Vision loss due to atypical bilateral edema of the optic nerve in a patient with hereditary angioedema: A case report

PURPOSE

To describe a rare case of vision loss due to bilateral edema of the optic nerve in a patient with Hereditary Angioedema, treated with prophylactic C1-esterase inhibitor.

METHODS

A 60-year-old Caucasian male affected by Hereditary Angioedema with unknown genetic defect (HAE- UNK) was admitted to our hospital presenting bilateral vision loss (best corrected visual acuity of 20/32 in the right eye and hand motion in the left eye) during an HAE attack. Intravenous administration of C1- esterase inhibitor (C1-INH, 1500 IU, Berinert, CSL Behring) determined the resolution of facial and periorbital swelling, however visual impairment persisted, in contrast with previous attacks experienced by the patient. Fundus examination revealed a vital optic disc without papilledema in both eyes. Magnetic resonance imaging (MRI) of the head and orbits showed bilateral edema of the optic nerve sheath. Treatment with intravenous and oral steroids was ineffective. Subsequently, a prophylactic treatment strategy with subcutaneous C1-esterase inhibitor was started (7000 IU every four days).

RESULTS

Complete regression of edema of the optic nerves was observed by imaging at two months of follow-up after chronic treatment with C1-esterase inhibitor (7000 IU every four days). Complete restoration of visual acuity was achieved (BCVA 20/20 in both eyes) and multimodal imaging of the optic nerves demonstrated the absence of anatomical and functional damage.

CONCLUSION

Patients affected by HAE may show atypical presentation with edema of the optic nerves without involvement of the optic nerve head. They may significantly benefit from prophylactic and chronic treatment with C1-esterase inhibitor.

Correlation between bituberous diameter and mode of delivery in a cohort of low-risk nulliparous women

OBJECTIVE

The aim our study was to evaluate the association between the antepartum clinical measurement of the Bituberous Diameter (BTD) and the occurrence of unplanned obstetrical intervention (UOI) due to labor dystocia, including either operative vaginal delivery or caesarean section in a cohort of low-risk, nulliparous at term.

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Tertiary maternity care.

INTERVENTIONS

With the women lying in lithotomic the distance between two ischial tuberosities was assessed using a tape measure during the routine antenatal booking between 37 and 38 weeks of gestation.

MEASUREMENTS AND FINDINGS

Overall, 116 patient were included, and of these 23(19.8%) were submitted to an UOI due to labor dystocia. Compared to women that had a spontaneous vaginal delivery, women submitted to an UOI had a shorter BTD (8.25 + 0.843 vs 9.60 + 1.12, p < 0.001), a higher frequency of epidural analgesia (21/23 or 91.3% vs 50/93 or 53.8%; p = 0.002) and of augmentation of labor (14/23 or 60.9% vs 19/93 or 20.4%; p < 0.001) as well as a longer first [455 (IQR 142-455 min vs 293 (IQR 142-455) min] and second stages of labor [129 (IQR 85-155) min vs 51 (IQR 27-78) min]. Multivariable logistic regression showed that the BTD (aOR 0.16, 95% CI 0.04-0.60; p = 0.007) and the length of the second stage of labor (aOR 6.83, 95% CI 2.10-22.23; p = 0.001) were independently associated with UOI. When evaluating the diagnostic accuracy of the BTD for the prediction of UOI due to labor dystocia, the BTD showed an AUC of 0.82 (95 %CI 0.73-0.91; p < 0.001) with an optimal cut-off value of 8.6 cm (78.3% (95 %CI 56.3-92.5) sensitivity, 77.4% (95 %CI 67.6-85.4) specificity, 46.2% (95% CI 30.1-62.8) PPV, 93.5% (95% CI 85.5-97.9) NPV, 3.5 (95% CI 2.3-5.4) positive LR, and 0.28 (95% CI 0.13-0.61) negative LR. A significant inverse correlation between the length of the second stage of labour and the BTD in patients that had a vaginal delivery was also demonstrated (Spearman's rho = -0.24, p = 0.01).

KEY CONCLUSIONS

Our study suggests that antepartum clinical assessment of the BTD might be used as a reliable predictor of UOI due to labor dystocia in low-risk, nulliparous women at term gestation.

IMPLICATIONS FOR PRACTICE

Antenatal identification of women at higher risk for labor dystocia might trigger some interventions during the second stage of labor, such as maternal position shifting, to increase the pelvic capacity and potentially improve outcomes or might prompt a referral of the patient to a district hospital prior to the onset of labor.

The relevance of MRI blood-sensitive sequences in the diagnostic assessment of late-onset epilepsy

OBJECTIVE

Sporadic cerebral amyloid angiopathy (CAA) is a degenerative brain small vessel disease of ageing resulting from progressive amyloid deposition in small arteries and arterioles of the cortex and leptomeninges. CAA may be diagnosed by the mean of Boston criteria, particularly with the use of the blood-sensitive T2* MRI sequences (GRE and SWI). Epileptic seizures have rarely been reported in CAA.

PATIENTS AND METHODS

We describe two patients with late-onset unprovoked seizures due to CAA. A short literature review on this topic is presented.

RESULTS

In our two patients with late-onset unprovoked seizures as the first manifestation of CAA, only GRE and SWI sequences lead to a correct diagnosis. In literature, only 15 patients with CAA presenting with seizures have been reported. In these subjects, data on seizures semiology and prognosis are scarce.

CONCLUSIONS

Our report highlights the importance to perform blood-sensitive sequences in all subjects with LOE of otherwise unknown etiology, not to miss a diagnosis of CAA.

Functional convergence spasm: an unexpected finding in a patient with focal epilepsy

OBJECTIVE

Convergence spasm is a clinical condition characterized by transient episodes of convergence, miosis and accommodation with strabismus and diplopia and it is usually a manifestation of a functional neurological disorder. We describe a patient with a challenging diagnosis of convergence spasm in the setting of occipital lobe epilepsy.

CASE REPORT

A 52-year-old woman came for the assessment of focal epilepsy due to left occipital cortical dysplasia. During ocular motility tests, she presented with episodes of short duration (~10-30 seconds) of convergent strabismus. Neuropsychological evaluation showed a severe mixed anxiety-depressive disorder with a tendency toward somatization.

RESULTS

Convergence spasm was recorded during video-EEG examination and no ictal activity was present.

CONCLUSIONS

To our knowledge, no other report of functional convergence spasm in the context of focal epilepsy associated with cortical dysplasia has been described in literature.

Health system resilience and health workforce capacities: health system responses during COVID-19

Background

The present crisis offers a unique opportunity to better understanding the specific contribution of the health workforce to health system resilience, and more specifically to the adaptive, absorptive and transformative capacities that influence how health systems respond to the COVID-19 pandemic.

Methods

The study examined different capacities in the context of the health system as the central prerequisite of health system resilience. We compared health policies and services responses in Austria, Denmark, Germany, Italy, the Netherlands and the UK. The selection is based on differences in types of health care systems and pandemic burdens in the first wave. Country experts complied descriptive case studies using written secondary and primary sources.

