Survival and complications in thalassemia.

The life expectancy of patients with thalassemia major has significantly increased in recent years, as reported by several groups in different countries. However, complications are still frequent and affect the patients' quality of life. In a recent study from the United Kingdom, it was found that 50% of the patients had died before age 35. At that age, 65% of the patients from an Italian long-term study were still alive. Heart disease is responsible for more than half of the deaths. The prevalence of complications in Italian patients born after 1970 includes heart failure in 7%, hypogonadism in 55%, hypothyroidism in 11%, and diabetes in 6%. Similar data were reported in patients from the United States. In the Italian study, lower ferritin levels were associated with a lower probability of experiencing heart failure and with prolonged survival. Osteoporosis and osteopenia are common and affect virtually all patients. Hepatitis C virus antibodies are present in 85% of multitransfused Italian patients, 23% of patients in the United Kingdom, 35% in the United States, 34% in France, and 21% in India. Hepatocellular carcinoma can complicate the course of hepatitis. A survey of Italian centers has identified 23 such cases in patients with a thalassemia syndrome. In conclusion, rates of survival and complication-free survival continue to improve, due to better treatment strategies. New complications are appearing in long-term survivors. Iron overload of the heart remains the main cause of morbidity and mortality.

Unusual combination of genetic defects in a Sicilian boy: G gamma delta beta thalassemia, G gamma A gamma heterocellular HPFH, beta (0) thalassemia, and albinism.

We describe the clinical and hematological findings in a 5-year-old boy with G gamma A gamma delta beta thalassemia, a G gamma A gamma heterocellular form of HPFH, beta(0) thalassemia, and albinism. Clinically he manifested only the characteristics of beta-thalassemia trait and not the typical picture of doubly heterozygous beta thal/delta beta thal. The simultaneous presence of heterocellular HPFH improves gamma chain synthesis, thus reducing the alpha chain excess. It is also possible that gene expression can be modified by the presence of other genetic anomalies.

Immune status and immune response to diphtheria-tetanus and polio vaccines in allogeneic bone marrow-transplanted thalassemic patients.

We evaluated the immune status against diphtheria (D), tetanus (T) and polio viruses (PV) and the immune response to re-administration of the respective vaccines in a series of 23 transplanted homozygous beta-thalassemic patients, aged 5-17 years (mean age 12.1 +/- 3.1 years). They had been given compulsory DT toxoids and types 1, 2 and 3 PV vaccine in infancy and had been successfully submitted to allogeneic BMT 2-6 years previously. Prior to revaccination, a high percentage of subjects (from 48% for type 2 PV to 83% for D) had antibody levels below the protective levels and low geometric mean titers (GMTs). After revaccination (three doses of DT toxoids and of inactivated PV vaccine) the percentage of subjects with protective levels of antibodies rose to 86-100% and the GMTs increased markedly. We conclude that: (1) the protection afforded by compulsory DT and PV vaccines administered in infancy is almost entirely lost in beta-thalassemic patients for several years after BMT, (2) revaccination is necessary in these subjects, and (3) at least three doses of DT and PV vaccines must be administered to recover adequate protection.

Immune status and the immune response to hepatitis B virus vaccine in thalassemic patients after allogeneic bone marrow transplantation.

We evaluated the immune status with respect to HBV and the immune response to readministration of HBV vaccine in a series of 20 patients with homozygous beta-thalassemia, aged 6-23 years (mean age: 13.0 +/- 4.2) who had undergone allogeneic bone marrow transplantation (BMT). Thirteen of them (group A), had received three doses of plasma-derived HBV vaccine from 7 to 5 years before BMT and 4-5 weeks after the last dose of vaccine, they had had high serum levels of HBV antibodies (anti-HBs). The remaining seven patients (group B) had had clinical symptoms and laboratory evidence of HBV infection in childhood with markedly elevated serum of anti-HBs. Before revaccination, a significantly lower percentage of patients (P < 0.005) with seropositive levels of anti-HBs was observed in group A than in group B. After administration of the second dose of HBV vaccine the percentage of subjects with protective levels of anti-HBs rose to 100% in both groups of patients even if the geometric mean of titers of anti-HBs increased more significantly in group B patients than in group A. We conclude that the serum levels of anti-HBs afforded by HBV vaccine administered from 7 to 5 years previously are very low and probably non-protective in most beta-thalassemic patients after allogeneic BMT, and that at least two doses of HBV vaccine should be readministered from 18 to 24 months after BMT to achieve adequate and long-term protection from HBV.

