Romano Arcieri

The Reverse Transcription Inhibitor Abacavir Shows Anticancer Activity in Prostate Cancer Cell Lines

Background Transposable Elements (TEs) comprise nearly 45% of the entire genome and are part of sophisticated regulatory network systems that control developmental processes in normal and pathological conditions. The retroviral/retrotransposon gene machinery consists mainly of Long Interspersed Nuclear Elements (LINEs-1) and Human Endogenous Retroviruses (HERVs) that code for their own endogenous reverse transcriptase (RT). Interestingly, RT is typically expressed at high levels in cancer cells. Recent studies report that RT inhibition by non-nucleoside reverse transcriptase inhibitors (NNRTIs) induces growth arrest and cell differentiation in vitro and antagonizes growth of human tumors in animal model. In the present study we analyze the anticancer activity of Abacavir (ABC), a nucleoside reverse transcription inhibitor (NRTI), on PC3 and LNCaP prostate cancer cell lines. Principal Findings ABC significantly reduces cell growth, migration and invasion processes, considerably slows S phase progression, induces senescence and cell death in prostate cancer cells. Consistent with these observations, microarray analysis on PC3 cells shows that ABC induces specific and dose-dependent changes in gene expression, involving multiple cellular pathways. Notably, by quantitative Real-Time PCR we found that LINE-1 ORF1 and ORF2 mRNA levels were significantly up-regulated by ABC treatment. Conclusions Our results demonstrate the potential of ABC as anticancer agent able to induce antiproliferative activity and trigger senescence in prostate cancer cells. Noteworthy, we show that ABC elicits up-regulation of LINE-1 expression, suggesting the involvement of these elements in the observed cellular modifications.

ISSQoL: A new questionnaire for evaluating the quality of life of people living with HIV in the HAART era*

Objective: To design a Health-related Quality of Life (HRQoL) instrument for HIV-infected people in the era of highly active antiretroviral therapy (HAART). Methods: The self-administered questionnaire was developed by an Italian network including researchers, physicians, people living with HIV, national institutions and community-based organizations (CBO) through several steps: (1) review of existing HRQoL literature and questionnaires for HIV-infected people; (2) selection of relevant domains measuring HRQoL in HIV-infected people, and identification of new domains related to new aspects of HRQoL concerning HAART-treated individuals; (3) conduction of two pre-test analyses in independent groups of Italian HIV-positive people (n≌100) distributed throughout the country. The objectives of the first pre-test were to verify the usefulness of the questionnaire, to construct a form easily understandable by everyone, to define the domains and their significance; the second pre-test aimed at evaluating and reshaping the questionnaire based on a statistical analysis of the outcomes of first pre-test; (4) validation analysis. A large cohort of people with HIV infection was recruited for the last step.Results: The internal consistence reliability (Cronbach’s α) was ≥0.70 for all domains. Most domains had Cronbach’s coefficient >0.80. All domains demonstrated convergent and discriminant validity. The final version of ISSQoL includes two sections: HRQoL Core Evaluation Form (9 domains) and Additional Important Areas for HRQoL (6 domains). The ISSQoL was administered together with two additional forms: a Daily Impact of Symptoms Form and a Demographic Information Form. The Additional Important Areas for HRQoL include social support, interaction with medical staff, treatment impact, body changes, life planning, and motherhood/fatherhood.Conclusion: The data reported in the present paper provide preliminary evidence of the reliability and validity of the ISSQoL questionnaire for the measurement of HRQoL in HIV-infected people. The direct involvement of HIV-positive people in all the phases of the project was a key aspect of our work.