Results

During the first wave of the pandemic, the contribution of the health workforce rested on a broad range of capacities. The absorptive capacity concerned the freeing up capacities for newly established Covid-19 wards in hospitals. The adaptive capacity focused on increasing health workers. The transformative capacity concerned new service offerings. The influence of health systems was most visible in relation to the substantive areas of health care delivery at play, and less so in relation to the specific range of capacities of the health workforce. The lack of distinct patterns was striking, considering the inclusion of health systems, which differ on many counts.

Conclusions

The study calls for a reconceptualization of the institutional perquisites of health system resilience to grasp more fully the manifold and unique health workforce contribution. Governance is the key to effective health system responses to the COVID-19 crisis, and health professions are part and parcel of governance as frontline workers and collective actors. This requires improving health workforce capacities and strengthening the integration of health professions in health governance.

Novel COL4A2 mutation causing familial malformations of cortical development

OBJECTIVE

This article aimed to describe a novel COL4A2 mutation and the phenotypic features of two family members presenting with epilepsy and cortical development malformations.

PATIENTS AND METHODS

The first patient is a 65-year-old woman with hematuria and adult-onset seizures. Brain MRI showed closed lip schizencephaly of right lateral sulcus associated with polymicrogyria of the surrounding cortex and areas of subcortical heterotopia. The second patient is a 40-year-old man, her son. He was born post-term with neonatal distress and psychomotor developmental delay with congenital left leg paresis and strabismus, as well as childhood-onset focal motor seizures. Brain MRI showed a right nucleus-capsular porencephalic cavitation with enlargement of the homolateral ventricle and a focal right occipital cortico-subcortical encephalomalacia. A small heterotopic band was also present in the frontal left subcortical region.

RESULTS

We tested both patients with a NGS panel for genetic epilepsies, which evidenced a missense mutation in COL4A2 gene (c.2972G>A, causing the aminoacidic substitution Gly991Glu).

CONCLUSIONS

The phenotypic spectrum associated with COL4A2 mutations has not been extensively described in the literature. Testing for COL4A mutations is indicated in patients with malformations of cortical development, particularly in the presence of familial conditions, even in the absence of porencephaly or early hemorrhagic strokes.

The Relationship between Body Dissatisfaction and Eating Disorder Symptoms in Young Women Aspiring Fashion Models: The Mediating Role of Stress

It is widely recognized that body dissatisfaction is an important public health concern. In the past, being a fashion model was almost synonymous with anorexia/bulimia, and even today, there are cases of eating disorders in young women whose ambition is to become a top model. Moreover, stress can play a substantial role within ill health via related behaviors such as smoking, substance abuse, and inappropriate eating. In our study, we examined 112 aspiring fashion models aged between 15 and 24 years (M = 19.5, SD = 2.08) from 32 different countries of the world during an international contest, and 100 students (control group), aged between 16 and 22 years (M = 18.6, SD = 1.39). The purpose of this cross-sectional study was to examine whether stress mediated the relationship between body dissatisfaction and eating disorders. The study included the administration of stress and self-efficacy and the locus of control dimensions, body (image) dissatisfaction, and eating attitude disorder. Results indicated higher scores on body dissatisfaction, stress level, and eating attitudes disorder among the group of fashion models compared to the control. Mediational analyses showed that body dissatisfaction was partially mediated by stress level on eating disorders. Especially in the aspiring fashion models, there are often many possibilities that competitive stress causes candidates to exacerbate attempts to maintain their body weight below normal weight/height parameters. These results indicated that appropriate intervention for the management of stress level could possibly defend against the negative impact of body dissatisfaction on eating disorder symptoms. The presence of skilled health workers in the field of nutrition and psychology can be extremely important in the field of fashion to maintain an adequate quality of life.

On-treatment serum albumin level can guide long-term treatment in patients with cirrhosis and uncomplicated ascites

BACKGROUND & AIMS

The ANSWER study reported that long-term albumin administration in patients with cirrhosis and uncomplicated ascites improves survival. During treatment, serum albumin increased within a month and remained stable thereafter. In this post hoc analysis, we aimed to determine whether on-treatment serum albumin levels could guide therapy.

METHODS

Logistic regression was used to assess the association between baseline serum albumin and mortality, as well as to determine on-treatment factors associated with mortality and to predict the achievement of a given on-treatment serum albumin level. Survival was assessed by Kaplan-Meier estimates and second-order polynomial regression. Patients whose on-treatment serum albumin remained below normal were compared with a subset of patients from the control arm matched by principal score.

RESULTS

Baseline serum albumin was closely associated with 18-month mortality in untreated patients; albumin treatment almost effaced this relationship. On-treatment serum albumin and MELD-Na at month 1 were the sole independent variables associated with mortality. Second-order polynomial regression revealed that survival improved in parallel with increased 1-month on-treatment serum albumin. Kaplan-Meier estimations showed that any value of 1-month on-treatment serum albumin (0.1 g/dl intervals) in the range 2.5-4.5 g/dl discriminated patient survival. In the normal range of serum albumin, the best discriminant value was 4.0 g/dl. Compared to untreated patients, survival even improved in patients whose on-treatment serum albumin remained below normal.

CONCLUSION

Baseline serum albumin per se should not guide the decision to start albumin therapy. Conversely, 1-month on-treatment serum albumin levels are strongly associated with outcomes and could guide the use of albumin - 4.0 g/dl being the target threshold. However, even patients whose serum albumin remains below normal benefit from long-term albumin administration.

LAY SUMMARY

The ANSWER study has shown that long-term albumin administration improves survival and prevents the occurrence of major complications in patients with cirrhosis and ascites. This study shows that the achievement of these beneficial effects is related to a significant increase in serum albumin concentration. Even though the best results follow the achievement of a serum albumin concentration of 4 g/dl, a survival benefit is also achieved in patients who fail to normalise serum albumin.

Significant chronic airway abnormalities in never-smoking HIV-infected patients

OBJECTIVES

The aim of the study was to describe chronic lung disease in HIV-infected never-smokers by looking at clinical, structural and functional abnormalities.

METHODS

This comparative cross-sectional study included 159 HIV-infected never-smoking patients [mean (± standard deviation) age 54.6 ± 9.1 years; 13.2% female; 98.1% with undetectable viral load] and 75 nonmatched never-smoking controls [mean (± standard deviation) age 52.6 ± 6.9 years; 46.7% female]. We examined calcium scoring computer tomography (CT) scans or chest CT scans, all with a lung-dedicated algorithm reconstruction, to assess emphysema and airway disease (respiratory bronchiolitis and/or bronchial wall thickening), tested pulmonary function using spirometry, lung volumes and the diffusion lung capacity of carbon monoxide (DLCO), and assessed respiratory symptoms using the Chronic Obstructive Pulmonary Disease (COPD) Assessment Test (CAT).

