Development of original analytical methods for the therapeutic drug monitoring of CNS druges: Antipsychotics, Antidepressants and Anxiolytics-hypnotics

Great strides have been made in the last few years in the pharmacological treatment of neuropsychiatric disorders, with the introduction into the therapy of several new and more efficient agents, which have improved the quality of life of many patients. Despite these advances, a large percentage of patients is still considered “non-responder” to the therapy, not drawing any benefits from it. Moreover, these patients have a peculiar therapeutic profile, due to the very frequent application of polypharmacy, attempting to obtain satisfactory remission of the multiple aspects of psychiatric syndromes. Therapy is heavily individualised and switching from one therapeutic agent to another is quite frequent. One of the main problems of this situation is the possibility of unwanted or unexpected pharmacological interactions, which can occur both during polypharmacy and during switching. Simultaneous administration of psychiatric drugs can easily lead to interactions if one of the administered compounds influences the metabolism of the others. Impaired CYP450 function due to inhibition of the enzyme is frequent. Other metabolic pathways, such as glucuronidation, can also be influenced. The Therapeutic Drug Monitoring (TDM) of psychotropic drugs is an important tool for treatment personalisation and optimisation. It deals with the determination of parent drugs and metabolites plasma levels, in order to monitor them over time and to compare these findings with clinical data. This allows establishing chemical-clinical correlations (such as those between administered dose and therapeutic and side effects), which are essential to obtain the maximum therapeutic efficacy, while minimising side and toxic effects. It is evident the importance of developing sensitive and selective analytical methods for the determination of the administered drugs and their main metabolites, in order to obtain reliable data that can correctly support clinical decisions. During the three years of Ph.D. program, some analytical methods based on HPLC have been developed, validated and successfully applied to the TDM of psychiatric patients undergoing treatment with drugs belonging to following classes: antipsychotics, antidepressants and anxiolytic-hypnotics. The biological matrices which have been processed were: blood, plasma, serum, saliva, urine, hair and rat brain. Among antipsychotics, both atypical and classical agents have been considered, such as haloperidol, chlorpromazine, clotiapine, loxapine, risperidone (and 9-hydroxyrisperidone), clozapine (as well as N-desmethylclozapine and clozapine N-oxide) and quetiapine. While the need for an accurate TDM of schizophrenic patients is being increasingly recognized by psychiatrists, only in the last few years the same attention is being paid to the TDM of depressed patients. This is leading to the acknowledgment that depression pharmacotherapy can greatly benefit from the accurate application of TDM. For this reason, the research activity has also been focused on first and second-generation antidepressant agents, like triciclic antidepressants, trazodone and m-chlorophenylpiperazine (m-cpp), paroxetine and its three main metabolites, venlafaxine and its active metabolite, and the most recent antidepressant introduced into the market, duloxetine. Among anxiolytics-hypnotics, benzodiazepines are very often involved in the pharmacotherapy of depression for the relief of anxious components; for this reason, it is useful to monitor these drugs, especially in cases of polypharmacy. The results obtained during these three years of Ph.D. program are reliable and the developed HPLC methods are suitable for the qualitative and quantitative determination of CNS drugs in biological fluids for TDM purposes.

Technical innovations for the diagnosis and the rehabilitation of motor and perceptive impairments of the child with Cerebral Palsy

