Cardiac and hepatic iron and ejection fraction in thalassemia major: multicentre prospective comparison of combined deferiprone and deferoxamine therapy against deferiprone or deferoxamine monotherapy.

BACKGROUND: Due to the limited data available in literature, the aim of this multi-centre study was to prospectively compare in thalassemia major (TM) patients the efficacy of combined deferiprone (DFP) and deferoxamine (DFO) regimen versus either DFP and DFO in monotherapy by cardiovascular magnetic resonance (CMR) over a follow up of 18 months. METHODS: Among the first 1135 TM patients in the MIOT (Myocardial Iron Overload in Thalassemia) network, we evaluated those who had received either combined regimen (DFO + DFP, N=51) or DFP (N=39) and DFO (N=74) monotherapies between the two CMR scans. Iron overload was measured by T2* multiecho technique. Biventricular function parameters were quantitatively evaluated by cine images. RESULTS: The percentage of patients that maintained a normal global heart T2* value was comparable between DFP+DFO versus both monotherapy groups. Among the patients with myocardial iron overload at baseline, the changes in the global heart T2* and in biventricular function were not significantly different in DFP+DFO compared with the DFP group. The improvement in the global heart T2* was significantly higher in the DFP+DFO than the DFO group, without a difference in biventricular function. Among the patients with hepatic iron at baseline, the decrease in liver iron concentration values was significantly higher with combination therapy than with either monotherapy group. CONCLUSIONS: In TM patients at the dosages used in the real world, the combined DFP+DFO regimen was more effective in removing cardiac iron than DFO, and was superior in clearing hepatic iron than either DFO or DFP monotherapy. Combined therapy did not show an additional effect on heart function over DFP.

Feasibility, reproducibility, and reliability for the T*2 iron evaluation at 3 T in comparison with 1.5 T.

This study aimed to determine the feasibility, reproducibility, and reliability of the multiecho T*(2) Magnetic resonance imaging technique at 3 T for myocardial and liver iron burden quantification and the relationship between T*(2) values at 3 and 1.5 T. Thirty-eight transfusion-dependent patients and 20 healthy subjects were studied. Cardiac segmental and global T*(2) values were calculated after developing a correction map to compensate the artifactual T*(2) variations. The hepatic T*(2) value was determined over a region of interest. The intraoperator and interoperator reproducibility for T*(2) measurements at 3 T was good. A linear relationship was found between patients' R *2 (1000/T*(2) ) values at 3 and 1.5 T. Segmental correction factors were significantly higher at 3 T. A conversion formula returning T*(2) values at 1.5 T from values at 3 T was proposed. A good diagnostic reliability for T*(2) assessment at 3 T was demonstrated. Lower limits of normal for 3 T T*(2) values were 23.3 ms, 21.1 ms, and 11.7 ms, for the global heart, mid-ventricular septum, and liver, respectively. In conclusion, T*(2) quantification of iron burden in the mid-ventricular septum, global heart, and no heavy-moderate livers resulted to be feasible, reproducible, and reliable at 3 T. Segmental heart T*(2) analysis at 3 T may be challenging due to significantly higher susceptibility artifacts.

Containment of an outbreak of KPC-3-producing Klebsiella pneumoniae in Italy.

From March 2009 to May 2009, 24 carbapenem-resistant Klebsiella pneumoniae isolates were recovered from 16 patients hospitalized in an Italian intensive care unit (ICU). All isolates contained KPC-3 carbapenemase and belonged to a single pulsed-field gel electrophoresis (PFGE) clone of multilocus sequence type 258 (designated as ST258). A multimodal infection control program was put into effect, and the spread of the KPC-3-producing K. pneumoniae clone was ultimately controlled without closing the ICU to new admissions. Reinforced infection control measures and strict monitoring of the staff adherence were necessary for the control of the outbreak.

Deferasirox, deferiprone and desferrioxamine treatment in thalassemia major patients: cardiac iron and function comparison determined by quantitative magnetic resonance imaging.

