The 1(st) and the 2(nd) Italian Consensus Conferences on low-density lipoprotein-apheresis. A practical synopsis and update

The clinical indications and guidelines for low-density lipoprotein (LDL)-apheresis set by the 1(st) Italian Consensus Conference held in Ostuni in 1990 and completed in 1992, but never published, are reported schematically. In 1994, within the Project "Prevention and control of the factors of the disease (FATMA)" by the Italian National Research Council, subproject 8 "Control of cardiovascular disease", a "Hearing on therapeutic apheresis: need for a target-oriented project" was organised. The meeting was the last scientific initiative on LDL-apheresis supported by public funds in Italy. After roughly two decades of use of LDL-apheresis, new guidelines were required based on the latest scientific evidence. In 2006, the Italian multicentre study on LDL-apheresis Working Group (IMSLDLa-WP), a scientific initiative at national level, was developed. It initially gathered together 19 Italian centres qualified for the application of lipid apheresis and LDL-apheresis (2007-2008), then 23 in 2010, located in the north, south, centre of Italy and in Sicily and Sardinia. The multicentre study aimed to validate the protocol for selecting patients and to create a network between the Italian centres. A secondary objective was the creation of a database of patients with familial hypercholesterolaemia and other severe forms of dyslipidaemia undergoing treatment with LDL-apheresis using the available techniques. Since LDL-apheresis has multidisciplinary treatment indications, the agreement on the new guidelines was reached through a panel of experts, of different medical and surgical specialties, with scientific and medical interest in the treatment indications, application and development of LDL-apheresis. The initiatives of the IMSLDLa-WP led to the 2(nd) Italian Consensus Conference on LDL-apheresis held in Rome in 2009. The previous and most recent guidelines are reported here synoptically

Lomitapide-a microsomal triglyceride transfer protein inhibitor for homozygous familial hypercholesterolemia

Purpose of Review: Homozygous familial hypercholesterolemia (HoFH) is a rare, genetic condition characterized by high levels of Low density lipoprotein cholesterol (LDL-C); overt, early-onset atherosclerotic cardiovascular disease (ASCVD); and premature cardiovascular events and mortality. Lomitapide is a first-in-class microsomal triglyceride transfer protein inhibitor for the treatment of HoFH. This review provides an update on data emerging from real-world studies of lomitapide following on from its pivotal phase 3 clinical trial in HoFH. Recent Findings: Recent registry data have confirmed that HoFH is characterized by delayed diagnosis, with many patients not receiving effective therapy until they are approaching the age when major adverse cardiovascular events may occur. Data from case series of varying sizes, and from a 163-patient registry of HoFH patients receiving lomitapide, have demonstrated that lomitapide doses are lower and adverse events less severe than in the phase 3 study. Lomitapide enables many patients to reach European Atherosclerosis Society LDL-C targets. Some patients are able to reduce frequency of lipoprotein apheresis or, in some cases, stop the procedure altogether—unless there is significant elevation of lipoprotein (a). Modelling analyses based on historical and clinical trial data indicate that lomitapide has the potential to improve cardiovascular outcomes and survival in HoFH. Summary: Real-world clinical experience with lomitapide has shown the drug to be effective with manageable, less marked adverse events than in formal clinical studies. Event modelling data suggest a survival benefit with lomitapide in HoFH

Relationship between Sustained Reductions in Plasma Lipid and Lipoprotein Concentrations with Apheresis and Plasma Levels and mRNA Expression of PTX3 and Plasma Levels of hsCRP in Patients with HyperLp(a)lipoproteinemia

The effect of lipoprotein apheresis (Direct Adsorption of Lipids, DALI) (LA) on plasma levels of pentraxin 3 (PTX3), an inflammatory marker that reflects coronary plaque vulnerability, and expression of PTX3 mRNA was evaluated in patients with hyperLp(a)lipoproteinemia and angiographically defined atherosclerosis/coronary artery disease. Eleven patients, aged 55 ± 9.3 years (mean ± SD), were enrolled in the study. PTX3 soluble protein levels in plasma were unchanged by 2 sessions of LA; however, a downregulation of mRNA expression for PTX3 was observed, starting with the first session of LA (p < 0.001). The observed reduction was progressively increased in the interval between the first and second LA sessions to achieve a maximum decrease by the end of the second session. A statistically significantly greater treatment-effect correlation was observed in patients undergoing weekly treatments, compared with those undergoing treatment every 15 days. A progressive reduction in plasma levels of C-reactive protein was also seen from the first session of LA, with a statistically significant linear correlation for treatment-effect in the change in plasma levels of this established inflammatory marker (R(2) = 0.99; p < 0.001). Our findings suggest that LA has anti-inflammatory and endothelium protective effects beyond its well-established efficacy in lowering apoB100-containing lipoproteins

Therapeutic efficacy of anti-MMP9 antibody in combination with nab-paclitaxel-based chemotherapy in pre-clinical models of pancreatic cancer