The treatment of the Cerebral Palsy (CP) is considered as the “core problem” for the whole field of the pediatric rehabilitation. The reason why this pathology has such a primary role, can be ascribed to two main aspects. First of all CP is the form of disability most frequent in childhood (one new case per 500 birth alive, (1)), secondarily the functional recovery of the “spastic” child is, historically, the clinical field in which the majority of the therapeutic methods and techniques (physiotherapy, orthotic, pharmacologic, orthopedic-surgical, neurosurgical) were first applied and tested. The currently accepted definition of CP – Group of disorders of the development of movement and posture causing activity limitation (2) – is the result of a recent update by the World Health Organization to the language of the International Classification of Functioning Disability and Health, from the original proposal of Ingram – A persistent but not unchangeable disorder of posture and movement – dated 1955 (3). This definition considers CP as a permanent ailment, i.e. a “fixed” condition, that however can be modified both functionally and structurally by means of child spontaneous evolution and treatments carried out during childhood. The lesion that causes the palsy, happens in a structurally immature brain in the pre-, peri- or post-birth period (but only during the firsts months of life). The most frequent causes of CP are: prematurity, insufficient cerebral perfusion, arterial haemorrhage, venous infarction, hypoxia caused by various origin (for example from the ingestion of amniotic liquid), malnutrition, infection and maternal or fetal poisoning. In addition to these causes, traumas and malformations have to be included. The lesion, whether focused or spread over the nervous system, impairs the whole functioning of the Central Nervous System (CNS). As a consequence, they affect the construction of the adaptive functions (4), first of all posture control, locomotion and manipulation. The palsy itself does not vary over time, however it assumes an unavoidable “evolutionary” feature when during growth the child is requested to meet new and different needs through the construction of new and different functions. It is essential to consider that clinically CP is not only a direct expression of structural impairment, that is of etiology, pathogenesis and lesion timing, but it is mainly the manifestation of the path followed by the CNS to “re”-construct the adaptive functions “despite” the presence of the damage. “Palsy” is “the form of the function that is implemented by an individual whose CNS has been damaged in order to satisfy the demands coming from the environment” (4). Therefore it is only possible to establish general relations between lesion site, nature and size, and palsy and recovery processes. It is quite common to observe that children with very similar neuroimaging can have very different clinical manifestations of CP and, on the other hand, children with very similar motor behaviors can have completely different lesion histories. A very clear example of this is represented by hemiplegic forms, which show bilateral hemispheric lesions in a high percentage of cases. The first section of this thesis is aimed at guiding the interpretation of CP. First of all the issue of the detection of the palsy is treated from historical viewpoint. Consequently, an extended analysis of the current definition of CP, as internationally accepted, is provided. The definition is then outlined in terms of a space dimension and then of a time dimension, hence it is highlighted where this definition is unacceptably lacking. The last part of the first section further stresses the importance of shifting from the traditional concept of CP as a palsy of development (defect analysis) towards the notion of development of palsy, i.e., as the product of the relationship that the individual however tries to dynamically build with the surrounding environment (resource semeiotics) starting and growing from a different availability of resources, needs, dreams, rights and duties (4). In the scientific and clinic community no common classification system of CP has so far been universally accepted. Besides, no standard operative method or technique have been acknowledged to effectively assess the different disabilities and impairments exhibited by children with CP. CP is still “an artificial concept, comprising several causes and clinical syndromes that have been grouped together for a convenience of management” (5). The lack of standard and common protocols able to effectively diagnose the palsy, and as a consequence to establish specific treatments and prognosis, is mainly because of the difficulty to elevate this field to a level based on scientific evidence. A solution aimed at overcoming the current incomplete treatment of CP children is represented by the clinical systematic adoption of objective tools able to measure motor defects and movement impairments. A widespread application of reliable instruments and techniques able to objectively evaluate both the form of the palsy (diagnosis) and the efficacy of the treatments provided (prognosis), constitutes a valuable method able to validate care protocols, establish the efficacy of classification systems and assess the validity of definitions. Since the ‘80s, instruments specifically oriented to the analysis of the human movement have been advantageously designed and applied in the context of CP with the aim of measuring motor deficits and, especially, gait deviations. The gait analysis (GA) technique has been increasingly used over the years to assess, analyze, classify, and support the process of clinical decisions making, allowing for a complete investigation of gait with an increased temporal and spatial resolution. GA has provided a basis for improving the outcome of surgical and nonsurgical treatments and for introducing a new modus operandi in the identification of defects and functional adaptations to the musculoskeletal disorders. Historically, the first laboratories set up for gait analysis developed their own protocol (set of procedures for data collection and for data reduction) independently, according to performances of the technologies available at that time. In particular, the stereophotogrammetric systems mainly based on optoelectronic technology, soon became a gold-standard for motion analysis. They have been successfully applied especially for scientific purposes. Nowadays the optoelectronic systems have significantly improved their performances in term of spatial and temporal resolution, however many laboratories continue to use the protocols designed on the technology available in the ‘70s and now out-of-date. Furthermore, these protocols are not coherent both for the biomechanical models and for the adopted collection procedures. In spite of these differences, GA data are shared, exchanged and interpreted irrespectively to the adopted protocol without a full awareness to what extent these protocols are compatible and comparable with each other. Following the extraordinary advances in computer science and electronics, new systems for GA no longer based on optoelectronic technology, are now becoming available. They are the Inertial and Magnetic Measurement Systems (IMMSs), based on miniature MEMS (Microelectromechanical systems) inertial sensor technology. These systems are cost effective, wearable and fully portable motion analysis systems, these features gives IMMSs the potential to be used both outside specialized laboratories and to consecutive collect series of tens of gait cycles. The recognition and selection of the most representative gait cycle is then easier and more reliable especially in CP children, considering their relevant gait cycle variability. The second section of this thesis is focused on GA. In particular, it is firstly aimed at examining the differences among five most representative GA protocols in order to assess the state of the art with respect to the inter-protocol variability. The design of a new protocol is then proposed and presented with the aim of achieving gait analysis on CP children by means of IMMS. The protocol, named ‘Outwalk’, contains original and innovative solutions oriented at obtaining joint kinematic with calibration procedures extremely comfortable for the patients. The results of a first in-vivo validation of Outwalk on healthy subjects are then provided. In particular, this study was carried out by comparing Outwalk used in combination with an IMMS with respect to a reference protocol and an optoelectronic system. In order to set a more accurate and precise comparison of the systems and the protocols, ad hoc methods were designed and an original formulation of the statistical parameter coefficient of multiple correlation was developed and effectively applied. On the basis of the experimental design proposed for the validation on healthy subjects, a first assessment of Outwalk, together with an IMMS, was also carried out on CP children. The third section of this thesis is dedicated to the treatment of walking in CP children. Commonly prescribed treatments in addressing gait abnormalities in CP children include physical therapy, surgery (orthopedic and rhizotomy), and orthoses. The orthotic approach is conservative, being reversible, and widespread in many therapeutic regimes. Orthoses are used to improve the gait of children with CP, by preventing deformities, controlling joint position, and offering an effective lever for the ankle joint. Orthoses are prescribed for the additional aims of increasing walking speed, improving stability, preventing stumbling, and decreasing muscular fatigue. The ankle-foot orthosis (AFO), with a rigid ankle, are primarily designed to prevent equinus and other foot deformities with a positive effect also on more proximal joints. However, AFOs prevent the natural excursion of the tibio-tarsic joint during the second rocker, hence hampering the natural leaning progression of the whole body under the effect of the inertia (6). A new modular (submalleolar) astragalus-calcanear orthosis, named OMAC, has recently been proposed with the intention of substituting the prescription of AFOs in those CP children exhibiting a flat and valgus-pronated foot. The aim of this section is thus to present the mechanical and technical features of the OMAC by means of an accurate description of the device. In particular, the integral document of the deposited Italian patent, is provided. A preliminary validation of OMAC with respect to AFO is also reported as resulted from an experimental campaign on diplegic CP children, during a three month period, aimed at quantitatively assessing the benefit provided by the two orthoses on walking and at qualitatively evaluating the changes in the quality of life and motor abilities. As already stated, CP is universally considered as a persistent but not unchangeable disorder of posture and movement. Conversely to this definition, some clinicians (4) have recently pointed out that movement disorders may be primarily caused by the presence of perceptive disorders, where perception is not merely the acquisition of sensory information, but an active process aimed at guiding the execution of movements through the integration of sensory information properly representing the state of one’s body and of the environment. Children with perceptive impairments show an overall fear of moving and the onset of strongly unnatural walking schemes directly caused by the presence of perceptive system disorders. The fourth section of the thesis thus deals with accurately defining the perceptive impairment exhibited by diplegic CP children. A detailed description of the clinical signs revealing the presence of the perceptive impairment, and a classification scheme of the clinical aspects of perceptual disorders is provided. In the end, a functional reaching test is proposed as an instrumental test able to disclosure the perceptive impairment. References 1. Prevalence and characteristics of children with cerebral palsy in Europe. Dev Med Child Neurol. 2002 Set;44(9):633-640. 2. Bax M, Goldstein M, Rosenbaum P, Leviton A, Paneth N, Dan B, et al. Proposed definition and classification of cerebral palsy, April 2005. Dev Med Child Neurol. 2005 Ago;47(8):571-576. 3. Ingram TT. A study of cerebral palsy in the childhood population of Edinburgh. Arch. Dis. Child. 1955 Apr;30(150):85-98. 4. Ferrari A, Cioni G. The spastic forms of cerebral palsy : a guide to the assessment of adaptive functions. Milan: Springer; 2009. 5. Olney SJ, Wright MJ. Cerebral Palsy. Campbell S et al. Physical Therapy for Children. 2nd Ed. Philadelphia: Saunders. 2000;:533-570. 6. Desloovere K, Molenaers G, Van Gestel L, Huenaerts C, Van Campenhout A, Callewaert B, et al. How can push-off be preserved during use of an ankle foot orthosis in children with hemiplegia? A prospective controlled study. Gait Posture. 2006 Ott;24(2):142-151.

