Comparison of Standard vs. Relative Risk Models to Define Candidates for Deintensification in Locoregionally Advanced P16+ Oropharyngeal Cancer

PURPOSE/OBJECTIVE(S)

Various methods to identify candidates for treatment deintensification with p16+ oropharyngeal squamous cell carcinoma (OPSCC) have been used, but the optimal approach is unknown.

MATERIALS/METHODS

Multi-institutional cohort study of 385 patients with previously untreated p16+ OPSCC undergoing definitive radiotherapy (RT) with or without systemic therapy between 2009-2020. Chemotherapy intensity was categorized as high (bolus cisplatin and/or induction chemotherapy), medium (weekly cisplatin), or low (non-cisplatin or RT alone). Standard favorable vs. unfavorable risk was defined using NRG HN005 eligibility criteria. High vs. low relative risk (RR) group was defined using the HNCIG omega score (≥ 0.80 vs. < 0.80), which quantifies the proportion of a patient's overall event risk due to cancer. We used multivariable ordinal logistic regression to estimate effects of age (yrs), sex, performance status (PS), Charlson comorbidity index (CCI), T/N (AJCC 8th), current smoking, and pack-years (> 10 vs. ≤ 10) on treatment allocation. Effects on relative event hazards were estimated using generalized competing event regression.

RESULTS

Median follow-up time was 44.2 months. Chemotherapy intensity was high in 206 (54%), medium in 108 (28%), and low in 71 (18%). 280 patients (73%) were unfavorable risk and 197 (51%) were high RR. 178 patients (46%) had discordant risk classification. On univariable analysis, significant predictors of higher intensity chemotherapy (normalized odds ratio (OR)) were CCI 0-1 (OR 1.49, 95% CI: 1.23-1.79), high omega score (OR 1.46; 1.20-1.77), decreased age (OR 1.43; 1.18-1.74), and PS 0 (OR 1.22; 1.01-1.48). Controlling for CCI, higher omega score was associated with significantly higher odds of intensive chemotherapy (OR 1.35; 1.10-1.65, but unfavorable risk (HN005 ineligibility) was not (OR 1.19; 0.98-1.44). Higher omega score was also associated with significantly higher RR for cancer recurrence (Rec) vs. competing mortality (CM) events (relative HR (rHR) 1.76; 1.12-2.75), but unfavorable risk was not (rHR 1.05; 0.63-1.75). Among patients receiving cisplatin, 50 favorable risk patients (58%) had high RR; all of their event risk was due to cancer recurrence (Table). The 110 unfavorable risk patients (48%) with low omega score had significantly lower RR for cancer events compared to the high omega score group (rHR 0.49; 0.29-0.84).

CONCLUSION

Many patients with favorable risk p16+ OPSCC have high relative risk for cancer events, which correlates with a benefit of intensive treatment. The HNCIG omega score is a strong predictor of allocation to intensive chemotherapy and may help identify candidates for deintensification.

A prospective registry to get insights into profile, management and outcome of cardiogenic shock patients

Background

Cardiogenic shock (CS) is the most severe form of acute heart failure, characterized by life-threatening end-organ hypoperfusion resulting from a low cardiac output state. Data on epidemiology of CS has been mostly drawn from registries focusing on acute myocardial infarction (AMI). However, recent evidence in a contemporary cohort in North America has shown that more than two thirds of all CS cases were related to causes other than AMI and that these patients had outcomes at least as poor as patients with AMICS.

Purpose

To provide data on profile, management, outcome, and evolution over time of CS patients admitted to ICCU/ICU and to compare them between patients with AMICS and acute decompensated heart failure (ADHF-CS).

