average, these "acute" pollution events were characterised by dramatic increases of BC (352%) and O3 (29%) levels compared with the remaining days.

Ten years of continuous observations of stratospheric ozone depleting gases at Monte Cimone (Italy)--comments on the effectiveness of the Montreal Protocol from a regional perspective

Halogenated gases potentially harmful to the stratospheric ozone layer are monitored worldwide in order to assess compliance with the Montreal Protocol requiring a phase out of these compounds on a global scale. We present the results of long term (2002-2011) continuous observation conducted at the Mt. Cimone GAW Global Station located on the highest peak of the Italian Northern Apennines, at the border of two important regions: the Po Valley (and the Alps) to the North and the Mediterranean Basin to the South. Bi-hourly air samples of CFC-12, CFC-11, CFC-114, CFC-115, H-1211, H-1301, methyl chloroform, carbon tetrachloride, HCFC-22, HCFC-142b, HCFC-124 and methyl bromide are collected and analysed using a gas chromatograph-mass spectrometer, providing multi annual time series. In order to appreciate the effectiveness of the Montreal Protocol from a regional perspective, trends and annual growth rates of halogenated species have been calculated after identification of their baseline values. A comparison with results from other international observation programmes is also presented. Our data show that the peak in the atmospheric mixing ratios of four chlorofluorocarbons, two halons and two chlorocarbons has been reached and all these species now show a negative atmospheric trend. Pollution episodes are still occurring for species like halon-1211, methyl chloroform and carbon tetrachloride, indicating fresh emissions from the site domain which could be ascribed both to fugitive un-reported uses of the compounds and/or emissions from banks. For the hydrofluorocarbons changes in the baseline are affected by emissions from fast developing Countries in East Asia. Fresh emissions from the site domain are clearly declining. Methyl bromide, for which the Mediterranean area is an important source region, shows, in a generally decreasing trend, an emission pattern that is not consistent with the phase-out schedule of this compound, with a renewed increase in the last two years of pollution episodes.

Ultrastructure of human mature oocytes after vitrification

Since the introduction of human assisted reproduction, oocyte cryopreservation has been regarded as an attractive option to capitalize the reproductive potential of surplus oocytes and preserve female fertility. However, for two decades the endeavor to store oocytes has been limited by the not yet optimized methodologies, with the consequence of poor clinical outcome or of uncertain reproducibility. Vitrification has been developed as the promising technology of cryopreservation even if slow freezing remains a suitable choice. Nevertheless, the insufficiency of clinical and correlated multidisciplinary data is still stirring controversy on the impact of this technique on oocyte integrity. Morphological studies may actually provide a great insight in this debate. Phase contrast microscopy and other light microscopy techniques, including cytochemistry, provided substantial morpho-functional data on cryopreserved oocyte, but are unable to unraveling fine structural changes. The ultrastructural damage is one of the most adverse events associated with cryopreservation, as an effect of cryo-protectant toxicity, ice crystal formation and osmotic stress. Surprisingly, transmission electron microsco py has attracted only limited attention in the field of cryopreservation. In this review, the subcellular structure of human mature oocytes following vitrification is discussed at the light of most relevant ultrastructural studies.

What near misses tell us about risk and safety in mental health care

How service providers and service users view near misses in their daily practice within the rubric of patient safety events is not well understood. Further no studies were located that explored near misses specifically in mental health settings in Canada. In this context, a qualitative study was undertaken to gain insight into how service providers and service users (mental health clients or their family members) experienced and defined near misses. Eight (8) focus groups (n= 88) with service providers and 28 semi-structured interviews with service users were conducted at three mental health care organizations. Content analysis was employed to the dataset that elucidated that near misses were (1) safety threats and vulnerabilities associated with experiencing mental illness; and (2) acts that avert harm and prevent something from happening. Findings are compared to what is currently known about in safety. Implications of findings for practice, research and policy are delineated.

Effects of phosphatidylcholine and sodium deoxycholate on human primary adipocytes and fresh human adipose tissue