Atomoxetine in the treatment of attention deficit hyperactivity disorder and suicidal ideation

Objective: Attention deficit hyperactivity disorder (ADHD) is the most common psychiatric childhood disorder. The most commonly used drugs in the treatment of ADHD are methylphenidate (MPH) and atomoxetine (ATX); the former of the two is prescribed in USA more than it is in Western Europe. Some of the most important safety concerns about ADHD drug treatment are sudden cardiac death and suicidal behavior. In this study, we present a series of cases of Italian children who had presented suicidal ideation during ADHD pharmacological therapy with ATX. Research design and methods: Data were obtained from the ADHD Italian Register. The data assessed the use of MPH and ATX, which had been prescribed to patients who were aged < 18 years and diagnosed with ADHD. All patients enrolled in the ADHD Italian Register treated with ATX or MPH who experienced suicidal thoughts or thoughts of self-harming were considered and assessed. Results: We describe the clinical cases of seven Italian children (enrolled in the ADHD Italian Register) treated with ATX and affected by suicidal ideation, self-harming or other similar symptoms. Our results highlighted that all seven patients developed suicidal ideation or intentional self-harming during pharmaceutical treatment with ATX and, particularly, after the dose increase of the drug. Conclusion: There is a need to improve our knowledge about the efficacy and safety of ATX, MPH and other drugs used in the treatment of ADHD both in children and adults during the post-marketing experience.

Attention-Deficit/Hyperactivity Disorder Drugs and Growth: An Italian Prospective Observational Study

OBJECTIVE This study was conducted to assess the long-term effect of methylphenidate (MPH) or atomoxetine (ATX) on growth in attention-deficit/hyperactivity disorder (ADHD) drug-naïve children. DESIGN The study was an observational, post-marketing, fourth phase study. METHODS Data on height and weight were collected at baseline and every 6 months up to 24 months. RESULTS Both ATX and MPH lead to decreased height gain (assessed by means of z-scores); the effect was significantly higher for ATX than for MPH. At any time, height z-score decrease in the ATX group was higher than the corresponding decrease observed in the MPH group, but the difference was significantly relevant only during the first year of treatment. An increment of average weight was observed both in patients treated with MPH and in those treated with ATX. However, using Tanners percentile, a subset of patients showed a degree of growth lower than expected. This negative effect was significantly higher for ATX than for MPH. CONCLUSIONS We conclude that ADHD drugs show a negative effect on linear growth in children in middle term. Such effect appears more evident for ATX than for MPH.

P-Selectin as a new gender associated biomarker in patients with metabolic syndrome

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Italian Registry of Congenital Bleeding Disorders

In Italy, the surveillance of people with bleeding disorders is based on the National Registry of Congenital Coagulopathies (NRCC) managed by the Italian National Institute of Health (Istituto Superiore di Sanità). The NRCC collects epidemiological and therapeutic data from the 54 Hemophilia Treatment Centers, members of the Italian Association of Hemophilia Centres (AICE). The number of people identified with bleeding disorders has increased over the years, with the number rising from approx. 7000 in 2000 to over 11,000 in 2015. The NRCC includes 4020 patients with hemophilia A and 859 patients with hemophilia B. The prevalence of the rare type 3 vWD is 0.20/100,000 inhabitants. Less common congenital bleeding disorders include the following deficiencies: Factor I (fibrinogen), Factor II (prothrombin), Factor V, Factor VII, Factor X, Factor XI and Factor XIII, which affect 1953 patients. Hepatitis C Virus (HCV) infection affects 1561 patients, more than 200 of whom have two infections (HCV + HIV). Estimated hemophilia-related drug consumption in 2015 was approx. 550 million IU of FVIII for hemophilia A patients and approx. 70 million IU of FIX for hemophilia B patients. The NRCC, with its bleeding disorder data set, is a tool that can provide answers to fundamental questions in public health, monitoring care provision and drug treatment, as well as facilitating clinical and epidemiological research.

