Analysis of clinical factors as possible predictors of response to omalizumab and relapse after treatment discontinuation in chronic spontaneous urticaria

Omalizumab is a monoclonal anti-IgE antibody which is effective in chronic spontaneous urticaria (CSU), although clinical response appears to be variable in the real-life setting. The aim of this study was to evaluate whether the response of CSU to omalizumab and disease relapse are associated with individual and/or clinical characteristics of patients. We retrospectively evaluated the clinical records of 124 patients treated with omalizumab for moderate to severe CSU refractory to antihistamines. Disease activity was assessed using the urticaria activity score over the last 7 days (UAS7). After 24 weeks of treatment, 91% of patients showed complete remission (UAS7 = 0) or good control (UAS7 < 7) of CSU. Omalizumab was re-administered in 45 patients because of recurrence of moderate to severe symptoms at week 8 after treatment discontinuation or later, and clinical results achieved with retreatment were similar to those observed in the first course. Among the parameters included in our analysis (age and sex of patients, documented history of atopy or autoimmune thyroid disease, CSU duration and baseline severity, concurrent angioedema, and association with chronic inducible urticaria), none was associated with response to omalizumab in our study population. Similarly, these parameters did not significantly differ between patients who experienced CSU relapse and those without relapse. Predictors of response to omalizumab treatment in CSU patients are still unclear, and further studies are needed to evaluate the presence of baseline factors that can influence treatment outcome.

Testicular leiomyoma and spermatogenic failure syndrome in a seabass from broodstock

Testicular leiomyomas and gonadal dysfunctions are not commonly reported in teleost and particularly in broodstock fish. In the present work, a testicular leiomyoma related to an unusual case of spermatogenic failure syndrome, in a broodstock seabass coming from an Italian aquaculture farm, is reported. At gross pathology, the circumscribed neoplasia showed several white nodular masses, originating from the gonad, deforming the anatomo-physiological shape. From light microscopy, the presence of neoplastic tissue islands with spindle cells with a whirling pattern and the low presence of connective tissue were evident and originated from smooth muscle cells. Seminiferous tubules showed severe azoospermia with the absence of sperm cells even closer to the neoplastic area. Immunohistochemical analysis was positive for alpha-SMA, desmin and vimentin but negative for S-100, confirming a diagnosis of leiomyoma. This is the first report of spermatogenic failure syndrome associated with a testicular leiomyoma in fish from broodstock. More efforts should be made in studying broodstock fish pathologies related to fish maintenance and hormonal treatments that could economically affect aquaculture production.

Gastric leiomyoma in a sea bass Dicentrarchus labrax broodfish

This report describes a spontaneously arising non-infiltrative neoplasm of gastric tunica muscularis in a broodstock sea bass Dicentrarchus labrax from an Italian aquaculture farm. Microscopically, the mass was circumscribed and non-encapsulated and was composed of spindle cells arranged in parallel interlacing bundles or, occasionally, a whirling pattern. Cells had a small quantity of eosinophilic cytoplasm with distinct cell borders. Neoplastic cells were immuno-reactive with smooth muscle actin, vimentin and desmin; S100 was negative. The mucosal epithelium was intact with no neoplastic involvement. A gastric leiomyoma was diagnosed based on the findings. More efforts should be made to study the possible etiology of leiomyoma affecting fish from aquaculture.

Living with Chronic Spontaneous Urticaria in Italy: A Narrative Medicine Project to Improve the Pathway of Patient Care

Chronic spontaneous urticaria (CSU) is perceived as a difficult to manage disease with negative impact on quality of life. The aim of this study was to highlight how to improve the care of people with CSU, using the methodology of narrative medicine. From June 2014 to March 2015, CSU-diagnosed patients and their physicians were asked to record their experiences of the condition in writing. Fourteen healthcare teams participated: 41% considered CSU as a challenge to overcome, while 22% experienced CSU as a big commitment. The number of professional involved was evaluated as insufficient in 11 hospitals. Seventy-five percent of the 190 Italian patients had visited 3 or more physicians before receiving a final diagnosis, with a perceived waste of time and resources. The therapeutic pathways were described as unsatisfactory in 83% of cases. As a result, anger and frustration were life-dominant emotions in 92% of patients. The critical points of the care pathway are related to organizational issues and lack of awareness.

