Adverse effects of sodium-glucose cotransporter-2 inhibitors in patients with heart failure: a systematic review and meta-analysis

Sodium-glucose cotransoporter-2 inhibitors (SGLT-2Is) improve prognosis in heart failure (HF) patients both with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). However, these drugs can have some side effects. To estimate the relative risk of side effects in HF patients treated with SGLT-2Is irrespective from left ventricular EF and setting (chronic and non-chronic HF). Five randomized controlled trials (RCTs) enrolling patients with HFrEF, 4 RCTs enrolling non-chronic HF, and 3 RCTs enrolling HFpEF were included. Among side effects, urinary infection, genital infection, acute kidney injury, diabetic ketoacidosis, hypoglycemia, hyperkalemia, hypokalemia, bone fractures, and amputations were considered in the analysis. Overall, 24,055 patients were included in the analysis: 9020 (38%) patients with HFrEF, 12,562 (52%) with HFpEF, and 2473 (10%) with non-chronic HF. There were no differences between SGLT-2Is and placebo in the risk to develop diabetic ketoacidosis, hypoglycemia, hyperkalemia, hypokalemia, bone fractures, and amputations. HFrEF patients treated with SGLT-2Is had a significant reduction of acute kidney injury (RR = 0.54 (95% CI 0.33-0.87), p = 0.011), whereas no differences have been reported in the HFpEF group (RR = 0.94 (95% CI 0.83-1.07), p = 0.348) and non-chronic HF setting (RR = 0.79 (95% CI 0.55-1.15), p = 0.214). A higher risk to develop genital infection (overall 2.57 (95% CI 1.82-3.63), p < 0.001) was found among patients treated with SGLT-2Is irrespective from EF (HFrEF: RR = 1.96 (95% CI 1.17-3.29), p = 0.011; HFpEF: RR = 3.04 (95% CI 1.88-4.90), p < 0.001). The risk to develop urinary infections was increased among SGLT-2I users in the overall population (RR = 1.13 (95% CI 1.00-1.28), p = 0.046) and in the HFpEF setting (RR = 1.19 (95% CI 1.02-1.38), p = 0.029), whereas no differences have been reported in HFrEF (RR = 1.05 (95% CI 0.81-1.36), p = 0.725) and in non-chronic HF setting (RR = 1.04 (95% CI 0.75-1.46), p = 0.806). SGLT-2Is increase the risk of urinary and genital infections in HF patients. In HFpEF patients, the treatment increases the risk of urinary infections compared to placebo, whereas SGLT-2Is reduce the risk of acute kidney disease in patients with HFrEF.

Techno-Economic Analysis and Life Cycle Assessment of High-Velocity Oxy-Fuel Technology Compared to Chromium Electrodeposition

Due to the toxicity associated with chromium electrodeposition, alternatives to that process are highly sought after. One of those potential alternatives is High Velocity Oxy-Fuel (HVOF). In this work, a HVOF installation is compared with chromium electrodeposition from environmental and economic points of view by using Life Cycle Assessment (LCA) and Techno-Economic Analysis (TEA) for the evaluation. Costs and environmental impacts per piece coated are then evaluated. On an economic side, the lower labor requirements of HVOF allow one to noticeably reduce the costs (20.9% reduction) per functional unit (F.U.). Furthermore, on an environmental side, HVOF has a lower impact for the toxicity compared to electrodeposition, even if the results are a bit more mixed in other impact categories.

C64 UNMASKING THE PREVALENCE OF AMYLOID CARDIOMYOPATHY IN THE REAL WORLD: RESULTS FROM PHASE 2 OF AC–TIVE STUDY, AN ITALIAN NATIONWIDE SURVEY

Background

Clinicians need to identify patients with amyloid cardiomyopathy (AC) at an early stage, due to the availability of disease–modifying therapies. Some echocardiographic findings may rise the suspicion of AC, also in patients with mild or no symptoms, addressing second level diagnostic tests.

Aim

To investigate the prevalence of AC in consecutive patients ≥55 years undergoing clinically indicated, routine transthoracic echocardiogram in Italy and presenting echocardiographic signs suggestive of AC.

Methods

This is a prospective multicentric study conducted in Italy. It comprises two phases: 1) a recording phase consisting in a national survey on prevalence of possible echocardiographic red flags of AC in consecutive unselected patients ≥55 years undergoing routine echocardiogram (previously published) and 2) an AC diagnostic phase involving a diagnostic work–up for AC to investigate AC prevalence among patients with at least one echocardiographic red flag (herein presented). Patients that in Phase 1 presented an “AC suggestive” echocardiogram (i.e., at least one red flag of AC in hypertrophic, non–dilated left ventricles with preserved ejection fraction) underwent clinical evaluation, blood and urine tests and scintigraphy with bone tracer. Diagnosis of transthyretin related–AC (ATTR–AC) was made in presence of grade 2–3 Perugini uptake at scintigraphy and absence of monoclonal protein. The study was registered at ClinicalTrials.gov (#NCT04738266).