Alpha-interferon treatment of chronic hepatitis C after bone marrow transplantation for homozygous beta-thalassemia.

No experience has been reported to date in treating chronic hepatitis C virus (HCV) infection with interferon (IFN) therapy after BMT, mainly due to concerns related to the impact of an immunomodulatory drug in patients who are immunologic and haematologic chimeras. However, chronic inflammatory activity related to HCV infection results in a chronic fibrogenous mechanism potentially leading to liver cirrhosis and hepatocellular carcinoma. Moreover, patients transplanted for beta-thalassemia could be at greater risk because of concomitant iron overload and pre-existing fibrous liver damage. Eleven patients with serological, biochemical, histological and molecular biological evidence of HCV infection were included in the study and treated for 6-12 months with recombinant IFN 24-65 months following BMT. The serum alanine aminotransferase (ALT) was persistently elevated (range 85-1242 U/l; mean 416) for at least 1 year prior to IFN treatment. Ten patients completed the protocol; five were considered as responders to treatment. In these five patients the liver histology showed an overall reduction of inflammation and necrosis: histological inflammatory activity improved from chronic active hepatitis (CAH) to chronic persistent hepatitis (three patients) or minimal residual inflammatory activity (two patients). The Knodell total activity score varied from 5.4 (range 3-9) to 1.4 (range 1-2; P = 0.05). All responding patients revealed negativization of serum HCV-RNA, that has been persistent in four (follow-up 1-3 years). ALT level fell to 15-80 U/l (mean 52; P = 0.0027). No major complications occurred during the therapy and no influence on marrow engraftment parameters were noted. We conclude that IFN therapy does not adversely interfere with engraftment and that it is a feasible therapy for treatment of chronic hepatitis C virus after BMT.

Interferon-alpha therapy in Sicilian and Sardinian polytransfused thalassaemic patients with chronic hepatitis C.

OBJECTIVE: Our study was designed to evaluate the effects of 2 dosage schedules of recombinant interferon (IFN)-alpha (IFNalpha-2a and IFNalpha-2b) in reducing serum ALT and eradicating serum hepatitis C virus (HCV) RNA in beta-thalassaemic patients with chronic hepatitis C. DESIGN: 38 Sicilian beta-thalassaemic patients (22 males and 16 females) received intramuscular IFNalpha-2a (Roferon-A((R)); Roche) 5 MU/m(2) 3 times weekly for 6 months, followed by 3 MU/m(2) 3 times weekly for a further 6 months. 13 Sardinian beta-thalassaemic patients (7 males and 6 females) received intramuscular IFNalpha-2b (Intron(R); Schering-Plough) 3 MU/m(2) 3 times weekly for 12 months. Parallel control groups (n = 20 and n = 8, respectively) did not receive IFNalpha. All patients received continuous subcutaneous desferoxamine infusion. RESULTS: 24 (63%) Sicilian patients had a positive clinical response to IFNalpha-2a therapy. Two different patterns of response were apparent: (i) early and progressive decrease in ALT values until stable normalisation; and (ii) slower reduction of ALT values, which fluctuated on the way to normalisation. Five (21%) patients relapsed during the 12-month follow-up period. ALT levels decreased early in 5 (38%) Sardinian patients and one patient (20%) relapsed during the 12-month follow-up period. In the control groups, ALT values spontaneously normalised in 3 (10%) untreated patients. None of the patients treated with IFNalpha developed anti-IFNalpha antibodies. Viral clearance was demonstrated in 19 (50%) of 38 patients in the Sicilian group and 4 of 13 patients (31%) in the Sardinian group. CONCLUSION: Treatment with intramuscular recombinant IFNalpha-2a 5 MU/m(2) 3 times weekly for 6 months, followed by 3 MU/m(2) 3 times weekly for 6 months, appeared to be more effective than intramuscular IFNalpha-2b 3 MU/m(2) 3 times weekly for 12 months.

