Skin microcirculatory effect of exogenous calcitonin gene-related peptide (CGRP) evaluated by laser Doppler flowmetry coupled with iontophoresis in healthy subjects

The aim of our study was to evaluate the feasibility of laser Doppler flowmetry (LDF) coupled with iontophoresis in exploring the skin vasodilator activity of exogenous calcitonin gene-related peptide (CGRP) in healthy subjects and to investigate the mechanisms involved in the skin vasodilator activity of this peptide. Forearm skin blood perfusion was measured in conventional perfusion unit (PU; 1 PU=10 mV), using a LDF apparatus (Periflux PF4001, Perimed, Sweden), before and following exogenous CGRP dissolved in distilled water (0.02%) or pure saline iontophoresis. Different iontophoresis protocols were used in a preliminary dose finding study in six subjects. Two pulses (0.1 mA for 30 s each) of anodal CGRP or saline iontophoresis were used in the definitive study in 20 subjects. Power spectral density (PSD) of skin blood flowmotion frequency intervals (FI), related to endothelial (0.009-0.02 Hz), sympathetic (0.02-0.06 Hz), myogenic (0.06-0.2 Hz), respiratory (0.2-0.6 Hz) and heart (0.6-1.6 Hz) activities, was also measured in PU(2)/Hz, by means of spectral analysis of the skin LDF signal registered before and following iontophoresis of CGRP or saline in the definitive study. A significantly higher per cent increase in skin perfusion compared to baseline was observed following CGRP than saline iontophoresis (548+/-369% vs. 326+/-192%, p<0.05), with higher hyperaemic response to pure saline than CGRP iontophoresis in only five subjects. A significant increase (p<0.05) in PSD mean value of the five FI considered, was also observed following CGRP iontophoresis, while saline iontophoresis elicited a significant increase (p<0.05) only in PSD of the FI related to endothelial, respiratory and heart activity. These findings demonstrated that LDF coupled with iontophoresis is a feasible method in evaluating the vasodilator effect of exogenous CGRP in human skin and suggest that this peptide directly or indirectly induces a smooth muscle vascular cells and sympathetic fibres stimulation.

Relationship of cellular immunity, cytokines and CRP with clinical course in breast cancer patients with endocrine-dependent distant metastases treated with immunotherapy

We have reported important benefits and survival with an immunotherapy schedule in patients with endocrine-dependent breast cancer and distant metastases. Here clinical outcome is updated and its correlation with new immunological data is shown. In 32 evaluated breast cancer patients with endocrine-dependent distant metastases treated with a new immunotherapy schedule (cyclic administration of beta-interferon and interleukin-2), cellular immunity, cytokines and CRP were related to the clinical course. Estimated and true 5-10 year overall survival rates from first line antiestrogen and distant metastases were higher than previously reported in a similar population. Interleukin-2 administration was followed by a significant increase in total lymphocytes, CD4+, CD8+, CD16+56+ (NK) cells, IL-6, IL-12, and CRP (from P<0.04 to P<0.000) but no change in IL-10 and TGFbeta1 during clinical benefit. During progressive disease no change was observed in the former parameters, concomitant with a significant increase in IL-10 (P=0.020) and a significant decrease in TGFbeta1 (P=0.023). These findings confirm that cellular immunity is significantly stimulated by IL-2 only during clinical benefit. Furthermore, these results demonstrate that different changes of proinflammatory cytokines, CRP and inhibiting factors are consistent with associated clinical benefit or with disease progression, respectively.

Absent post-ischemic increase of blood flowmotion in the cutaneous microcirculation of healthy chronic cigarette smokers

The aim of the study was to investigate whether chronic cigarette smoke habit is associated with changes of laser Doppler (LD) skin blood flowmotion (SBF). We performed spectral analysis of skin forearm LD signal detected by a LD flowmetry (Periflux PF4, Perimed, Sweden) before and during forearm post-ischemic hyperaemia, in 14 healthy chronic smoker subjects and 14 age and sex matched nonsmoker subjects. Forearm skin ischemia was obtained by a pneumatic cuff, positioned at the right arm and inflated for 3 minutes to 30 mmHg above systolic blood pressure. Power spectral density (PSD) of the SBF total spectrum (0.009-1.6 Hz), as well as 0.009-0.02 Hz , 0.02-0.06 Hz, 0.06-0.2 Hz, 0.2-0.6 Hz and 0.6-1.6 Hz frequency intervals (FI), referred to endothelial, sympathetic, myogenic, respiratory and heart activity, respectively, were measured in LD conventional perfusion units (PU)/Hz. Smokers showed a basal SBF total spectrum PSD mean values not significantly different from nonsmokers (2.14+/-1.58 PU/Hz and 1.93+/-1.35 PU/Hz, respectively). Following ischemia, PSD mean value of SBF total spectrum, as well of five FI considered, significantly increased in nonsmokers (p<0.01), while it did not significantly change in smokers. Smokers and nonsmokers did not differ in basal and post-ischemic skin LD perfusion mean values. The absent post-ischemic increase of the SBF and of its FI related to endothelial and myogenic activity in smokers can be an early sign of skin microcirculatory impairment, suggesting an endothelial and smooth muscle skin microvascular dysfunction associated with the chronic smoking habit.

