Background: Interleukin (IL)-1 plays a crucial role in the pathogenesis of Adult onset Still’s disease (AOSD).Objectives: To evaluate the efficacy and safety of anakinra (ANA) and canakinumab (CAN) in a large group of AOSD patients.Methods: Data on clinical, serological features, and concomitant treatments were retrospectively collected at baseline and after 3, 6, and 12 months from AOSD patients (Yamaguchi criteria) referred by 18 Italian centers. Pouchot’s score was used to evaluate disease severity.Results: One hundred forty patients were treated with ANA; 4 were subsequently switched to CAN after ANA failure. The systemic pattern of AOSD was identified in 104 (74.2%) of the ANA-treated and in 3 (75%) of the CAN-treated groups; the chronic-articular type of AOSD was identified in 48 (25.8%) of the ANA-treated and in 1 (25%) of the CAN-treated groups. Methotrexate (MTX) was the most frequent disease modifying anti-rheumatic drug (DMARD) used before beginning ANA or CAN [91/140 (75.8%), 2/4 (50%), respectively]. As a second-line biologic DMARD therapy in 29/140 (20.7%) of the patients, ANA was found effective in improving all clinical and serological manifestations (p < 0.0001), and Pouchot’s score was found to be significantly reduced at all time points (p < 0.0001). No differences in treatment response were identified in the ANA-group when the patients were stratified according to age, sex, disease pattern or mono/combination therapy profile. ANA primary and secondary inefficacy at the 12-month time point was 15/140 (10.7%) and 11/140 (7.8%), respectively. Adverse events (AEs) [mainly represented by in situ (28/47, 59.5%) or diffuse (12/47, 25.5%) skin reactions and infections (7/47, 14.8%)] were the main causes for discontinuation. Pouchot’s score and clinical and serological features were significantly ameliorated at all time points (p < 0.0001) in the CAN-group, and no AEs were registered during CAN therapy. Treatment was suspended for loss of efficacy only in one case (1/4, 25%).Conclusion: This is the largest retrospective observational study evaluating the efficacy and safety of IL-1 inhibitors in AOSD patients. A good response was noted at 3 months after therapy onset in both the ANA- and CAN-groups. Skin reaction may nevertheless represent a non-negligible AE during ANA treatment.
BackgroundArrhythmias are frequent in Systemic Sclerosis (SSc) and portend a bad prognosis, accounting alone for 6% of total deaths. Many of these patients die suddenly, thus prevention and intensified risk-stratification represent unmet medical needs. The major goal of this study was the definition of ECG indexes of poor prognosis.MethodsWe performed a prospective cohort study to define the role of 24h-ECG-Holter as an additional risk-stratification technique in the identification of SSc-patients at high risk of life-threatening arrhythmias and sudden cardiac death (SCD). One-hundred SSc-patients with symptoms and/or signs suggestive of cardiac involvement underwent 24h-ECG-Holter. The primary end-point was a composite of SCD or need for implantable cardioverter defibrillator (ICD).ResultsFifty-six patients (56%) had 24h-ECG-Holter abnormalities and 24(24%) presented frequent ventricular ectopic beats (VEBs). The number of VEBs correlated with high-sensitive cardiac troponin T (hs-cTnT) levels and inversely correlated with left-ventricular ejection fraction (LV-EF) on echocardiography. During a mean follow-up of 23.1±16.0 months, 5 patients died suddenly and two required ICD-implantation. The 7 patients who met the composite end-point had a higher number of VEBs, higher levels of hs-cTnT and NT-proBNP and lower LV-EF (p = 0.001 for all correlations). All these 7 patients had frequent VEBs, while LV-EF was not reduced in all and its range was wide. At ROC curve, VEBs>1190/24h showed 100% of sensitivity and 83% of specificity to predict the primary end-point (AUROC = 0.92,p<0.0001). Patients with VEBS>1190/24h had lower LV-EF and higher hs-cTnT levels and, at multivariate analysis, the presence of increased hs-cTnT and of right bundle branch block on ECG emerged as independent predictors of VEBs>1190/24h. None of demographic or disease-related characteristics emerged as predictors of poor outcome.ConclusionsVEBS>1190/24h identify patients at high risk of life-threatening arrhythmic complications. Thus, 24h-ECG-Holter should be considered a useful additional risk-stratification test to select SSc-patients at high-risk of SCD, in whom an ICD-implantation could represent a potential life-saving intervention.