Results

Of the 5315 screened echocardiograms, 381 exams (7.2%) were classified as “AC suggestive” and proceeded to Phase 2. 217 patients completed Phase 2 investigations. Main reasons for the 164 non–entering patients into Phase 2 were death (n = 49) and refusal to participate (n = 66). A final diagnosis of AC was made in 62 patients with an estimated prevalence of 28,6% (95% CI: 22,5%–34,7%). ATTR–AC was diagnosed in 51 and AL–AC in 11 patients, ascertaining a prevalence of 23,5% (95% CI: 17,8%–29,2%) and 5,1% (95% CI: 2,2%–8,0%), respectively.

Conclusion

Among a cohort of consecutive unselected patients ≥55 years with echocardiographic findings suggestive of AC, the prevalence of AC ranged from 23% up to 35%. Although ATTR–AC was predominant, AL–AC was diagnosed in a significant number of cases. Echocardiography has a fundamental role in screening patients, raising the suspicion of disease and orienting diagnostic work–up for AC.

Appropriate admission to rehabilitation: definition of a set of criteria through the Delphi Method

Background

Controlling inappropriateness of care, a widespread phenomenon, should be a global target in order to improve the quality of care, save money and ensure system sustainability. Inappropriateness is a relevant issue in public health and in rehabilitation medicine specifically. In fact, admitting a patient to a rehabilitation hospital or unit is a complex decision also due to the absence of shared and objective admission criteria. Aim of this study is to define clinical admission criteria and rules in rehabilitation medicine.

Methods

A three-round Delphi survey was conducted on a sample of rehabilitation medicine experts skilled in both rehabilitation and healthcare organization. The two initial rounds consisted of an electronic online questionnaire concerning appropriateness of admission to intensive rehabilitation while in the third one a report of the results was provided to the participants. The experts had to score their agreement with each item in the questionnaires, based on either a Likert scale or a dichotomous statement. Consensus between the experts was assessed.

Results

A total of 53 health professionals completed the Delphi survey. 19 out of 20 Italian regions were represented. The first round consisted of 8 multiple-choice questions questionnaire. The second round was designed thanks to the suggestions provided by the panelists in the previous one and consisted of a twelve items questionnaire. At the end of the survey, eight criteria of appropriateness of admission to rehabilitation were identified and five rules defining an appropriate admission to a rehabilitation facility were elaborated.

Conclusions

This study represents an attempt to create a worthwhile and reliable tool for a more conscious clinical practice in admission to rehabilitation, based on a set of shared criteria and rules.

Key messages

Improving appropriateness in healthcare delivery must be a primary goal in public health and in rehabilitation medicine specifically. Delphi method was applied to define shared clinical admission criteria and rules in rehabilitation.

Evidence-Based Medicine and Clinical Practice: the first Italian attempt to define the appropriateness of rehabilitation admission criteria through the application of the Delphi method

BACKGROUND

One of the consequences of today's global economic crisis is the need to control healthcare spending, in particular by improving the level of appropriateness. Thus, admission to rehabilitation has become an issue, especially as regards inappropriateness of resource allocation. The scientific literature suggests that more attention should be paid to the problem of clinical appropriateness in order to better identify the patients' actual needs. For the first time in Italy, this study aims at defining the appropriateness of intensive rehabilitation admission criteria through use of the Delphi method involving a panel of national experts.

MATERIAL AND METHODS

A three-round Delphi survey was conducted according to international guidelines. Electronic questionnaires were individually sent via e-mail to ensure the participants' anonymity throughout the process. Questions were mostly based on rehabilitation literature.

RESULTS

During the Delphi process, a total of 79 items were submitted to a heterogenous panel of rehabilitation experts who were asked to express their level of agreement to the item contents on a five-point Likert scale. At the end of the survey, a list of 19 appropriate criteria for admission to intensive rehabilitation facilities and 21 reasons for inappropriateness was drawn up.

CONCLUSION

This study represents the first attempt in Italy to define shared and objective appropriateness criteria for admission to intensive rehabilitation. Out of the total number of experts invited to participate (31), only 16 completed the entire survey. This poor participation rate unfortunately demonstrates the lack of awareness among Italian rehabilitation professionals, which is a further sign of both the scarcity of scientific evidence in this area and the need to reach consensus on admission criteria.

Efficacy of self-administered complex decongestive therapy on breast cancer-related lymphedema: a single-blind randomized controlled trial

PURPOSE

After surgery, breast cancer-related lymphedema (BCRL) is a frequent chronic condition. The complex decongestive therapy (CDT) delivered by physiotherapists at hospitals is the state-of-the-art treatment choice. As lymphedema requires continuous management, we designed a 1-month-long course to train women to professionally carry out a self-administered CDT (saCDT) and tested its efficacy while keeping the benefits of CDT.