Polymorphic analysis of the matrix metalloproteinase-9 gene and susceptibility to sporadic abdominal aortic aneurysm

Abdominal aortic aneurysm (AAA) has a multifactorial aetiology and the importance of genetic components is getting increasing interest. Alteration in the structure of the vascular extracellular matrix has been described in AAA. Matrix metalloproteinases (MMPs) degrade extracellular matrix proteins which alter the vessel wall stability. We evaluated two different polymorphisms, a CA repeat and a cytosine to thymidine transition in the promoter sequence of MMP-9 gene for frequency in 146 patients with AAA. We compared the results with those of 156 healthy subjects. No difference was found in the allelic distribution of either polymorphisms. We therefore found no evidence that MMP-9 is a marker of susceptibility for AAA.

Insulin resistance and low urinary citrate excretion in calcium stone formers

Epidemiological data suggest an association between kidney stones and some features of metabolic syndrome such as an overweight condition, arterial hypertension or glucose intolerance. However, mechanisms remain to be elucidated. This study aimed to evaluate insulin resistance, as assessed by homeostasis model assessment (HOMA-IR), and urine composition analysis in patients affected by calcium nephrolithiasis. A cohort of 61 (38 male, 29-57 years of age) non-diabetic calcium stone formers was studied. Data about body mass index, arterial blood pressure, serum biochemistry including parathyroid hormone and calcitriol were recorded in all the patients; fasting glucose and insulin were determined to calculate HOMA-IR value and accordingly the patients were grouped into tertiles. Urine pH and urinary excretion of calcium, citrate, phosphate, oxalate, uric acid, urea and creatinine were measured on 24h urine samples. Patients of the highest HOMA-IR tertile showed lower urine citrate levels than patients of the lowest HOMA-IR tertile (475+/-243 vs. 630+/-187 mg/24h, p<0.05), whereas no difference was detected as far as urinary oxalate, calcium, uric acid, phosphate, and urine pH and urine volume output were concerned. HOMA-IR values were positively related to uric acid serum levels (r=0.31, p<0.05) and negatively to urinary citrate excretion (r=-0.26, p<0.05). Hypocitraturic patients showed higher levels of HOMA-IR than normocitraturic ones (3.03+/-0.92 vs. 2.25+/-1.19, p<0.05). This study shows that a higher level of insulin resistance is associated with lower urinary citrate excretion, and that hypocitraturic patients show a greater insulin resistance than normocitraturic calcium stone formers. This may be related to changes in citrate, Na(+)-K(+) and H(+) renal tubule transports, which have been described in insulin resistance. In conclusion, insulin resistance may contribute to an increased risk of calcium stone formation by lowering urinary citrate excretion. This finding suggests the need for a careful metabolic assessment in patients known to form calcium stones in order to ensure stone recurrence prevention and cardiovascular protection.

Intensive post-operative follow-up of breast cancer patients with tumour markers: CEA, TPA or CA15.3 vs MCA and MCA-CA15.3 vs CEA-TPA-CA15.3 panel in the early detection of distant metastases

Background

In breast cancer current guidelines do not recommend the routine use of serum tumour markers. Differently, we observed that CEA-TPA-CA15.3 (carcinoembryonic (CEA) tissue polypeptide (TPA) and cancer associated 115D8/DF3 (CA15.3) antigens) panel permits early detection and treatment for most relapsing patients. As high sensitivity and specificity and different cut-off values have been reported for mucin-like carcinoma associated antigen (MCA), we compared MCA with the above mentioned tumour markers and MCA-CA15.3 with the CEA-TPA-CA15.3 panel.

Methods

In 289 breast cancer patients submitted to an intensive post-operative follow-up with tumour markers, we compared MCA (cut-off values, ≥ 11 and ≥ 15 U/mL) with CEA or CA15.3 or TPA for detection of relapse. In addition, we compared the MCA-CA15.3 and CEA-TPA-CA15.3 tumour marker panels.

