Paolo Cortesi

Anti-Inhibitor Coagulant Complex Prophylaxis in Hemophilia with Inhibitors

BACKGROUND Patients with severe hemophilia A and factor VIII inhibitors are at increased risk for serious bleeding complications and progression to end-stage joint disease. Effective strategies to prevent bleeding in such patients have not yet been established. METHODS We enrolled patients with hemophilia A who were older than 2 years of age, had high-titer inhibitors, and used concentrates known as bypassing agents for bleeding in a prospective, randomized, crossover study comparing 6 months of anti-inhibitor coagulant complex (AICC), infused prophylactically at a target dose of 85 U per kilogram of body weight (±15%) on 3 nonconsecutive days per week, with 6 months of on-demand therapy (AICC at a target dose of 85 U per kilogram [±15%] used for bleeding episodes). The two treatment periods were separated by a 3-month washout period, during which patients received on-demand therapy for bleeding. The primary outcome was the number of bleeding episodes during each 6-month treatment period. RESULTS Thirty-four patients underwent randomization; 26 patients completed both treatment periods and could be evaluated per protocol for the efficacy analysis. As compared with on-demand therapy, prophylaxis was associated with a 62% reduction in all bleeding episodes (P<0.001), a 61% reduction in hemarthroses (P<0.001), and a 72% reduction in target-joint bleeding (≥3 hemarthroses in a single joint during a 6-month treatment period) (P<0.001). Thirty-three randomly assigned patients received at least one infusion of the study drug and were evaluated for safety. One patient had an allergic reaction to the study drug. CONCLUSIONS AICC prophylaxis at the dosage evaluated significantly and safely decreased the frequency of joint and other bleeding events in patients with severe hemophilia A and factor VIII inhibitors. (Funded by Baxter BioScience; Pro-FEIBA ClinicalTrials.gov number, NCT00221195.).

Relationship between biological control, incidence of hypovirulence, and diversity of vegetative compatibility types of Cryphonectria parasitica in France.

ABSTRACT In France, chestnut blight, caused by Cryphonectria parasitica, has been controlled since 1974 in orchards, but never in coppice forests, by releasing hypovirulent strains infected with CHV1 hypovirus. We tested the hypothesis that this biological control (BC) has lead to a decrease in blight severity, spread of hypovirulence, and change in C. parasitica populations. The low severity of chestnut blight was confirmed in the six regions studied (subdivided into zones). The remission of cankers was associated with the presence of white isolates presumed to be hypovirulent. These two parameters were also correlated, at the zonal level, to the frequency of sites where BC was used. However, the estimates of the natural background level of hypovirulence, independent of BC, ranged from 4% in forests in Dordogne to 60% in orchards in Lozère. Differences in the rate of hypovirulent isolates among regions were consistent with the diversity of vegetative compatibility (VC) types in populations of C. parasitica. The highest VC-type diversity and mean allelic diversity for known vegetative incompatibility (vic) genes were observed in Dordogne. We showed that the current diversity of VC types in populations of C. parasitica was lower than in 1981. We found 30 VC types among 1,113 isolates of C. parasitica. Ten VC types were incompatible with known EU testers, suggesting that one additional vic gene or allele at one of the six vic loci known should be present in Europe.

Programmed cell death correlates with virus transmission in a filamentous fungus.

Programmed cell death (PCD) is an essential part of the defence response in plants and animals against pathogens. Here, we report that PCD is also involved in defence against pathogens of fungi. Vegetative incompatibility is a self/non–self recognition system in fungi that results in PCD when cells of incompatible strains fuse. We quantified the frequency of cell death associated with six vegetative incompatibility (vic) genes in the filamentous ascomycete fungus Cryphonectria parasitica. Cell death frequencies were compared with the effects of vic genes on transmission of viruses between the same strains. We found a significant negative correlation between cell death and virus transmission. We also show that asymmetry in cell death correlates with asymmetry in virus transmission; greater transmission occurs into vic genotypes that exhibit delayed or infrequent PCD after fusion with an incompatible strain. Furthermore, we found that virus infection can have a significant, strain–specific, positive or negative effect on PCD. Specific interactions between vic gene function and viruses, along with correlations between cell death and transmission, strongly implicate PCD as a host–mediated pathogen defence strategy in fungi.

Distribution and diversity of vegetative compatibility types in subpopulations of Cryphonectria parasitica in Italy

Using a medium that discriminated with high resolution, 20 vegetative compatibility (vc) types were detected among a sample of 716 isolates of Cryphonectria parasitica from 11 widely separated subpopulations throughout Italy. Each isolate was assigned unambiguously to a single vc type; no isolates were compatible with more than one vc type. Most isolates (85%) were in four common vc types; the other 16 vc types were represented by only a few isolates each. Vegetative compatibility type frequencies were markedly different between northern and southern Italy. Three of the most common vc types (I-1, I-2 and I-5) were found mostly in the North, where diversity was greatest, while two others (I-10 and I-12) were primarily found in the South.

