Safety and tolerability of intra-articular hyaluronic acid (Sinovial®/GELSYN-3tm) injections in the treatment of knee osteoarthritis

Osteoarthritis (OA) is a progressively degenerative joint disease, with a very high prevalence rate that is expected to increase worldwide with the ageing of the population. Considering that OA requires long-term treatment, therapies with minimal side effects and which can be repeated as needed are warranted. Hyaluronic acid (HA), a natural glycosaminoglycan with viscoelastic properties, is a major component of synovial fluid and the extracellular matrix of the joint cartilage, and plays key roles in maintaining synovial fluid viscosity and the bio-mechanical integrity of healthy cartilage. Intra-articular administration of exogenous HA has therefore been used to successfully improve the viscoelastic properties of the joint to improve lubrication, modulate inflammation and modify the catabolic micro-environment. Sinovial®/GELSYN-3TM is a sterile, non-pyrogenic formulation of highly purified, chemically unmodified HA of bio-fermentative origin, which has been introduced in several different concentrations in clinical use within the European market. This expert opinion reports on the published data regarding the efficacy and tolerability of first and multiple injection series of Sinovial®-based product formulations. The data regarding the tolerability of Sinovial® in patients with knee osteoarthritis were analyzed, showing that this formulation, beside favourable therapeutic effects, has a very good tolerability profile, with only mild, transient, and easily managed, local injection-site reactions and absence of systemic reactions. In particular, repetitive cycles of HA have been shown to yield positive results in terms of both efficacy and safety and therefore should be offered to patients who had undergone a successful first course of therapy when their symptoms reoccur.

Risk factors associated to bilateral rotator cuff tears

INTRODUCTION

Overuse, micro-traumas, and impingement, isolated or combined, are the more common etiological factors for rotator cuff tears. Metabolic disorders (diabetes, adiposity, hypercholesterolemia), hypertension, cigarette smoking and a genetic predisposition are considered risk factors. However, no study has compared the prevalence of these risk factors in subjects with bilateral and monolateral tears.

HYPOTHESIS

Controlateral tears can be observed in patients with symptomatic monolateral rotator cuff lesions, especially in those with comorbidities.

MATERIAL AND METHODS

In patients with symptomatic rotator cuff tear, the controlateral shoulders were evaluated by means of ultrasound imaging. Age, BMI, diabetes, hypercholesterolemia, hypertension, cigarette smoking, work habits were registered. Risk factors in subjects with bilateral tears were compared with those with monolateral lesions.

RESULTS

Of the 180 subjects recruited, 69 had a tear in the controlateral shoulder. Higher age and BMI values, heavy repetitive work and diabetes were significantly prevalent in these patients. At multivariate analysis, these factors were independently related to a higher probability to detect bilateral tears.

DISCUSSION

Metabolic risk factors are more heavily involved in presence of bilateral rotator cuff tears, in comparison to monolateral.

TYPE OF STUDY

Original study.

LEVEL OF PROOF

IV.

Ultrasound-guided Percutaneous Lavage in the Treatment of Calcific Tendinopathy of Elbow Extensor Tendons: A Case Report

We report the efficacy of the ultrasound-guided percutaneous treatment in the management of elbow extensor tendons calcific tendinopathy. The ultrasound-guided percutaneous treatment is broadly used with positive results in patients suffering from rotator cuff calcific tendinopathy. However, this interventional method has been reported only in one patient in the medical literature. A 34 years-old female who complained pain, swelling and severe functional limitation of the right elbow was referred to our unit. Elbow radiographs and ultrasound examination showed a soft-fluid calcification above the origin of the extensor tendons. Ultrasound-guided percutaneous treatment was therefore performed. After one year, the patient reported no pain and regained complete range of elbow motion. This method, in well trained hands, is an alternative treatment in the management of the uncommon elbow calcific deposit.

An arthroscopic-assisted minimal invasive method for the reconstruction of the scapho-lunate ligament using a bone-ligament-bone graft

We report the outcomes of an arthroscopic-assisted minimally invasive technique to reconstruct the scapho-lunate ligament using a bone-ligament-bone graft in 11 patients (11 wrists). The mean follow-up time was 29 months (range 20 to 38). The preoperative mean wrist flexion, extension, grip strength and patient-rated wrist evaluation score values were 61°, 54°, 115 N and 54, respectively. The postoperative mean values were 64°, 58°, 142 N and 15, respectively. There were no statistical differences between the pre- and postoperative wrist flexion and extension, whereas changes in grip strength and patient-rated wrist evaluation score were significant. Scapho-lunate angles decreased significantly from 69° to 60°. Based on our clinical outcomes, this method provides a reliable alterative for the reconstruction of the scapho-lunate ligament in patients with persistent Geissler type 3 and 4 lesions in the short-term.