Computational investigations of ion conduction mechanisms using enhanced sampling methods

Proper ion channels’ functioning is a prerequisite for a normal cell and disorders involving ion channels, or channelopathies, underlie many human diseases. Long QT syndromes (LQTS) for example may arise from the malfunctioning of hERG channel, caused either by the binding of drugs or mutations in HERG gene. In the first part of this thesis I present a framework to investigate the mechanism of ion conduction through hERG channel. The free energy profile governing the elementary steps of ion translocation in the pore was computed by means of umbrella sampling simulations. Compared to previous studies, we detected a different dynamic behavior: according to our data hERG is more likely to mediate a conduction mechanism which has been referred to as “single-vacancy-like” by Roux and coworkers (2001), rather then a “knock-on” mechanism. The same protocol was applied to a model of hERG presenting the Gly628Ser mutation, found to be cause of congenital LQTS. The results provided interesting insights about the reason of the malfunctioning of the mutant channel. Since they have critical functions in viruses’ life cycle, viral ion channels, such as M2 proton channel, are considered attractive targets for antiviral therapy. A deep knowledge of the mechanisms that the virus employs to survive in the host cell is of primary importance in the identification of new antiviral strategies. In the second part of this thesis I shed light on the role that M2 plays in the control of electrical potential inside the virus, being the charge equilibration a condition required to allow proton influx. The ion conduction through M2 was simulated using metadynamics technique. Based on our results we suggest that a potential anion-mediated cation-proton exchange, as well as a direct anion-proton exchange could both contribute to explain the activity of the M2 channel.

Studio della funzionalità respiratoria in soggetti con sindrome di Turner

The aim of this study is to evaluate the pulmonary function in subjects with diagnosis of Turner Syndrome, in charge at the Syndromology Ward of the Paediatric Clinic of S.Orsola-Malpighi hospital. There are very few datas about lung function in patients with Turner syndrome’s genotype and phenotype in medical literature. Since the thorax of these subjects have peculiar anatomic shape (as “shield” or “overturned triangle”), we presupposed that these subjects could have also a peculiar respiratory function. Moreover we look for the possibility of correlation between pulmonary function and estroprogestinic replacement therapy and/or growth hormone (GH) replacement therapy. Material and methods: we studied 48 patients, with diagnosis of Turner Syndrome; they all made spirometry voluntarily and, when capable, also plethismografy. Results: - the parametres of pulmonary function are a little higher of the predicted values for age and sex but they are a little lower if they're corrected for each patient’s ideal high and weight: so we can conclude that in Turner Syndrme subjects pulmonary function is normal; -there’s not a statistically significant correlation between pulmonary function and GH therapy; -there’s not a statistically significant correlation between GH therapy’s length and pulmonary function except for Total Lung Capacity which increases with the number of years of GH therapy; - there’s not a statistically significant correlation between pulmonary function and estroprogestinic replacement herapy.

Autoantibodies in patients with psoriasis on anti-TNFalpha therapy

Introduction: Anti-TNF-alfa therapy has been effective in the treatment of patients with refractory psoriasis and psoriasic arthritis. However, the risk of developing autoantibodies in these patients undergoing this therapy is not clear. Objective: To evaluate the induction of specific autoantibodies after anti-TNFα therapy in patients with psoriasis and psoriasic arthritis and, to evaluate the influence of the use of methotrexate on the values of autoantibodies developed during this therapy. Patients and methods: Serum samples from 120 patients, obtained before(baseline) the introduction of anti-TNF-alpha therapy and approximately each 3-6 months during the therapy.O f these 120 patients, 113 were found negative for autoantibodies before starting anti -TNFalpha therapy, 7 were found positive for ANA. The analysis included detection of antinuclear antibodies (ANA) and anti-dsDNA antibodies (indirect immunofluorescence on Hep-2 cells and Crithidia luciliae, respectively); anti extractable nuclear antigens antibodies( ENA)(ELISA). RESULTS: Infliximab is associated with the highest occurrence rate of ANA, anti-dsDNA, ENA with approximately 69,2%, 11,5%, 7,6% of patients treated testing positive. In comparison, only 20%, 6,6%, 2,2% of patients treated with Adalimumab, and 19%, 2,3%, 2,3% of patients treated with Etanercept were positive for ANA, Anti-dsDNA, ENA respectively. As regard the seven patients who were positive at baseline, six of them (85.7%) in addition to being remained positive during the therapy they have also increased the autoantibodies ’s titers. Conclusion: our study have shown that Infliximab is associated with the highest rate of autoantibodies. The concomitant treatment with methotrexate did not modify the titers of autoantibodies developed during the therapy anti-TNFalph. The incidence of ANA, anti-dsDNA antibodies did not correlate with development of Lupus-like syndromes. The difference in the frequency of autoantibodies between psoriasis and psoriatic arthritis was not statistically significant (p = 0.867).