Recent studies introduced the novel concept of chemical lipolysis where phosphatidylcholine (PC), an active component of commercial preparations, plays a pivotal role. Other studies suggested that sodium deoxycholate (DOC), an excipient contained in medical preparations, could be the real active component performing an adipocytolytic action. We investigated the effects of PC and DOC on human primary adipocyte cultures and on human fresh adipose tissue. Human adipocytes isolated by Rodbell's method, were cultured onto type I collagen-coated glass coverslips, placed into 24-well tissue culture plates. Cells were incubated with or without DOC (5-7-9%), PC (5%) or DOC/PC mixture and observed under phase contrast microscope. After incubation, cells were stained with Oil Red-O and with acridine orange/ethidium bromide to observe necrotic cells with phase contrast microscope and fluorescent microscope, respectively. Histological specimens from adipose tissue biopsies were observed with phase contrast microscopy and with scanning electron microscopy. To investigate the lipid pattern variability in the different experimental conditions, culture medium obtained from the different treatments was subjected to lipid extraction and subsequently to thin layer chromatography (TLC). Microscopic observation of adipocytes showed that DOC treatment led to a detrimental morphological effect in a dose-dependent manner. PC treatment did not significantly affect adipocyte viability. On the contrary, results from experiments aimed to analyze the effects of PC/DOC combined treatment suggested a PC protective role against the DOC harmful effects on adipocytes. Results indicated that clinical effects, observed in local treatment with pharmaceutical preparation, could be due only to DOC, a detergent inducing nonspecific lysis of cell membranes following adipocyte necrosis. On the other hand, PC could likely be incorporated in the lipid bilayer, thus strongly reducing the disruptive DOC effects.

The ABC-Pyramid Atmospheric Research Observatory in Himalaya for aerosol, ozone and halocarbon measurements

In this work we present the new ABC-Pyramid Atmospheric Research Observatory (Nepal, 27.95 N, 86.82 E) located in the Himalayas, specifically in the Khumbu valley at 5079 m a.s.l. This measurement station has been set-up with the aim of investigating natural and human-induced environmental changes at different scales (local, regional and global). After an accurate instrumental set-up at ISAC-CNR in Bologna (Italy) in autumn 2005, the ABC-Pyramid Observatory for aerosol (physical, chemical and optical properties) and trace gas measurements (ozone and climate altering halocarbons) was installed in the high Khumbu valley in February 2006. Since March 2006, continuous measurements of aerosol particles (optical and physical properties), ozone (O3) and meteorological parameters as well as weekly samplings of particulate matter (for chemical analyses) and grab air samples for the determination of 27 halocarbons, have been carried out. These measurements provide data on the typical atmospheric composition of the Himalayan area between India and China and make investigations of the principal differences and similarities between the monsoon and pre-monsoon seasons possible. The study is carried out within the framework of the Ev-K2-CNR "SHARE-Asia" (Stations at High Altitude for Research on the Environment in Asia) and UNEP-"ABC" (Atmospheric Brown Clouds) projects. With the name of "Nepal Climate Observatory-Pyramid" the station is now part of the Observatory program of the ABC project.

Localization of source regions of selected hydrofluorocarbons combining data collected at two European mountain stations

Ground-based in situ measurements of hydrofluorocarbons HFC-125, HFC-134a, and HFC-152a, which are regulated under the Kyoto Protocol, are carried out at four European sites within the SOGE (System of Observation of Halogenated Greenhouse Gases in Europe) program. Concentrations measured at the high mountain stations of Jungfraujoch (Switzerland) and Mte Cimone (Italy) together with back-trajectory statistical analysis are used in order to identify potential source regions on a European scale. Combining concentration data recorded at the two sites allows to reduce one of the problem which is inherent to the back-trajectory approach, i.e. the localisation of "ghost" sources in the wake of real sources. In this way, a more reliable picture of the location of European potential source regions is given.

The wall paintings in the Oratorio of San Giovanni Battista in Urbino: a study finalized to a correct conservation project

The walls of the Oratorio of San Giovanni Battista in Urbino are decorated with outstanding mural paintings dating back to the 15th century. Due to degradation processes that have occurred in the past years, such paintings require a conservative restoration project. In order to evaluate reasons of the decay, some scientific studies have been performed. They consist of macroscopic observations and chemical (EDS), morphological (SEM) and mineralogical (XRD) analyses of samples both from the original preparatory layers under the painted layers and from the restored plasters at the surbase of the wall. In addition, environmental studies have been performed to verify microclimatic conditions of the church in which the mural paintings are located. Finally, a conservative restoration project was proposed.

Matrix metalloproteinases. Their role in degenerative chronic diseases of abdominal aorta

BACKGROUND

The main chronic degenerative diseases of the abdominal aorta, namely aneurysmatic and steno-obstructive pathologies, have a common denominator: atherosclerosis. Both pathologies are characterised by the destruction of the structural integrity of the extracellular protein matrix (ME). A number of studies have shown the presence and involvement of a group of enzymes with proteolytic activity towards one or more ME components, the matrix metalloproteinases (MMPs), in the pathogenesis of aneurysms of the abdominal aorta. Other authors have underlined the role of MMPs in the proliferation and migration process of smooth muscle cells into the intima in the pathogenesis of atheromasic plaque. The aim of this study was to evaluate the possible role of these enzymes in the pathogenesis of chronic degenerative diseases of the aorta.