METHODS

Consecutive patients treated with CDT over a 1-year period at an Italian facility were randomly assigned to either experimental (EXP, saCDT course) or control (CTRL, usual care) group. Women were assessed before, at 1, and 6 months from enrolment. Pain assessed by the numerical pain rating scale (NPRS) was the primary outcome. Arm asymmetry assessed by the excess limb volume (ELV) was the secondary outcome. Outcome variations were compared to their MCID to classify women as improved, stable, or worsened.

RESULTS

Forty-one women were included. The proportion of stable or improved women was significantly different between EXP and CTRL groups at 6 months after enrolment for both arm pain (p = 0.01) and asymmetry (p < 0.01). Noteworthy, only one EXP woman had worsened after 6 months. NPRS significantly decreased in the EXP group only, with a median variation of 2 points. Arm ELV significantly decreased with respect to the baseline value in the EXP group only, with a median reduction of 8%.

CONCLUSIONS

Teaching saCDT to women with BCRL is effective in maintaining or improving the benefits of CDT and can be used as a self-care tool in the management of BCRL.

Boron nitride nanomaterials: biocompatibility and bio-applications

Boron nitride has structural characteristics similar to carbon 2D materials (graphene and its derivatives) and its layered structure has been exploited to form different nanostructures such as nanohorns, nanotubes, nanoparticles and nanosheets.

A statistical approach to discriminate between non-fallers, rare fallers and frequent fallers in older adults based on posturographic data

BACKGROUND

Identification of future non-fallers, infrequent and frequent fallers among older people would permit focusing the delivery of prevention programs on selected individuals. Posturographic parameters have been proven to differentiate between non-fallers and frequent fallers, but not between the first group and infrequent fallers.

METHODS

In this study, postural stability with eyes open and closed on both a firm and a compliant surface and while performing a cognitive task was assessed in a consecutive sample of 130 cognitively able elderly, mean age 77(7)years, categorized as non-fallers (N=67), infrequent fallers (one/two falls, N=45) and frequent fallers (more than two falls, N=18) according to their last year fall history. Principal Component Analysis was used to select the most significant features from a set of 17posturographic parameters. Next, variables derived from principal component analysis were used to test, in each task, group differences between the three groups.

FINDINGS

One parameter based on a combination of a set of Centre of Pressure anterior-posterior variables obtained from the eyes-open on a compliant surface task was statistically different among all groups, thus distinguishing infrequent fallers from both non-fallers (P<0.05) and frequent fallers (P<0.05).

INTERPRETATION

For the first time, a method based on posturographic data to retrospectively discriminate infrequent fallers was obtained. The joint use of both the eyes-open on a compliant surface condition and this new parameter could be used, in a future study, to improve the performance of protocols and to verify the ability of this method to identify new-fallers in elderly without cognitive impairment.

Upper limb evaluation with robotic exoskeleton. Normative values for indices of accuracy, speed and smoothness

BACKGROUND

Robotic rehabilitation devices for upper limb function (ULF) provide global indicators of a patient's ability, but the temporal evolution of motion related to motor control is disregarded.

OBJECTIVE

To determine normative values for indices of accuracy, speed and smoothness in the evaluation of upper limb function.

METHODS

Twenty-five healthy individuals performed the Armeo®Spring device "Vertical Capture" task. Custom stand-alone software was developed to provide the following indices: global Hand Path Ratio (HPR), local HPR in the target area (locHPR), vertical and horizontal overshoot (vertOS, horOS), maximum and mean velocity (maxVel, meanVel), mean/maximum velocity, number of peaks in velocity profiles (NVelPeaks) and normalized jerk (NormJerk). The dependence of indices on task characteristics was analyzed by an ANCOVA test. Indices inner relationships were assessed by a correlation and a factor analysis. Normative values were then provided.

RESULTS

4,268 single reaching movements were analyzed. Four indices were not affected by movement direction. Indices were minimally influenced by the difficulty level. Based upon correlation and factor analysis indices and can be grouped into three assessment fields, dealing with precision, velocity and smoothness.

CONCLUSIONS

We have developed a tool to assess ULF in dynamic condition. Normative values were obtained to be used as references in assessing patients.

[Lung eosinophilic syndrome: clinical presentation and cases report]

INTRODUCTION

Pulmonary eosinophilia syndrome is characterized by a group of diseases that present clinical-radiological conditions, pulmonary eosinophilia or peripheral lung parenchyma in its evolution. We described the clinical and radiological presentation.

METHODS

Retrospective descriptive analysis of medical records of 7 patients between 2007 and 2010.

RESULTS

The highest numbers of cases were observed in women, with peripheral eosinophilia with values between 550 and 10,000 cells/mm3. The more frequent signs and symptoms were cough, dyspnea, fever and wheezing. The more prevalent radiological findings were alveolar interstitial and alveolar pattern. At CT scan, the most frequent pattern was ground glass. The main diagnoses made were acute and chronic eosinophilic pneumonia in equal proportions, both with response to steroids.

CONCLUSIONS

The pulmonary eosinophilia syndrome shares common features with clinical and radiological entities most prevalent, particularly community-adquired pneumonia.