Applicazioni cliniche e sperimentali dell’ecografia toracica in pneumologia: la diagnostica precoce delle patologie pleuropolmonari

Lung ultrasound use is increasing in respiratory medicine thanks to its development in the latest years. Actually it allows to study diseases of the chest wall (traumas, infections, neoplasms), diaphragm (paralysis, ipokinesis), pleura (effusions, pneumothorax, thickenings, neoplasms) and lung parenchyma (consolidations, interstitial syndromes, peripheral lesions). One of the most useful application of chest ultrasound is the evaluation of effusions. However, no standardized approach for ultrasound-guided thoracenthesis is available. Our study showed that our usual ultrasonographic landmark (“V-point”) could be a standard site to perform thoracenthesis: in 45 thoracenthesis no pneumothorax occurred, drainage was always successful at first attempt. Values of maximum thickness at V-point and drained fluid volume showed a significative correlation. Proteins concentration of ultrasound patterns of effusions (anechoic, ipoechoic, moving echoic spots, dense moving spots, hyperechoic) were compared to those of the macroscopic features of fluids showing connection between light-yellow fluid and echoic moving spots pattern and between ipoechoic/dense moving spots and cloudy-yellow/serum-haematic fluids. These observations suggest that ultrasound could predict chemical-physical features of effusions. Lung ultrasound provides useful information about many disease of the lung, but actually there is not useful in obstructive bronchial diseases. Analysing diaphragmatic kinetics using M-mode through transhepatic scan we described a similarity between diaphragm excursion during an expiratory forced maneuver and the volume/time curve of spirometry. This allowed us to identify the M-mode Index of Obstruction (MIO), an ultrasound-analogue of FEV1/VC. We observed MIO values of normal subjects (9) and obstructed patients (9) comparing the two groups. FEV1/VC and MIO showed a significant correlation suggesting that MIO may be affected by airways obstruction; MIO values were significatively different between normal and obstructed so that it could identify an obstructive syndrome. The data show that it is possible to suspect the presence of obstructive syndrome of the airways using ultrasonography of the diaphragm.

Strategies to identify and further characterize novel and known genes involved in regulation of skeletogenesis

372 osteochondrodysplasias and genetically determined dysostoses were reported in 2007 [Superti-Furga and Unger, 2007]. For 215 of these conditions, an association with one or more genes can be stated, while the molecular changes for the remaining syndromes remain illusive to date. Thus, the present dissertation aims at the identification of novel genes involved in processes regarding cartilage/ bone formation, growth, differentiation and homeostasis, which may serve as candidate genes for the above mentioned conditions. Two different approaches were undertaken. Firstly, a high throughput EST sequencing project from a human fetal cartilage library was performed to identify novel genes in early skeletal development (20th week of gestation until 2nd year of life) that could be investigated as potential candidate genes. 5000 EST sequences were generated and analyzed representing 1573 individual transcripts, corresponding to known (1400) and to novel, yet uncharacterized genes (173). About 7% of the proteins were already described in cartilage/ bone development or homeostasis, showing that the generated library is tissue specific. The remaining profile of this library was compared to previously published libraries from different time points (8th–12th, 18th–20th week and adult human cartilage) that also showed a similar distribution, reflecting the quality of the presented library analyzed. Furthermore, three potential candidate genes (LRRC59, CRELD2, ZNF577) were further investigated and their potential involvement in skeletogenesis was discussed. Secondly, a disease-orientated approach was undertaken to identify downstream targets of LMX1B, the gene causing Nail-Patella syndrome (NPS), and to investigate similar conditions. Like NPS, Genitopatellar syndrome (GPS) is characterized by aplasia or hypoplasia of the patella and renal anomalies. Therefore, six GPS patients were enrolled in a study to investigate the molecular changes responsible for this relatively rare disease. A 3.07 Mb deletion including LMX1B and NR5A1 (SF1) was found in one female patient that showed features of both NPS and GPS and investigations revealed a 46,XY karyotype and ovotestes indicating true hermaphroditism. The microdeletion was not seen in any of the five other patients with GPS features only, but a potential regulatory element between the two genes cannot be ruled out yet. Since Lmx1b is expressed in the dorsal limb bud and in podocytes, proteomic approaches and expression profiling were performed with murine material of the limbs and the kidneys to identify its downstream targets. After 2D-gel electrophoresis with protein extracts from E13.5 fore limb buds and newborn kidneys of Lmx1b wild type and knock-out mice and mass spectrometry analysis, only two proteins, agrin and carbonic anhydrase 2, remained of interest, but further analysis of the two genes did not show a transcriptional down regulation by Lmx1b. The focus was switched to expression profiles and RNA from newborn Lmx1b wild type and knock-out kidneys was compared by microarray analysis. Potential Lmx1b targets were almost impossible to study, because of the early death of Lmx1b deficient mice, when the glomeruli, containing podocytes, are still immature. Because Lmx1b is also expressed during limb development, RNA from wild type and knock-out Lmx1b E11.5 fore limb buds was investigated by microarray, revealing four potential Lmx1b downstream targets: neuropilin 2, single-stranded DNA binding protein 2, peroxisome proliferative activated receptor, gamma, co-activator 1 alpha, and short stature homeobox 2. Whole mount in situ hybridization strengthened a potential down regulation of neuropilin 2 by Lmx1b, but further investigations including in situ hybridization and protein-protein interaction studies will be needed.

The role of mitochondria in the regulation of gamma rays induced mTOR-dependent senescence

The first aims of this study were to demonstrate if mitochondrial biogenesis and senescence can be induced simultaneously in cell lines upon exposure to a genotoxic stress, and if the presence of mtDNA mutations which impair the functionality of respiratory complexes can influence the ability of a cell to activate senescence. The data obtained on the oncocytic model XTC.UC1 demonstrated that the presence of mitochondrial dysfunction is involved in the maintenance of a senescent phenotype induced by γ-rays treatment. The involvement of mTORC1 in the regulation of senescence has been shown in this cell line. On the other hand, in cells which do not present mitochondrial dysfunction it has been verified that genotoxic stress determines the activation of both mitochondrial biogenesis and senescence. Further studies are necessary in order to verify if mitochondrial biogenesis sustains the activation of senescence. The second aim of this thesis was to determine the involvement of mTORC1 in the regulation of PGC-1α expression, in order to verify what is the cause of the development of oncocytoma in patients affected by two hereditary cancer syndromes; Cowden and Birt-hogg-Dubé . The study of oncocytic tumors developed by patients affected by these syndromes suggested that the double heterozigosity of the two causative genes, PTEN and FLCN respectively, induce the activation of mTORC1 and therefore the activation of PGC-1α expression. On XTC.UC1 cell line, the most suitable in vitro model, experiments of complementation of PTEN and FLCN were conducted. To date, these results demonstrated that mTORC1 is not involved in the regulation of PGC-1α expression, and PTEN and FLCN seem to have opposite effect on PGC-1α expression.