BACKGROUND: Oral deferiprone was suggested to be more effective than subcutaneous desferrioxamine for removing heart iron. Oral once-daily chelator deferasirox has recently been made commercially available but its long-term efficacy on cardiac iron and function has not yet been established. Our study aimed to compare the effectiveness of deferasirox, deferiprone and desferrioxamine on myocardial and liver iron concentrations and bi-ventricular function in thalassemia major patients by means of quantitative magnetic resonance imaging. DESIGN AND METHODS: From the first 550 thalassemia subjects enrolled in the Myocardial Iron Overload in Thalassemia network, we retrospectively selected thalassemia major patients who had been receiving one chelator alone for longer than one year. We identified three groups of patients: 24 treated with deferasirox, 42 treated with deferiprone and 89 treated with desferrioxamine. Myocardial iron concentrations were measured by T2* multislice multiecho technique. Biventricular function parameters were quantitatively evaluated by cine images. Liver iron concentrations were measured by T2* multiecho technique. RESULTS: The global heart T2* value was significantly higher in the deferiprone (34 ± 11 ms) than in the deferasirox (21 ± 12 ms) and the desferrioxamine groups (27 ± 11 ms) (P = 0.0001). We found higher left ventricular ejection fractions in the deferiprone and the desferrioxamine versus the deferasirox group (P = 0.010). Liver iron concentration, measured as T2* signal, was significantly lower in the desferrioxamine versus the deferiprone and the deferasirox group (P = 0.004). CONCLUSIONS: The cohort of patients treated with oral deferiprone showed less myocardial iron burden and better global systolic ventricular function compared to the patients treated with oral deferasirox or subcutaneous desferrioxamine.

Sequential alternating deferiprone and deferoxamine treatment compared to deferiprone monotherapy: main findings and clinical follow-up of a large multicenter randomized clinical trial in -thalassemia major patients.

In ß-thalassemia major (ß-TM) patients, iron chelation therapy is mandatory to reduce iron overload secondary to transfusions. Recommended first line treatment is deferoxamine (DFO) from the age of 2 and second line treatment after the age of 6 is deferiprone (L1). A multicenter randomized open-label trial was designed to assess the effectiveness of long-term alternating sequential L1-DFO vs. L1 alone iron chelation therapy in ß-TM patients. Deferiprone 75 mg/kg 4 days/week and DFO 50 mg/kg/day for 3 days/week was compared with L1 alone 75 mg/kg 7 days/week during a 5-year follow-up. A total of 213 thalassemia patients were randomized and underwent intention-to-treat analysis. Statistically, a decrease of serum ferritin level was significantly higher in alternating sequential L1-DFO patients compared with L1 alone patients (p = 0.005). Kaplan-Meier survival analysis for the two chelation treatments did not show statistically significant differences (log-rank test, p = 0.3145). Adverse events and costs were comparable between the groups. Alternating sequential L1-DFO treatment decreased serum ferritin concentration during a 5-year treatment by comparison to L1 alone, without significant differences of survival, adverse events or costs. These findings were confirmed in a further 21-month follow-up. These data suggest that alternating sequential L1-DFO treatment may be useful for some ß-TM patients who may not be able to receive other forms of chelation treatment.

Long-term sequential deferiprone-deferoxamine versus deferiprone alone for thalassaemia major patients: a randomized clinical trial.

A multicentre randomized open-label trial was designed to assess the effectiveness of long-term sequential deferiprone-deferoxamine (DFO-DFP) versus DFP alone to treat thalassaemia major (TM). DFP at 75 mg/kg, divided into three oral daily doses, for 4 d/week and DFO by subcutaneous infusion (8-12 h) at 50 mg/kg per day for the remaining 3 d/week was compared with DFP alone at 75 mg/kg, administered 7 d/week during a 5-year follow-up. The main outcome measures were differences between multiple observations of serum ferritin concentrations. Secondary outcomes were survival analysis, adverse events, and costs. Consecutive thalassaemia patients (275) were assessed for eligibility; 213 of these were randomized and underwent intention-to-treat analysis. The decrease of serum ferritin levels during the treatment period was statistically significant higher in sequential DFP-DFO patients compared with DFP-alone patients (P = 0.005). Kaplan-Meier survival analysis for the two chelation treatments did not show any statistically significant differences (long-rank test, P = 0.3145). Adverse events and costs were comparable between the groups. The trial results show that sequential DFP-DFO treatment compared with DFP alone significantly decreased serum ferritin concentration during treatment for 5 years without significant differences regarding survival, adverse events, or costs.