Variation in Tolerance and Virulence in the Chestnut Blight Fungus-Hypovirus Interaction

ABSTRACT Chestnut blight, caused by the fungus Cryphonectria parasitica, has been effectively controlled with double-stranded RNA hypoviruses in Europe for over 40 years. The marked reduction in the virulence of C. parasitica by hypoviruses is a phenomenon known as hypovirulence. This virus-fungus pathosystem has become a model system for the study of biological control of fungi with viruses. We studied variation in tolerance to hypoviruses in fungal hosts and variation in virulence among virus isolates from a local population in Italy. Tolerance is defined as the relative fitness of a fungal individual when infected with hypoviruses (compared to being uninfected); virulence is defined for each hypovirus as the reduction in fitness of fungal hosts relative to virus-free hosts. Six hypovirus-infected isolates of C. parasitica were sampled from the population, and each hypovirus was transferred into six hypovirus-free recipient isolates. The resulting 36 hypovirus-fungus combinations were used to estimate genetic variation in tolerance to hypoviruses, in hypovirus virulence, and in virus-fungus interactions. Four phenotypes were evaluated for each virus-fungus combination to estimate relative fitness: (i) sporulation, i.e., the number of asexual spores (conidia) produced; (ii) canker area on field-inoculated chestnut trees, (iii) vertical transmission of hypoviruses into conidia, and (iv) conidial germination. Two-way analysis of variance (ANOVA) revealed significant interactions (P < 0.001) between viruses and fungal isolates for sporulation and canker area but not for conidial germination or transmission. One-way ANOVA among hypoviruses (within each fungal isolate) and among fungal isolates (within each hypovirus) revealed significant genetic variation (P < 0.01) in hypovirus virulence and fungal tolerance within several fungal isolates, and hypoviruses, respectively. These interactions and the significant genetic variation in several fitness characters indicate the potential for future evolution of these characters. However, biological control is unlikely to break down due to evolution of tolerance to hypoviruses in the fungus because the magnitudes of tolerance and interactions were relatively small.

Clonal population structure of the chestnut blight fungus in expanding ranges in southeastern Europe

Expanding populations are often less genetically diverse at their margins than at the centre of a species’ range. Established, older populations of the chestnut blight fungus, Cryphonectria parasitica, are more variable for vegetative compatibility (vc) types than in expanding populations in southeastern Europe where C. parasitica has colonized relatively recently. To test whether vc types represent clones, we genotyped 373 isolates of C. parasitica from southern Italy, Romania, Bulgaria, Macedonia, Greece and Turkey using 11 sequence‐characterized amplified region (SCAR) markers. Ten SCAR loci and six vegetative incompatibility (vic) loci were polymorphic in these samples. These populations are clonal by all criteria tested: (i) among 373 isolates, we found only eight multilocus haplotypes, and the same haplotypes were found in multiple countries, sometimes separated in time by as much as 12 years; (ii) the number of haplotypes observed was significantly less than expected under random mating; (iii) populations are in linkage disequilibrium; (iv) the two sets of independent markers, SCARs and vc types, are highly correlated; and (v) sexual structures of C. parasitica were found only in Bulgaria and Romania. One mating type (MAT‐1) was found in 98% of the isolates sampled. In contrast, a population in northern Italy, in the central part of the range in Europe, had 12 multilocus haplotypes among 19 isolates. The spread of a few clones could be the result either of founder effect and restricted migration, or these clones have greater fitness than others and spread because they are better adapted to conditions in southeastern Europe.

Cleistothecia of Uncinula necator : An additional source of inoculum in Italian vineyards

Density and viability of populations of cleistothecia of Uncinula necator from bark, leaves, and soil were determined in three vineyards in the Florence and Siena provinces of Tuscany for 3 years. A higher density of cleistothecia was found on fallen leaves than on bark. However, the percentage of viable cleistothecia was higher on bark. No viable cleistothecia were recovered from soil. U. necator overwintered as mycelium in dormant infected buds, which gave rise to flag shoots, only in Santa Cristina, where 20 and 92 flag shoots per hectare were detected before bloom in 1994 and 1995, respectively. Disease incidence and severity increased similarly at Corti, Fornace, and at Santa Cristina, although powdery mildew epidemics started from ascospores only in Corti and Fornace, whereas flag shoots were present at Santa Cristina. Cleistothecia were formed in autumn in both 1994 and 1995, and their dispersal started in late September to mid-October, with the maximum number of cleistothecia trapped in funnels during the second half of October. Cleistothecia appear to function as the sole source of primary inoculum for grape powdery mildew in some Italian vineyards and serve as additional sources of inoculum where the pathogen also overwinters in infected buds. In Australia but not in New York, the pathogen also overwinters as cleistothecia on fallen leaves.