High evolutionary dynamism in 5S rDNA of fish: state of the art

The 5S ribosomal DNA (rDNA) consists of one transcriptional unit of about 120 base pairs, which is separated from the next unit by a non-transcribed spacer (NTS). The coding sequence and the NTS together form a repeat unit which can be found in hundreds to thousands of copies tandemly repeated in the genomes. The NTS regions seem to be subject to rapid evolution. The first general model of evolution of these multigene families was referred to as divergent evolution, based on studies using hemoglobin and myoglobin as model systems. Later studies showed that nucleotide sequences of different multigene family members are more closely related within species than between species. This observation led to a new model of multigene family evolution, termed concerted evolution. Another model of evolution, named the birth-and-death model, has been found to be more suitable to explain the long-term evolution of these multigene families. According to this model, new genes originate by successive duplications, and these new genes are either maintained for a long time or are lost, or else degenerate into pseudogenes. In this review we describe different sources of variability in the 5S rDNA genes observed in several distinct fish species. This variability is mainly referred to NTSs and includes the presence of other multigene families (mainly LINEs, SINEs, non-LTR retrotransposons, and U snRNA families). Different types of microsatellites have also been found to contribute to the increase of variability in this region. Our recent results suggest that horizontal transfer contributes to the increase of diversity in the NTSs of some species. Variability in the 5S rDNA coding region affecting the stability of the structure, but without effects on the function of the 5S rRNA, is also described. Retrotransposons seem to be responsible for the high dynamism of 5S rDNA, while microsatellites acting as recombination hot spots could stabilize a wide variety of unusual DNA structures, affecting DNA replication and enhancing or decreasing promoter activity in gene expression. The relationship between the high variability found at molecular level and the low variability found at chromosomal level is also discussed.

Inter-laboratory consistency of gait analysis measurements

The dissemination of gait analysis as a clinical assessment tool requires the results to be consistent, irrespective of the laboratory. In this work a baseline assessment of between site consistency of one healthy subject examined at 7 different laboratories is presented. Anthropometric and spatio-temporal parameters, pelvis and lower limb joint rotations, joint sagittal moments and powers, and ground reaction forces were compared. The consistency between laboratories for single parameters was assessed by the median absolute deviation and maximum difference, for curves by linear regression. Twenty-one lab-to-lab comparisons were performed and averaged. Large differences were found between the characteristics of the laboratories (i.e. motion capture systems and protocols). Different values for the anthropometric parameters were found, with the largest variability for a pelvis measurement. The spatio-temporal parameters were in general consistent. Segment and joint kinematics consistency was in general high (R2>0.90), except for hip and knee joint rotations. The main difference among curves was a vertical shift associated to the corresponding value in the static position. The consistency between joint sagittal moments ranged form R2=0.90 at the ankle to R2=0.66 at the hip, the latter was increasing when comparing separately laboratories using the same protocol. Pattern similarity was good for ankle power but not satisfactory for knee and hip power. The force was found the most consistent, as expected. The differences found were in general lower than the established minimum detectable changes for gait kinematics and kinetics for healthy adults.

A method to differentiate the causes of stiff-knee gait in stroke patients

Stiff-knee gait (SKG) is a common abnormal gait pattern in patients after stroke characterized by insufficient knee flexion (KF) during swing. Overactivity of the rectus femoris (RF) is considered the primary cause of SKG. Inadequate push-off has been indicated as an additional cause in the recent literature, as KF depends on knee flexion velocity in preswing (KFV). We used the peak of vertical acceleration of the malleolus (PMVA) as a kinematic-based indirect measure of push-off and studied its relationship with KF and KFV in a sample of 20 healthy subjects walking fast (v = 95 ± 5%heights(-1)), at self-selected speed (v = 74 ± 5%heights(-1)), slow (v = 54 ± 6%heights(-1)) and very slow (v = 38 ± 5%heights(-1)) and in a sample of 52 stroke patients with SKG (age 60 ± 11, v = 20 ± 11%heights(-1)). In healthy subjects PMVA occurred before knee flexion acceleration (p<0.001) and hip flexion acceleration (p<0.001). KF appeared as a bottom-up mechanism driven by the ankle push-off. From a regression analysis, the PMVA-KFV cause-effect relationship resulted strictly linear, with R(2) = 0.967, KFV = 0+7.1×PMVA, P<0.0001. Data from SKG patients were compared to this normal cause-effect model. For 44/52 patients the reduced KFV was combined with lack of push-off. Data from 8/52 patients only were statistically outside the 95%CI of the model, thus requiring for a braking mechanism to explain KFV reduction. In stroke adults of our sample the push-off impairment (85% of cases) and not the inappropriate knee extension moment produced by the thigh muscles was the primary cause of SKG. This result could explain the low average efficacy (<10°) of focal and surgical treatments at the quadriceps. The presented model could be used to differentiate the primary cause of SKG between inadequate push-off and braking activity of the thigh muscles, thus increasing the effectiveness of the selected treatment.