RESULTS

Twenty-five (17.2%) of the HIV-infected patients versus two (2.7%) of the controls had a CAT score > 10. Only 5% of the HIV-infected patients showed FEV1% < 80%, and 25% had DLCO < 75% of the predicted value. Based on the CT scans, they had increased prevalences, compared with the controls, of airway disease (37% versus 7.9%, respectively) and emphysema (18% versus 4%, respectively), with more severe and more frequent centrilobular disease. After correction for age, sex and clinical factors, HIV infection was significantly associated with CAT > 10 [odds ratio (OR) 7.7], emphysema (OR 4), airway disease (OR 4.5) and DLCO < 75% of predicted (OR 4).

CONCLUSIONS

Although comparisons were limited by the different enrolment methods used for HIV-infected patients and controls, the results suggest that never-smoking HIV-infected patients may present with chronic lung damage characterized by CT evidence of airway disease. A minority of them showed respiratory symptoms, without significant functional abnormalities.

Long-Term Outcomes with Subcutaneous C1-Inhibitor Replacement Therapy for Prevention of Hereditary Angioedema Attacks

BACKGROUND

For the prevention of attacks of hereditary angioedema (HAE), the efficacy and safety of subcutaneous human C1-esterase inhibitor (C1-INH[SC]; HAEGARDA, CSL Behring) was established in the 16-week Clinical Study for Optimal Management of Preventing Angioedema with Low-Volume Subcutaneous C1-Inhibitor Replacement Therapy (COMPACT).

OBJECTIVE

To assess the long-term safety, occurrence of angioedema attacks, and use of rescue medication with C1-INH(SC).

METHODS

Open-label, randomized, parallel-arm extension of COMPACT across 11 countries. Patients with frequent angioedema attacks, either study treatment-naive or who had completed COMPACT, were randomly assigned (1:1) to 40 IU/kg or 60 IU/kg C1-INH(SC) twice per week, with conditional uptitration to optimize prophylaxis (ClinicalTrials.gov registration no. NCT02316353).

RESULTS

A total of 126 patients with a monthly attack rate of 4.3 in 3 months before entry in COMPACT were enrolled and treated for a mean of 1.5 years; 44 patients (34.9%) had more than 2 years of exposure. Mean steady-state C1-INH functional activity increased to 66.6% with 60 IU/kg. Incidence of adverse events was low and similar in both dose groups (11.3 and 8.5 events per patient-year for 40 IU/kg and 60 IU/kg, respectively). For 40 IU/kg and 60 IU/kg, median annualized attack rates were 1.3 and 1.0, respectively, and median rescue medication use was 0.2 and 0.0 times per year, respectively. Of 23 patients receiving 60 IU/kg for more than 2 years, 19 (83%) were attack-free during months 25 to 30 of treatment.

CONCLUSIONS

In patients with frequent HAE attacks, long-term replacement therapy with C1-INH(SC) is safe and exhibits a substantial and sustained prophylactic effect, with the vast majority of patients becoming free from debilitating disease symptoms.

Comparative study of OMNIgene®•SPUTUM reagent versus cold-chain for the transportation of sputum samples to GeneXpert®MTB/RIF testing sites in Malawi

BACKGROUND

The study was conducted in a remote sputum sample collection sites and GeneXpert® MTB/RIF testing centers to detect Mycobacterium tuberculosis in Malawi. The main purpose of the study was to evaluate whether sputum samples stored and transported with OMNIgene®•SPUTUM (OM-S) medium perform comparably to the routine cold-chain stored and transported samples for GeneXpert testing to detect Mycobacterium tuberculosis.

METHODS

Two sputum samples from each of 362 tuberculosis suspects were randomly assigned to the OMNIgene treated (OM-S group) or the standard-of-care group (SOC; transported via cold chain). All specimens were tested at regional GeneXpert testing sites using the expectorated (raw) sputum protocol. Demographic, clinical, transport/storage and Xpert data were recorded for each specimen pair. Agreement between the SOC and OM-S groups' Xpert results was evaluated using Cohen's kappa analysis.

RESULTS

Mean patient age was 42.3 years (range 2-79 years), 77% of patients were female, and 80% were HIV-positive. Mean transport/storage time was 6.7 days (range, 0-29 days). The rates of MTB positivity for the OM-S and SOC groups were comparable (11.8 and 11.2%, respectively), inter-test agreement was "very good" (κ = 0.97), and overall percent agreement was 99%. Two specimen pairs (both mucoid, one 13 days transport, one 1 day transport) had discordant Xpert results.

CONCLUSION

OM-S-treated sputum specimens can undergo multi-day ambient-temperature storage as well as transport and yield Xpert results comparable to those of cold-chain-transported samples in Malawi.

Cep Regimen (Ccnu, Etoposide, Prednimustine) for Relapsed/Refractory Hodgkin's Disease

Aims and background

Although initial treatment of Hodgkin's disease induces a complete remission in most patients, approximately 50% of patients with advanced disease will not achieve a complete remission or will relapse following the first complete remission.

Patients and methods

Twenty-three patients with relapsed/resistant Hodgkin's disease, observed between January 1991 and October 1993, underwent CEP combination chemotherapy (CCNU, etoposide, prednimustine). All patients had previously received MOPP and ABVD regimens, in combination at diagnosis or sequentially (at diagnosis and at the first relapse).

Results

Thirteen (56%) patients achieved complete responses and 4 (18%) had partial responses. Two partial responders obtained a complete remission after a successive autologous bone marrow transplantation. The complete remission was not influenced by the timing of MOPP and ABVD treatments, presence of extranodal involvement or presence of bulky disease, but was affected by the presence of a primary disease refractory to the first standard programs. All the complete responders but 2 were alive and relapse-free at a median follow-up of 15 months; no major toxic effects were recorded.

Conclusions

These data suggest, as did those of other studies, that CEP is an effective regimen in patients with Hodgkin's disease in first or second relapse, also to reduce the tumor burden and to determine chemosensitivity before contingent bone marrow or peripheral blood stem cell support.

Long-term albumin administration in decompensated cirrhosis (ANSWER): an open-label randomised trial

BACKGROUND

Evidence is scarce on the efficacy of long-term human albumin (HA) administration in patients with decompensated cirrhosis. The human Albumin for the treatmeNt of aScites in patients With hEpatic ciRrhosis (ANSWER) study was designed to clarify this issue.

METHODS

We did an investigator-initiated multicentre randomised, parallel, open-label, pragmatic trial in 33 academic and non-academic Italian hospitals. We randomly assigned patients with cirrhosis and uncomplicated ascites who were treated with anti-aldosteronic drugs (≥200 mg/day) and furosemide (≥25 mg/day) to receive either standard medical treatment (SMT) or SMT plus HA (40 g twice weekly for 2 weeks, and then 40 g weekly) for up to 18 months. The primary endpoint was 18-month mortality, evaluated as difference of events and analysis of survival time in patients included in the modified intention-to-treat and per-protocol populations. This study is registered with EudraCT, number 2008-000625-19, and ClinicalTrials.gov, number NCT01288794.