Il registro dell'ADHD: valutazione post-marketing del profilo beneficio-rischio dei farmaci e promozione dell'appropriatezza

INTRODUCTION: The Register was aimed at assessing the benefit-risk profile of the treatment of attention deficit hyperactivity disorder (ADHD) with atomoxetine and methylphenidate. METHODS: Post-marketing observational study, phase IV. Prescription medication to children and adolescents with ADHD aged between 6 and 18 years in the centres of reference for ADHD accredited by the Italian regions. RESULTS: In the period from September 2007 to October 2011, 1098 children and adolescents were treated with methylphenidate and 951 with atomoxetine. 411 (21.5%) patients are released from the register: 274 treated with atomoxetine and 167 with methylphenidate, with a greater risk of discontinuation for atomoxetine: RR 1.4 (1.3-1.6) p<0.001. The length of treatment at the time of removal from the register is 4.1 months for atomoxetine and 2 months for methylphenidate. Patients treated with atomoxetine are more likely to experience an adverse event compared to those treated with methylphenidate (RR 2.8; 1.9-4.2). The total number of serious adverse events observed was 110: 82 (75%) patients treated with atomoxetine and 28 (25%) individuals treated with methylphenidate. For 98 patients with serious adverse events, the adverse event led to the interruption of treatment with exit from the registry. The chance of a serious adverse event among those treated with atomoxetine compared to those with methylphenidate is RR 2.8 (1.8-4.2). There have been 14 cardiovascular events, all grown positively. 69 were found with a ECG alterations, with an increased risk for methylphenidate (RR 2.4; 1.4-4.2). The incidence of suicidal ideation was 4.5/1000 patients treated with atomoxetine. Hepatic alterations occurred with an incidence of 1/1000 subjects treated with methylphenidate and 4/1000 of those who received atomoxetine. DISCUSSION: The survey was carried out on a population which represents appropriately the paediatric population. The observed prevalence of ADHD corresponds to the expectation based on data from previous epidemiological investigations in Italy but considerably lower than what is reported in the international scientific literature. The rate of exposure to pharmacological treatments is similar to that of other European countries.

Present and future challenges in the treatment of haemophilia: the patient’s perspective

Haemophilia is a rare bleeding disorder, caused by a mutation in the genes for factor VIII (Haemophilia A) and factor IX (Haemophilia B). Patients with severe haemophilia, with a factor plasma level of 1% or less, are affected by frequent episodes of spontaneous or excessive bleeding into joints and muscles. The current management of haemophilia is based on treatment with plasma-derived and recombinant factor VIII (FVIII) or factor IX products (FIX)1. Home treatment has shown to improve both life expectancy and quality of life of patients with haemophilia and other inherited coagulation disorders (PWH), with a reduction of musculoskeletal damage2.

Clinical and organisational aspects of haemophilia care: the patients' view.