Results

Distant metastases occurred 19 times in 18 (6.7%) of the 268 patients who were disease-free at the beginning of the study. MCA sensitivity with both cut-off values was higher than that of CEA or TPA or CA15.3 (68% vs 10%, 26%, 32% and 53% vs 16%, 42%, 32% respectively). With cut-off ≥ 11 U/mL, MCA showed the lowest specificity (42%); with cut-off ≥ 15 U/mL, MCA specificity was similar to TPA (73% vs 72%) and lower than that of CEA and CA15.3 (96% and 97% respectively). With ≥ 15 U/mL MCA cut-off, MCA sensitivity increased from 53% to 58% after its association with CA15.3. Sensitivity of CEA-TPA-CA15.3 panel was 74% (14 of 19 recurrences). Eight of the 14 recurrences early detected with CEA-TPA-CA15.3 presented as a single lesion (oligometastatic disease) (5) or were confined to bony skeleton (3) (26% and 16% respectively of the 19 relapses). With ≥ 11 U/mL MCA cut-off, MCA-CA15.3 association showed higher sensitivity but lower specificity, accuracy and positive predictive value than the CEA-TPA-CA15.3 panel.

Conclusion

At both the evaluated cut-off values serum MCA sensitivity is higher than that of CEA, TPA or CA15.3 but its specificity is similar to or lower than that of TPA. Overall, CEA-TPA-CA15.3 panel is more accurate than MCA-CA15.3 association and can "early" detect a few relapsed patients with limited metastatic disease and more favourable prognosis. These findings further support the need for prospective randomised clinical trial to assess whether an intensive post-operative follow-up with an appropriate use of serum tumour markers can significantly improve clinical outcome of early detected relapsing patients.

Large needle percutaneous aspiration biopsy of the testicle in men with nonobstructive azoospermia: technical performance

The aim of this study was to relate retrospectively in 215 percutaneous large needle aspiration biopsy (LNAB) of the testicles the number of seminiferous tubules (ST) per testicular biopsy, from differently sized testicles, to the size of the needle used in order to obtain information useful for selecting the needle size according to the testicular size. Clinical, ultrasonographic and pathologic data of 134 patients with nonobstructive azoospermia examined with LNAB were retrospectively analyzed. One hundred and sixty-three testicles with volume>or=10 ml, 39<10 ml and>or=6 ml, 13<6 ml underwent 215 LNABs. In the larger testicle group the prevalence of adequate biopsies (ST>/=20) varied from 83% to 50% with a statistically significant difference among the needle groups (P=0.028) and being 83% in the biopsies with the 18 gauge (g.) needle. The mean number of ST obtained with the 18 g. needle was significantly higher than that obtained with the other needles (P=0.000). In the medium volume testicle group the adequate biopsy incidence varied from 20% to 83.3% with statistical significance among the various needle groups (P=0.042) being 83.3% in the biopsies with the 22 g. needle. In the smaller testicle group the mean number of ST obtained with the 22 g. needle was significantly higher than with the 20 g. needle (71 versus 25, P=0.011). In the patients with nonobstructive azoospermia, the 18 g. needle seemed to offer the best performance in the larger testicles, while in the medium and lower sized testicles the smaller 22 g. needle gave results comparable to or slightly better than the other larger needles.

Diazepam administration prevents testosterone decrease and lipofuscin accumulation in testis of mouse exposed to chronic noise stress

Lipofuscin is an autofluorescent and undegradable material, which accumulates in tissues during ageing and under different types of stress. Among these, oxidative stress represents a major trigger for lipofuscin formation. However, prolonged noise exposure is also an effective stressful stimuli. Diazepam may inhibit lipofuscinogenesis in liver and prevent the noise-induced reduction of the steroidogenesis in the adrenal gland. The aim of the study was to ascertain whether chronic noise exposure causes lipofuscin accumulation in mouse testis, and to evaluate the effects of diazepam administration. Eight-week old mice were either exposed for 6 weeks (6 h day(-1)) to white-noise (group A), or received diazepam (3 mg kg(-1), i.p.) before noise exposures (group B), while a further group was used as control (group C). Light fluorescence and transmission electron microscopy revealed lipofuscin in large amounts in the Leydig cells in mice of group A, which concomitantly had low serum testosterone levels; pre-treatment with diazepam occluded both effects. The present study indicates that: (i) chronic noise exposure causes lipofuscin accumulation at the level of the Leydig cells and a decrease in testosterone; (ii) all these effects are suppressed by pre-treatment with diazepam. As the Leydig cells represent the only cellular type of the interstitial testicular tissue having peripheral benzodiazepine receptors, these results could be explained by the capacity of the peripheral benzodiazepine receptors to prevent reactive oxygen species damage and to increase the resistance of these cells to oxidative stress.