Methods

The Altshock-2 Registry is a multicenter national prospective data collection, part of the Italian Altshock-2 program. Recruitment started on 2 March 2020 with 11 Italian Centers contributing to patients' enrolment. A total of 238 patients were hospitalized with confirmed diagnosis of CS between March 2020 and February 2022 in a multicenter national initiative. The mean age of this patient population was 64 years (interquartile range [IQR] 54–74) and 76% were male. Ninety-seven patients (41%) were admitted for AMICS, whereas 84 patients (35.3%) had ADHF-CS; 57 patients (24%) had other causes. As compared to AMICS patients, those admitted for ADHF-CS were younger, but with a higher burden of comorbidities (renal, liver, thyroid disease, atrial fibrillation, anemia), pre-existing decreased ejection fraction and a higher number of chronic drugs. Patients with ADHF-CS had a prevalent cardio-metabolic phenotype upon admission with prevalent congestion. Mechanical ventilation was more commonly used in patients with AMICS, compared to ADHF-CS, along with an increased inotropic score. Conversely, sodium nitroprusside was used in about sixty percent of patients with ADHF-CS. Sixty percent of the included population received a temporary mechanical circulatory support (MCS) device, which was intra-aortic balloon pump (IABP) in the eighty percent of the supported patients. Pulmonary artery catheter was used for monitoring only in the 18% of the included patients whereas an extensive echocardiographic approach was applied. Twenty-one patients (25%) underwent heart replacement therapy in the ADHF-CS patients versus 2 (2%) in the AMICS. Thirty-day mortality occurred in 32 patients (33%) in the AMICS group versus 23 (27%) in the ADHF-CS group (p=0.41).

Conclusions

Different diagnostic approaches and uses of mechanical circulatory support devises and inotropes are implemented in transatlantic settings. Uniform definitions and more homogenous protocols tailored on CS etiologies and clinical and biochemical phenotypes are needed in prospective initiatives in order to effectively compared results and outcome.

Funding Acknowledgement

Type of funding sources: None.

Enhancing the role of occupational health services in the battle against Corona Virus Disease 2019

Occupational risk assessment is the core of any practice in occupational health and safety at the workplace. In Italy, the implementation of the preventive measures required by law (DPCM of April 26, 2020 and subsequent modifications and integrations) can exempt the employers from legal disputes in case of COVID-19 infection among employees. However, these laws have made meaningless the risk assessment process, which is the ideal setting where the preven-tive and protective measures must be identified and enhanced by individual employers, in collaboration with health and safety managers and occupational physicians, in the true exposure conditions. In this commentary, the authors stressed the role of workplace risk assessment and occupational health services for the valuable contribution that they may give to the battle against COVID-19, in terms of prevention, contact-tracing activity and COVID-19 rates of vaccinal coverage.

Withdrawal of active treatments in terminally ill heart failure patients

INTRODUCTION

Heart failure (HF) constitutes a growing public health problem in aging societies: when pharmacological therapies fail, HF can be sustained intensively if patients are eligible for either orthotopic heart transplantation (OHT) or mechanical ventricular assistance, otherwise additional treatments could be inappropriate. In December 2017 Italian Legislator brought in the provisions regarding the end-of-life choices, including indications for withdrawing and withholding life-sustaining therapies. The aim of our study was to provide an overview of the daily practice of our center with regard to terminally ill HF patients.

METHODS AND RESULTS

In April 2019 the 7 intensivist cardiologists and 21 nurses of a tertiary ICCU were asked in, to complete a questionnaire relating to a hypothetical terminally ill HF patient for whom the decision to withdraw active treatment had been made. To assess current practice, we also identified patients who died in the previous 12 months. Out of 29 deceased patients, 18 were identified as terminally ill HF, with no indications for therapy upgrading. We observed a striking disparity between belief and practice.

CONCLUSIONS

Our survey showed that the care of terminally ill HF patients in our ICCU was characterized by aggressive use of medical therapy and invasive technology. The wide disparity between belief and practice could be in part a consequence of lack of professional training, with regard to law, ethics and communication techniques.

Metal removal processes in a pilot hybrid constructed wetland for the treatment of semi-synthetic stormwater