Hypersensitivity reaction to ranitidine: description of a case and review of the literature

Ranitidine is an H2-receptor antagonist which is usually well tolerated. Hypersensitivity reactions to ranitidine, as well as other H2 antihistamines, have been rarely described. We report the case of a 47-year-old woman who developed an anaphylactic reaction to ranitidine used as intravenous premedication before anesthesia induction. The patient's history revealed that previous use of oral ranitidine for a peptic ulcer disease did not cause any adverse reaction. Intradermal test with ranitidine at a dilution of 1:100 gave an intense positive reaction. The protective role of H2-receptor antagonists as premedication is still unclear and should be carefully reconsidered on the basis of the available controversial evidence and the possible risk of hypersensitivity reactions.

Comparison of the plasma pharmacokinetics of lamivudine during twice and once daily administration in patients with HIV

OBJECTIVE

To compare the plasma pharmacokinetics of lamivudine 150mg twice daily and 300mg once daily in patients with HIV-1 infection.

DESIGN

Nonblind, sequential, pharmacokinetic study.

PARTICIPANTS

13 patients with HIV-1 infection (median age 36 years).

METHODS

Patients were tested during twice daily and then once daily regimens of lamivudine. In both regimens, the total daily dose of lamivudine was identical (300 mg/day). Blood samples for pharmacokinetic analysis were taken over a 12-hour period after > or =7 days of twice daily administration, and again over a 24-hour period after 7 days of once daily administration,.

RESULTS

12 patients completed the study. Lamivudine pharmacokinetic parameters (mean +/- SD) after administration of 150mg twice daily were: peak plasma concentration (Cmax) 2077+/-816 microg/L; trough plasma concentration (Cmin) 332+/-219 microg/L; elimination half-life (t 1/2beta) 6.1+/-1.9h; time to Cmax (t(max)) 1.6+/-0.7h; average concentration over the dosage interval (Cav) 711+/-269 microg/L; and area under the concentration-time curve (AUC) over 2 dosage intervals (24h) 17085+/-6464 microg x h/L. Corresponding values after administration of 300mg once daily were: Cmax 3461+/-854 microg/L; Cmin 146+/-87 microg/L; t1/2 7.9+/-3.4h; t(max) 2.2+/-1.3h; Cav 705+/-177 microg/L; and AUC over 1 dosage interval (24h) 16644+/-4150 microg x h/L. Statistical analysis showed a significant difference (p < 0.05) between the 2 schedules for Cmax and Cmin values, whereas no significant differences emerged for the other parameters.

CONCLUSIONS

Once daily lamivudine leads to a similar exposure in plasma as twice daily administration of the same total daily dose. Since once daily administration may result in improved compliance, these results provide the pharmacokinetic basis for using lamivudine in a once daily regimen. Randomised clinical studies are needed to confirm this pharmacokinetic finding.

Lamivudine treatment can overcome cytotoxic T-cell hyporesponsiveness in chronic hepatitis B: new perspectives for immune therapy

The hepatitis B virus (HBV) cytotoxic T lymphocyte (CTL) response in patients with chronic HBV infection is generally weak or totally undetectable. This inability to mount protective CTL responses is believed to be a crucial determinant of viral persistence, and its correction represents an important objective of immune therapies for chronic hepatitis B. However, amplification of CTL responses in vivo may be ineffective if HBV-specific CD8 cells are either absent or nonresponsive to exogenous stimulation. In this study, we asked whether antiviral treatments able to inhibit viral replication and to reduce viral and antigen load can successfully reconstitute CTL responses creating the appropriate conditions for their therapeutic stimulation. For this purpose, the HBV-specific CTL response before and during lamivudine therapy was studied longitudinally in 6 HLA-A2-positive patients with HBeAg+ chronic hepatitis B. Both HBV-specific cytotoxic T cell activity measured by chromium release assay on peptide stimulation in vitro and CD8+ T cell frequency measured ex vivo by HLA-A2/peptide tetramer staining were significantly augmented by lamivudine therapy. This enhancement followed the reconstitution of CD4 reactivity and the decline of viral load induced by therapy. Our study shows that lamivudine treatment in chronic hepatitis B can restore CTL reactivity, making CTL susceptible to exogenous stimulation. This effect may enhance the probability that T cell-based immune therapies delivered after lamivudine treatment can successfully reconstitute a protective CTL response able to cure chronic HBV infection.