In vitro sensitivity of B-CLL cells to fludarabine and interferons.

In this study we evaluated the cytotoxicity of Fludarabine (FAMP) both alone and in combination with alpha and beta interferon (IFN) against B-cells from patients affected by chronic lymphocytic leukemia (CLL). We used an in vitro colorimetric assay based on the bioreduction of the tetrazolium salt XTT by viable cells. Fludarabine concentrations ranging from 0.03 to 30 microM were tested on cells collected from 22 B-CLL patients. For each fludarabine concentration, 800 I.U. of either alpha or beta IFN were added. Interferon alone did not exert any cytotoxic effect, while Fludarabine showed a strong cytotoxicity against B-CLL cells. The concentration of Fludarabine required to induce a 50% cytotoxicity (IC50) was below 3 microM (the achievable serum level after standard dose in vivo administration) for 19 out of 22 patients. After IFNs supplementation to Fludarabine, it was possible to identify three groups of samples. The first in which IFNs addition did not produce almost any significant change in Fludarabine cytotoxicity (13/22), the second in which there was an improvement in FAMP IC50 (6/22), and finally the third group in which IFNs worsened it (3/22). Stage of disease was the only identified factor accounting for these different results. The second group included samples from 5 patients at stage A and one at stage B, while in the third group all three samples were from patients at stage C. Interferon-alpha and -beta induced the same degree of FAMP IC50 variation.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of Taxol cytotoxicity on B-CLL cells in vitro.

Taxol is a new antimicrotubule agent that, besides a well known efficacy against solid tumors, has shown activity in non-Hodgkin's lymphomas too. We therefore investigated its in vitro cytotoxic activity against cells from patients affected by chronic lymphocytic leukemia (CLL). Peripheral blood lymphocytes from 46 CLL patients were incubated for four days with Taxol at doses ranging from 0.01 to 10 mM and the cytotoxicity was evaluated by a colorimetric method (XTT). In most samples Taxol was inactive and the IC50 was > 10 mM in 40 out of 46 patients. It is worthwhile noting that four of the six in vitro responsive patients had unfavourable clinical features. In three unresponsive patients we also observed that Taxol was not able to induce apoptosis in vitro. In conclusion, based on in vitro data, it seems that Taxol is not an active drug in standard CLL but we cannot exclude some efficacy in other more rapidly proliferating lymphoproliferative disorders.

Distribution and antibiotic resistance of isolates from lower respiratory tract and blood cultures from patients in three Italian intensive care units: a 2-year comparison.

The distribution and antibiotic resistance of major pathogens isolated from patients in ICUs were studied by three Italian microbiological laboratories. Consecutive aerobic strains were collected over two different time periods from protected brushing bronchoscopy, broncho-alveolar lavage and blood cultures. A total of 420 strains were isolated during the first period (47.3% gram-negative and 52.7% gram-positive) and 412 over the second period (50.5% gram-negative and 49.5% gram-positive). Pseudomonas aeruginosa was the most frequently isolated organism from the respiratory tract followed by Staphylococcus aureus. Methicillin resistance was 47.9 and 44.5% in S. aureus and 63.0 and 65.1% in coagulase-negative staphylococci over the two periods. No glycopeptide-resistance was found in gram-positive organisms. Ceftazidime-resistance in Klebsiella pneumoniae was very high.