This study investigates the reliability of a pilot hybrid constructed wetland (H-CW), located in Eastern Sicily (Italy). To address the uncertainty associated with implementing representative monitoring during highly variable storm events, unique to Mediterranean conditions, a recipe for semi-synthetic stormwater was used to evaluate the removal efficiency of the system. This was characterised by metals (Cd, Cr, Fe, Pb, Cu, Zn) and relative concentrations typically found in urban stormwater runoff (SR). Approximately one month of intensive monitoring activities were carried out and quality analyses were conducted on three matrices comprising the pilot H-CW: water, biomass (Canna indica, Typha latifolia), and volcanic gravel substrate. Metal retention in early clogging matter (SS) was also examined. The results showed a significantly high H-CW efficiency for the removal of all metals (70-98%) already at the horizontal flow unit outflow, confirming its strategic role. A metal mass balance analysis was also conducted to describe the retention capacity and influence of each system component on the overall efficiency (ranging from 87.8% for Cr to 99.2% for Pb). Metal removal was mostly related to sediment and substrate processes, while plants exhibited root bioaccumulation and phytostabilisation capacity even with a limited impact on overall system retention. The pilot H-CW exhibits characteristics suitable for the treatment of metal-enriched stormwater runoff and validates the useful application of decentralised natural systems for water resource management.

Agitation and delirium in intensive cardiac care unit. A multicenter prospective registry

Background

Patients with acute cardiovascular disease admitted to the Intensive Cardiac Care Unit (ICCU), especially those with more severe critical illness, experiment agitation and delirium during hospitalization. Iatrogenic, environmental, or related to the severity of acute illness factors may concur to determine these two conditions. However, their epidemiological, clinical, and prognostic relevance in this specific clinical context are not well defined, yet. As a result, current recommendations on the evaluation and management of these complications are lacking.

The aim of this prospective, multicenter, observational registry was to evaluate the incidence of agitation and delirium in patients admitted to the ICCU for an acute cardiac event, their in-hospital prognostic impact, and their treatment.

Methods

We enrolled consecutive patients with acute cardiovascular events in four Italian tertiary-care centers. Agitation levels were ranked from Richmond Assessment Sedation Scale (RASS), and the presence of delirium was detected by Confusion Assessment Method-Intensive Care Unit (CAM ICU) at least twice a day and in case of variation of the state of consciousness. The primary endpoint was the incidence of agitation and/or delirium. The secondary endpoints were: 1) the association between these complications and in-hospital outcome and 2) the therapies adopted for their management.

Results

Overall, 723 patients were included in the registry. Of them, 116 (16%) presented agitation and/or delirium during ICCU stay. Delirium subtypes were: 6% hypoactive, 64% hyperactive, and 30% mixed. Patients with agitation/delirium had worse in-hospital outcomes than patients without.. Indeed, they had a higher ICCU mortality (10% vs. 2%; P&lt;0.001) and a higher rate of major complications: ventricular arrhythmias (26% vs. 12%; P&lt;0.001), atrial fibrillation (29% vs. 15%; P&lt;0.001), sepsis (15% vs. 9%; P=0.06), and bleeding (17% vs. 7%; P&lt;0.001). Moreover, they were more frequently treated with mechanical procedures: invasive and non-invasive ventilation (58% vs. 18%; P&lt;0.001), circulatory support (20% vs. 5%; P&lt;0.001), continuous renal replacement therapy (6% vs. 1%; P&lt;0.001). Finally, ICCU length of stay was longer (8 vs. 4 days; P&lt;0.001). The drugs more likely used for agitation treatment were benzodiazepine (32%), dexmedetomidine (31%), opioids (10%), and antipsycotic drugs (1%). Delirium was mainly treated with dexmedetomidine (46%), benzodiazepine (23%), antipsycotic drugs (16%), and opioids (8%).

Conclusions

This study demonstrates that agitation and delirium are frequent complications also in the acute cardiac setting and are associated with poor in-hospital outcome. In this particular context, the treatment of choice and its possible impact on prognosis remain to be established.

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): Centro Cardiologico Monzino, IRCCS, MIlan, Italy.

Hazardous workers and risk for third parties

Impaired workers, unable to practice their activities with effective skills and adequate safety protection because of physical or mental illness, alcohol and drug addiction, inappropriate behaviour as a consequence of fatigue, sleepiness, or distress, may be hazardous for colleagues and customers.

To properly manage these workers, public health must resolve the ethical dilemma arising from the legitimate interests of all stakeholders. The sick worker's interests include career expectations, role in organization, right to privacy, and right to freedom from discrimination. The customer's interests include protection from harm, right to autonomy, and right to informed choice. The society's interests include maintaining effective and affordable public services, as well as the benefits and burdens of any policies. Traditional ethics, oriented toward the individual relationship, failed to find an uncontroversial solution to these complex issues. Our research pointed to the organisation level.