This study focused on changes in fibrous and protein fractions, changes in fiber digestibility and amount of indigestible neutral detergent fiber (NDF) as a consequence of increased maturity in alfalfa. A total area of 720 m(2) was divided in 18 blocks randomly assigned to 3 treatments, differing in cutting intervals. Treatment 1 was harvested with a 21-d cutting schedule, at a prebloom stage; treatment 2 with a 28-d schedule, at about first-bloom stage; whereas a full bloom was observed in treatment 3, harvested with a 35-d cutting schedule. Treatments were replicated 4 times through the spring-summer period for 2 subsequent years, 2011 and 2012. Statistical differences were observed for crude protein [treatment 1: 20.8%, treatment 2: 17.3%, and treatment 3: 17.0%; standard error of the mean (SEM)=0.83], soluble protein, and nonprotein nitrogen among treatments on a dry matter basis. Similar results were observed for acid detergent lignin (6.3, 6.9, and 7.3%, respectively; SEM=0.39), lower in treatment 1 compared with others, and in vitro NDF digestibility at 24 or 240 h. Indigestible NDF at 240 h resulted in lower values for treatment 1 compared with treatments 2 and 3 (15.5, 17.2, and 18.3%, respectively; SEM=1.54). Moreover, the indigestible NDF:acid detergent lignin ratio varied numerically but not statistically among treatments, being as much as 9% greater than the 2.4 fixed value applied for rate of digestion calculation and Cornell Net Carbohydrate Protein System (Cornell University, Ithaca, NY)-based model equations. Assuming the diet composition remained unchanged, treatment 3 (35-d cutting interval) would be expected to yield 1.4 kg less milk per day based on energy supply, and 2.8 kg less milk daily based on protein supply than treatment 1.
The role of indigestible NDF is essential in relation to OM digestibility prediction, total tract digestibility, rumen fill, passage rate, and digestion kinetics. Moreover, the truly indigestible NDF (iNDF) represents a core point in dynamic models used for diet formulations. However, despite its wide possible applications, few trials have been conducted to quantify iNDF and even fewer to investigate whether or not it is consistent among different forage sources. The objective of this study was to predict the iNDF by measuring the residual NDF after 240-h in vitro fermentation to determine the unavailable NDF (uNDF) within and among various forage types. Finally, a mathematical approach was investigated for the estimation of the uNDF fraction. In all, 688 forages were analyzed in this study. This pool included 122 alfalfa hays, 282 corn silages, and 284 grass hays. Values of uNDF varied among different forages and within the same type (22.7% ± 4.48%, 20.1% ± 4.23%, and 11.8% ± 3.5% DM for grass hay, alfalfa hay, and corn silages, respectively). The relationship among uNDF and ADL was not constant and, for grass hay and corn silage, was different ( 0.05) from the 2.4 × lignin value applied by the traditional Chandler equation. The observed uNDF:ADL ratio was 3.22 for grass hay and 3.11 for corn silage. Relationships among chemical and biological parameters and uNDF were investigated via simple and multiple regression equations. The greatest correlation with a single variable was obtained by ADL and ADF when applied to the whole data set ( = 0.63). Greater coefficients of determination resulted from a multiple regression equation for the whole data set ( = 0.80) and within each forage type ( = 0.65, 0.77, and 0.54 for grass hay, alfalfa hay, and corn silage, respectively). In conclusion, a regression approach requires specific equations and different regression coefficients for each forage type. The direct measurement of uNDF represented the best approach to obtain an accurate prediction of the iNDF and to optimize its specific purpose in dynamic nutrition models.