Italian population-based values of EQ-5D health states

OBJECTIVE To estimate a value set for the calculation of Italian-specific quality-adjusted life years (QALYs), based on preferences elicited on EuroQol five-dimensional (EQ-5D) questionnaire health states using the time trade-off technique. METHODS The revised standard Measurement and Valuation of Health protocol was followed. Twenty-five health states, divided into three groups and given to 450 subjects, were selected to obtain 300 observations per state. Subjects aged 18 to 75 years were recruited to be representative of the Italian general adult population for age, sex, and geographical distribution. To improve efficiency, face-to-face interviews were conducted by using the Computer Assisted Personal Interviewing approach. Several random effects regression models were tested to predict the full set of EQ-5D questionnaire health states. Model selection was based on logical consistency of the estimates, sign and magnitude of the regression coefficients, goodness of fit, and parsimony. RESULTS The model that satisfied the criteria of logical consistency and was more efficient includes 10 main effect dummy variables for the EQ-5D questionnaire domain levels and the D1 interaction term, which accounts for the number of dimensions at levels 2 or 3 beyond the first. This model has an R(2) of 0.389 and a mean absolute error of 0.03, which are comparable to or better than those of models used in other countries. The utility estimates after state 11111 range from 0.92 (21111) to -0.38 (33333). Italian utility estimates are higher than those estimated in the United Kingdom and Spain and used so far to assess QALYs and conduct cost-utility evaluations in Italy. CONCLUSIONS A specific value set is now available to calculate QALYs for the conduction of health economic studies targeted at the Italian health care system.

Identification and spread of Fomitiporia punctata associated with wood decay of grapevine showing symptoms of esca

ABSTRACT A full understanding of the pathology of esca, a chronic disease of grapevines, has been problematic, in part because the identity of the pathogen (or pathogens) has been difficult to determine. The wood decay symptoms of esca have been most often associated with Phellinus igniarius or Fomitiporia punctata. However, Kochs postulates have not been completely fulfilled because symptoms take many years to develop. The goal of this study was to determine the identity and mode of spread of basidiomycetes associated with wood decay in vines showing esca symptoms in Italian vineyards. Vineyards were intensively studied for the presence of basidiocarps, and mycelium was isolated from symptomatic vines. Fruiting bodies were identified by morphology, while mycelial isolates were identified by restriction fragment length polymorphism analysis of the internal transcribed spacer region of the nuclear ribosomal RNA gene cluster. Fomitiporia punctata fruiting bodies and mycelium were associated with approximately 50% of the vines showing esca symptoms in two vineyards; P. igniarius was not found in any samples. Fruiting bodies of F. punctata were found in five of six vineyards examined, but at low frequencies except in one vineyard. The diversity of somatic incompatibility types was very high; isolates from almost every vine had different somatic incompatibility types. With few exceptions, symptomatic and dead vines were not spatially aggregated within 12 vineyards. The combination of diverse somatic incompatibility types and lack of spatial aggregations are not consistent with the hypothesis that the disease is spread clonally through roots or by pruning tools. The correct identity of basidiomycetes associated with wood decay of vines with esca symptoms is important for understanding the epidemiology of this disease because F. punctata is found commonly on many woody hosts in Europe, which may represent a potential inoculum source for this disease.

Distribution and retention of cleistothecia of Uncinula necator on bark of grapevines.

Clesitothecia of Uncinula necator were dispersed by late summer and early autumn rain to the bark of grapevines. Rain-dispersed ascocarps accumulated rapidly on bark during a 10-wk period and were then retained on bark through subsequent rain events between leaf abscission and budbreak the following spring. The density of populations on bark was significantly correlated (r = 0.72-0.88) with catches of cleistothecia in filter-paper funnels attached to the trunk of grapevines. The density of populations on bark during winter was not correlated with several measures of disease incidence and severity from the previous growing season. We concluded that while incidence and severity may determine the potential population available for dispersal, rain events determine the actual efficiency of transfer from infected organs to the bark of the vine. The percentage of ascocarps that reacted positively with the fluorescent vital stain fluorescein diacetate ranged from 50 to 62% and did not change significantly during overwintering until cleistothecia began to dehisce in spring. Therefore, the density and viability of populations of cleistothecia on bark at the time of budbreak appear to have been determined at the time of leaf fall the previous autumn and were not modified by subsequent environmental conditions. The densest aggregations of cleistothecia occurred on the cordons of cordon-trained vines, with successively lower densities occurring on the bark of the upper and lower trunks. The pruning and training system of vines of Vitis labrusca cv. Concord did not affect the density of populations of cleistothecia on bark