Constitutive Notch2 signaling in neural stem cells promotes tumorigenic features and astroglial lineage entry

Recent studies identified a highly tumorigenic subpopulation of glioma stem cells (GSCs) within malignant gliomas. GSCs are proposed to originate from transformed neural stem cells (NSCs). Several pathways active in NSCs, including the Notch pathway, were shown to promote proliferation and tumorigenesis in GSCs. Notch2 is highly expressed in glioblastoma multiforme (GBM), a highly malignant astrocytoma. It is therefore conceivable that increased Notch2 signaling in NSCs contributes to the formation of GBM. Here, we demonstrate that mice constitutively expressing the activated intracellular domain of Notch2 in NSCs display a hyperplasia of the neurogenic niche and reduced neuronal lineage entry. Neurospheres derived from these mice show increased proliferation, survival and resistance to apoptosis. Moreover, they preferentially differentiate into astrocytes, which are the characteristic cellular population of astrocytoma. Likewise, we show that Notch2 signaling increases proliferation and resistance to apoptosis in human GBM cell lines. Gene expression profiling of GBM patient tumor samples reveals a positive correlation of Notch2 transcripts with gene transcripts controlling anti-apoptotic processes, stemness and astrocyte fate, and a negative correlation with gene transcripts controlling proapoptotic processes and oligodendrocyte fate. Our data show that Notch2 signaling in NSCs produces features of GSCs and induces astrocytic lineage entry, consistent with a possible role in astrocytoma formation.

Delayed onset of electromyographic activity of vastus medialis obliquus relative to vastus lateralis in subjects with patellofemoral pain syndrome

Patellofemoral Pain Syndrome (PFPS) is a common musculoskeletal complaint. The presence of a delay between vastus medialis obliquus (VMO) and vastus lateralis (VL) muscle onset has been suggested in the literature as a possible cause of PFPS, with poor agreement amongst authors on the value of the delay. In this study we computed the delay in the activation of VMO and VL in 15 PFPS patients and 20 age-matched controls (Ctrls) during the following tasks: sit to stand, stand to sit, squat, step up and step down. Activation instants were detected from surface EMG data by a double-threshold statistical detector. In order to compare the muscle activity throughout the task, we computed the delay between the instants in which the VMO and VL normalised envelopes reached subsequent normalised amplitude levels, until the envelope peak. In all investigated tasks but sit to stand, the onset delay was lower or equal then 0.02s, without group differences. Similarly, no differences between Ctrls and PFPS timing were found throughout all tasks, until the peak. Our results do not support the hypothesis that an onset delay between VMO and VL can be one of the causes of PFPS.

Botulinum toxin type A versus phenol. A clinical and neurophysiological study in the treatment of ankle clonus

AIM

To reduce ankle clonus in patients with spastic paresis either phenol nerve block of the tibialis posterior nerve or botulinum toxin type A (BTA) injection in triceps surae muscles can be used. This study aims to compare the efficacy over time of phenol nerve block and BTA injection in the inhibition of ankle clonus.

METHODS

Twenty-two patients with spastic paresis presenting with ankle clonus were randomly treated with phenol nerve block of the tibialis posterior nerve or BTA injection in triceps surae muscles. Ankle passive dorsiflexion, clonus, M and H responses and H/M ratio were measured in all patients prior to treatment and 15 days afterwards, as well as one, three and six months later in 12 patients. Patient satisfaction was also recorded.

RESULTS

Both patient groups showed significant clonus reduction over time with the effect of phenol being greater than that of BTA. In one month, the degree of passive dorsiflexion significantly increased in both groups without any significant difference between them. H/M ratio reduced after phenol treatment and remained almost constant during the following six months, whereas it remained at baseline level after BTA treatment.

CONCLUSION

While both treatments led to reduction in ankle clonus, phenol showed greater clinical efficacy. The difference in the neurophysiological results suggests that the two drugs have different action mechanisms with a more prevalent reduction of alpha motoneuron excitability in phenol-treated patients.

Inherited cavernous malformations of the central nervous system: clinical and genetic features in 19 Swiss families

Cavernous malformations (CCMs) are benign, well-circumscribed, and mulberry-like vascular malformations that may be found in the central nervous system in up to 0.5% of the population. Cavernous malformations can be sporadic or inherited. The common symptoms are epilepsy, hemorrhages, focal neurological deficits, and headaches. However, CCMs are often asymptomatic. The familiar form is associated with three gene loci, namely 7q21-q22 (CCM1), 7p13-p15 (CCM2), and 3q25.2-q27 (CCM3) and is inherited as an autosomal dominant trait with incomplete penetrance. The CCM genes are identified as Krit 1 (CCM1), MGC4607 (CCM2), and PDCD10 (CCM3). Here, we present the clinical and genetic features of CCMs in 19 Swiss families. Furthermore, surgical aspects in such families are also discussed.