FINDINGS

From April 2, 2011, to May 27, 2015, 440 patients were randomly assigned and 431 were included in the modified intention-to-treat analysis. 38 of 218 patients died in the SMT plus HA group and 46 of 213 in the SMT group. Overall 18-month survival was significantly higher in the SMT plus HA than in the SMT group (Kaplan-Meier estimates 77% vs 66%; p=0·028), resulting in a 38% reduction in the mortality hazard ratio (0·62 [95% CI 0·40-0·95]). 46 (22%) patients in the SMT group and 49 (22%) in the SMT plus HA group had grade 3-4 non-liver related adverse events.

INTERPRETATION

In this trial, long-term HA administration prolongs overall survival and might act as a disease modifying treatment in patients with decompensated cirrhosis.

FUNDING

Italian Medicine Agency.

Non Conventional Fractionation in Radiotherapy of the Musculo-Skeletal Sarcomas

In 1989 we started an accelerated hyperfractionated schedule of radiotherapy (two 1.6 Gy daily fractions) in standard risk localized Ewing's sarcoma of bone, with the aim at reducing late effects in young patients and at improving disease control through a better integration of treatment modalities. From 1991, the same schedule was used in preoperative radiotherapy of adult soft tissue sarcomas of the extremities: the main purpose was to reduce the time to surgery and to evaluate surgical complications in comparison with a previous experience of hypofractionated radiotherapy (one 3 Gy daily fraction). From 1991 to 1997, 76 patients with Ewing's sarcoma and 24 patients with soft tissue sarcoma were treated at our Institution. Results and complication rates are analyzed in comparison with historical data. In Ewing's sarcoma, a correct evaluation of improvement in local control was difficult because of changing treatment policy (bulky disease was not included in the present series). Late effects, as evaluated in patients with a minimum follow-up of 3 years, occurred with similar incidence, but at higher total dose levels in patients treated with accelerated hyperfractionation. In patients with soft tissue sarcomas, incidence of surgical complications is reduced as compared to historical experience. Major problems of wound healing were seen in association with intraoperative brachitherapy boost.

Subclinical Ductal Carcinoma in Situ of the Breast: Treatment with Conservative Surgery and Radiotherapy

Aims and Background

In spite of the fact that ductal carcinoma in situ (DCIS) of the breast is a frequently encountered clinical problem, there is no consensus about the optimal treatment of clinically occult (i.e., mammographic presentation only) DCIS. Interest in breast conservation therapy has recently increased. Few data are available in Italy on the conservative treatment with surgery and adjuvant postoperative radiotherapy.

Methods

A retrospective multi-institutional study was performed in 15 Radiation Oncology Departments in northern Italy involving 112 women with subclinical DCIS of the breast treated between 1982 and 1993. Age of the patients ranged between 32 and 72 years (median, 50 years). All of them underwent conservative surgery: quadrantectomy in 89, tumorectomy in 11, and wide excision in 12 cases. The most common histologic subtype was comedocarcinoma (37%). The median pathologic size was 10 mm (range 1 to 55 mm). Axillary dissection was performed in 83 cases: all the patients were node negative. All the patients received adjunctive radiation therapy with 60Co units (77%) or 6 MV linear accelerators (23%) for a median total dose to the entire breast of 50 Gy (mean, 49.48 Gy; range, 45-60 Gy). Seventy-six cases (68%) received a boost to the tumor bed at a dose of 8-20 Gy (median 10 Gy) for a minimum tumor dose of 58 Gy.

Results

At a median follow-up of 66 months, 8 local recurrences were observed, 4 intraductal and 4 invasive. All recurrent patients had a salvage mastectomy and are alive and free of disease at this writing. The 10-year actuarial overall, cause-specific, and recurrence-free survival was of 98.8%, 100%, and 91%, respectively.

Conclusions

The retrospective multicentric study, with a local control rate of more than 90% at 10 years with 100% cause-specific survival, showed that conservative surgery and adjuvant radiation therapy is a safe and efficacious treatment for patients with occult, non-palpable DCIS.

Temporal integration of soil N2O fluxes: validation of IPNOA station automatic chamber prototype

The assessment of nitrous oxide (N₂O) fluxes from agricultural soil surfaces still poses a major challenge to the scientific community. The evaluations of integrated soil fluxes of N₂O are difficult owing to their lower emissions when compared with CO₂. These emissions are also sporadic as environmental conditions act as a limiting factor. A station prototype was developed to integrate annual N₂O and CO₂ emissions using an automatic chamber technique and infrared spectrometers within the LIFE project (IPNOA: LIFE11 ENV/IT/00032). It was installed from June 2014 to October 2015 in an experimental maize field in Tuscany. The detection limits for the fluxes were evaluated up to 1.6 ng N-N₂O m² s^-1 and 0.3 μg C-CO₂ m² s^-1. A cross-comparison carried out in September 2015 with the "mobile IPNOA prototype"; a high-sensibility transportable instrument already validated provided evidence of very similar values and highlighted flux assessment limitations according to the gas analyzers used. The permanent monitoring device showed that temporal distribution of N₂O fluxes can be very large and discontinuous over short periods of less than 10 days and that N₂O fluxes were below the detection limit of the instrumentation during approximately 70% of the measurement time. The N₂O emission factors were estimated to 1.9% in 2014 and 1.7% in 2015, within the range of IPCC assessments.

Prevention of Hereditary Angioedema Attacks with a Subcutaneous C1 Inhibitor

BACKGROUND

Hereditary angioedema is a disabling, potentially fatal condition caused by deficiency (type I) or dysfunction (type II) of the C1 inhibitor protein. In a phase 2 trial, the use of CSL830, a nanofiltered C1 inhibitor preparation that is suitable for subcutaneous injection, resulted in functional levels of C1 inhibitor activity that would be expected to provide effective prophylaxis of attacks.

METHODS

We conducted an international, prospective, multicenter, randomized, double-blind, placebo-controlled, dose-ranging, phase 3 trial to evaluate the efficacy and safety of self-administered subcutaneous CSL830 in patients with type I or type II hereditary angioedema who had had four or more attacks in a consecutive 2-month period within 3 months before screening. We randomly assigned the patients to one of four treatment sequences in a crossover design, each involving two 16-week treatment periods: either 40 IU or 60 IU of CSL830 per kilogram of body weight twice weekly followed by placebo, or vice versa. The primary efficacy end point was the number of attacks of angioedema. Secondary efficacy end points were the proportion of patients who had a response (≥50% reduction in the number of attacks with CSL830 as compared with placebo) and the number of times that rescue medication was used.