METHODS

Fragments of aortic wall were removed from patients undergoing elective aortic surgery for aneurysms (14 patients) or aortic steno-obstruction (4 patients). The samples obtained were treated appropriately and then subject to immunohistochemical analysis. The preparations were incubated with specific anti-MMP antibodies and were also incubated with substrate and chromogen, forming a pigmented precipitate on the site of the antigen, before being observed using an optic microscopic at an enlargement of 250x. Nuclear positivity linked to the presence of the antigen testified the validity of staining. Lastly, the MMP INDEX, or in other words the number of positive cells out of 100, was stained in the adventitia and in the tunica media in each preparation.

RESULTS

MMPs were divided into three main groups: interstitial collagenase (MMP1) which degrade type I and III native collagen; gelatinases (MMP9, MMP2) which act on elastin and type IV collagen; stromelysins (MMP3) with specific proteolytic action towards proteoglycans, fibronectin and laminine. In our experience, those preparations obtained from aorta affected by steno-obstructive pathologies (4 patients) revealed the presence of MMPs with a preferential localisation on the intimal side of the tunica media. In particular, the increased activity of gelatinases MMP9 in atherosclerotic aorta might be responsible for destroying the internal elastic lamina and fostering the proliferation and migration of smooth muscle cells and the formation of atheromasic plaque. On the other hand, preparations obtained from aneurysmatic aorta (14 patients) showed an opposite situation with a preferential localisation within the adventitia and on the adventitial side of the media. Above all, the loss of elastin represents an essential stage in the formation of aortic aneurysms.

CONCLUSIONS

This study concords with numerous authors who have demonstrated the involvement of proteinase MMPs in the development of aortic aneurysms and their possible role in the pathogenesis of atheromasic plaque. The different origin of these enzymes (inflammatory cells and macrophages or endothelial cells) may be the result of different pathogenetic mechanisms. Although they present different pathogenetic features, aortic aneurysms and steno-obstructions have a common denominator in atherosclerosis. The mechanisms responsible for their evolution towards one or other form are not known. The different expression of MMPs in the context of the aortic wall represents a field for future research.

Introducing Quality Assurance in Radiotherapy

Introducing a Quality Assurance methodology appears particularly useful in Radiation Oncology due to the complexity of the procedures involved and the heterogeneity of the standards adopted, if any, in the great majority of the Centers. There are two possible ways of evaluating quality in the Health Environment: a formal, Institutional certification, or a voluntary one obtained through a mechanism of peer review. The European Society for Therapeutic Radiology and Oncology (ESTRO) started in 1994 with the publication of a methodological Report intended to be adopted by the individual national Societies, and this paper is an invitation to do it.

[Loco-regional thrombolysis in deep venous thrombosis]

Anticoagulation, by means of heparin and warfarin is, till now, the most common treatment in deep venous thrombosis. Although thrombolytic agents have been available for over 10 years, their use remains quite low, ranging from 15 to 20% of deep venous thromboses. This is due to the relatively high incidence of contraindications as well as to the fact that the potential advantages versus heparin are diminished by the increased bleeding risk and by the potential risk of pulmonary embolism (migration of partially lysed thrombi). Following the example of the "triple armed therapy" proposed by Rosenthal for the treatment of pulmonary embolism, we will evaluate if loco-regional thrombolysis, with the catheter wedged against the thrombus, associated with a temporary vena cava interruption by means of an intraluminal filter, can achieve a better lysis of the thrombus without pulmonary embolism. In our Unit 18 patients affected by proximal deep venous thrombosis were submitted to thrombolytic therapy, 6 to systemic treatment, 3 to local treatment and the last 9 to loco-regional thrombolysis, using recombinant tissue-type Plasminogen Activator. We obtained 10 complete lyses, 1 with systemic and 9 with loco-regional treatment. There were no major complications. Thus, we think that venous loco-regional thrombolysis with rt-PA at lower doses, associated with temporary caval interruption, can probably achieve a better lysis than systemic treatment without risk of pulmonary embolism and with a very low haemorrhagic risk, as in arterial loco-regional thrombolysis. Furthermore, loco-regional thrombolysis, by means of a faster thrombus dissolution, could better prevent post-phlebitic syndrome.