Matrix metalloproteinase 9 (MMP9) is involved in the proteolysis of extracellular proteins and plays a critical role in pancreatic ductal adenocarcinoma (PDAC) progression, invasion and metastasis. The therapeutic potential of an anti-MMP9 antibody (αMMP9) was evaluated in combination with nab-paclitaxel (NPT)-based standard cytotoxic therapy in pre-clinical models of PDAC. Tumour progression and survival studies were performed in NOD/SCID mice. The mechanistic evaluation involved RNA-Seq, Luminex, IHC and Immunoblot analyses of tumour samples. Median animal survival compared to controls was significantly increased after 2-week therapy with NPT (59%), Gem (29%) and NPT+Gem (76%). Addition of αMMP9 antibody exhibited further extension in survival: NPT+αMMP9 (76%), Gem+αMMP9 (47%) and NPT+Gem+αMMP9 (94%). Six-week maintenance therapy revealed that median animal survival was significantly increased after NPT+Gem (186%) and further improved by the addition of αMMP9 antibody (218%). Qualitative assessment of mice exhibited that αMMP9 therapy led to a reduction in jaundice, bloody ascites and metastatic burden. Anti-MMP9 antibody increased the levels of tumour-associated IL-28 (1.5-fold) and decreased stromal markers (collagen I, αSMA) and the EMT marker vimentin. Subcutaneous tumours revealed low but detectable levels of MMP9 in all therapy groups but no difference in MMP9 expression. Anti-MMP9 antibody monotherapy resulted in more gene expression changes in the mouse stroma compared to the human tumour compartment. These findings suggest that anti-MMP9 antibody can exert specific stroma-directed effects that could be exploited in combination with currently used cytotoxics to improve clinical PDAC therapy

NASCITA DI UN FIGLIO SORDO. FAMIGLIE UDENTI E SORDE A CONFRONTO

Nel corso della storia diversi sono stati gli approcci di studio che hanno cercatodi indagare il “mondo della sordità”.Nel passato, soprattutto, la sordità è stata analizzata esclusivamente da un puntodi vista medico. Veniva osservato esclusivamente l’età di insorgenza, il grado di sorditàe la risposta protesica.Secondo quest’ottica il sordo per potersi realmente integrare nel mondo degliudenti doveva nascondersi, rendersi il più “normale” possibile.Attualmente, invece, le cose stanno cambiando. La sordità viene osservata da unpunto di vista culturale, secondo questo modello la persona appartiene ad una culturadi minoranza. In questo caso, quindi, non serve solo conoscere la cartella clinica delsordo, ma,bisogna sapere se conosce la LIS e che ruolo riveste all’interno dellacomunità.Secondo quest’ottica l’ integrazione si potrà realmente realizzare se sia i sordiche gli udenti si riconosceranno appartenenti a due culture diverse.Perché ci sia l’integrazione a livello sociale è necessario che il sordo sperimentida subito, quindi all’interno della propria famiglia, i sentimenti di accettazione rispettoe amore che gli permetteranno, appena sarà adulto di essere consapevole di far parte diuna minoranza culturale.È, quindi, la famiglia che, attraverso le proprie scelte educative, forma ilbambino sordo prima e l’adulto poi.Le scelte effettuate dalle famiglie sono tra loro molto diverse e dipendonosoprattutto dal fatto che siano o meno composte da sordi

Novel experimental therapies for intestinal ischaemia and reperfusion injury

Intestinal ischaemia and reperfusion (I/R) contributes to the pathogenesis of numerous clinical conditions in all age groups. Many of these diseases, including neonatal necrotizing enterocolitis (NEC), result in significant morbidity and mortality through multiple organ dysfunction, and available treatment is currently limited to supporting vital functions. My aims were: to investigate novel therapeutic strategies such as moderate hypothermia and peroxynitrite decomposition catalyst FeTMPyP [5,10,15,20- tetrakis(N-methyl-4'-pyridyl)porphyrinato iron (III)] in experimental models of adult and infant intestinal I/R; and to characterise the inflammatory process in human NEC, evaluating its relationship with clinical outcome. In an adult rat model, total-body moderate hypothermia applied throughout ischaemia and reperfusion counteracts oxidative stress in both the intestine and distant organs. This suggests that hypothermia could be beneficial as a preventative measure when intestinal ischaemia can be foreseen. However, in clinical practice therapy can usually be commenced only after ischaemia has occurred. In two sets of experiments, I showed that rescue hypothermia applied after mesenteric ischaemia improves outcome in both adult and neonatal rats, and this benefit is maintained after rewarming. Hypothermic protection could result from prevention of multiple organ dysfunction through several different pathways, including modulation of hepatic phosphoenergetics, pulmonary inflammatory infiltrate, cardiac energy metabolism, and systemic oxidative stress. Administration of peroxynitrite decomposition catalyst FeTMPyP as a rescue therapy at reperfusion also exerts a protective effect in neonatal rats, possibly via inhibition of adhesion molecule expression, leukocyte recruitment, and lipid peroxidation in the intestine, leading to prevention of systemic oxidative stress. In a study conducted on human specimens from neonates with NEC, tissue injury seems to be mediated via increased expression of endothelial adhesion molecules ICAM-1 and P-Selectin, leading to macrophage and neutrophil infiltration. Endothelial E-Selectin is expressed exclusively in NEC patients, and appears to be a marker of rapidly evolving disease and distant organ failure