RESULTS

Of the 90 patients who underwent randomization, 79 completed the trial. Both doses of CSL830, as compared with placebo, reduced the rate of attacks of hereditary angioedema (mean difference with 40 IU, -2.42 attacks per month; 95% confidence interval [CI], -3.38 to -1.46; and mean difference with 60 IU, -3.51 attacks per month; 95% CI, -4.21 to -2.81; P<0.001 for both comparisons). Response rates were 76% (95% CI, 62 to 87) in the 40-IU group and 90% (95% CI, 77 to 96) in the 60-IU group. The need for rescue medication was reduced from 5.55 uses per month in the placebo group to 1.13 uses per month in the 40-IU group and from 3.89 uses in the placebo group to 0.32 uses per month in the 60-IU group. Adverse events (most commonly mild and transient local site reactions) occurred in similar proportions of patients who received CSL830 and those who received placebo.

CONCLUSIONS

In patients with hereditary angioedema, the prophylactic use of a subcutaneous C1 inhibitor twice weekly significantly reduced the frequency of acute attacks. (Funded by CSL Behring; COMPACT EudraCT number, 2013-000916-10 , and ClinicalTrials.gov number, NCT01912456 .).

Plasma Levels of Inflammatory Biomarkers in Peripheral Arterial Disease: Results of a Cohort Study

Previous research analyzed the level of plasma inflammatory markers in patients with coronary disease, but very few studies have evaluated these markers in patients with peripheral arterial disease (PAD). The objective of this study was to investigate the plasma levels of inflammatory markers in patients with PAD and in healthy controls. The following plasma levels of biomarkers were measured in 80 patients with PAD (mean age 68 ± 5 years) and in 72 healthy participants (mean age 67 ± 6 years): interleukin 6 (IL-6), tumor necrosis factor α (TNF-α), L-selectin (LS), neopterin (N), P-selectin (PS), E-selectin (ES), vascular cell adhesion molecule 1 (VCAM-1), intercellular adhesion molecule 1 (ICAM-1), and matrix metalloproteinase 2 (MMP-2), and 9 (MMP-9). Significantly higher levels of IL-6 (P < .001), TNF-α (P < .0001), ES (P < .0001), LS (P < .0001), PS (P < .0001), ICAM-1 (P < .001), VCAM-1 (P < .001), N (P < .001), MMP-2 (P < .001), and MMP-9 (P < .005) were found in the patients with PAD. Patients with PAD show a inflammation marker profile different from that of control participants. Reducing the high plasma levels of inflammatory markers could be a new therapeutic approach both for the prevention and the treatment of PAD.

Current status of implementation of self-administration training in various regions of Europe, Canada and the USA in the management of hereditary angioedema

Results from a 16-question survey about self-administration of hereditary angioedema (HAE) therapy, administered in Europe, Canada and the USA, were used to guide discussion at an international HAE expert meeting. The aim was to capture information about current practice in self-administered HAE therapy in these countries, including self-administration training, the key benefits of switching to self-administration, the barriers to self-administration and trends in self-administration. Overall, switching to self-administration therapy is looked upon favourably from both patient and clinician perspectives by virtue of the potential improvement in quality of life arising from optimisation of therapy and early intervention. The recent changes to product licences allowing self-administration provide additional options for the management of HAE.

Neopterin: a potential marker in chronic peripheral arterial disease

Neopterin is a marker of macrophage activation that has exhibited high plasma levels in atherosclerotic diseases including coronary heart disease and critical limb ischemia. The role of neopterin in chronic peripheral arterial disease (PAD) has yet to be elucidated. In the present study, neopterin (Ν) serum concentrations were analyzed in asymptomatic (AsP) and symptomatic (SyP) patients with PAD as well as controls (C). In total 120 subjects, 40 AsP [ankle brachial index (ABI) ≤0.90], 40 SyP (ABI ≤0.90 plus pain in legs) and 40 controls (ABI >0.9) were enrolled. The results of the present study showed that neopterin plasma levels were statistically different among the groups. These findings demonstrated that activation of N‑mediated monocyte‑macrophage, was also observed in chronic PAD.

Hepatitis C infection, antiviral treatment and mental health: a European expert consensus statement

Mental health problems frequently occur in chronic infection with the hepatitis C virus (HCV) and during antiviral treatment with pegylated interferon-alpha (PegIFNα) and ribavirin. Depression is one of the most important complications during antiviral treatment of chronic hepatitis C infection. However, an increased prevalence of depression, fatigue, and cognitive disturbances has also been reported in untreated HCV-positive patients. Patients with psychiatric disorders or drug addiction also have an increased risk of HCV infection. Furthermore, because of possible drug-drug interactions, new antivirals administered together with PegIFNα and ribavirin may complicate psychiatric side effect management, even if no specific psychiatric adverse events are known so far for these new drugs. The European liver patient's organization (ELPA) organised a European expert conference to review the literature and develop expert recommendations for the management of mental health problems in HCV infected patients. This paper results from the output of the 2011 EASL meeting and subsequent dialogue with patient groups and relevant experts in Europe. It summarises the current knowledge of HCV infection and the brain; prevalence, course, and neurobiology of IFN-α associated psychiatric side effects; possible risk factors for IFN-α associated depression and suicide attempts; psychiatric management of HCV infected patients before and during antiviral treatment; prevention of IFN- α associated psychiatric side effects; and psychiatric aspects of the new antivirals. The summarised current knowledge about mental health changes before and during antiviral treatment should improve interdisciplinary management of HCV infected patients.

Carotid intima-media thickness and liver histology in hemodialysis patients with nonalcoholic Fatty liver disease

The prevalence of atherosclerotic cardiovascular disease in chronic hemodialysis (HD) patients has been demonstrated to be higher than in healthy people. Severe liver fibrosis is strongly associated with early carotid atherosclerosis and it might reduce the survival of patients who undergo both renal replacement therapy and transplantation. We wanted to assess whether nonalcoholic fatty liver disease (NAFLD) was associated with altered intima-media thickness (IMT) in HD patients as an independent marker of subclinical atherosclerosis. We enrolled 42 patients undergoing HD and 48 patients with normal renal function, all of them with high levels of aminotransferases and an ultrasonographic diagnosis of liver steatosis. The control group consisted of 60 healthy subjects. Laboratory tests for inflammatory and oxidative markers, ultrasonographic liver evaluation, carotid IMT measurement, and liver biopsy were performed. Different degrees of fibrosis were detected in our study cohort. Worse liver histopathological scores and higher plasmatic levels of C-reactive protein, reactive oxygen species, and vascular cell adhesion molecule-1 were found in HD patients. Carotid IMT was significantly higher (p < 0.005) in patients with histological steatosis. HD patients may develop active and progressive chronic hepatitis faster than patients with normal renal function and the thickness of their carotid intima-media might be markedly increased. These two conditions seem to be independent on classical risk factors and on metabolic syndrome. They might be related to the high levels of oxidants and to the inflammatory state, which are typical of patients undergoing HD. Independently related with the traditional risk factors for cardiovascular disease, nonspecific inflammation and oxide-reductive imbalance may play an important role in the progression of NAFLD and atherosclerotic disease in HD patients.