Cytokines in breast cancer

In recent decades many advances have occurred in the understanding of the role of cytokines in breast cancer. New signalling pathways of interleukin (IL)-1 family, IL-6, IL-11, IL-18, interferons (IFNs) and interferon regulatory factors 1 (IRF-1) and 2 (IRF-2) have been found within tumour microenvironments and in metastatic sites. Some cytokines (IL-1, IL-6, IL-11, TGFbeta) stimulate while others (IL-12, IL-18, IFNs) inhibit breast cancer proliferation and/or invasion. Similarly, high circulating levels of some cytokines seem to be favourable (soluble IL-2R) while others are unfavourable (IL-1beta, IL-6, IL-8, IL-10, IL-18, gp130) prognostic indicators. So far IL-2, IFNalpha, IFNbeta and occasionally IFNgamma, IL-6, IL-12 have been the cytokines used for anti tumour treatment of advanced breast cancer either to induce or increase hormone sensitivity and/or to stimulate cellular immunity. Disappointing results occurred in most trials; however, two long-term pilot studies suggest that IL-2 and IFNbeta, when used appropriately can have a positive effect on clinical benefit and overall survival of patients with minimal residual disease after chemotherapy or with disseminated disease controlled by conventional endocrine therapy.

Progress in the preoperative diagnosis of thyroid nodules: managing uncertainties and the ultimate role for molecular investigation

The preoperative evaluation of thyroid nodules currently relies on a clinical assessment of risk factors and an algorithm based on imprecise tests. With serum TSH, thyroid ultrasound and fine-needle aspiration (FNA) with or without ultrasound guide, accounting for the routine initial evaluation, indeterminate aspirates remain the major obstacle for confidently advising patients whether to have surgery or not. Recent clinical guidelines have attempted to settle various controversies but many inherent errors of clinical testing result in delayed diagnosis and unnecessary surgery. A better solution may ultimately involve the use of molecular markers of thyroid carcinogenesis but further research is still needed regarding the basic biology of thyroid cancer.

Effects of molecular weight and surface functionalization on surface composition and cell adhesion to Hyaluronan coated titanium

This paper describes the effect of surface functionalization on surface composition and cell adhesion to titanium samples by high and low molecular weight Hyaluronan (HA). HA was covalently linked to aminated Ti surfaces obtained by two different surface functionalization techniques, that is polyethyleneimine (PEI) adsorption and deposition from allylamine plasma. The two approaches yield very different surface densities of available amino groups, affecting this way the number and frequency of surface-HA bonds and the configurational freedom of the latter. Results of cell adhesion test are dependent on the surface functionalization approach adopted, low molecular weight HA coupled to PEI functionalized Ti does not yield the same degree of resistance to cell adhesion found on other samples. These results indicate that the details of the surface functionalization step are crucial for surface engineering of implant devices by biological molecules.

Electrochemotherapy a novel approach to the treatment of metastatic nodules on the skin and subcutaneous tissues

Electrochemotherapy (ECT) is a new treatment for metastatic nodules of solid tumors on the skin or subcutaneous tissue. ECT is a combination of a physical effect, cell membrane poration, and cytotoxic drug administration. Cell membrane poration is achieved by applying short intense electric filed pulses. Pore formation on the cell membrane allows low permeant drugs like bleomycin or cisplatin to enter the cell and thus locally increase their toxicity: up to 10.000 times for bleomycin and 80 times for cisplatin. ECT has been investigated in a multicenter study European Standard Operating Procedures for Electrochemotherapy (ESOPE) that demonstrates how by ECT over 80% of the cutaneous or subcutaneous metastatic nodules can be healed, thus confirming the results of previous studies. ECT efficacy is independent of tumor histology. The experience gathered in the ESOPE study allowed to prepare standard operating procedures that are key to the dissemination of the technology. ECT is safe effective, the treatment is completed in one session usually on an out-patient basis with minimum side-effects. ECT is cost-effective and, although palliative, it ameliorates patients' quality of life. ECT is the treatment of choice for tumors refractory to conventional treatment, can be used in form of cytoreductive therapy before conventional treatment for organ sparing and functions saving, finally can be adopted to treat hemorrhagic or painful nodules, it can be applied in previously irradiated areas.