Improving survival with deferiprone treatment in patients with thalassemia major: a prospective multicenter randomised clinical trial under the auspices of the Italian Society for Thalassemia and Hemoglobinopathies.

The prognosis for thalassemia major has dramatically improved in the last two decades. However, many transfusion-dependent patients continue to develop progressive accumulation of iron. This can lead to tissue damage and eventually death, particularly from cardiac disease. Previous studies that investigated iron chelation treatments, including retrospective and prospective non-randomised clinical trials, suggested that mortality, due mainly to cardiac damage, was reduced or completely absent in patients treated with deferiprone (DFP) alone or a combined deferiprone-deferoxamine (DFP-DFO) chelation treatment. However, no survival analysis has been reported for a long-term randomised control trial. Here, we performed a multicenter, long-term, randomised control trial that compared deferoxamine (DFO) versus DFP alone, sequential DFP-DFO, or combined DFP-DFO iron chelation treatments. The trial included 265 patients with thalassemia major, with 128 (48.3%) females and 137 (51.7%) males. No deaths occurred with the DFP-alone or the combined DFP-DFO treatments. One death occurred due to graft versus host disease (GVHD) in a patient that had undergone bone marrow transplantation; this patient was censored at the time of transplant. Only one death occurred with the DFP-DFO sequential treatment in a patient that had experienced an episode of heart failure one year earlier. Ten deaths occurred with the deferoxamine treatment. The main factors that correlated with an increase in the hazard ratio for death were: cirrhosis, arrhythmia, previous episode of heart failure, diabetes, hypogonadism, and hypothyroidism. In a Cox regression model, the interaction effect of sex and age was statistically significant (p-value<0.013). For each increasing year of age, the hazard ratio for males was 1.03 higher than that for females (p-value<0.013). In conclusion, the results of this study show that the risk factors for predicting mortality in patients with thalassemia major are deferoxamine-treatment, complications, and the interaction effect of sex and age.

Emotional impact in beta-thalassaemia major children following cognitive-behavioural family therapy and quality of life of caregiving mothers.

BACKGROUND: Cognitive-Behavioural Family Therapy (CBFT) can be an effective psychological approach for children with beta-thalassaemia major, increasing compliance to treatment, lessening the emotional burden of disease, and improving the quality of life of caregivers. DESIGN AND METHODS: Twenty-eight beta-thalassaemic major children that followed CBFT for one year were compared with twenty-eight age-matched healthy children, focusing particularly on behavioural, mood, and temperamental characteristics as well as compliance with chelation, assessed using the Child Behaviour Checklist (CBCL), Children's Depression Inventory (CDI), Multidimensional Anxiety Scale for Children (MASC), and Emotionality, Activity, Sociability and Shyness Scale (EAS). We also monitored the quality of life of caregiving mothers using the World Health Organization Quality Of Life (WHOQOL-BREF) questionnaire. Data were analysed with non-parametric standard descriptive statistics. RESULTS: 90% of beta-Thalassaemic children showed good compliance with chelation therapy; however they had significantly increased somatic complains, physical symptoms and separation panic. Moreover, temperamental assessment revealed high emotionality and poor sociability in treated thalassaemic children and in their mothers. Physical and psychological domains concerning individual's overall perception of quality of life resulted impaired in mothers of beta-thalassaemic children. CONCLUSION: CBFT can be a valid tool to increase the compliance with chelation therapy in beta-thalassaemic children; however, treated children continue to show an important emotional burden; moreover, CBFT therapy seems not to have any positive impact on the quality of life of caregiving mothers, who may therefore need additional psychological support.

Pseudomonas aeruginosa carriage, colonization, and infection in ICU patients.