La terapia demetilante con 5-azacitidina nelle sindromi mielodisplastiche: esperienza clinica del Nostro Istituto e correlazione con i dati biologici

Sulla base delle evidenze della letteratura (Fenaux, 2009; Lyons, JCO 2009), a partire da Settembre 2004 nel Nostro Istituto sono stati trattati 57 pazienti affetti da Sindrome Mielodisplastica (MDS) mediante terapia demetilante con 5-Azacitidina. Sono stati utilizzati differenti regimi terapeutici a seconda della classe di rischio IPSS: i pazienti a rischio basso/intermedio-1 hanno ricevuto Azacitidina 75 mg/mq/die sottocute per 5 giorni/mese (schema 5) per 8 cicli; i pazienti a rischio alto/intermedio-2 hanno ricevuto Azacitidina 50 mg/mq/die sottocute per 10 giorni/mese (schema 5+2+5) o Azacitidina 75 mg/mq/die per 7 giorni/mese (schema 7) fino a perdita della risposta. Su una casistica totale di 57 pazienti (15 a rischio basso/int-1; 41 rischio alto/int-2), l’87.7% (50 pazienti) sono risultati valutabili. Tra questi le risposte osservate sono state del 68% (34 pazienti), di cui il 14% (7 pazienti) ha ottenuto una Remissione Completa (CR) ed il 54% (27 pazienti) ha ottenuto un Hematologic Improvement (HI). La valutazione della risposta è stata eseguita secondo i criteri dell’International Working Group 2006 (IWG, Cheeson 2006). Le principali tossicità osservate sono state rappresentate da reazioni cutanee locali nel sito d’iniezione, tossicità gastrointestinale (stipsi e/o diarrea), mielotossicità, neutropenia febbrile, sepsi (3 pazienti). Tra i pazienti trattati abbiamo osservato la presenza di risposta ematologica prolungata (≥ 20 mesi) in 10 pazienti (20% dei pazienti valutabili). Inoltre, grazie alla collaborazione con il Dipartimento di Anatomia Umana dell’Università di Bologna (Prof. L. Cocco, Dott.ssa M.Y. Follo), tutti i pazienti trattati sono stati valutati per i livelli di espressione genica e metilazione del gene della fosfolipasi PI-PLC-beta1. I dati biologici così ottenuti sono stati correlati con quelli clinici, evidenziando la presenza di una correlazione tra i livelli di espressione genica e mutilazione della PI-PLC-beta1 e la risposta alla terapia demetilante con 5-Azacitidina.

Caratterizzazione Citogenetico-Molecolare delle alterazioni cromosomiche 3q26 e 1p36 nelle Sindromi Mieloproliferative

L’overespressione dei geni EVI1(3q26) e PRDM16(1p36), è descritta sia in presenza che in assenza di riarrangiamenti 3q26 e 1p36 in specifici sottogruppi citogenetici di LAM, ed è associata ad una prognosi sfavorevole. Lo scopo principale del nostro studio è stato identificare e caratterizzare tramite FISH e RQ-PCR, alterazioni di EVI1 e PRDM16 in pazienti con alterazioni cromosomiche 3q e 1p.Riarrangiamenti di EVI1 si associavano ad alterazioni cromosomiche 3q26, ma, in 6 casi (6/35;17,1%) erano presenti in assenza di coinvolgimenti, in citogenetica convenzionale, della regione 3q26, a causa di meccanismi complessi e/o alterazioni ‘criptiche’. Inoltre, abbiamo identificato quattro nuovi riarrangiamenti di EVI1, tra cui due nuove traslocazioni simili presenti in due fratelli. Riarrangiamenti e/o amplificazioni di PRDM16 erano spesso associate ad alterazioni 1p36 (7/14;50%). L’analisi di EVI1 e PRDM16 è stata estesa ad altri casi con alterazioni -7/7q-, con cariotipo normale, con alterazioni 3q per PRDM16 e con alterazioni 1p per EVI1. L’overespressione di EVI1 era presente solo nel gruppo -7/7q- (10/58;17.2%) ed in un caso si associava ad amplificazione genica, mentre PRDM16 era overespresso in casi di tutti i gruppi analizzati,sia con cariotipi complessi, dove si associava in alcuni casi ad amplificazione genica, sia con cariotipi normali o con singole alterazioni. Il nostro studio dimostra come la FISH permetta di identificare alterazioni dei geni EVI1 e PRDM16, anche in assenza di coinvolgimenti delle regioni 3q26 e 1p36. Riarrangiamenti complessi e/o una scarsa qualità dei preparati citogenetici sono le cause principali per la mancata identificazione di queste alterazioni. La RQ-PCR permette di identificare l’overespressione anche nei casi in cui non sia dovuta ad alterazioni citogenetiche. È importante confermare con FISH e/o RQ-PCR il coinvolgimento di questi due geni, per individuare alla diagnosi pazienti con prognosi sfavorevole e che potranno beneficiare di terapie maggiormente aggressive e/o di trapianto allogenico di cellule staminali.