Dear Sir, Over the last years, the life expectancy of patients with haemophilia has become ever closer to that of the general population and the patients’ quality of life has improved dramatically1. These advances have been achieved thanks to a continuous improvement in factor VIII product availability in most countries, which has allowed the use of coagulation factor replacement therapy on a larger scale, particularly in western countries. In the early 1980s, viral infections had a dramatic impact on the haemophilia community. The improvement of methods for inactivating or removing viruses from plasma products, together with a concomitant application of stringent donor selection criteria and nucleid acid amplification testing of donations have increased the safety profile of plasma-derived products. As a result, no cases of blood-borne transmission of known viruses from these products have been observed in the last two decades. In the late 1980s, on the other hand, the advent of recombinant technology offered the possibility of an innovative change in patients’ treatment which contributed to restoring patients’ trust in replacement therapy and compliance, which had been severely compromised by the blood-borne virus epidemics. In fact, the manufacturing process of recombinant factor VIII products evolved quickly, with the goal of eliminating the risk of pathogen transmission. This goal has been pursued through the improvement of protein purification techniques and viral inactivation steps and progressive elimination of human and animal proteins from the various phases of production. We, on behalf of our community of haemophiliacs, are aware that there are still old problems to be solved as well as new challenges to be dealt with, such as cardiovascular diseases, malignancies and other age-related co-morbidities. The unresolved problems include major clinical issues such as inhibitor development and how to eradicate such inhibitors. The ongoing scientific debate on these issues is lively2,3. As far as concerns inhibitors, unless undisputed evidence from prospective clinical trials shows a real difference in clinical practice, it cannot be claimed that plasma-derived factor VIII products are superior to recombinant factor VIII products4. Even their equivalence should be scientifically demonstrated by controlled clinical trials. Continuity of care, intended as maintenance of treatment with the product that offers the best clinical benefit to each patient, is essentially the only indisputable therapeutic approach for the community of haemophiliacs. However, in times of global recession, when financial constrictions are jeopardising the current levels of health care, governments and health-care decision-makers may be tempted to turn the clock back and, in the name of cost-saving, to adopt policies that might compromise access to the best available therapies and put the continuity of care in haemophilia management at serious risk. In such a context, small changes in clinical guidelines, for example, those concerning the choice of treatment for previously untreated patients, if supported only by low-level evidence, such as that from uncontrolled and/or retrospective studies, could have a knock-on effect putting well-established landmarks in patients’ treatment at risk. Therefore, as patients’ representatives, with the endorsement of the World Federation of Hemophilia, we have many expectations on the potential of the Study on Inhibitors in Plasma-Products Exposed Toddlers (SIPPET) to give the final word on inhibitor development rate in previously untreated patients managed with recombinant or plasma-derived products. In conclusion, we strongly believe that patient empowerment and engagement, according to the endorsement given by the World Federation of Hemophilia, involves all aspects of haemophilia care, including clinical and organisational aspects and programmes. Patients’ representatives, together with all the other stakeholders, should be involved in the discussion of clinical organisational guidelines and health care programmes, as stated by the fourth principle of the European Principles of Haemophilia Care5. In this context, the Italian Federation of Haemophilia Associations (FedEmo) has promoted the definition of an accreditation scheme for haemophilia treatment centres and haemophilia programme guidelines by Italian Regions based on the European Principles of Haemophilia Care.

Recommendations for factor VIII product source to treat patients with haemophilia A

Dear Sir, We appreciate that Coppola, together with the whole Executive Committee of the Italian Association of Haemophilia Centres (AICE)1, agreed with us2 on the reasons underlying the increased consumption of plasma-derived factor VIII products recorded in Italy between 2011 and 2014. We also agree with them that previously-untreated patients with severe haemophilia A are unlikely to have contributed to the observed increase, not only because very few of them are born in Italy each year (15-20 cases) but also because being infants of small body weight they cannot be large consumers of factor VIII in absolute terms. Even though being a previously-untreated patient is by definition a short-lasting condition, these are the people with haemophilia who are at the highest risk of developing inhibitors. Thus, it is to be hoped that the forthcoming new Principles of Treatment from AICE will provide meaningful, specific recommendations on how to choose factor VIII products for this critical category of patients. We also agree with Coppola et al.1 that the forthcoming AICE recommendations should emphasise once more and forever that the choice of the source of factor VIII products by haemophilia doctors should be based upon shared decision-making involving patients and their families. This principle of shared decision-making was illustrated by Mannucci et al.3 in an article published in 2012 with one of Coppolas co-authors (ES). In that article on how to choose factor VIII products, the authors stated that the informed choice should take into account the perception that recombinant factor VIII products are safer from the point of view of the theoretical risk of transmission of infections. The perception that plasma factor VIII products are safer from the point of view of inhibitor risk was also mentioned in the frame of shared decision-making3. The striking current novelty is that the results of SIPPET (Survey of Inhibitors in Plasma-Products Exposed Toddlers), a study with a randomised design4 (thus providing the highest level of clinical evidence), have transformed the aforementioned perception into evidence, and that this new information should be now conveyed without ambiguity to patients during the decision-making process. Disclaimer of conflicts of interest The Authors declare no conflicts of interest, with the exception of PMM who declares having received in the past 12 months honoraria for lectures as a speaker or for chairing symposia organised by Alexion, Bayer, BaxaltaShire, Grifols, Kedrion, LFB, and Novo Nordisk. He has also acted as a scientific consultant for Bayer and Kedrion.