Acute paraplegia after myelography: decompensation of a herniatad thoracic disc

A 71-year-old patient presented with low back pain and slowly progressive weakness of both legs. Within a few hours after lumbar myelography, paraplegia below level L2 evolved. MR-imaging revealed a discogenic stenosis at level Th10/11. Immediate decompression by costo-transversectomy led to reversal of the neurological deficits.

Effect of electrode location on EMG signal envelope in leg muscles during gait

The aim of the study was to assess the variability of EMG signal envelope with electrode location during gait. Surface EMG signals were recorded from 10 healthy subjects from the tibialis anterior (TA), peroneus longus (PL), gastrocnemius medialis (GM), gastrocnemius lateralis (GL), and soleus (SO) muscles. From TA, PL, GL and GM, signals were acquired using a two-dimensional grid of 4 x 3 electrodes (10 x 15 mm in size, as used in most gait laboratories) with 20-mm interelectrode distance in both directions. A similar grid of 3 x 3 electrodes was used for SO. EMG envelope was characterized by its peak value, area after normalization by the peak value, and time instant corresponding to the maximum. The maximum relative change in peak value with electrode location, expressed as a percentage of the peak value in the central location, was (mean+/-SD) 31+/-18% for TA, 29+/-13% for PL, 25+/-15% for GL, 14+/-8% for GM, and 26+/-14% for SO. The maximum relative change in area was 29+/-13% for TA, 73+/-40% for PL, 31+/-23% for GL, 35+/-20% for GM, 20+/-13% for SO, and in the position of maximum, computed as distance from the maximum position in the central channel, it was 5+/-10% of the gait cycle for TA, 26+/-16% for PL, 3+/-2% for GL, 3+/-1% for GM, 3+/-3% for SO. A crosstalk index, defined on the basis of the expected intervals of muscle activation for healthy subjects, indicated that estimated crosstalk was present between TA and PL, in an amount which depended on electrode location. It was concluded that the estimate of muscle activation intensity during gait from surface EMG is variable with location of the electrodes while timing of muscle activity is more robust to electrode displacement and can be reliably extracted in those cases in which crosstalk is limited. These results are valid for healthy subjects, where the level of muscular activity during gait is much lower than maximum.

Carcinoma broncogênico primário em felino. Relato de caso

O artigo não apresenta resumo.

Múltiplos sarcomas atípicos recidivantes em um felino. Relato de caso

O artigo não apresenta resumo.

Hipertemia não pirogênica. Relato de casos

O artigo não apresenta resumo.

Linfoma felino de grandes grânulos. Relato de caso

O artigo não apresenta resumo.

Comparing monoclonal antibodies and small peptidic hormones for local targeting of malignant gliomas

Monoclonal antibodies, F(ab')2 fragments and peptidic vectors have been clinically tested for systemic and locoregional treatment of malignant gliomas. Since these brain-intrinsic neoplasms are characterized by relentless tumor cell infiltration of normal brain parenchyma, targeting agents require diffusive properties in order to reach invading tumor cell clusters that migrate along vascular clefts and axonal pathways. Tumor uptake was significantly improved by using small peptidic hormone receptors, e.g. modified octreotide, following systemic injections as compared to macromolecules which only led to limited stabilization of the disease. More importantly, biodistribution was found to be superior following direct intratumoral injection by using these small drug-like radioconjugates. Rapid and extensive distribution within 30 minutes was observed in large tumors, even crossing the corpus callosum in bihemispheric lesions following injection of 2-3 ml of the radiopharmakon injected into the center of non-resected tumors. Distribution was far more extensive after direct intratumoral injection as compared to intracavitary injection after surgical debulking. Increased interstitial pressure gradients and the much larger and chaotic structure of the interstitial space of a tumor compared to the extremely tight architecture of normal brain tissue might explain this unexpected biodistribution pattern. Peptidic hormone vectors might become useful agents to deliver radiopharmaceuticals into human invasive gliomas.

Local injection of the 90Y-labelled peptidic vector DOTATOC to control gliomas of WHO grades II and III: an extended pilot study

We have previously presented preliminary observations on targeting somatostatin receptor-positive malignant gliomas of all grades by local injection of the radiolabelled peptidic vector 90Y-DOTATOC. We now report on our more thorough clinical experience with this novel compound, focussing on low-grade and anaplastic gliomas. Small peptidic vectors have the potential to target invisible infiltrative disease within normal surrounding brain tissue, thereby opening a window of opportunity for early intervention. Five progressive gliomas of WHO grades II and III and five extensively debulked low-grade gliomas were treated with varying fractions of 90Y-DOTATOC. The vectors were locally injected into the resection cavity or into solid tumour. The activity per single injection ranged from 555 to 1,875 MBq, and the cumulative activity from 555 to 7,030 MBq, according to tumour volumes and eloquence of the affected brain area, yielding dose estimates from 76+/-15 to 312+/-62 Gy. Response was assessed by the clinical status, by steroid dependence and, every 4-6 months, by magnetic resonance imaging and fluorine-18 fluorodeoxyglucose positron emission tomography. In the five progressive gliomas, lasting responses were obtained for at least 13-45 months without the need for steroids. Radiopeptide brachytherapy had been the only modality applied to counter tumour progression. Interestingly, we observed the slow transformation of a solid, primarily inoperable anaplastic astrocytoma into a resectable multi-cystic lesion 2 years after radiopeptide brachytherapy. Based on these observations, we also assessed the feasibility of local radiotherapy following extensive debulking, which was well tolerated. Targeted beta-particle irradiation based on diffusible small peptidic vectors appears to be a promising modality for the treatment of malignant gliomas.