The impact of cardiac rehabilitation on lifestyles, psychological correlates and the clinical course of cardiac disease

Objectives: The aim of this research was to evaluate the impact of Cardiac Rehabilitation (CR) on risky lifestyles, quality of life, psychopathology, psychological distress and well-being, considering the potential moderating role of depression, anxiety and psychosomatic syndromes on lifestyles modification. The influence of CR on cardiac morbidity and mortality was also evaluated. Methods: The experimental group (N=108), undergoing CR, was compared to a control group (N=85) of patients affected by cardiovascular diseases, not undergoing CR, at baseline and at 1-month, 6- and 12-months follow-ups. The assessment included: the Structured Clinical Interview for DSM-IV, the structured interview based on Diagnostic Criteria for Psychosomatic Research (DCPR), GOSPEL questionnaire on lifestyles, Pittsburgh Sleep Quality Index, Morisky Medication Adherence Scale, MOS 36-Item Short Form Health Survey, Symptom Questionnaire, Psychological Well-Being Scale and 14-items Type D Scale. Results: Compared to the control group, CR was associated to: maintenance of the level of physical activity, improvement of correct dietary behaviors and stress management, enhancement of quality of life and sleep; reduction of the most frequently observed psychiatric diagnoses and psychosomatic syndromes at baseline. On the contrary, CR was not found to be associated with: healthy dietary habits, weight loss and improvement on medications adherence. In addition, there were no relevant effects on sub-clinical psychological distress and well-being, except for personal growth and purpose in life (PWB). Also, CR did not seem to play a protective role against cardiac recurrences. The presence of psychosomatic syndromes and depressive disorders was a mediating factor on the modification of specific lifestyles. Conclusions: The findings highlight the need of a psychosomatic assessment and an evaluation of psychological sub-clinical symptomatology in cardiac rehabilitation, in order to identify and address specific factors potentially associated with the clinical course of the heart disease.

Untersuchungen über ADAMTS13 in Gerinnungsfaktorpräparaten

Zusammenfassung rnIn der vorliegenden Arbeit wurden sechs VWF/FVIII Gerinnungsfaktorkonzentrate unterschiedlicher Chargen auf ihre ADAMTS13 Aktivität, Antigen und VWF Multimere untersucht. Grund dafür ist die Annahme, dass bei der Aufkonzentrierung des VWFs möglicherweise auch erhöhte Mengen an ADAMTS13 vorhanden sind. Wäre dies nachweisbar, könnten die entsprechenden Konzentrate auch Anwendung bei TTP Patienten finden. Neben den Gerinnungsfaktorkonzentraten wurden ebenfalls die zur Plasmapherese verwendeten Therapeutika FFP und s/d Plasma analysiert. Es soll getestet werden, ob Unterschiede hinsichtlich der Qualität zwischen den Präparaten bestehen und inwiefern die Blutgruppen eine Auswirkung auf die ADAMTS13 Aktivität/Antigen haben. Überdies wurde die Bedeutung von ADAMTS13 als wichtiges diagnostisches Merkmal im Rahmen der Gegenüberstellung von Patienten mit thrombotischen Mikroangiopathien erörtert. Alle angewandten Methoden wurden zudem kritisch miteinander verglichen und auf ihre Eignung für die klinische Diagnostik getestet. Zur Untersuchung der ADAMTS13 Aktivität kamen drei unterschiedliche Methoden zur Anwendung, die BCS-Methode nach Böhm und zwei FRET Kits (Technozym®ADAMTS13/ActifluorTMADAMTS13). Für die Bestimmung des ADAMTS13 Antigen wurde das Technozym®ADAMTS13 Kit verwendete als auch der Imubind®ELISA angewendet. Mittels der SDS-Gelelektrophorese konnten die VWF Multimere dargestellt werden. Die Untersuchungen konnten zeigen, dass nur in Haemate®P, deutlich höhere ADAMTS13 Aktivitäten (12,3% bzw. 470ng/ml) sowie ein physiologische Antigenwerte vorlagen. Die anderen Faktorkonzentrate wiesen entweder nur sehr geringe bzw. keine Aktivitäten auf. Das Antigen lag bei allen Konzentraten im nachweisbaren Bereich. Folglich ist ein Einsatz von Haemate®P bei der Therapie der TTP, insbesondere bei hereditären Formen sowie bei Kindern, die durch eine Plasmapherese stark belastet werden, und bei Schwangeren, könnten, in Erwägung zu ziehen und innerhalb der Klinik zu testen. Die Plasmapräparate FFP und Octaplas® wiesen in allen Untersuchungen ADAMTS13 Aktivitäten und Antigen im mittleren bis hohen physiologischen Bereich auf. Insbesondere bei Blutgruppe 0 ließ sich beiden Präparaten eine höhere ADAMTS13 Aktivität und Antigen gegenüber den drei anderen Blutgruppen darstellen. Insgesamt waren die interindividuellen Schwankungen bei FFP deutlich höher als bei Octaplas®, was sich in der unterschiedlichen Herstellung der Präparate begründen lässt. Octaplas® ist also genauso geeignet zur Plasmapherese bei der TTP wie FFP, kann jedoch aufgrund seiner intensiveren Virusinaktivierung eine größere Sicherheit aufweisen und stellt sich auch in der Klinik als nebenwirkungsärmer dar. Bei der Gegenüberstellung der thrombotischen Mikroangiopathien konnte gezeigt werden, dass eine verminderte ADAMTS13 Aktivität ein wichtiges Unterscheidungsmerkmal ist und auch während der Remission schon diagnostizierbar werden kann. Auf der Grundlage der labordiagnostischen Werte und dem klinischen Erscheinungsbild im akuten Schub und in der Remission konnte ein diagnostischer Algorithmus für den klinischen Alltag erstellt werden. In der Methodenvalidierung erwies sich der ActifluorTMADAMTS13 Kit als der beste Kit, da er innerhalb kürzester Zeit zuverlässige Werte in Standardeinheiten liefert. Nach neuesten Erkenntnissen, bei der eine Unterscheidung von ADAMTS13 Aktivitäten über und unter 5 % von großer prognostischer Bedeutung sind, ist die BCS-Methode nach Böhm mit einer unteren Nachweisgrenze von 6,2% zu ungenau und auch hinsichtlich ihres Zeitaufwandes eher ungünstig.rn