LEVEL OF EVIDENCE

IV.

Modulation of aldose reductase activity by aldose hemiacetals

BACKGROUND

Glucose is considered as one of the main sources of cell damage related to aldose reductase (AR) action in hyperglycemic conditions and a worldwide effort is posed in searching for specific inhibitors of the enzyme. This AR substrate has often been reported as generating non-hyperbolic kinetics, mimicking a negative cooperative behavior. This feature was explained by the simultaneous action of two enzyme forms acting on the same substrate.

METHODS

The reduction of different aldoses and other classical AR substrates was studied using pure preparations of bovine lens and human recombinant AR.

RESULTS

The apparent cooperative behavior of AR acting on glucose and other hexoses and pentoses, but not on tethroses, glyceraldehyde, 4-hydroxynonenal and 4-nitrobenzaldehyde, is generated by a partial nonclassical competitive inhibition exerted by the aldose hemiacetal on the reduction of the free aldehyde. A kinetic model is proposed and kinetic parameters are determined for the reduction of l-idose.

CONCLUSIONS

Due to the unavoidable presence of the hemiacetal, glucose reduction by AR occurs under different conditions with respect to other relevant AR-substrates, such as alkanals and alkenals, coming from membrane lipid peroxidation. This may have implications in searching for AR inhibitors. The emerging kinetic parameters for the aldoses free aldehyde indicate the remarkable ability of the enzyme to interact and reduce highly hydrophilic and bulky substrates.

GENERAL SIGNIFICANCE

The discovery of aldose reductase modulation by hemiacetals offers a new perspective in searching for aldose reductase inhibitors to be developed as drugs counteracting the onset of diabetic complications.

Association between baseline serum vascular endothelial growth factor levels and response to electroconvulsive therapy

OBJECTIVE

Several studies have shown that vascular endothelial growth factor (VEGF) is implicated in different neuronal processes involved in major depressive disorder (MDD) and in the mechanisms of action of antidepressants. The aim of this study was to investigate whether VEGF serum levels before treatment might be associated with the antidepressant response.

METHOD

Two groups of patients were enrolled. One was composed of 50 MDD patients receiving an antidepressant drug treatment. Illness severity was measured before the treatment (T0) and after 12 weeks (T1). The second group was composed of 67 treatment-resistant depressed (TRD) patients undergoing electroconvulsive therapy (ECT). Illness severity was assessed before the treatment (T0) and 1 month after the end of ECT (T1). Blood samples for VEGF measurements were collected for both groups at the baseline (T0).

RESULTS

A significant correlation was observed between baseline VEGF serum levels and the percentage reduction in depressive symptomatology after ECT (P = 0.003). In particular, VEGF levels at baseline were significantly lower in patients showing no response to ECT at follow-up (P = 0.008). No correlation between T0 VEGF concentrations and drug treatment outcome was found.

CONCLUSION

Our results suggest that VEGF plays a role in the mechanism of response to ECT.

Platelet-rich plasma in the conservative treatment of painful tendinopathy: a systematic review and meta-analysis of controlled studies

BACKGROUND

Platelet-rich plasma (PRP) seeks to meet the multifaceted demand of degenerated tendons providing several molecules capable of boosting healing.

AREAS TIMELY FOR DEVELOPING RESEARCH

PRP is used for managing tendinopathy, but its efficacy is controversial.

SOURCES OF DATA

Electronic databases were searched for clinical studies assessing PRP efficacy. Methodological quality was evaluated using the methods described in the Cochrane Handbook for systematic reviews.

AREAS OF AGREEMENT

Thirteen prospective controlled studies, comprising 886 patients and diverse tendons were included; 53.8% of studies used identical PRP protocol.

AREAS OF CONTROVERSY

Sources of heterogeneity included different comparators, outcome scores, follow-up periods and diverse injection protocols, but not PRP formulation per se.