The supplementation of acetyl-L-carnitine decreases fatigue and increases quality of life in patients with hepatitis C treated with pegylated interferon-α 2b plus ribavirin

The aim of this study was to evaluate whether supplementation of acetyl-L-carnitine (ALC) to pegylated-interferon-α 2b (Peg-IFN-α 2b) and ribavirin (RBV) improves the health-related quality of life during the treatment for chronic hepatitis C, thereby decreasing the risk of treatment discontinuation. Sixty patients with chronic hepatitis C underwent treatment with Peg-IFN-α 2b + RBV (group A; n = 29) or Peg-IFN-α 2b + RBV + ALC (group B; n = 31) for 12 months. At the end of the study, the comparison between group A and group B showed significant differences in aspartate aminotransferase (AST) (-80.9 versus -110.3; P < 0.001), alanine aminotransferase (-111.6 versus -134.7; P < 0.001), Viremia (-3.26 versus -3.82; P < 0.05), mental health (0 versus 11; P < 0.001), physical functioning (-1 versus 8; P < 0.001), role-physical (1 versus 13; P < 0.001), bodily pain (1 versus 12; P < 0.001), general health (3 versus 12; P < 0.001), vitality (3 versus 13; P < 0.001), social functioning (3 versus 10; P < 0.001), physical fatigue (2.1 versus -5.4; P < 0.001), mental fatigue (-0.7 versus -2.7; P < 0.001), and fatigue severity scale (-3.4 versus -12; P < 0.001). ALC supplementation reduced both mental and physical fatigue, improved health-related quality of life, and, therefore, has the potential to increase patient adherence to the combination regimen. This, in turn, may increase the percentage of patients achieving a sustained virological response.

Evaluation of circulating CD4+CD25+ and liver-infiltrating Foxp3+ cells in HCV-associated liver disease

In hepatitis C virus (HCV)-associated liver disease, the immune system is unable to clear the viral infection. Previous studies have raised the possibility of an involvement of regulatory T cells (Tregs). In this study, we analysed the peripheral blood from 30 patients with HCV-associated chronic liver disease and 20 healthy controls by flow cytometry for the evaluation of the Treg population [CD4⁺CD25hi forkhead box protein 3 (Foxp3)⁺], as well as the activated/effector CD4⁺ T cells (CD4⁺CD25low) and IFN-γ-secreting cells. We also analysed liver biopsies of the patients by immunohistochemical evaluation of Foxp3⁺ cells. Our results showed higher proportions of CD4⁺CD25low and IFN-γ⁺ cells in the patients than in the controls. By contrast, the proportions of peripheral CD4⁺CD25hi cells did not significantly differ. The 11 patients displaying Foxp3⁺ cells in the liver infiltrates showed significantly higher proportions of peripheral CD4⁺CD25low cells. Moreover, we found lower serum transaminase levels in the patients than in the controls, as shown by Foxp3⁺ immunohistochemistry, although these results were only statistically significant as regards alanine transaminase (ALT). In conclusion, these data suggest that the presence of Tregs infiltrating the liver is associated with high levels of activated/effector T cells in the peripheral blood and lower activity of hepatitis. Therefore, liver-infiltrating Tregs may play a role in limiting tissue damage and may thus support an effective immune response against HCV.

[Relation of non-alcoholic hepatic steatosis to early carotid atherosclerosis in diet-controlled impaired glucose tolerance subjects]

AIMS

To compare carotid artery intima-media thickness values, as a reliable marker of early atherosclerosis, in individuals with and without nonalcoholic hepatic steatosis, and to evaluate whether such differences are mediate by metabolic syndrome variables.

MATERIALS AND METHODS

Carotid intima-media thickness (by ultrasonography), hepatic steatosis (by ultrasonography), insulin resistance (by Homeostasis Model Assessment-HOMA), steatohepatitis (by histologic specimen) were measured in 54 non-alcoholic steatohepatitis, and 54 IGT, compared with 54 healthy subjects.

RESULTS

Subjects with nonalcoholic steatohepatitis had markedly greater carotid intima-media thickness measurements (1.38±0.12 vs 1.12±0.10 mm; p<0.001) than controls. The marked differences in carotid intima-media thickness that were observed between the groups were little affected by adjustment for age, sex, body mass index, waist/hip ratio, diabetes duration, blood pressure, lipids.

CONCLUSIONS

These results suggest that in IGT non smoking subjects, the significant increase of carotid intima-media thickness in presence of nonalcoholic steatohepatitis cannot be mediated by HOMA-estimated insulin resistance; thus the NAFDL and NASH can be independent features of metabolic syndrome and other unknown factors can be responsible to progression of steatosis to NAFLD and NASH.

Oxidative stress, glutathione status, sirtuin and cellular stress response in type 2 diabetes

Oxidative stress has been suggested to play a main role in the pathogenesis of type 2 diabetes mellitus and its complications. As a consequence of this increased oxidative status a cellular adaptive response occurs requiring functional chaperones, antioxidant production and protein degradation. This study was designed to evaluate systemic oxidative stress and cellular stress response in patients suffering from type 2 diabetes and in age-matched healthy subjects. Systemic oxidative stress has been evaluated by measuring plasma reduced and oxidized glutathione, as well as pentosidine, protein carbonyls lipid oxidation products 4-hydroxy-2-nonenal and F2-isoprostanes in plasma, and lymphocytes, whereas the lymphocyte levels of the heat shock proteins (HSP) HO-1, Hsp72, Sirtuin-1, Sirtuin-2 and thioredoxin reductase-1 (TrxR-1) have been measured to evaluate the systemic cellular stress response. Plasma GSH/GSSG showed a significant decrease in type 2 diabetes as compared to control group, associated with increased pentosidine, F2-isoprostanes, carbonyls and HNE levels. In addition, lymphocyte levels of HO-1, Hsp70, Trx and TrxR-1 (P<0.05 and P<0.01) in diabetic patients were higher than in normal subjects, while sirtuin-1 and sirtuin-2 protein was significantly decreased (p<0.05). In conclusion, patients affected by type 2 diabetes are under condition of systemic oxidative stress and, although the relevance of downregulation in sirtuin signal has to be fully understood, however induction of HSPs and thioredoxin protein system represent a maintained response in counteracting systemic pro-oxidant status. This article is part of a Special Issue entitled: Antioxidants and Antioxidant Treatment in Disease.

L-carnitine supplementation improves hematological pattern in patients affected by HCV treated with Peg interferon-α 2b plus ribavirin

AIM: To evaluate the efficacy of L-carnitine on alleviating anemia, thrombocytopenia and leukopenia, and minimizing dose reductions in patients with chronic hepatitis C virus (HCV) in treatment with Interferon α (IFN-α) plus ribavirin.

METHODS: Sixty-nine patients with chronic hepatitis C were enrolled in the study and divided into two groups. group A (n = 35) received Peg-IFN-α 2b plus ribavirin plus L-carnitine, and group B (n = 34) received Peg-IFN-α and ribavirin for 12 mo. All patients underwent laboratory investigations including: red cell count, hemoglobin, white cell count, platelets, bilirubin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), and viremia.