OBJECTIVE: We evaluated whether Pseudomonas aeruginosa associated nosocomial infections in our ICU originate mainly from patients' endogenous flora or from exogenous cross-transmission. DESIGN AND SETTING: A 6-month prospective surveillance survey was performed according to standardized protocols at the interdisciplinary ICU of the Azienda Ospedaliera Cannizzaro. PATIENTS: The study analyzed 121 patients and focused on three different states: carriage upon admission, colonization of sterile sites, and infections during ICU stay. RESULTS: We identified 138 P. aeruginosa isolates from 45 patients. The cumulative incidence of P. aeruginosa sustained colonization in the ICU was 29.9/100 patients, and the incidence density was 16.2/1,000 patient-days. The cumulative incidence of P. aeruginosa-sustained infections in the ICU was 36.7/100 patients, and the incidence density was 19.9/1,000 patient-days. The most frequent infection type was ventilator-associated pneumonia. PFGE analysis of P. aeruginosa isolates led to the identification of a major clone represented by 60.8% of isolates involving 45.9% of patients. The impact of cross-transmission, i.e., the preventable proportion of P. aeruginosa acquisition, was estimated to be at least 59.5% of all colonization or infection episodes. Acquisition of multidrug-resistant P. aeruginosa was significantly associated with cross-transmission. CONCLUSIONS: Our results suggest that the ICU personnel and environment served as reservoirs for cross-transmission and emphasize the importance of exogenous acquisition of multidrug-resistant P. aeruginosa, of reduction in antibiotic pressure, and prompt enforcement of infection control measures.

Added value of multi-pathogen probe-based real-time PCR SeptiFast in the rapid diagnosis of bloodstream infections in patients with bacteraemia.

The commercial multi-pathogen probe-based real-time PCR SeptiFast (SF) was evaluated as a rapid and complementing tool for the microbiological diagnosis of bloodstream infections (BSIs) in a series of 138 matched blood samples from 65 patients with bacteraemia, hospitalized in an intensive care unit, when antibiotics had already been administered. SF was positive in 32.6 % of the samples, whereas blood culture (BC) was positive in 21.7 % (P < 0.05). SF identified more pathogens (11 versus 5; specificity, 90.7 %) and reduced the time of aetiological diagnosis, with a mean of 16.3 versus 55.4 h needed for BC (P < 0.05). SF enabled appropriate pathogen-oriented therapy in 72 % (36/50) of the BSI group of patients on the basis of epidemiological data. According to our data, the use of SF provided important added value to BC, in terms of earlier aetiological diagnosis of BSIs, enabling pathogen-oriented therapy in patients receiving empirical antibiotic treatment.

Survival and complications in patients with thalassemia major treated with transfusion and deferoxamine.

BACKGROUND AND OBJECTIVES: Seven Italian centers reported data on survival, causes of death and appearance of complications in patients with thalassemia major. The interactions between gender, birth cohort, complications, and ferritin on survival and complications were analyzed. DESIGN AND METHODS: Survival after the first decade was studied for 977 patients born since 1960 whereas survival since birth and complication appearance was studied for the 720 patients born after 1970. Better survival was demonstrated for patients born in more recent years (p<0.00005) and for females (p=0.0003); 68% of the patients are alive at the age of 35 years. In the entire population 67% of the deaths were due to heart disease. RESULTS: There was a significant association between birth cohort and complication-free survival (p<0.0005). The prevalence of complications was: heart failure 6.8%, arrhythmia 5.7%, hypogonadism 54.7%, hypothyroidism 10.8%, diabetes 6.4%, HIV infection 1.7%, and thrombosis 1.1%. Lower ferritin levels were associated with a lower probability of heart failure (hazard ratio =3.35, p<0.005) and with prolonged survival (hazard ratio = 2.45, p<0.005), using a cut-off as low as 1,000 ng/mL. INTERPRETATION AND CONCLUSIONS: Survival and complication-free survival of patients with thalassemia major continue to improve, especially for female patients born shortly before or after the availability of iron chelation.

Left ventricular rotational dynamics in Beta thalassemia major: a speckle-tracking echocardiographic study.