[Treatment of brain metastases]

The treatment of metastastic disease to the brain requires integration of neurosurgical, radiotherapeutic and oncological principles. Surgical resection is mandatory if a brain tumor manifests as an apparently unifocal lesion of a newly discovered neoplastic disorder. Furthermore, surgery is to be selected to alleviate signs and symptoms of increased intracranial pressure which can be caused by a mass effect and/or by obstruction of the CSF pathways. With regard to local tumor control of a single brain metastasis, resection followed by whole brain irradiation has proven superior to radiotherapy alone. Alternatively, a brain metastasis with a diameter of less than 3 cm can also be treated with Gamma-knife radio-surgery, a therapeutic modality that has also proven valuable in the control of multiple brain metastases and for local control following resection. Sometimes, local control can also be improved with a boost of conventional external beam radiotherapy onto a pre-irradiated site. Multiple brain metastases with lesions displaying a diameter of more than 3 cm not well suited for resection can also be treated with whole brain radiotherapy. Occasionally, a chemoresponsive tumor can be controlled with cytotoxic drugs. In conclusion, a carefully tailored therapeutic strategy can be very rewarding for both the patient and the specialists involved that definitively improves the quality of life by extending progression-free survival.

Successful diffusible brachytherapy (dBT) of a progressive low-grade astrocytoma using the locally injected peptidic vector and somatostatin analogue [90Y]-DOTA0-D-Phe1-Tyr3-octreotide (DOTATOC)

We present the therapeutic effect of diffusible brachytherapy (dBT), an innovative approach for the management of symptomatic low grade gliomas [1]. This protocol uses a radiolabelled small diffusible peptidic vector which is a somatostatin analogue to target somatostatin type 2 (sst-2) receptors. The stable radioconjugate [90Y]-DOTA0-D-Phe1-Tyr3-octreotide (DOTATOC) is repeatedly injected via catheters placed into the resection cavity or into tumour nodules. We report on the four year follow-up after initiation of dBT to treat progressive disease in a patient with a complex eleven year history of fibrillary low-grade astrocytoma. The radiopharmakon was not only locally injected into the resection cavity following debulking surgery, but also administered by slow infusion technique to target recurrent and infiltrative tumour zones in the subventricular region around the inferior and posterior horns. In conclusion, peptidic vector based dBT was found to be safe, of mild and transitory toxicity, and effective in long-term tumour control.

Successful diffusible brachytherapy (dBT) of a progressive low-grade astrocytoma using the locally injected peptidic vector and somatostatin analogue [90Y]-DOTA0-D-Phe1-Tyr3-octreotide (DOTATOC)

We present the therapeutic effect of diffusible brachytherapy (dBT), an innovative approach for the management of symptomatic low grade gliomas [1]. This protocol uses a radiolabelled small diffusible peptidic vector which is a somatostatin analogue to target somatostatin type 2 (sst-2) receptors. The stable radioconjugate [90Y]-DOTA0-D-Phe1-Tyr3-octreotide (DOTATOC) is repeatedly injected via catheters placed into the resection cavity or into tumour nodules. We report on the four year follow-up after initiation of dBT to treat progressive disease in a patient with a complex eleven year history of fibrillary low-grade astrocytoma. The radiopharmakon was not only locally injected into the resection cavity following debulking surgery, but also administered by slow infusion technique to target recurrent and infiltrative tumour zones in the subventricular region around the inferior and posterior horns. In conclusion, peptidic vector based dBT was found to be safe, of mild and transitory toxicity, and effective in long-term tumour control.

CD85/LIR-1/ILT2 and CD152 (cytotoxic T lymphocyte antigen 4) inhibitory molecules down-regulate the cytolytic activity of human CD4+ T-cell clones specific for Mycobacterium tuberculosis