Elevation of interleukin 6 levels in patients with chronic hepatitis due to hepatitis C virus.

Interleukin 6 (IL-6) is a pleiotropic cytokine produced by a wide variety of lymphoid and non-lymphoid tissues. We studied the relationship between IL-6 and the liver in an attempt to elucidate this cytokine's role in hepatitis C-induced liver inflammation. We investigated the behavior of serum IL-6 in 25 patients with chronic hepatitis C (divided into three groups depending on severity) and in 27 healthy controls. Our results showed a significant elevation (P < 0.0001) in serum IL-6 levels in the patients with chronic hepatitis C, correlated with the histological activity index (HAI) and their HCV-RNA serum levels. This rise may represent the expression of the hepatitis C virus-induced inflammatory state.

Interleukin-6 in hepatitis C cirrhosis.

Interleukin-6 (IL-6) is a pleiotropic cytokine involved in numerous diseases but the correlation between liver fibrosis and IL-6 role is not clear. We studied IL-6 levels in 50 HCVAb+ patients with liver cirrhosis (grouped into A, B and C, Child classes) and in 27 healthy control subjects. IL-6 serum levels were significantly increased in the former (p < 0.005) suggesting that IL-6 stimulates and sustains liver fibrosis. In cirrhotic subjects, the rise in IL-6 serum levels is due to impaired hepatic clearance of this cytokine, while its production remains steady.

Antibodies against ox-LDL serum levels in patients with hepatocellular carcinoma.

AIM: Hepatocellular carcinoma (HCC) is a malignancy with high incidence worldwide. The related cachexia is induced by proinflammatory cytokines, responsible for a wide number of metabolic disorders, essentially including lipidic and oxidative metabolism. Oxidized LDL (ox-LDL), produced by LDL-cholesterol oxidation, are one of the risk factors for atheromatosis. Also, ox-LDL act on the deliverance of some cytokines involved in the development and progression of a lot of human tumours. The removal of ox-LDL from the blood is performed by the liver. The intracellular amount of ox-LDL, through various cytokines, might induce HCC by reduction of the apoptotic mechanism of protection. Our aim was to evaluate the behaviour of serum antibodies against ox-LDL levels in order to study their possible changes and influences on a study series composed of HCC patients. METHODS: We enrolled 41 patients (29 males, mean age 67.45+/-8.28 years and 12 females, mean age 64.62+/-7.2 years) with primitive HCC and 30 healthy control subjects (15 males and 15 females, mean age 61.86+/-2.51 years). Diagnosis of HCC was performed on the basis of clinical, laboratory and instrumental findings (Ultrasonography, Computed Tomography and Magnetic Nuclear Resonance, liver biopsy). Of the 41 HCC patients, 30 were affected by hepatitis C virus (HCV), 5 were HBsAg and HBcAg positive and 6 virus B and C negative but consumers of more than 150 g/day of alcohol. Liver biopsy confirmed the presence of HCC derived from cirrhosis in 10 of HCV positive patients, as well as in the patients with high alcohol consumption. Serum IgG antibodies versus the ox-LDL levels have been evaluated by ELISA method and oLAB reactive by Biomedica-Austria. Data have been analysed by 2 tailed Student's "t" test and a value of p<0.05 was considered significant. RESULTS: Lipid pattern values were within the normal ranges except for the Lp(a), that presented low serum levels in both groups. Twenty-five patients presented HCC as well as severe chronic active hepatitis. Serum mean levels of ox-LDL antibodies (ox-LDL Ab), still being within the normal ranges, were significantly lower than in control subjects (p<0.001) in both sexes. CONCLUSION: We hypothesize that the lower ox-LDL Ab serum levels in our HCC patients may be related to the smaller feeding of HCC patients or to the greater uptake of these modified lipoproteins by the hepatic reticular endothelial system. This phenomenon might result especially in the release of cytokines and growth factors for hepatocytes that may induce HCC development and progression.