Avanti 3: A Randomized, Double-Blind Trial to Compare the Efficacy and Safety of Lamivudine plus Zidovudine versus Lamivudine plus Zidovudine plus Nelfinavir in HIV-1-Infected Antiretroviral-Naive Patients

The objective of our randomized, multicentre, double-blind, placebo-controlled study was to investigate the safety, tolerability, and antiretroviral and immunological effect of double and triple combination therapy regimens. A total of 105 antiretroviral therapy-naive patients were randomized to receive either zidovudine (300 mg twice per day) plus lamivudine (150 mg twice per day) plus nelfinavir placebo (three times per day) ( n=52), or zidovudine/lamivudine (dose as before) plus nelfinavir (750 mg three times per day) ( n=53) for 28 weeks. After this time, patients were allowed to switch to open-label zidovudine/lamivudine/nelfinavir. The overall log10 reduction from baseline in plasma HIV-1 RNA was significantly greater in the zidovudine/lamivudine/nelfinavir group than the zidovudine/lamivudine group ( P=0.001; median treatment difference, –1.01 log10 copies/ml; 95% confidence interval –1.23 to –0.79), as measured by the average area under the curve minus baseline over 28weeks. Increases from baseline in CD4 cell counts were statistically significantly greater in the zidovudine/lamivudine/nelfinavir group (101.5 cells/ml) than the zidovudine/lamivudine group (47.0 cells/ml; P=0.027) at week 28.

Of note, the addition of nelfinavir from weeks 28–52 led to an increase in the proportion of subjects with plasma HIV-1 RNA <400 copies/ml from 17% (9/52 patients on zidovudine/lamivudine) to 50% (13/26 patients who switched to zidovudine/lamivudine/nelfinavir). Incidence of drug-related adverse events was similar in the two groups, except for nausea (more common in zidovudine/lamivudine group; 40 versus 17%) and diarrhoea (more common in zidovudine/lamivudine/nelfinavir group; 45 versus 14%). In conclusion, our study confirms the efficacy of triple combination therapy with two nucleoside analogues and a protease inhibitor compared with double-nucleoside therapy. Interestingly, the addition of nelfinavir to zidovudine/lamivudine, even after 6 months of double nucleoside therapy, led to a substantial virological benefit that was sustained over 24weeks in a subset of patients.

Lamivudine treatment can restore T cell responsiveness in chronic hepatitis B

High viral and/or antigen load may be an important cause of the T cell hyporesponsiveness to hepatitis B virus (HBV) antigens that is often observed in patients with chronic HBV infection. Reduction of viral and antigen load by lamivudine treatment represents an ideal model for investigating this hypothesis. HLA class II restricted T cell responses and serum levels of HBV-DNA, HBsAg, and HBeAg were studied before and during lamivudine treatment in 12 patients with hepatitis B e antigen positive chronic active hepatitis B to assess possible correlations between viral and/or antigen load and vigor of the T cell response. Cell proliferation to HBV nucleocapsid antigens and peptides and frequency of circulating HBV nucleocapsid-specific T cells were assessed to characterize CD4-mediated responses. A highly significant enhancement of the CD4-mediated response to HBV nucleocapsid antigens was already detectable in most patients 7-14 d after the start of lamivudine treatment. This effect was dramatic and persistent in 10 patients but undetectable in 2. It occurred concomitant with a rapid and marked reduction of viremia. Interestingly, lamivudine also enhanced the responses to mitogens and recall antigens, showing that its effect was not limited to HBV-specific T cells. In conclusion, an efficient antiviral T cell response can be restored by lamivudine treatment in patients with chronic hepatitis B concurrently with reduction of viremia, indicating the importance of viral load in the pathogenesis of T cell hyporesponsiveness in these patients. Since lamivudine treatment can overcome T cell hyporeactivity, combining lamivudine with treatments directed to stimulate the T cell response may represent an effective strategy to induce eradication of chronic HBV infection.