The La.R.A. Study group on Hazardous Workers was set up in 1999 in Italy, to study how to protect the health and safety of impaired workers and that of third parties, without prejudice to the civil rights of workers. The group includes many subject matter experts like: doctors from different specialties, jurists, bioethicists, employees' and employers' representatives. It is independent and not financed.

The ethical, legal and operational aspects of each specific problem are discussed from different points of view and at the end a consensus document containing the practical indications for the prevention operators is produced. Over the years, Lara has produced 10 consensus documents on specific problems and has stimulated companies to develop policies for hazardous workers, preferably according to a bottom-up participatory model.

The collective definition of methods and solutions allows management of hazardous workers.

Key messages

Disability management is preferable to exclusion from work. A shared company policy is the basic principle of management of hazardous workers.

COVID-19 and staff mental health: is there an evidence? An Italian field study

Since the early months of the COVID-19 epidemic, a large number of scientific papers have considered the possibility that healthcare professionals (HCWs) were affected by depression, anxiety, post-traumatic stress, and psychological distress. The abundance of research has also made it possible to produce several systematic reviews and meta-analyzes. All the studies retrieved in these reviews, however, were cross-sectional. Depressive symptoms and anxiety in HCWs were compared to “normal values”, administrative staff, or external sample; moreover, some studies had no control group. No longitudinal study has been produced so far. Some studies had negative results. Overall, there is still little evidence of an increase in mental health problems and sleep disturbances in HCWs during the outbreak.

To fill this gap, we investigated the mental health of workers who have been monitored for many years in an Italian local health unit. Mental health was investigated with standardized questionnaires. 82 HCWs who tested positive at the COVID-19 nasopharyngeal swab, 152 exposed workers who tested negative and 361 unexposed controls participated in the survey. Anxiety was reported by 16.6% of COVID-19 cases and depression by 20.3%, with a significant increase in the estimated risk (OR = 4.3; CI95%=2.4-7.4 for anxiety, OR = 3.5; CI95% =2.0-6.0 for depression). In test-positive cases, sleep was a significant moderating factor in the relationship between occupational stress or PJ and anxiety. Exposed, negative HCWS also had an increased OR for anxiety (1.84, CI95% 1.1-3.1) and depression (2.2 CI95% 1.4-3.5).

The frequency of anxiety and depression disorders in the population examined was not higher than that recorded in the years preceding the epidemic during periodic occupational health checks in the workplace. Mental health support and organizational interventions must mainly concern workers with positive tests and should also tend to improve sleep quality.

Environmental electroactive consortia as reusable biosensing element for freshwater toxicity monitoring

The development of tools to monitor water quality is mandatory in a scenario where clean water resources are decreasing. Here, the biosensing capability of an electroactive river sediment consortium was tested towards three model contaminants (glutaraldehyde, nickel(II) and chromium(III)). The proposed biosensor is a small membrane-less single chamber Microbial Fuel Cell (MFC), fabricated by 3D printing. Its semi-continuous mode of operation resulted in long-term current profile stability and reproducibility. A linear trend of response was obtained for glutaraldehyde in a concentration range of 5-1000 ppm. After the recovery of the electroactive consortium activity, the MFC-based biosensors were shown to be sensitive towards Ni(II) and Cr(III), at concentrations above 2 mg L^-1. To effectively analyze biosensor response, a novel algorithm was proposed, offering advantages for the realization of energy-saving protocols for MFC-biosensor data transmission. Implementation of the device and method, from laboratory test to real environment, can offer a low cost in situ system for detection of water contaminants.

Crash sign: new first-trimester sonographic marker of spina bifida

OBJECTIVES

To describe a new first-trimester sonographic sign, the 'crash sign', associated with fetal open spina bifida, and to evaluate its clinical usefulness in the first-trimester diagnosis of spina bifida.