Ambulatory blood pressure monitoring and endothelium-dependent vasodilation in the elderly athletes

AIM

Regular exercise is a key component of cardiovascular risk prevention strategies, because it is associated with a variety of beneficial metabolic and vascular effects that reduce mortality and the incidence of cardiovascular adverse events. Endothelium plays an important role in the local regulation of vascular tone and structure, mainly by nitric oxide (NO) synthesis and action. Aim of the present study was to evaluate in elderly athletes the effect of regular aerobic exercise on arterial blood pressure (BP) and on endothelium-dependent flow-mediated dilation (FMD) of the brachial artery.

METHODS

The study population included 30 male subjects (mean age 65.6+/-5.6 years), who had practiced endurance running at a competitive level for at least 40 years, and 28 age- and sex-matched subjects (mean age 64.5+/-4.5 years) with sedentary lifestyle and free of cardiovascular disease. Athletes and control subjects underwent standard 12-lead ECG, clinic BP, 24-h ambulatory BP monitoring and endothelium-dependent FMD and endothelium-independent response to glyceryl trinitrate (GTN), 400 microg, in the brachial artery by high-resolution ultrasonography.

RESULTS

Systolic clinic and ambulatory 24-h BP were significantly lower in the athletes, than in the controls (P<0.001, respectively). Systolic and diastolic 24-h BP variability, when assessed either by the standard deviation (S.D.), or by the coefficient of variation (CV), were also significantly lower in the athletes (P<0.01). The athletes also had a lower 24-h, day-time and night-time heart rate (HR) (P<0.01), as well as a lower HR variability (P<0.01). As regards circadian BP change, the %Delta was statistically significant greater in athletes (P<0.05). Elderly athletes showed higher FMD than elderly sedentary subjects (P<0.001), whereas no differences were shown in the response to GTN.

CONCLUSIONS

Our results, suggest that long-term physical activity can counteract the age-related endothelial dysfunction that characterizes sedentary aging, preserving the capacity of the endothelium-dependent vasodilation and reduces BP values improving arterial pressure control.

An in vitro study on the free radical scavenging capacity of ergothioneine: comparison with reduced glutathione, uric acid and trolox

BACKGROUND

Treatment of oxidative stress-related pathologies is a possible therapeutical strategy for the future. Natural product with antioxidant properties could trigger this goal. The aim of this in vitro study was to assess the antioxidant activity of the natural product ergothioneine (EGT), a compound of plant origin, which is assimilated and conserved by mammals in erythrocytes, kidney, seminal fluid and liver.

METHODS

We measured the antioxidant activity of EGT as its ability to antagonize the oxidation of alpha-keto-gamma-methiolbutyric acid (KMBA) by hydroxyl radical, peroxyl radicals and peroxynitrite. The results are expressed as total oxyradical scavenging capacity (TOSC) units. Glutathione (GSH), uric acid and 6-hydroxy-2,5,7,8-tetramethylchroman-2-carboxylic acid (trolox), the water-soluble analog of vitamin E, were used as the reference antioxidants.

RESULTS

EGT was the most active scavenger of free radicals as compared to classic antioxidants as GSH, uric acid and trolox. In particular, the highest antioxidant capacity exhibited by EGT vs. peroxyl radicals (5.53 +/- 1.27 units) resulted 25% higher than the value obtained with the reference antioxidant trolox (4.4 +/- 0.6 units, P < 0.01). The scavenging capacity of EGT towards hydroxyl radicals (0.34 +/- 0.09 units) was 60% higher, as compared to uric acid (0.21 +/- 0.04 units, P < 0.001), which represent the reference antioxidant vs. hydroxyl radicals. Finally, EGT showed the highest antioxidant activity also towards peroxynitrite (5.2 +/- 1.0 units), with a scavenging capacity 10% higher than that of uric acid (4.7 +/- 0.9 units, P < 0.05).

CONCLUSIONS

This study showed that EGT has potent intrinsic anti-hydroxyl, anti-peroxyl and anti-peroxynitrite radicals antioxidant activity, as compared to classic molecules with antioxidant capacity as GSH, trolox and uric acid. This appears of interest, given the increasing use of non-vitamins cocktails for therapeutical approaches to many oxidative-induced pathologies.