[Role of interleukin 6 in hepatocellular carcinoma]. / Rôle de l'interleukine 6 dans le carcinome hépatocellulaire.

Interleukin 6 (IL-6) is a pleiotropic cytokine which possesses a broad spectrum of action in diverse pathological conditions. It is mainly produced and metabolised in the liver where it carries out one of its best known actions in the mediation of the acute phase response. We studied its behaviour in hepatocellular carcinoma to evaluate its clinical prognostic role. We determined serum IL-6 concentrations in 39 patients with hepatocarcinoma (27 males and 12 females) and 25 healthy controls (15 males and ten females). Our results showed a significant increase in serum IL-6 concentrations in hepatocarcinoma subjects compared with controls (P < 0.005) and an elevated positive correlation (r = 0.616) between IL-6 and size of the hepatocarcinoma. Our study demonstrated that IL-6 is able to influence hepatocarcinoma progression by acting as an autocrine tumoral growth factor and depleting immune surveillance.

[Influence of transfusion regime on precocious fusion of the proximal humeral epiphysis in thalassemia major]. / Influenza del regime trasfusionale sulla precoce fusione dell'epifisi prossimale dell'omero nella talassemia major.

The precocious fusion of the proximal humeral epiphysis has been reported in adolescents with thalassemia major. We evaluated the incidence of this skeletal abnormality in two groups of patients characterized by a different timing of the hypertransfusional regimen (i.e., before or after 10 years of age). Precocious epiphyseal fusion was significantly more common among patients who started hypertransfusional regimen after 10 years of age. Starting hypertransfusional regimen since early life may prevent epiphyseal fusion as a result of a permanent block of marrow proliferation.

[Biliary lithiasis in thalassemia major]. / La litiasi biliare nella talassemia major.

The presence of cholelithiasis was diagnosed by ultrasonography in 10 patients with thalassemia major aged 16 to 33 years. Other 10 patients aged 7 to 19 years showed acalculous cholecystopathy. Serum liver enzymes and ferritin levels, as well as splenectomy do not influence significantly the production of gallstones. Significant differences were observed in the age of patients with gallstones when compared to subjects without gallstones or with acalculous cholecystopathy. Although, in the last years, the high transfusional regimen has decreased the incidence of cholelithiasis, the frequent liver disease could be a cause of acalculous cholecystopathy in younger thalassemic patients.

[Alpha 1-antitrypsin in thalassemia major]. / L'alfa 1-antitripsina nella talassemia major.

The authors investigated a possible relationship between alpha 1-antitrypsin (alpha 1AT) phenotypes, serum levels of alpha 1AT and liver disease in transfusion dependent thalassemia major subjects. The distribution of alpha 1AT phenotypes suggest the absence of association between alpha 1AT variants and thalassemic genes and underlines again the low incidence of pathologic variants in Italian population. Mean concentration of alpha 1AT was significantly increased in thalassemic patients and was not related to transaminase levels. These results show that other factors are responsible for the development of liver disease in transfusion dependent thalassemic subjects.

[Chelating therapy in beta-thalassemia]. / La terapia chelante nella beta-talassemia.

The iron overload is the most common cause of death among transfusion dependent subjects affected by thalassemia major and other congenital anemias. The lesions caused by iron overload are found especially in liver, endocrine glands and heart. Among the various drugs able to remove the iron excess from the organs, desferrioxamine (DF) remains the only one used. The Authors report their experience with this drug in beta-thalassemia major and in beta-thalassemia intermedia patients. The results demonstrate that the subcutaneous administration of DF (40 mg/kg/die) is able to take the patients with thalassemia major in iron negative balance since their third year of life. No important untoward effects are reported. Periodic check with slit lamp has revealed no ocular alteration in 35 subjects. In thalassemia intermedia there is also iron overload due to increased iron absorption. It is probable that these patients too can present the same alterations observed in transfusion dependent beta-thalassemia omozygotes. In order to prevent these lesions it will be necessary to reduce iron absorption since early childhood.