Psychosocial correlates of rehabilitation from stroke: a longitudinal study

The general aim of this dissertation was to uncover the association between psychosocial factors and rehabilitation outcome after stroke. METHOD. A sample of patients with stroke (n=40) and their caregivers (n=36) were assessed at admission to and six months after discharge from rehabilitation hospital, using the following instruments: Structured Clinical Interview for DSM-IV, structured interview based on Diagnostic Criteria for Psychosomatic Research, Symptom Questionnaire, Psychosocial Index, Psychological Well-Being Scales, and Family Assessment Device. 40 subjects from the general population underwent the same psychological assessment. In addition, patients' functional status was measured using the Functional Independence Measure. RESULTS. Stroke survivors reported lower education and higher alcohol consumption than controls. No significant differences emerged between the two groups in the prevalence of psychiatric diagnoses or psychosomatic syndromes, however patients reported significantly higher levels of anxiety, depression, somatic symptoms, and lower autonomy than controls. Caregivers reported significantly higher scores in anxiety, depression, and somatic symptoms compared to normative data, while no impairments emerged in psychological well-being and family functioning. At six-month follow-up, in patients a significant decrease in smoking habit and an increase in DSM diagnoses were reported. Both stroke survivors and caregivers showed significant reductions in anxiety, with patients displaying also a decrease in somatic symptoms, an increase in stress and a deterioration in quality of life. Significant deteriorations in several aspects of family functioning was perceived only by patients. An association between patients' functional recovery in the cognitive domain and family behavior control emerged. For caregivers, family functioning significantly predicted hostility and somatic symptoms were associated with family affective involvement. CONCLUSIONS. These data highlight the utility in the Italian setting of the adoption of a psychosocial assessment and a family-systems approach in stroke rehabilitation, in order to development interventions properly targeted to the characteristics of patients and their family members.

Spatial and temporal flower presentation in Apiaceae-Apioideae

Alle Doldengewächse (Apiaceae), darunter die größte, weltweit verbreitete Unterfamilie der Apioideen, weisen in ihren Blütenständen sehr einheitliche Merkmale auf. Die ‚Doppeldolden´ werden aus kleinen, weißen oder gelben Blüten gebildet und von vielen unspezialisierten Insekten besucht. Der uniforme Eindruck, der damit erweckt wird, ist unter Umständen ein Grund, dass die zugrundeliegende Morphologie bislang wenig untersucht wurde. Gegenstand der vorliegenden Dissertation ist es daher, die ‚verborgene Diversität´ im Blütenstandsbereich der Apiaceae -Apioideen mit dem Ziel darzustellen, den Einfluss der Architektur der Pflanzen auf die Art der Blütenpräsentation in Raum und Zeit und damit auf das Reproduktionssystem der Art zu ermitteln. Im ersten Kapitel zeigt der Vergleich von neun ausgewählten Arten, dass in den selbstfertilen und unspezifisch bestäubten Pflanzen durch Synchronisation und Rhythmik in der Präsentation von Blüten Fremdbefruchtung gefördert wird. Entweder durchlaufen die Pflanzen dabei nur eine getrennte männliche und weibliche Blühphase (Xanthoselinum alsaticum) oder der moduläre Bau der Pflanzen führt zu einer Folge männlicher und weiblicher Blühphasen (multizyklische Dichogamie). Die Diözie in Trinia glauca kann in diesem Zusammenhang als eine Trennung der Blühphasen auf verschiedengeschlechtliche Individuen gesehen werden. Für die andromonözischen Arten wird gezeigt, dass der Anteil funktional männlicher Blüten mit steigender Doldenordnung nicht einheitlich zu- oder abnimmt. Dadurch fungieren die Pflanzen zu verschiedenen Zeiten und mit unterschiedlicher Stärke eher als Pollenrezeptoren oder Pollendonatoren. Es wird deutlich, dass das ‚uniforme Muster‘ der Apioideen mit Dolden verschiedener Ordnungen, dichogamen Blüten und deren diversen Geschlechtsausbildungen ein komplexes Raum-Zeit-Gefüge zur Optimierung des Reproduktionssystems darstellt. Das zweite Kapitel stellt die Ergebnisse von Manipulationsexperimenten (Handbestäubung, Bestäuberabschirmung, Entfernen von Dolden niedriger Ordnung) an Chaerophyllum bulbosum dar, die zeigen, dass das Raum-Zeit-Gefüge in der Präsentation der Blüten der Art erlaubt, flexibel auf Umwelteinflüsse zu reagieren. Es stellt sich heraus, dass mechanische Beschädigungen kaum Einfluss auf den Andromonöziegrad und prozentualen Fruchtansatz der Individuen nehmen. Grundvoraussetzung der Reaktionsfähigkeit ist wiederum deren modulärer Bau. Dieser erlaubt es den Pflanzen, zusammen mit dem andromonöziebedingten Reservoir an - geschlechtlich flexiblen - männlichen Blüten, in den später angelegten Dolden fehlenden Fruchtansatz der Blüten früh blühender Dolden zu kompensieren. Im dritten Kapitel wird eine vergleichende Merkmalsanalyse an 255 Apioideen-Arten vorgelegt, die alle Verwandtschaftskreise, Wuchsformen und Verbreitungsgebiete der Gruppe repräsentieren. Ziel der Analyse war die Identifizierung von Merkmalssyndromen, die den Zusammenhang zwischen Architektur und Reproduktionssystem verdeutlichen sollten. Interessanterweise sind die einzigen Merkmale, die miteinander einhergehen, Protogynie und die graduelle Abnahme männlicher Blüten mit steigender Doldenordnung. Alle anderen Merkmale variieren unabhängig voneinander und erzeugen auf vielen verschiedenen Wegen immer wieder das gleiche Funktionsmuster, das als ‚breeding syndrome‘ der Apioideae gedeutet werden kann. Die Arbeit leistet einen wichtigen Beitrag zum Verständnis der Blütenstände der Apiaceen und darüber hinaus zu morphologischer Variation in ‚unspezialisierten‘ Reproduktionssystemen. Offensichtlich liegt in den Apioideen der Selektionsdruck auf der Aufrechterhaltung der generalisistischen Bestäubung und überprägt alle morphologisch-phylogenetischen Merkmalsvarianten.