Antigen-specific cytolytic CD4+ T lymphocytes control Mycobacterium tuberculosis infection by secreting cytokines and by killing macrophages that have phagocytosed the pathogen. However, lysis of the latter cells promotes microbial dissemination, and other macrophages engulf the released bacteria. Subsequently, CD4+ T-cell-mediated killing of macrophages goes on, and this persistent process may hamper control of infection, unless regulatory mechanisms maintain a subtle balance between lysis of macrophages by cytolytic CD4+ cells and activation of cytolytic CD4+ cells by infected macrophages. We asked whether inhibitory molecules expressed by CD4+ cytolytic T lymphocytes could play a role in such a balance. To this end, human CD4+ T-cell clones specific for M. tuberculosis were produced that displayed an autologous major histocompatibility complex class II-restricted lytic ability against purified protein derivative (PPD)-pulsed antigen-presenting cells. All T-cell clones expressed CD152 (cytotoxic T-lymphocyte antigen 4 [CTLA-4]) and CD85/leukocyte immunoglobulin-like receptor 1 (LIR-1)/immunoglobulin-like transcript 2 (ILT2) inhibitory receptors, but not CD94 and the killer inhibitory receptor (or killer immunoglobulin-like receptor [KIR]) p58.2. CD3-mediated activation of the clones was inhibited in a redirected killing assay in which CD152 and CD85/LIR-1/ILT2 were cross-linked. Specific antigen-mediated proliferation of the clones was also sharply reduced when CD152 and CD85/LIR-1/ILT2 were cross-linked by specific monoclonal antibody (MAb) followed by goat anti-mouse antiserum. In contrast, blockade of the receptors by specific MAb only increased their proliferation. Production of interleukin 2 (IL-2) and gamma interferon (IFN-gamma) by the T-cell clones was also strongly reduced when CD152 and CD85/LIR-1/ILT2 were cross-linked. The lytic activity of the T-cell clones against PPD-pulsed autologous monocytes or Epstein-Barr virus-activated B cells was increased by blockade and decreased by cross-linking of the receptors. These results indicate that CD152 and CD85/LIR-1/ILT2 play a role in the regulation of the antigen-specific activity of CD4+ cytolytic T lymphocytes against PPD-presenting cells.

PTEN-independent induction of caspase-mediated cell death and reduced invasion by the focal adhesion targeting domain (FAT) in human astrocytic brain tumors which highly express focal adhesion kinase (FAK)

Increased expression of focal adhesion kinase (FAK) was consistently observed in low- and high-grade astrocytomas and during glioblastoma progression after radiotherapy, but not in the more benign oligodendroglioma. In glioblastoma cell lines deficient for p53, p16(INK4A), and p14(ARF), FAK was inhibited in a dominant-negative manner by the focal adhesion targeting (FAT) domain, reducing invasion. In addition, caspase-3 activity was increased after serum withdrawal, or by cisplatin in the presence of serum, or upon loss of substrate attachment, and was in each case independent of PTEN status. Our results identify FAK as a potential target for anti-invasive strategies against infiltrating glioma cells.

In vitro immunosuppressive activity of soluble HLA class I and Fas ligand molecules: do they play a role in autologous blood transfusion?

BACKGROUND

The immunomodulatory effects of allogeneic blood transfusion may contribute to a poor prognosis in patients with cancer who are undergoing surgery, and clinical trials have been carried out to investigate whether these patients would benefit from autologous blood donation. As the immunomodulatory effects of allogeneic blood transfusion have been related to soluble molecules released from residual WBCs during storage, the in vitro immunomodulatory activity of soluble molecules detected in supernatants from stored autologous blood was evaluated.

STUDY DESIGN AND METHODS

Blood was donated by four healthy volunteers. Packed WBC-reduced RBCs were obtained and stored for 30 days, and supernatants were collected. FFP and serum were also obtained. The concentration of soluble molecules was determined by immunoenzymatic assays. The in vitro immunomodulatory activity of undiluted blood component supernatant was assessed by antigen-specific cytotoxic T-cell activity and mixed lymphocyte reactions in autologous combinations and by apoptosis induction in Fas+ cells.

RESULTS

The concentrations of soluble Fas-ligand and HLA class I molecules were higher in packed RBCs than in WBC-reduced RBCs, FFP, and serum. Undiluted supernatants of packed RBCs strongly inhibited functional assays and induced apoptosis in Fas+ cells. The immunomodulatory effects were correlated with the amount of soluble Fas ligand and HLA class I molecules.

CONCLUSION

The results of the present study are comparable with those already reported in allogeneic blood components, and they indicate that undiluted supernatants of autologous blood components may exert immunosuppressive effects in vitro.

Loss of focal adhesion kinase (FAK) inhibits epidermal growth factor receptor-dependent migration and induces aggregation of nh(2)-terminal FAK in the nuclei of apoptotic glioblastoma cells

In glioblastoma cells, inhibition of focal adhesion kinase (FAK) by the focal adhesion targeting domain attenuated epidermal growth factor receptor (EGFR) signaling, inhibiting epidermal growth factor-dependent migration. Although the EGFR-specific antagonist PD153035 increased caspase-3 activity, this was independent of FAK activity. Instead, the increase in apoptosis upon inhibition of FAK induced the aggregation of an NH(2)-terminal FAK fragment normally present in the nucleus. A recombinant NH(2)-terminal FAK construct was also targeted to the nucleus and aggregated in apoptotic cells upon coexpression with the focal adhesion targeting domain. Therefore, loss of FAK from the focal adhesions inhibits EGFR signaling at the cell membrane and transmits a proapoptotic signal to an NH(2)-terminal variant of FAK present in the nucleus.