GROWING POINTS

Pooling pain outcomes over time and across different tendons showed that L-PRP injections ameliorated pain in the intermediate-long term compared with control interventions, weighted mean difference (95% CI): 3 months, -0.61 (-0.97, -0.25); 1 year, -1.56 (-2.27, -0.83). However, these findings cannot be applied to the management of individual patients given low power and precision.

RESEARCH

Further studies circumventing heterogeneity are needed to reach firm conclusions. Available evidence can help to overcome hurdles to future clinical research and bring forward PRP therapies.

Comparison of cutaneous termic response to a standardised warm up in trained and untrained individuals

AIM

Warm up prior to exercise induces an increased production of metabolic heat, which triggers the thermoregulatory system to initiate heat loss mechanisms. Variations in cutaneous tissue temperature have been already reported in trained subjects, by means of high resolution thermal imaging. Purpose of this paper was to quantitatively evaluate, by means of infrared thermography, the differences in the cutaneous temperature among trained and untrained subjects.

METHODS

Forty male volunteers performed a standard warm up exercise on a stationary cycle, divided in three steps: 1) 0-5 minutes at 100 Watt; 2) 5-10 minutes at 130 Watt; and 3) 10-15 minutes at 160 Watt. Thermal images from thorax and upper limbs were collected during the exercise. Heart rate was also measured.

RESULTS

In comparison to baseline, trained subjects exhibited a significant temperature reduction in the third step (trunk, P<0.01; upper limbs, P<0.009), while no difference was observed in untrained subjects. In the comparison between groups, a statistically significant difference was observed in both regions of interest, in the second (trunk, P<0.01; upper limbs, P<0.02), and in the third step (trunk, P<0.0002; upper limbs, P<0.0008). During the whole exercise, heart rate increased progressively in all participants, but more markedly in untrained subjects.

CONCLUSION

Cutaneous thermoregulatory response differs among trained and untrained participants. Infrared thermal imaging is useful in detecting these differences, providing additional data to the physiological evaluation of subjects performing sport activities.

Neoangiogenesis is reduced in chronic tendinopathies of type 2 diabetic patients

In diabetes, the prevalence of tendon degeneration is increased. As neoangiogenesis is impaired in several diabetic complications, the aim of this study is to evaluate the neovessel formation in tendinopathies. Patients aged > 55 years were selected, and divided in two groups: a) type 2 diabetic patients, and b) non-diabetic subjects. In both groups, those with ultrasound features of tendinopathy were included, and intratendinous vascularisation was estimated by means of Power Doppler. Ultrasound features of tendinopathy were observed in 104 diabetic subjects and in 221 controls. Neovascularisation, with higher Power Doppler scores, was found more frequently in controls, while lower Power Doppler scores were prevalent in diabetic subjects. In subjects with diabetes, tendinopathic features are significantly higher than healthy controls, while the prevalence of neovascularisation inside tendons is less represented.

Ovine amniotic epithelial cells: in vitro characterization and transplantation into equine superficial digital flexor tendon spontaneous defects

In vitro expanded and frosted ovine amniotic epithelial cells (oAECs) were evaluated for their phenotype, stemness and attitude to differentiate into tenocytes. Fifteen horses with acute tendon lesions were treated with one intralesional injection of oAECs. Tendon recovery under controlled training was monitored. In vitro expanded oAECs showed a constant proliferative ability, a conserved phenotype and stable expression profile of stemness markers. Differentiation into tenocytes was also regularly documented. US controls showed the infilling of the defect and early good alignment of the fibers and 12 horses resumed their previous activity. Histological and immunohistochemical examinations in an explanted tendon demonstrated the low immunogenicity of oAECs that were able to survive in the healing site. In addition, oAECs supported the regenerative process producing ovine collagen type I amongst the equine collagen fibers. Considering our results, oAECs can be proposed as a new approach for the treatment of spontaneous equine tendon injuries.