The objective of this study was to investigate the effects of 2 alfalfa hays differing in undigested neutral detergent fiber content and digestibility used as the main forage source in diets fed to high producing cows for Parmigiano-Reggiano cheese production. Diets were designed to have 2 different amounts of undigestible NDF [high (Hu) and low (Lu)], as determined by 240-h in vitro analysis (uNDF). Alfalfa hay in vitro digestibility [% of amylase- and sodium sulfite-treated NDF with ash correction (aNDFom)] at 24 and 240 h was 40.2 and 31.2% and 53.6 and 45.7% for low- (LD) and high-digestibility (HD) hays, respectively. The 4 experimental diets (Hu-HD, Lu-HD, Hu-LD, and Lu-LD) contained 46.8, 36.8, 38.8, and 30.1% of alfalfa hay, respectively, 8.6% wheat straw, and 35.3% corn (50% flake and 50% meal; DM basis). Soy hulls and soybean meal were used to replace hay to balance protein and energy among diets. Eight multiparous Holstein cows (average milk production = 46.0 ± 5.2 kg/d, 101 ± 38 d in milk, and 662 ± 42 kg of average body weight) were assigned to a 4 × 4 Latin square design, with 2 wk of adaptation and a 1-wk collection period. Dry matter and water intake, rumination time, ruminal pH, and milk production and composition were measured. Diets and feces were analyzed for NDF on an organic matter basis (aNDFom), acid detergent fiber, acid detergent lignin, and uNDF to estimate total-tract fiber digestibility. Dry matter intake and rumination times were higher in HD diets compared with LD diets, regardless of forage amount. Rumination time was constant per unit of dry matter intake but differed when expressed as a function of uNDF, aNDFom, or physically effective NDF intake. No differences were found among treatments on average ruminal pH, but the amount of time with pH <5.8 was lower in Hu-HD diets. Milk production and components were not different among diets. Total-tract aNDFom and potentially digestible neutral detergent fiber fraction digestibility was higher for the LD diets (88.3 versus 85.8% aNDFom in HD), for which lower feed intakes were also observed. The Hu-HD diet allowed greater dry matter intake, longer rumination time, and higher ruminal pH, suggesting that the limiting factor for dry matter intake is neutral detergent fiber digestibility and its relative rumen retention time.
Objective To outline the clinical, histological and prognostic features of systemic sclerosis (SSc) endomyocardial biopsy-proven myocarditis with respect to those of diverse endomyocardial biopsy-proven virus-negative myocarditis (VNM). Methods We retrospectively analysed data from three cohorts of endomyocardial biopsy-proven myocarditis: SSc-related VNM (SSc-VNM); isolated VNM (i-VNM); and VNM related to other systemic autoimmune diseases (a-VNM). The degree of myocardial fibrosis was expressed as relative percentage and fibrotic score (0–3). Clinical data, cardiac enzymes, echocardiogram, 24 h ECG Holter and cardiac magnetic resonance were obtained at baseline and during follow-up. Non-parametric tests were used. Results We enrolled 12 SSc-VNM [11 females, mean age 49.3 (14.2) years; seven diffuse-SSc, five early-SSc], 12 i-VNM [12 females, mean age 47.7 (10.8) years] and 10 a-VNM [four females, mean age 48.4 (16.3) years] patients. SSc patients had higher degrees of myocardial fibrosis as assessed by both percentage [SSc-VNM: 44.8 (18.8)%; a-VNM: 28.6 (16.5)%; i-VNM: 24.9 (10.3)%; P = 0.019] and score [SSc-VNM: 2.3 (0.8); a-VNM: 1.4 (1.1); i-VNM: 1.2 (0.7); P = 0.002]. Myocardial fibrosis directly correlated with skin score (r = 0.625, P = 0.03) and number of ventricular ectopic beats on 24 h ECG Holter in SSc patients (r = 0.756, P = 0.01). Dyspnoea class was higher at presentation in SSc-VNM patients (P = 0.041) and we found heart failure only in SSc patients (25%) (P = 0.05). At cardiac magnetic resonance, myocardial oedema was nearly undetectable in SSc-VNM patients compared with others (P = 0.02). All patients received immunosuppressive treatment. The number of patients who died during follow-up due to cardiac complications was significantly higher in SSc-VNM patients (50%), as compared with a-VNM (0%) and i-VNM (8.3%) patients (P = 0.006). Patients who died during follow-up had higher degrees of myocardial fibrosis [52.2 (11.6)% vs 27.5 (12.9)%, P = 0.024; fibrotic score: 2.83 (0.41) vs 1.4 (0.9), P < 0.001]. Conclusion SSc has unique clinical and histological features, as it tends to present more frequently with heart failure and a higher dyspnoea class and to show higher degrees of myocardial fibrosis. These specific features are paralleled by a worse cardiac prognosis.
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