[Validity of computer simulation in closed circuit anesthesia]

Developing a computer program to simulate the uptake, distribution, and elimination of inhalational anesthetics allow the anesthesiologist to address specific problems, but intense skills are required to translate the involved process first into a set of mathematical equations and then into a satisfactory computer program. The first step is facilitated by solutions offered in the literature. The second step by personal computer program now currently available as Gus, this program simulates anesthetic uptake and distribution using a numerical model with 12 compartments. Transport of anesthetic agents among the compartment occurs via convection of gas and blood during discrete iteration of the simulation. As initial clinical validation of the linear 12 compartment basic model the current study examined the predictive performance in 20 patients by comparing quantitatively the predicted and the measured alveolar concentration-time profiles after achievement of end tidal concentration of isoflurane (C-alv%) injected into a heated chamber (75 degrees) and then transported in closed circuit system during mechanical ventilation. With regard to the use of isoflurane 20 patients were adequately anesthetized with only 88 ml of liquid isoflurane and that is the same in simulation achieved by computer.

[Obstetric complications associated with DIC. Importance of D-dimer in the diagnosis and treatment. A clinical case]

The case of a 32-year old woman with 36-week pregnancy presented at hospital because of spontaneous vaginal bleeding, anemia and mild hypotension is reported. Fetal mors in utero, abruptio placentae and diffuse intravascular coagulation were diagnosed. The patient subsequently underwent cesarean section and large retroplacental hematoma was removed and obviously fetum. The DIC was easily controlled by means of recently introduced method of determination of fibrin D-dimer.

[The use of intravenous nifedipine for the treatment of severe hypertensive crisis. A clinical case]

Nifedipine is a calcium channel antagonist. Hypertensive crisis during anaesthesia may be elicited during the induction period or by the surgical manipulating of intrapelvic viscera. We report a case in which nifedipine given intravenously (currently an investigational dosage form) was effective in controlling a severe hypertensive crisis at dose averaging 3.4 mcg/kg/min initially and half as much for maintenance. Arterial pressure was controlled as quickly as with nitroprusside, but with no change in heart rate or cardiac output and without other untoward effects during anaesthesia.

[Comparison of 2 techniques of anesthesia induction in modern closed-circuit anesthesia]

The application of low flow anesthesia goes back already for more than 65 years when Ralph Waters introduced and applied cyclopropane with a very simple canister technique. The guide-lines for the clinical use of the closed circuit anesthesia were published in Chicago and Los Angeles by Professor Lin and Professor Lowe 15 years ago. We examined and followed these procedures on a modern anesthesia machine and easily achieved a good clinical performance. Our results were consistent with the modern anesthesia standard in closed circuit t.i.: economical benefits, environment savage of waste gases, heat production and humidification and last but not least in both techniques a quick anesthesia plane on 10-12 minutes that was consistent with theoretical considerations.

[Poisoning with shoe dye. A clinical case]

The paper reports the case of a young male which was severely poisoned by anilyne shoe black. After a few hours, he was in a semicomatose state, accompanied by "very dark" arterial blood gases with oxygen tension in excess of 100 mmHg. Following the administration of intravenous methylene blue (2 mg/kg), methemoglobin was reduced to hemoglobin and the level of consciousness immediately improved.

[Hydrothorax as a complication of subclavian vein catheterization. Pathogenetic mechanism and description of a clinical case]

We report a case of possible detouring and malfunctioning of the left subclavian catheter in the homolateral internal mammary vein or of perforation form its tip of the wall of the left innominate vein. The tip of the catheter was rigid and sharp, may be the contractions of the heart or turbulent flow impinged it against the vein wall and have enhanced the perforation. The result was a hydrothorax that allowed a severe cardiac simile tamponed syndrome. The pathophysiology was also discussed.

[Hemofiltration and dialysis in a case of rhabdomyolysis]

The effect of CAVDH was evaluated in a patient with rhabdomyolysis due to extreme low temperature and also to carbon monoxide poisoning. Since renal failure im myoglobinuria has a relatively good prognosis, we recommend in this case the use of a soft technique such as continuous arteriovenous hemofiltration with dialysis.

[Continuous arteriovenous hemofiltration and hemofiltration using dialysis. Presentation of clinical cases]

The authors describe case reports in which the CAVH and the CAVDH was of paramount importance in improving hemodynamic parameters in ARDS and MOF and various cardiac failure. The technique was very simple and results good in intensive care.

[Septic shock in a case of purulent pericarditis. Usefulness of hemodynamic study with Swan-Ganz catheterization]

In a case of cardiac tamponade the hemodynamic study with Swan-Ganz catheter was useful to confirm the diagnosis and to assess the correct therapy, otherwise the case was complicated with septic shock by purulent pericarditis and could mislead the diagnosis.