[A comparative study of 2 schedules of antibiotic prophylaxis using ceftazidime in the prevention of infections in elective surgery of the biliary surgery. Preliminary results]

The authors compared short-term and ultrashort-term antibiotic prophylaxis with ceftazidime for the prevention of infections in selective biliary surgery. The multicenter (180 centers) study involved 1800 patients; at present data are available for 44 centers (392 patients, 129 males, 263 females, age range 18-87 years). Treatment schedule consisted of a single i.v. administration of 2 g ceftazidime concurrent with anesthesia induction (group 1) whereas short-term prophylaxis comprised administration of 1 g ceftazidime with preanesthesia, 30 min before the beginning of surgery and 6 and 12 hrs. after the first dose (group 2). The two groups (193 and 199 patients respectively) were similar for age, sex, concomitant pathology, presurgical diagnosis, risk factors (both as to incidence and type), biliary drainage. The difference in success rate between the two groups was 2.3% (92.2% in group 1; 94.5% in group 2) with a 90% confidence interval of 2.4 and 6.9%; this difference was not significant (p = 0.491). These preliminary findings indicate the administration of a single dose of ceftazidime as a valid alternative to short-term prophylaxis in view of its practical and economic advantages.

[Ceftazidime in common infections in childhood. Experience in 262 cases]

We analyzed the clinical data collected from an open multicentre study (in 40 Hospital and University centres) with aim to evaluate clinical and bacteriological efficacy and safety of Ceftazidime (CTZ) in common infections of pediatric patients. The data were from 262 patients (137 M, 125 F) mean age 5.13 +/- 3.65 yrs (range 3 m. to 12 yrs). 158 pts with low respiratory tract infection, 32 pts. with upper respiratory tract infection and 72 pts. with urinary tract infection, were treated with CTZ (dose 50 mg/kg/die; i.v. or i.m.) for a mean of 9.4 days. The overall success rate was 96.2% (76.7% cured + 19.5% improved). In the evaluable cases (108) the bacteriological eradication rate was 92.18%. The safety of CTZ was good; adverse events (2 rash and 1 diarrhoea) were observed only in 3 patients. All events had moderate intensity and did not require drug withdrawal.

[Ceftazidime in the therapy of chronic bronchitis relapses in elderly hospitalized patients]

We studied the clinical and bacteriological efficacy and the safety of ceftazidime in elderly patients suffering from recurrent chronic bronchitis. 33 hospitalized subjects (10 F. 23 M: mean age 78.5 +/- 6 yrs) were treated with ceftazidime (1 g b.i.d.) for a mean of 9 +/- 1.5 days. At the end of treatment all patients had positive clinical results, with bacteriological eradication equal to 95%. Only one case of relapse was observed at the follow up assessment. As to safety only one case of vomiting was observed (but did not require treatment withdrawal).

The efficacy, safety and tolerance of ceftazidime for the treatment of bacterial infections in the elderly

An open multicentre trial to study the efficacy and safety of ceftazidime in elderly patients has been conducted in four geriatric units on 135 subjects suffering from urinary-tract or respiratory-tract infections. Sixty-two patients were cured (45.9%), and 60 improved (44.4%). Of the evaluable cases bacteriological eradication was achieved in 91.3%. No adverse events were recorded.