Sentinel node mapping and biopsy in thyroid cancer: a surgical perspective

The clinical role of sentinel node biopsy (SNB) in thyroid cancer remains an open matter in literature. The main reason of this fact is that nodal disease is considered a non-relevant prognostic factor by some authors in differentiated thyroid cancer (DTC). Aim of this study was to investigate the efficacy of radiocolloid lymphoscintigraphy and of hand held gamma probe procedure for SNB in patients with DTC and its potential clinical role. Forty-one consecutive pts with a small thyroid nodule highly suspected for malignancy at fine-needle aspiration cytology (FNAC) and without clinical and ultrasonographic (US) evidence of lymph node involvement entered the study. All patients underwent lymphoscintigraphy 3 hours before intervention using a 99mTc-nanocolloid solution. One single intratumoral injection of 4-9 MBq in 0.1-02 ml normal saline was obtained under US-guidance followed by a dynamic lymphoscintigraphy. After total thyroidectomy central and lateral compartments of the neck were scanned with a hand held gamma probe. The hottest node and any lymph node with a count rate of more than 10% of the hottest node were removed. SLNs were sent to frozen section analysis and a surgical enlargement of corresponding compartment was performed when at least one SLN was positive at histology. Preoperative lymphoscintigraphy was able to identify one node in six cases, two nodes in five cases, three nodes in 14 cases, four or more nodes in 16 cases. A papillary thyroid carcinoma (PTC) was diagnosed in 39 cases, a mixed papillary-medullary carcinoma in one case and a micro-follicular adenoma in one case. In 21/40 patients (pts) positive lymph nodes were found: in 16/21 patient one node showed micrometastasis only, in 5/21 patients more nodes were metastatic. In particular in 11 cases the first hottest node was involved (true SLN), in 10 cases a second or third hot lymph node was involved. In our preliminary experience lymphoscintigraphy with 99mTc-nanocolloid resulted highly sensitive: in fact at least one lymph node was visualized in all cases and the surgeon was able to detect by means of hand held probe during intervention al least one hot SLN in all cases. In 21/40 pts (more than 50% of cases) metastatic lymph nodes were found despite preoperative clinical and US examination negative for lymph node involvement. In prospective SLN technique might be proposed as a relevant tool in lymphoadenectomy decision in DTC patients with a small tumor.

Metastatic breast cancer: an updating

This article reports on recent advances on metastatic breast cancer. Detection, prognostic factors, predictors of response to therapy and therapy, with particular regard to targeted therapies, were examined.

DETECTION

Unlike current guidelines that yet do not routinely recommend intensive clinical-instrumental post-operative follow-up of breast cancer patients, relatively large data collected in the last decades have shown that an intensive post-operative follow-up with 'dynamic evaluation' of a suitable tumour marker panel precedes a few months as average the clinical and/or instrumental sign of a pending relapse in most relapsed patients and largely limits the use of the common instrumental examinations.

PROGNOSIS AND THERAPY PREDICTORS

Disease-free interval (DFI)<or=24 months, adjuvant chemotherapy, liver and distant soft tissue involvement or DFI>24 months and disease confined to bony skeleton are prognostic factors more often correlated with relatively poor or prolonged survival, respectively. Estrogen receptor (ER) expression in primary tumour and at the relapse correlates strongly with response to salvage hormone therapy and data from large trials showed that 38-59% of ER and/or PR+ post-menopausal patients had clinical benefit from first line tamoxifen or aromatase inhibitors. An inverse correlation of ER with epidermal growth factor receptor (EGFR) has been found. The co-expression of HER-2/neu and/or elevated serum HER-2/neu protein level were associated with a low rate and shorter duration of response of ER+ patients to first line hormone therapy. Accordingly, ER-EGFR- compared with ER-EGFR+ tumours are usually more responsive to endocrine therapy. High class III beta-tubulin expression or fall in insulin-like growth factor binding protein-3 (IGFBP-3) from baseline levels have been found to significantly predict resistance to chemotherapeutic agents.