[The echocardiography in thalassemia major (author's transl)]. / L'ecocardiografia nella talassemia major.

Echocardiographic findings were studied in seventeen subjects with beta-Thalassemia major in order to see whether cardiac lesions caused by iron were related to the age and chelating therapy. The results demonstrate that the alterations of the heart can be early detected by echocardiography. In fact no patient with echocardiographic alterations showed clinical signs of cardiac dysfunction and only four patients showed E.C.G. alterations. Moreover the thickening of posterior wall and left ventricular diastolic diameter were related to iron overload, as demonstrated by urinary excretion after desferrioxamine. Since the patients regularly treated with desferrioxamine were few and younger aged it is not possible in this study to show the positive effect of desferrioxamine treatment in preventing cardiac lesions due to iron overload.

Spread of a carbapenem- and colistin-resistant Acinetobacter baumannii ST2 clonal strain causing outbreaks in two Sicilian hospitals.

BACKGROUND: Infections caused by multidrug-resistant (MDR) Acinetobacter baumannii have become an important healthcare-associated problem, particularly in intensive care units (ICUs). AIM: To investigate the emergence of carbapenem- and colistin-resistant A. baumannii infections in two Sicilian hospitals. METHODS: From October 2008 to May 2011, a period which included two Italian Nosocomial Infections Surveillance in ICUs network (SPIN-UTI) project surveys, all carbapenem-resistant A. baumannii isolates from the ICUs of two hospitals in Catania, Italy, were prospectively collected. Minimum inhibitory concentrations (MICs) were measured by agar dilution, and phenotypic testing for metallo-ß-lactamase (MBL) production was performed. Carbapenem resistance genes and their genetic elements were identified by polymerase chain reaction and sequencing. Genotypic relatedness was assessed by pulsed-field gel electrophoresis (PFGE) and multi-locus sequence typing. Patient-based surveillance was conducted using the SPIN-UTI protocol and previous antibiotic consumption was recorded. FINDINGS: Twenty-six carbapenem-resistant A. baumannii were identified. Imipenem and meropenem MICs ranged from 4 to >32 mg/L, and 15 isolates exhibited high-level colistin resistance (MICs >32 mg/L). PFGE demonstrated that all isolates belonged to a unique clonal type and were assigned to ST2 of the international clone II. They harboured an intrinsic blaOxA-51-like carbapenemase gene, blaOxA-82, which was flanked upstream by ISAba1. CONCLUSIONS: The dissemination of clonally related isolates of carbapenem-resistant A. baumannii in two hospitals is described. Simultaneous resistance to colistin in more than half of the isolates is a problem for effective antibiotic treatment. Prior carbapenem and colistin consumption may have acted as triggering factors.

Prognostic value of CD34+ peak in peripheral blood during mobilization in intermediate-risk AML patients treated in first CR by autologous or allogeneic transplantation.

Ninety-six AML patients in 1st CR were evaluated for peak CD34+ cell levels in peripheral blood (PB) during PBSC mobilization and harvest. Distribution of CD34+ cell peaks was determined and cases were grouped on the basis of 50th and 75th percentile: group A, those having a CD34+ cell peak ≤70 × 10(9)/L (n=48); group B, those having a CD34+ cell peak between 70 and 183 × 10(9)/L (n=24); group C, those having a CD34+ cell peak >183 × 10(9)/L (n=24). Irrespective of post-remission treatment received, group A had a disease free survival (DFS) of 73%, group B a DFS of 51% and group C of 30% (P=0.0003). In intermediate cytogenetic risk patients, those treated by autologous transplantation had a DFS of 68, 33 and 14% in the groups A, B and C, respectively, (P=0.01) whereas after allogeneic transplantation DFS was 87% in group A+B vs 50% in group C (P=0.009). The peak of CD34+ cells in PB, was an independent predictor for DFS in multivariate analysis.