Entwicklung eines Screeningverfahrens zum simultanen Nachweis von Opioiden in menschlichen Körperflüssigkeiten, Geweben und Haaren für forensisch-toxikologische und klinische Untersuchungen

In den letzten Jahren stieg in Deutschland der Gebrauch bzw. Missbrauch von Opioid-Analgetika zunehmend an. Das entwickelte Verfahren sollte unter Einbeziehung neuer Substanzen möglichst viele verschiedene Opioide und auch ihre pharmakologisch aktiven Stoffwechselprodukte berücksichtigen.rnVor Analyse wurden Blut-, Serum- oder Urinproben mit Phosphatpuffer versetzt und mittels Festphasenextraktion an C18-Säulenmaterial aufgearbeitet. Post-Mortem-Gewebematerial wurde mit isotonischer Kochsalzlösung versetzt, homogenisiert und anschließend durch eine Festphasenextraktion aufgereinigt. Haarproben wurden nach Zerkleinerung mit Methanol unter Ultrabeschallung extrahiert. Die Flüssigchromatographie gekoppelt mit Tandem-Massenspektrometrie (Elektrosprayionisation im positiven Modus) erwies sich als geeignetes Verfahren für die simultane Bestimmung der Opioide in biologischem Probenmaterial (Körperflüssigkeiten, Gewebe und Haaren). Der Multi-Analyt Assay erlaubt die quantitative Analyse von 35 verschiedenen Opioiden. Die Analyten wurden durch eine Phenyl-Hexyl Säule und einen Wasser/Acetonitril Gradienten durch eine UPLC 1290 Infinity gekoppelt mit einem 6490 Triple Quadrupol von Agilent Technologies separiert.rnDie LC/MS Methode zur simultanen Bestimmung von 35 Opioiden in Serum und Haaren wurde nach den Richtlinien der Gesellschaft für Toxikologische und Forensische Chemie (GTFCh) validiert. Im Fall der Serumvalidierung lagen die Nachweisgrenzen zwischen 0.02 und 0.6 ng/ml und die Bestimmungsgrenzen im Bereich von 0.1 bis 2.0 ng/ml. Die Kalibrationskurven waren für die Kalibrationslevel 1 bis 6 linear. Wiederfindungsraten lagen für alle Verbindungen zwischen 51 und 88 %, außer für Alfentanil, Bisnortiliidn, Pethidin und Morphin-3-Glucuronid. Der Matrixeffekt lag zwischen 86 % (Ethylmorphin) und 105 % (Desomorphin). Für fast alle Analyten konnten akzeptable Werte bei der Bestimmung der Genauigkeit und Richtigkeit nach den Richtlinien der GTFCh erhalten werden. Im Fall der Validierung der Haarproben lagen die Nachweisgrenzen zwischen 0.004 und 0.6 ng/Probe und die Bestimmungsgrenzen zwischen 0.1 ng/Probe und 2.0 ng/Probe. Für die Kalibrationslevel 1 bis 6 waren alle Kalibrationsgeraden linear. Die Wiederfindungsraten lagen für die Opioide im Bereich von 73.5 % (Morphin-6-Glucuronid) und 114.1 % (Hydrocodon). Die Werte für die Bestimmung der Richtigkeit lagen zwischen - 6.6 % (Methadon) und + 11.7 % (Pholcodin). Präzisionsdaten wurden zwischen 1.0 % für Dextromethorphan und 11.5 % für Methadon ermittelt. Die Kriterien der GTFCh konnten bei Ermittlung des Matrixeffekts für alle Substanzen erfüllt werden, außer für 6-Monoacetylmorphin, Bisnortilidin, Meperidin, Methadon, Morphin-3-glucuronid, Morphin-6-glucuronid, Normeperidin, Nortilidin und Tramadol.rnZum Test des Verfahrens an authentischem Probenmaterial wurden 206 Proben von Körperflüssigkeiten mit Hilfe der simultanen LC/MS Screening Methode untersucht. Über 150 Proben wurden im Rahmen von forensisch-toxikologischen Untersuchungen am Instituts für Rechtsmedizin Mainz analysiert. Dabei konnten 23 der 35 Opioide in den realen Proben nachgewiesen werden. Zur Untersuchung der Pharmakokinetik von Opioiden bei Patienten der anästhesiologischen Intensivstation mit Sepsis wurden über 50 Blutproben untersucht. Den Patienten wurde im Rahmen einer klinischen Studie einmal täglich vier Tage lang Blut abgenommen. In den Serumproben wurde hauptsächlich Sufentanil (0.2 – 0.8 ng/ml in 58 Fällen) und Piritramid (0.4 – 11 ng/ml in 56 Fällen) gefunden. Außerdem wurden die Proben von Körperflüssigkeiten und Gewebe von 13 verschiedenen Autopsiefällen mit Hilfe des Multi-Analyt Assays auf Opioide untersucht.rnIn einem zweiten Schritt wurde die Extraktions- und Messmethode zur Quantifizierung der 35 Opioide am Forensic Medicine Center in Ho Chi Minh City (Vietnam) etabliert. Insgesamt wurden 85 Herzblutproben von Obduktionsfällen mit Verdacht auf Opiatintoxikation näher untersucht. Der überwiegende Teil der untersuchten Fälle konnte auf eine Heroin- bzw. Morphin-Vergiftung zurückgeführt werden. Morphin wurde in 68 Fällen im Konzentrationsbereich 1.7 – 1400 ng/ml und der Heroinmetabolit 6-Monoactetylmorphin in 34 Fällen (0.3 – 160 ng/ml) nachgewiesen werden.rnSchließlich wurden noch 15 Haarproben von Patienten einer psychiatrischen Klinik, die illegale Rauschmittel konsumiert hatten, mit Hilfe der simultanen Opioid-LC/MS Screeningmethode gemessen. Die Ergebnisse der Untersuchung wurden mit früheren Auswertungen von gaschromatographischen Analysen verglichen. Es zeigte sich eine weitgehende Übereinstimmung der Untersuchungsergebnisse für die Opioide 6-Monoacetylmorphin, Morphin, Codein, Dihydrocodein und Methadon. Mit der LC/MS Methode konnten weitere Substanzen, wie zum Beispiel Bisnortilidin, Dextromethorphan und Tramadol in den Haarproben gefunden werden, die bislang nicht entdeckt worden waren.rn