The influence of gender on clinical and social characteristics of patients at psychosis onset: A report from the Psychosis Incident Cohort Outcome Study (PICOS)

BACKGROUND. This paper examined the hypothesis that males with first-episode psychosis (FEP) experience lower pre-morbid adjustment, greater social disability and more self-perceived needs at illness onset than females(by controlling for duration of untreated psychosis, diagnosis, age and symptoms at onset). Results disconfirming this hypothesis were thought to suggest the potentially mediating role of social context in determining the impact of symptoms and disability on the everyday lives of male patients in the early phase of psychosis. METHOD. A large epidemiologically representative cohort of FEP patients (n=517) was assessed within the Psychosis Incident Cohort Outcome Study (PICOS) framework – a multi-site research project examining incident cases of psychosis in Italy's Veneto region. RESULTS. Despite poorer pre-morbid functioning and higher social disability at illness onset, males reported fewer unmet needs in the functioning domain than females did. An analysis of help provided by informal care givers showed that males received more help from their families than females did. This finding led us to disconfirm the second part of the hypothesis and suggest that the impact of poorer social performance and unmet needs on everyday life observed in male patients might be hampered by higher tolerance and more support within the family context.CONCLUSIONS. These findings shed new light on rarely investigated sociocultural and contextual factors that may account for the observed discrepancy between social disability and needs for care in FEP patients. They also point to a need for further research on gender differences, with the ultimate aim of delivering gender-sensitive effective mental health care.

Xylan-degrading enzymes in male and female flower nectar of Cucurbita pepo

BACKGROUND AND AIMS

Nectar is a very complex mixture of substances. Some components (sugars and amino acids) are considered primary alimentary rewards for animals and have been investigated and characterized in numerous species for many years. In contrast, nectar proteins have been the subject of few studies and little is known of their function. Only very recently have detailed studies and characterization of nectar proteins been undertaken, and then for only a very few species. This current work represents a first step in the identification of a protein profile for the floral nectar of Cucurbita pepo. In this regard, the species studied is of particular interest in that it is monoecious with unisexual flowers and, consequently, it is possible that nectar proteins derived from male and female flowers may differ.

METHODS

Manually excised spots from two-dimensional (2-D) electrophoresis were subjected to in-gel protein digestion. The resulting peptides were sequenced using nanoscale LC-ESI/MS-MS (liquid chromatography-electrospray ionization/tandem mass spectrometry). An MS/MS ions search was carried out in Swiss-Prot and NCBInr databases using MASCOT software.

KEY RESULTS

Two-dimensional electrophoresis revealed a total of 24 spots and a different protein profile for male and female flower nectar. Four main proteins recognized by 2-D electrophoresis most closely resemble β-d-xylosidases from Arabidopsis thaliana and have some homology to a β-d-xylosidase from Medicago varia. They were present in similar quantities in male and female flowers and had the same molecular weight, but with slightly different isoelectric points.

CONCLUSIONS

A putative function for xylosidases in floral nectar of C. pepo is proposed, namely that they may be involved in degrading the oligosaccharides released by the nectary cell walls in response to hydrolytic enzymes produced by invading micro-organisms. Several types of oligosaccharides have been reported to increase the pathogenic potential of micro-organisms. Thus, it is possible that such a mechanism may reduce the virulence of pathogens present in nectar.

Diagnostic failure of ciprofloxacin-induced spontaneous bilateral Achilles tendon rupture: case-report and medical-legal considerations

Rare side-effects of fluoroquinolone therapy are tendinitis and tendon rupture. Many reports have demonstrated that the concomitant use of corticosteroids, in patients aged 60 years or older, increase the risk substantially. We present a case of spontaneous bilateral Achilles tendon rupture induced by ciprofloxacin and methylprednisolone. A 61-year-old woman was diagnosed with Bronchiolitis Obliterans with Organizing Pneumonia (BOOP) and was started on oral ciprofloxacin 500 mg twice daily for 3 weeks and on oral methylprednisolone 16 mg twice daily for 2 weeks. The diagnosis was made after doctors, rather than stop drug therapy and advise complete rest, had mistakenly prescribed for the woman to undergo physiotherapy and local NSAIDs, thus favoring the onset of tendon ruptures and resulting in surgical and legal implications. Inspired by this case, we also submit a brief review on professional liability in Orthopaedics.

Percutaneous steroidal treatment in relapses of chronic tendinopathies: a pilot study