RESULTS: After 12 mo in group A compared to group B we observed significant differences in AST 108.8 vs 76.8 (IU/L; P < 0.001), ALT 137.9 vs 112.3 (IU/L; P < 0.001), viremia 4.04 vs 2.36 (× 10⁶ copies/mL; P < 0.001), Hb 1 vs 3.5 (g/dL; P < 0.05), red blood cells 0.3 vs 1.1 (× 10¹²/L; P < 0.001), white blood cells 1.5 vs 3 (× 10⁹/L; P < 0.001) and platelets 86 vs 85 (× 10⁹/L; P < 0.001). The end treatment responders were 18 vs 12 (60% vs 44%) and the non responders were 12 vs 15 (40% vs 50%) [odds ratio (OR) 1.65, 95% CI = 0.65-5.37, P < 0.05]. In group A compared to group B there was a significant improvement of sustained virological response in 15 vs 7 patients (50% vs 25%), while the relapsers were 3 vs 5 (10% vs 18%) (OR 3.57, 95% CI = 0.65-19.3, P < 0.001).

CONCLUSION: L-carnitine supplementations modulate erythropoiesis, leucopoiesis and thrombocytopoiesis, and may be useful in patients treated for HCV. L-carnitine treatment offers the possibility of achieving a sustained virological response while preventing overtreatment.

Diagnostic and prognostic value of alpha-fetoprotein, des-γ-carboxy prothrombin and squamous cell carcinoma antigen immunoglobulin M complexes in hepatocellular carcinoma

The hepatocellular carcinoma (HCC) is one of the most common malignant tumors. It carries a poor survival rate and has an increasing incidence worldwide. In most cases, HCC is diagnosed at a late stage. Therefore, the prognosis of patients with HCC is generally poor and has a less than 5% 5-year survival rate. The aim of this study was compare the accuracy of α-fetoprotein (AFP), des-γ- carboxy prothrombin (DCP), squamous cell carcinoma antigen-immunoglobulin M complexes (SCCA-IgM Cs) in the early diagnosis and in the prognosis of HCC. A literature search identified the markers for hepatocellular carcinoma. A search of the literature was made using cancer literature and the PubMed database for the following keywords: "markers and HCC", "α-fetoprotein (AFP) and HCC", "Des-γ-carboxy prothrombin"(DCP) and HCC, "squamous cell carcinoma antigen-immunoglobulin M complexes" (SCCA-IgM Cs). Despite the large number of studies devoted to the immunohistochemistry of HCC, at the present time, the absolute positive and negative markers for HCC are still lacking, and even those characterized by very high sensitivity and specificity do not have an universal diagnostic usefulness. In conclusion none of the three biomarkers (AFP, DCP, SCCA-IgM Cs) is optimal. According to recent reviews, these biomarkers should be measured simultaneously and in combination with imaging techniques to increase the sensitivity, specificity, diagnostic accuracy and to make a reliable prognosis. Currently the recommended screening strategy for patients with cirrhosis includes the determination of serum AFP levels and an abdominal ultrasound every six months to detect HCC at an earlier stage.

Relationship between circulating interleukin-10 and histological features in patients with chronic C hepatitis

BACKGROUND AND OBJECTIVES

An imbalance in cytokine production may be involved in the pathogenesis of chronic C hepatitis. The aim of the study was to investigate circulating levels of interleukin-10 (IL-10) in a selected cohort of patients affected by chronic C hepatitis.

DESIGN AND SETTING

Retrospective study based on consecutive hepatitis C virus patients, affected by chronic active hepatitis, attending the general hospital of hepatology unit from June to September 2009

PATIENTS AND METHODS

A total of 49 patients with chronic C hepatitis and 20 healthy control subjects similar in gender and age were examined. Circulating IL-10 was assessed by ELISA commercial kit (R and D Systems) in all investigated subjects.

RESULTS

There was no significant difference in IL-10 values between controls and overall patients (P>.05). Nevertheless, among patients, subjects with more severe necroinflammation had higher values than others (P<.001). Moreover, a close relationship was found between IL-10 values and serum aspartate aminotransferase (r=0.61; P<.001).

CONCLUSIONS

These findings suggest that IL-10 may be a useful additional marker to assess necroinflammation and to monitor the evolution of liver damage. They also argue for a potential pathophysiological role for IL-10 in the persistence and progression of hepatitis.

High frequency of Chlamydophila pneumoniae infections: patients with peripheral arterial disease and those with risk factors for cardiovascular diseases compared to normal subjects

The role of bacterial infections, mainly Chlamydophila pneumoniae, on atherosclerotic processes as well as the therapeutic utility of additional antibiotic treatment is still an open question. In this study we compared the serological profiles of 160 patients (80 with peripheral arterial disease (PAD), diagnosed with an ankle/brachial index (ABI) ≤ 0.9 and 80 with risk factors for cardiovascular disease - CVD) with those of 80 healthy subjects, serum levels of specific C. pneumoniae antibodies using the microimmunofluorescence test. Our results show that PAD patients had a higher frequency of C. pneumoniae infection than those with risk factors for cardiovascular disease. This frequency was lower if compared to the previous two groups in controls. 44 out of the 80 (55%) patients with PAD and 34 out of the 80 (42.58%) subjects with risk factors for cardiovascular disease were seropositive while only 24 of the 80 (30%) healthy subjects showed seropositivity to C. pneumoniae. Furthermore, higher anticorpal titers were also found in patients with peripheral arterial disease and in patients with cardiovascular risk factors if compared to healthy subjects. On the basis of these results, we confirm that C. pneumoniae infection is frequent in peripheral arterial disease patients and we believe that it could be considered as an additional risk factor involved in the pathogenesis of this disease.

Effects of long-term hormone replacement therapy: results from a cohort study

The positive effects of hormonal replacement therapy (HRT) in protecting the cardiovascular system in women have been supported by several observational studies, while also being questioned by other randomized controlled trials. Today, it is unclear whether HRT plays a crucial role, or even whether there is any role at all, for this therapy in preventing or in lowering cardiovascular disease (CVD). In the present study, we have evaluated the effectiveness of long-term HRT in post-menopausal women on the incidence of cardiovascular events and arterial remodeling, as well as on some metabolic factors. Eighty-four post-menopausal women (mean age: 46.3 ± 5.2; age range: 42-66 yr) underwent HRT for 10.9 ± 1.2 yr (range: 8-12 yr). None of these subjects showed new cardiovascular events, and we found a reduction of the intima-media thickness (baseline: 1.39 ± 0.2, 1.35 ± 0.2, 1.31 ± 0.2 mm) and total cholesterol, LDL and antithrombin III levels were lower, while HDL and fibrinogen levels increased. The study highlights a number of positive effects both on vascular conditions and metabolic and coagulative markers that are usually considered as generic and crucial risk factors for CVD. The relatively low number of patients is perhaps a limitation of this study, however, the long-term period of followup should be considered an interesting and important factor. Furthermore, this study underlines the real-life clinical experience of a Menopause Center.