THERAPY

Liposomes as carrier of doxorubicin (Caelix, Evacet, Myocet) is one approach to decrease the anthracycline-related cardiac toxicity. Weekly paclitaxel or docetaxel and oral formulation of vinorelbine and 5-fluorouracil (5-FU) (capecitabine) provide new effective and well tolerated options that reach greater dose intensity and cumulative dose than with the conventional schedules. As to the so called 'tailored' or targeted therapies, the more potent and highly selective third generation of aromatase inhibitors (letrozole, anastrozole, exemestane) targeting ER+ tumours by estrogen deprivation, challenge tamoxifen as current standard first line therapy in postmenopausals. One pilot study showed that stimulation of cellular immunity by the addition of beta-interferon-interleukin-2 sequence in patients on clinical benefit on first line tamoxifen significantly prolonged median overall survival (OS) and duration of response compared to that observed in similar patients only treated with tamoxifen. Trastuzumab, a humanised monoclonal antibody to extracellular domain of HER-2, plus conventional chemotherapy has become a standard of care for women with overexpressing HER-2 tumours. Bevacizumab is a recombinant humanised monoclonal antibody to vascular endothelial growth factor (VEGF) that in refractory metastatic breast cancer doubled the response rate of capecitabine although it did not affect survival. Finally, the so called 'oligometastatic' and a few stage IV diseases are conditions amenable to be rendered with no evidence of disease (NED) after local surgery and/or radiation. In both, as well as in complete responders to chemotherapy, minimal residual disease (m.r.d.) likely continues to be present. Recent data suggest that 'biological' therapy (immunomodulators and/or retinoids with or without hormone therapy), might be suitable to be successfully tested in these patients as maintenance treatment given soon after local intervention or chemotherapy.

Serum thyroglobulin measurement: clinical background and main methodological aspects with clinical impact

It is worldwide recognized that circulating thyroglobulin (Tg) measurement represents a fundamental tool in the follow-up of patients affected by differentiated thyroid cancer (DTC). In the last American and European Consensus Conferences, a surveillance guideline has been extended to the use of thyrotropin (TSH)-stimulated Tg levels for thyroidectomized patients without clinical evidence of residual tumor with Tg below 1 microg/l during TSH suppression. Therefore, sensitivity of the methods is critical to detect small amounts of Tg and/or to observe minimal changes in Tg concentration in the management of DTC patients. It has been proposed that only methods providing the greatest distinction between the lower limit of euthyroid reference range (approximately 3.0 microg/l) and the functional sensitivity limit (at least 1 microg/l) of the assay may offer a suitable clinical sensitivity for detecting small amounts of functioning thyroid tissue in TSH-suppressed state (1 g of normal thyroid tissue results in a serum Tg of approximately 1 microg/l when TSH is normal and about 0.5 microg/l when TSH is suppressed). In the last 30 years sensitivity of Tg measurements has been greatly improved, nowadays methods can achieve very good analytical and functional sensitivity to give reliable results also in the very low concentration range (between 0.1 and 1 microg/l). In addition, with the introduction of fully automated assays, results can be readily available to the clinician while patients are still in the ambulatory area. However, despite the large clinical use of Tg measurement, wide differences (by threefold) still remain between results produced in different laboratories due to poor standardization, heterogeneity of circulating Tg, interference from auto-antibodies, differences in the epitope recognition by antibodies used in the assays.

Magnetic shells for gastrointestinal endoscopic capsules as a means to control their motion

Wireless endoscopic video capsules are becoming largely used today for non-invasive explorations of the digestive tube. Traditional types of such capsules present a major drawback: their motion can not be controlled, since they proceed by means of the visceral peristalsis only. In order to enable a wireless control of their motion, this paper describes a new concept based on the use of external magnetic fields. The proposed technique exploits magnetic shells to be applied to traditional capsules prior to their use. The shells are capable of interacting with an imposed external magnetic field, providing a means to control the capsule movement and orientation. This solution is readily and cheaply applicable to any commercial endoscopic capsule, avoiding internal modifications. The paper reports results of preliminary bench tests. Prototype elastic shells made of a silicone elastomer mixed with magnetic particles were fabricated and tested with the Given Imaging M2A capsule in simplified experimental conditions. These tests permitted to demonstrate translations, rotations and roto-translations of the capsule/shell complex onto pieces of bovine tissues.

Effect of L-thyroxine treatment on left ventricular function in subclinical hypothyroidism