Relapses are frequently observed in subjects with chronic tendinopathies. Corticosteroid injections are usually performed with positive results, but are uncomfortable for the patient and not free from side effects. The aim of this pilot study is to evaluate the short-term efficacy and tolerability of an occlusive Betamethasone Valerate medicated Plaster (BMVP). Fifteen subjects with relapses of chronic tendinopathies (clinical and ultrasound diagnosis) were enrolled, and treated according to RICE (Rest - Ice - Compression - Elevation) protocol. An BMVP plaster was also applied on the affected tendon. Clinical examination, at baseline and after 7, 14, 21 and 28 days, included pain (VAS at rest and during activities) and functional evaluation. Local side effects on the area and drop-outs were also recorded. Pain, both at rest and during activities, significantly decreased at 28 days (from 3.7 ± 2.7 to 1.1 ± 1.7 p < 0.01, and from 7.3 ± 1.7 to 3.3 ± 1.4 p < 0.0000, respectively). Moreover, the patients reported a significant improvement in the functional limitation. Five subjects dropped out of the study. No side effects were reported. The release of the steroid in pharmacologically-active concentrations over 12 - 24 hours and the good penetration of the drug in subcutaneous tissues explain the positive results. BMVP application may be considered a reliable first therapeutic approach in relapses of chronic tendinopathies.

Limited joint mobility in diabetes and ageing: recent advances in pathogenesis and therapy

Limited joint mobility is frequently observed in elderly people and in patients suffering from diabetes, who represent a growing segment of the population of western countries. Our review wishes to offer the state of art about this interesting topic, which may have important clinical implications, leading to impairment of both basic and instrumental activities of daily living. The main causes of a reduced range of motion are degenerative joint diseases and increased stiffness of collagen tissue. The main biochemical abnormality, common to aging and diabetes, is the non-enzymatic glycosilation of collagen, with advanced glycation end product (AGE) formation, which in turn leads to an increase of collagen cross-links. The most extensive accumulation of AGEs occurs in tissues that contain proteins with low turnover, such as the collagen in the extracellular matrix of articular capsule, ligaments and muscle-tendon units. The increase in collagen cross-linking alters the mechanical properties of these tissues with a decrease in elasticity and tensile strength, and an increase in mechanical stiffness. Besides this, AGEs react with specific cell surface receptors (RAGEs). The engagement of the ligand by RAGEs triggers cell-specific signalling, resulting in enhanced generation of reactive oxygen species and sustained up-regulation of pro-inflammatory mediators and adhesion molecules. An appropriate control of the glucose levels and a diet rich in antioxidant agents are recommended in patients with diabetes. Stretching and strengthening programmes are widely used, in order to prevent and to reduce joint stiffness, but the improvements with physiotherapy are little and short-lasting. Several drugs, which can interfere with AGE formation and removal, or with the cellular effects of AGEs, are under study (among them pyridoxamine, an active form of Vitamin B6, AGE-breaker compounds, glucosamine, rutin and derivatives, soluble RAGE isoforms, and statins). In experimental animal models, these drugs are effective in reducing diabetic complications due to AGE formation; however, further study is necessary before their extensive use in the clinical setting.

Viscosupplementation with intra-articular hyaluronic acid for treatment of osteoarthritis in the elderly

Osteoarthritis (OA) is very disabling condition in the elderly. The current therapeutic approaches (analgesics, NSAIDs, COX-2 inhibitors, steroids) do not delay the OA progression or reverse joint damage. Moreover, they may cause relevant systemic side effects. Hyaluronic acid (HA) is a physiologic component of the synovial fluid and is reduced in OA joints. Therefore, intra-articular injection of HA, due to its viscoelastic properties and protective effect on articular cartilage and soft tissue surfaces of joints, can restore the normal articular homoeostasis. These effects are evident when HA is properly administered into the articular space; therefore, the use of "image-guided" infiltration techniques is mandatory. Viscosupplementation (VS), with different HA preparations (Low and High molecular weight), can be considered when the patient has not found pain relief from other therapies or is intolerant to analgesics or NSAIDs. A 3-5 doses regimen is usually recommended with 1 week interval between each injection. Several studies have shown the efficacy of HA for the treatment of knee OA, with positive effects on pain, articular function (Western Ontario and Mc Master Universities Osteoarthritis Index [WOMAC], Lequesne Index [LI], Range of Motion [ROM]), subjective global assessment and reduction in NSAIDs consumption. In general, the benefit is evident within 3 months and persists in the following 6-12 months. Encouraging but inconclusive results have also been observed for the treatment of shoulder, carpo-metacarpal, hip and ankle OA. However there is the need of better designed studies to prove the effectiveness of these medications, in order to rule out a placebo effect. The therapy is well tolerated with absence of systemic side effects and only with limited local discomfort.