BACKGROUND: Iron-mediated cardiomyopathy is the leading cause of death in patients with thalassemia major (TM). The identification of subclinical cardiac involvement in the early phases of the disease is important to optimize therapeutic strategies. The aim of this study was to identify early markers of cardiac dysfunction through new parameters of cardiac rotational dynamics and to look for a relationship with parameters of iron overload. METHODS: Twenty-seven asymptomatic patients with TM and 27 healthy control subjects were prospectively enrolled. All subjects underwent standard echocardiography and subsequent offline analysis to assess left ventricular (LV) rotation and longitudinal mechanics using speckle-tracking echocardiography. In all patients with TM, ferritin levels were measured, and a subgroup underwent cardiac magnetic resonance imaging. RESULTS: All subjects had normal parameters of cardiac function, although patients with TM showed significantly lower S' values (P = .030) and E' values (P = .025), with increased E/E' ratio (P = .003) and indexed left atrial volumes (P = .022). Compared with controls, patients with TM had significantly reduced systolic apical rotation (P = .006), LV twist (P = .002), and LV torsion (P = .001). Systolic and diastolic rotational peak velocities at the apical level were also significantly decreased in the TM group (P = .003 and P = .011, respectively) with reductions of twisting and untwisting rates (P = .003 and P = .001, respectively). Patients with TM also showed a significant reduction of longitudinal displacement from the two-chamber apical view (P = .042) but preserved longitudinal strain and strain rate. Patients with T2* values > 20 msec had preserved rotational function, while those with T2* values < 20 msec showed significantly lower mean values of LV peak basal systolic rotation (-3.1 ± 1.4° vs -6.2 ± 2.6°, P = .016), LV peak apical systolic rotation (3.4 ± 1.3° vs 6.4 ± 3.1°, P = .045), LV twist (4.8 ± 2.5° vs 10.9 ± 4.9°, P = .012), and LV torsion (0.6 ± 0.2°/cm vs 1.4 ± 1.6°/cm, P = .010). LV torsion was negatively related to ferritin levels (r = -0.47, P = .013) and directly to T2* values (r = 0.64, P = .007). CONCLUSIONS: LV rotational dynamics in asymptomatic patients with TM are negatively related to iron overload. Rotational function of the left ventricle is preserved in patients with normal T2* values. These new parameters are useful for an early diagnosis of cardiac involvement.

Acquisition and spread of Acinetobacter baumannii and Stenotrophomonas maltophilia in intensive care patients.

Acinetobacter baumannii and Stenotrophomonas maltophilia are increasingly important pathogens, especially in the intensive care units (ICUs). This study was designed to investigate the clonality, the mode of transmission and the patients' risk profile for acquisition of A. baumannii and S. maltophilia at the ICU of an Italian Hospital. Patterns of A. baumannii and S. maltophilia acquisition in the ICU during the period of the survey were carriage, colonization and infection. Characterization of A. baumannii was performed by ARDRA and genotyping of both pathogens by PFGE. Our study provided evidence for the occurrence of an outbreak sustained by the two organisms in study involving 27.3% of patients enrolled into the surveillance. The spread of a unique A. baumannii epidemic clone was demonstrated. A major clone of S. maltophilia was responsible for the epidemic spread of S. maltophilia (55.5% of isolates), thus confirming A. baumannii cross-transmission and showing--among few published reports--the clonal spread of S. maltophilia. Outliers analysis suggested colonized patients as the probable epidemic sources. Mechanical ventilation was confirmed as risk factor for infection (OR 8.4; 95%C.I.: 2.6-27.5). A multimodal intervention program was introduced, followed in later months with a drastic restriction of infection and colonization due to A. baumannii and S. maltophilia and subsequently with the successful control of the outbreak. Active surveillance of infection and colonization by high-risk clones, together with implementation of control strategies, including strict hand hygiene, proved to be effective to reduce the epidemic spread of both alert pathogens in our ICU.

Cardiac morbidity and mortality in deferoxamine- or deferiprone-treated patients with thalassemia major.

Deferoxamine (DFO) therapy has been associated with improved survival of thalassemia patients. However, cardiac disease remains the main cause of death in those patients. In 1995, the oral chelator deferiprone became available for clinical use. We compared the occurrence of cardiac disease in patients treated only with DFO and in those whose therapy was switched to deferiprone during the period of observation, from January 31, 1995, to December 31, 2003. All patients with thalassemia major treated in 7 Italian centers who were born between 1970 and 1993 and who had not experienced a cardiac event prior to January 1995 were included. DFO only was given to 359 patients, and 157 patients received deferiprone for part of the time. A total of 3,610 patient-years were observed on DFO and 750 on deferiprone. At baseline, the 2 groups were comparable for age and sex, while ferritin levels were significantly higher in patients switched to deferiprone. Fifty-two cardiac events, including 10 cardiac deaths, occurred during therapy with DFO. No cardiac events occurred during deferiprone therapy or within at least 18 months after the end of it. In the setting of a natural history study, deferiprone therapy was associated with significantly greater cardiac protection than deferoxamine in patients with thalassemia major.