Aim of this study was to investigate the effects of thyroxine treatment on myocardial regional left ventricular (LV) systolic and diastolic function in patients with subclinical hypothyroidism (SH) by tissue Doppler imaging (TDI). Forty-two patients (29 women and 13 men; mean age 52.2+/-15.1 years) with SH, as judged by elevated serum thyroid-stimulating hormone (TSH) levels (>3.6 mIU/l; range, 3.8-12.0) and free thyroid hormones (FT4 and FT3) within the normal range, and 30 euthyroid volunteers (21 women and nine men; mean age 50.4+/-17.1 years) underwent standard echocardiography and TDI-derived early (Em) and late (Am) diastolic velocities, systolic (Sm) velocity, and isovolumetric relaxation time (IVRTm). Patients were randomly assigned to receive or not L-thyroxine replacement therapy. All patients returned after 6 months to repeat thyroid function tests and the evaluation of all parameters. No significant differences were seen in the Sm peak between SH and control groups. Respect to controls, SH patients exhibited a lower Em, a higher Am, and, subsequently, a reduced Em/Am ratio of both lateral wall (LW) and interventricular septum (IVS) (P<0.001 for both). The IVRTm was distinctly longer in SH patients, as compared to controls (P<0.001). At 6 months, L-thyroxine-treated patients showed a significant increase of Em (P<0.01) and a subsequent increase of the Em/Am ratio (P<0.01), whereas IVRTm significantly reduced (P<0.05). No significant change in any of these parameters was observed in the untreated group. Our data suggest that SH is associated with a subtle, reversible impairment of myocardial function. TDI analysis detects and extends these functional defects by displaying alterations in regional myocardial function. L-T4 replacement therapy should be advised for these patients with the aim to correct preclinical cardiac dysfunction and prevent the development of clinically significant myocardial dysfunction.

The investigation of skin blood flowmotion: a new approach to study the microcirculatory impairment in vascular diseases?

Skin blood flow oscillation, the so called flowmotion, is a consequence of the arteriolar diameter oscillations, i.e. vasomotion, and it is thought to play a critical role in favoring the optimal distribution of blood flow in the skin microvascular bed. Investigation of skin blood flowmotion, using spectral analysis of the skin laser Doppler flowmetry (LDF) signal, showed different flowmotion waves of endothelial, sympathetic or myogenic mediated vasomotion origin. Using this method in peripheral arterial obstructive disease (PAOD) patients an impairment of all the three flowmotion waves was found at level of the diseased leg following ischemia in the II stage of the disease and basally in critical limb ischemia. In patients with essential arterial hypertension (EHT) forearm skin blood flowmotion showed a post-ischemic impairment of myogenic and sympathetic components in newly diagnosed patients, and of endothelial and sympathetic components in long standing patients. In diabetic patients there was a selective impairment of skin flowmotion wave mediated by sympathetic activity in basal conditions. Investigation of skin blood flowmotion in response to different vasoactive substances demonstrated an important role of nitric oxide (NO) in controlling the endothelial component of vasomotion and an insulin action on smooth muscle cells of skin microvessels. All these data suggest that the study of skin blood flowmotion can become a method to early and easily detect skin microvascular impairment in vascular diseases and to investigate the mechanisms of substances active on skin microvascular bed.

Heart rate variability and QT dispersion in patients with subclinical hypothyroidism

The effect of subclinical hypothyroidism (SH) on cardiovascular autonomic function and ventricular repolarization has not been yet elucidated. The aim of the present study was to evaluate the dispersion of QT interval, i.e. an index of inhomogeneity of repolarization, and heart rate variability (HRV), i.e. a measure of cardiac autonomic modulation, in SH patients.

METHODS

The study included 42 patients (29 women and 13 men; mean age 53.2+/-14.2 years; body surface area 1.76+/-0.14 m2) with SH, as judged by elevated serum TSH levels (>3.6 mIU/l; range, 3.8-12.0) and normal free thyroid hormones (FT4 and FT3) and 30 euthyroid volunteer. Subjects with cardiac, metabolic, neurological disease or any other systemic disease that could affect autonomic activity were excluded from the study. Patients with SH and control subjects underwent a full history, physical examination, standard 12-lead ECG, and 24-h ambulatory ECG monitoring. To evaluate the effect of treatment with L-thyroxine on QT dispersion and HRV, 15 patients with SH were randomly assigned to receive therapy with L-thyroxine. All the subjects were evaluated at enrolment and after 6 months.

RESULTS

Patients with SH showed higher QT dispersion and lower HRV measures than healthy controls (P<0.01 for all). In SH patients, the standard deviation of N-Ns (SDNN) was negatively related to TSH (r=-0.42, P=0.006), while low frequency (LF)/high frequency (HF) ratio was positively related to TSH (r=0.42, P=0.006). Moreover, in SH patients both QT dispersion and QTc dispersion were positively related to TSH (r=0.64 and r=0.63, P<0.001 for both). After 6 months, the patients treated with L-tiroxine exhibited a reduction of QT dispersion and an increase of HRV parameters.

CONCLUSION

The results of the present study demonstrated that SH can alter autonomic modulation of heart rate and cause increased inhomogeneity of ventricular recovery times. Accordingly, early L-thyroxine treatment may be advised not only to prevent progression to overt hypothyroidism but also to improve abnormal cardiac autonomic function and ventricular repolarization inhomogeneity.