Rosuvastatin reduces nonalcoholic fatty liver disease in patients with chronic hepatitis C treated with α-interferon and ribavirin: Rosuvastatin reduces NAFLD in HCV patients

BACKGROUND

Nonalcoholic fatty liver disease develops in patients with chronic hepatitis C. Interferon and ribavirin combination therapy is the standard treatment for chronic hepatitis C, but if present, NAFLD can reduce the virological response to anti-HCV therapies.

OBJECTIVES

We determined whether the addition of rosuvastatin to interferon and ribavirin improves the sustained virological response (SVR) and reduces steatosis.

PATIENTS AND METHODS

This study was a prospective, randomized, open-label trial. Between January 2004 and December 2007, 65 patients with chronic hepatitis (27 women and 38 men, mean age 48 years) aged 32-63 years (median 46 years) were consecutively enrolled. Patients were randomly assigned to receive leukocyte interferon alpha (3 MIU 3 times per week) plus ribavirin (1200 mg per day) for 12 months or interferon alpha and ribavirin at the same dosages plus rosuvastatin (5 mg per day). The primary endpoints were measurements in SVR, liver enzyme, cholesterol, triglyceride, CRP, glucose, and insulin levels; and Homa-IR, fibrosis, and steatosis scores.

RESULTS

After 12 months of treatment, we observed a significant improvement in SVR in 51% of patients who received interferon plus ribavirin plus rosuvastatin compared with 18% of relapsers (OR 1.52; 95% CI = 0.41-5.64; RR 1.13). There were 23 responders (69%) and 10 nonresponders (30%) (OR 1.38; 95% CI = 0.49-16.5; RR 1.11). When comparing interferon plus ribavirin group vs interferon plus ribavirin and rosuvastatin group after 12 months, we observed a significant difference in AST (85.70 vs.106.5.00 IU/ml) (OR 1.2; 95% CI= 0.29-4.94; RR 1.04; p<0.001), ALT (81.80 vs. 126.2 IU/ml) (OR 1.2; 95% CI = 0.29-4.94; RR 1.04; p < 0.001), LDL-cholesterol (0.01 vs. 0.60 mmol/l) (OR 14; 95% CI = 3.98-49.16; p RR 2.96; < 0.001), triglycerides (0.17 vs. 0.2 mmol/l) (OR 20; 95% CI = 4.94-80.89; RR 5.38; p < 0.05), and Viremia (1.8 vs. 2.48 UI/ml, p < 0.05). Mean fibrosis score decreased 0.10 vs. 0.50 (OR 4.5; 95% CI = 0.89-22.66; RR 1.5; p < 0.05), and mean steatosis score declined 0.30 vs. 0.50 (OR 11.2; CI = 2.88-43.53; RR 2.75; p < 0.001).

CONCLUSIONS

In HCV patients with NAFLD, the addition of rosuvastatin to interferon and ribavirin significantly reduces viremia, steatosis, and fibrosis without causing side effects.

Liver immunolocalization and plasma levels of MMP-9 in non-alcoholic steatohepatitis (NASH) and hepatitis C infection

Non-alcoholic steatohepatitis (NASH) is a progressive fibrotic disease. Many issues related to the pathogenesis of this disease remain unresolved. Because of NASH association with the activation of liver fibrogenesis, we examined the plasma levels and liver immunolocalization of matrix metalloprotease-9 (MMP-9), a molecule involved in the remodelling processes of fibrogenesis. In addition, patients with chronic hepatitis C (HCV) were analyzed. Plasma concentrations of MMP-9 were determined by ELISA from peripheral blood and immunohistochemistry of the same protein was carried out in formalin-fixed and paraffin wax-embedded liver specimens. The mean value of circulating concentrations of MMP-9 in healthy controls was 39.7 ng/ml (SD: +/-4.6). In NASH and HCV-infected patients, MMP-9 concentrations were higher: 69.0 ng/ml (SD: +/-14.5) and 61.7 ng/ml (SD: +/-11.0), respectively. In NASH livers, MMP-9 was mainly immunolocalized on neutrophils, whereas in HVC-infected livers it was mainly localized over biliary canaliculi, bile ducts and hepatocyte cytoplasm. The different MMP-9 immunolocalization patterns in the examined diseases suggest the presence of a different pathophysiological involvement of this protease in the fibrogenesis underlying these diseases.

Epoetin alpha improves the response to antiviral treatment in HCV-related chronic hepatitis

BACKGROUND

The conventional antiviral treatment of chronic hepatitis related to hepatitis C virus (HCV) often leads to anemia. In this case, it is necessary to reduce ribavirin dose or stop treatment, thus reducing the rate of sustained virological response.

AIM

We investigated whether epoetin alpha administration improves treatment adherence and leads to higher percentage of response at the end of therapy and sustained virological response.

METHODS

Two hundred and fourteen individuals with genotype 1b HCV-related chronic hepatitis underwent treatment with pegylated (peg)-interferon alpha-2A 180 μg once weekly and ribavirin 1,000-1,200 mg/day; 174 were responders. Forty individuals completed treatment with no hemoglobin reduction; 134 developed anemia during therapy. Anemic responders were distributed randomly into two groups: group 1 continued therapy with epoetin alpha addiction; group 2 continued antiviral therapy with ribavirin reduction only.

RESULTS

Patients in group 1 achieved better control of hemoglobin levels (13.8 ± 1.2 g/dl at the end of therapy) than those in group 2 (11.5 ± 0.8 g/dl). Sustained virological response was 59.7% in group 1 compared with 34.4% in group 2 (p<0.01).

CONCLUSIONS

In patients with 1b HCV-related chronic hepatitis who develop anemia during antiviral treatment, administration of epoetin alpha increases hemoglobin levels and the end-of-treatment rate and sustains virological response by improving treatment adherence.

Study on Unrecognized Peripheral Arterial Disease (PAD) by Ankle/Brachial Index and Arterial Comorbidity in Catania, Sicily, Italy

Peripheral arterial disease (PAD) is under diagnosed and early diagnosis decreases consequences. We screened unrecognized PAD focusing on arterial co-morbidities. In the 3412 subjects, screened from 10 general practices in the city of Catania (Sicily, Italy), ankle brachial index (ABI) measurements were performed. An ABI ≤0.9 was considered as valid in diagnosing PAD. ABI value ≤0.9 was found in 2.3%, and a significant rate of carotid stenosis was also found Echocardiographic markers left ventricular diameter (LVD) >55 mm, interventricular septum (IVS) >11 mm, left ventricular diastolic volume (LVDV) was found > 100 ml), and ejection fraction (EF) was <50% were found with high frequency in those with ABI ≤0.9. Unrecognized PAD is lower compared with other findings but our prevalence resulted higher than other prevalence previously found by other study performed in Italy. Unrecognized PAD shows significant arterial co-morbidities and the ABI is a useful method to screen asymptomatic PAD.