Antibiotic prophylaxis in ear, nose and throat surgery: a comparison of a single preoperative dose with three peri-operative doses of ceftazidime

An open prospective randomized trial was conducted in three Italian ear, nose and throat (ENT) surgery departments on 120 patients aged 10 to 84 years, to compare a single pre-operative dose vs. three peri-operative doses of ceftazidime in surgical prophylaxis. Sixty patients in group I received 1 g ceftazidime intramuscularly (im) or intravenously (iv) 1 h before surgery, and 60 in group II received three 1 g doses of ceftazidime, im or iv, 1 h before, and 6 and 12 h after surgery. Post-operative infections were observed in six group I patients (10.1%) and seven group II patients (11.6%). All infections arose in patients who had undergone 'moderate-risk' (6.7%) or 'high-risk' surgery (30.5%). We conclude that a single pre-operative 1 g dose of ceftazidime is as efficacious as multiple peri-operative doses in the prophylaxis of infectious complications following this type of surgery.

Effects of acetate on glucose metabolism and cellular ATP content during hemodialysis

In view of multiple interactions of acetate with intermediary metabolism, we studied the effects of the exogenous acetate load during dialysis on glucose and energy metabolism. IV glucose tolerance test (glucose 0.33 g/kg BW) and platelet ATP content were evaluated in 16 patients before and after a single hemodialysis session with acetate 38 mEq/l in the dialysate. IV glucose tolerance was greatly impaired in all patients after hemodialysis (K: 1.08 +/- 0.30 vs predialysis value of 2.05 +/- 0.85, p less than 0.001). Platelet ATP content was unchanged by dialysis (3.74 +/- 1.02 mumol/10(11) PLTs before and 3.55 +/- 0.69 mumol/10(11) PLTs after), however, individual variations in platelet ATP content ranged from +32 to -31% of the initial values. Postdialysis plasma acetate levels ranged from 1.5 to 9.2 mmol/l and were inversely correlated with postdialysis glucose tolerance test (r: -0.61, p less than 0.01) and platelet ATP content variations (r: -0.51, p less than 0.05). Our study demonstrates that glucose utilization is acutely impaired by acetate dialysis and suggests that the reduced glycolytic activity may be due to a negative feed-back mechanism in the presence of exogenous fuel. It also demonstrates a great variability in platelet ATP content following hemodialysis, which probably depends on the different patients' ability to oxidize acetate.

Effect of protein-restricted diet on serum lipids and atherosclerosis risk factors in patients with chronic renal failure

Early changes in lipid metabolism and appearance of atherosclerosis risk factors play a key role in the development of cardiovascular disease of chronic renal failure (CRF). In the effort to evaluate the effects of protein restricted diet on dyslipidemia, we studied 122 patients with CRF (S-creatinine 1.3-9 mg/dl); 58.2% of whom were on antihypertensive drugs treatment. Patients had been separated into 6 groups: group 1 was kept on a free diet; groups 2, 3, 4, 5, 6 were kept on a protein-restricted diet from 12, 24, 36, 48, 60 months, respectively. We found hypertriglyceridemia, pathologic levels of esterified cholesterol in high density lipoprotein (HDL-C) and pathologic apolipoprotein A1/B ratio in group 1; the comparison with other groups--whose values were normal range after 12, 24 months of treatment--showed significant differences. The lipidic parameters were independent of the duration of CRF and of patients' age. Serum creatinine showed a significant correlation with tryglicerides and HDL-C values only in group 1. Total cholesterol and apolipoprotein B were significantly greater in hypertensives than in normotensives. In our opinion, a moderate restriction in protein intake could be effective in preventing and in halting the early alterations of lipid metabolism in CRF.

Clinical status and acid-base balance during biofiltration in patients with acetate dialysis intolerance

Nine patients intolerant to acetate hemodialysis were treated with biofiltration. This consisted in a 4-h acetate hemodialysis during which an additional 2 liters of ultrafiltrate were replaced by a bicarbonate solution (100 mEq/l). Hypotensive episodes disappeared and six out of nine patients were symptom-free during the session. Compared to standard hemodialysis, arterial blood bicarbonate and pO2 did not drop during biofiltration. The anion gap did not change during standard hemodialysis, but was significantly reduced during biofiltration (24.5 +/- 2.9 vs 19.9 +/- 1.4 mEq/l). In our conditions clinical results were positive with biofiltration. On the basis of anion gap changes and preliminary results of plasma acetate determinations, it is suggested that a better cellular metabolism of acetate may be induced by bicarbonate infusion.