Ultrasound-Guided Hyaluronic Acid Injection in Carpometacarpal Osteoarthritis: Short-Term Results

Carpometacarpal osteoarthritis (CMC-OA) is a disabling condition, characterized by pain and functional impairment. The aim of the present study is to evaluate the efficacy of a single ultrasound-guided injection of hyaluronic acid (HA) in patients suffering from CMC-OA. Eighteen patients with CMC-OA, grade 2–3 Kellgren and Lawrence score, attending the Orthopaedic Department of the University Hospital of Chieti, were enrolled. They underwent clinical evaluation at baseline and after one month follow-up, evaluating: grading of pain (VAS at rest and during activities), function (Dreiser Index), grip and pinch strengths (Jamar dynamometer), as well as NSAIDs consumption. Each patient received a single ultrasound- guided injection of HA into the articular CMC joint. The results were that pain at rest and during activities decreased from 1.8 ± 1.07 to 0.5 ± 0.68 (p < 0.001) and from 8.05 ± 0.94 to 4.15 ± 1.42 (p < 0.001), respectively. Dreiser Functional Index showed a significant improvement (+11.59 %; p < 0.004), as well as pulp pinch strength (24.07 %; p < 0.001). The consumption of NSAIDs was also clearly reduced, from 16 to 7 patients (-45%) and from 2.45 ± 1.98 to 1.15 ± 1.30 tablets per week (p < 0.02). Mild local side effects, lasting less than 3 hours, were observed only in 2 cases. A single ultrasound guided injection of HA is a safe and effective procedure in CMC-OA, with a significant improvement in terms of pain and function. However, studies with larger samples and longer term follow-up are warranted.

Frailty in the elderly: the physical dimension

Frailty may be considered as a vulnerable status, which can precede the onset of overt disability. Operational definitions of frailty vary widely according to the conceptual framework: some authors consider frailty in a broad sense, which encompasses the physical, social, cognitive, psychological dimensions and comorbidity, whereas others define the syndrome more restrictively, mainly on the basis of performance parameters, such as gait speed, grip strength and physical activity. All these definitions are provided of a high predictive value for adverse outcomes, such as disability, hospitalization and mortality. Sarcopenia (i.e. the reduction of muscular mass and function) plays a predominant role in the pathogenesis of frailty. Among the factors responsible for sarcopenia (such as proinflammatory cytokines, low growth hormone and testosterone levels, increased production of oxygen free radicals, malnutrition and reduced neurological drive), immobility and lack of exercise have a preponderant role. Therefore, the diagnosis of frailty is mandatory for the early identification of a subset of elderly subjects at high risk, which can receive benefit from rehabilitation. A self-report and objective evaluation of physical performance are the best indicators of frailty in elderly subjects, a poor performance suggesting the need of an early and proper intervention. Structured exercise programs are effective in contrasting the progression of frailty, but an healthy and active lifestyle may be sufficient for delaying the onset of disability. In conclusion, there is clear evidence for prescription of exercise within the mainstream of the medical practice, rather than as an optional adjunct to standard care of the oldest old, given the public health implication of frailty, whose prevalence is going to increase in western populations.

Sarcopenia: age-related skeletal muscle changes from determinants to physical disability

Human aging is characterized by skeletal muscle wasting, a debilitating condition which sets the susceptibility for diseases that directly affect the quality of life and often limit life span. Sarcopenia, i.e. the reduction of muscle mass and/or function, is the consequence of a reduction of protein synthesis and an increase in muscle protein degradation. In addition, the capacity for muscle regeneration is severely impaired in aging and this can lead to disability, particularly in patients with other concomitant diseases or organ impairment. Immobility and lack of exercise, increased levels of proinflammatory cytokines, increased production of oxygen free radicals or impaired detoxification, low anabolic hormone output, malnutrition and reduced neurological drive have been advocated as being responsible for sarcopenia. It is intriguing to notice that multiple pathways converge on skeletal muscle dysfunction, but the factors involved sometimes diverge to different pathways, thus intersecting at critical points. It is reasonable to argue that the activity of these nodes results from the net balance of regulating mechanisms, as in the case of the GH/IGF-1 axis, the testosterone and cortisol functions, the pro- and anti-inflammatory cytokines and receptors. Both genetic and epigenetic mechanisms operate in regulating the final phenotype, the extent of muscle atrophy and reduction in strength and force generation. It is widely accepted that intervention on lifestyle habits represents an affordable and practical way to modify on a large scale some detrimental outcomes of aging, and particularly sarcopenia. The identification of the molecular chain able to reverse sarcopenia is a major goal of studies on human aging.