METHODS

This was a retrospective review of patients referred to three fetal medicine centers in the first trimester (11 + 0 to 13 + 6 weeks) with suspected spina bifida. Spina bifida was confirmed by direct visualization of the spinal defect on ultrasound by two experts and, when possible, by fetal postmortem examination. Ultrasound images were reviewed for the presence of the crash sign, which is the posterior displacement of the mesencephalon and deformation against the occipital bone in the axial view. The first-trimester ultrasound images of a mixed group of 10 cases and 40 control fetuses without spina bifida were assessed for the presence of the crash sign by two assessors blinded to the diagnosis.

RESULTS

The crash sign was present in 48 out of 53 confirmed cases of spina bifida. Of these, 27 had isolated spina bifida and 21 had an associated anomaly. Of the five cases without the crash sign, one had isolated spina bifida and four had an associated anomaly. The crash sign was not reported in any of the control fetuses.

CONCLUSIONS

We have described a new first-trimester sonographic marker for the diagnosis of spina bifida. Our results suggest that the crash sign may be a useful tool in the first-trimester detection of spina bifida. Prospective evaluation of the crash sign would be beneficial, ideally in a routine clinical screening ultrasound setting. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

RAS testing of liquid biopsy correlates with the outcome of metastatic colorectal cancer patients treated with first-line FOLFIRI plus cetuximab in the CAPRI-GOIM trial

Background

Liquid biopsy is an alternative to tissue for RAS testing in metastatic colorectal carcinoma (mCRC) patients. Little information is available on the predictive role of liquid biopsy RAS testing in patients treated with first-line anti-EGFR monoclonal antibody-based therapy.

Patients and methods

In the CAPRI-GOIM trial, 340 KRAS exon-2 wild-type mCRC patients received first-line cetuximab plus FOLFIRI. Tumor samples were retrospectively assessed by next generation sequencing (NGS). Baseline plasma samples were analyzed for KRAS and NRAS mutations using beads, emulsion, amplification, and magnetics digital PCR (BEAMing). Discordant cases were solved by droplet digital PCR (ddPCR) or deep-sequencing.

Results

A subgroup of 92 patients with available both NGS data on tumor samples and baseline plasma samples were included in this study. Both NGS analysis of tumor tissue and plasma testing with BEAMing identified RAS mutations in 33/92 patients (35.9%). However, 10 cases were RAS tissue mutant and plasma wild-type, and additional 10 cases were tissue wild-type and plasma mutant, resulting in a concordance rate of 78.3%. Analysis of plasma samples with ddPCR detected RAS mutations in 2/10 tissue mutant, plasma wild-type patients. In contrast, in all tissue wild-type and plasma mutant cases, ddPCR or deep-sequencing analysis of tumor tissue confirmed the presence of RAS mutations at allelic frequencies ranging between 0.15% and 1.15%. The median progression-free survival of RAS mutant and wild-type patients according to tissue (7.9 versus 12.6 months; P = 0.004) and liquid biopsy testing (7.8 versus 13.8 moths; P < 0.001) were comparable. Similar findings were observed for the median overall survival of RAS mutant and wild-type patients based on tissue (22.1 versus 35.8 months; P = 0.016) and plasma (19.9 versus 35.8 months; P = 0.013) analysis.

Conclusion

This study indicates that RAS testing of liquid biopsy results in a similar outcome when compared with tissue testing in mCRC patients receiving first-line anti-EGFR monoclonal antibodies.

The novel HBx mutation F30V correlates with hepatocellular carcinoma in vivo, reduces hepatitis B virus replicative efficiency and enhances anti-apoptotic activity of HBx N terminus in vitro

OBJECTIVE

We aimed to investigate HBx genetic elements correlated with hepatitis B virus (HBV) -related hepatocellular carcinoma (HCC) and their impact on (a) HBV replicative efficiency, (b) HBx binding to circular covalently closed DNA (cccDNA), (c) apoptosis and cell-cycle progression, and (d) HBx structural stability.

METHODS

This study included 123 individuals chronically infected with HBV: 27 with HCC (77.9% (21/27) genotype D; 22.1% (6/27) genotype A) and 96 without HCC (75% (72/96) genotype D; 25.0% (24/96) genotype A). HepG2 cells were transfected by wild-type or mutated linear HBV genome to assess pre-genomic RNA (pgRNA) and core-associated HBV-DNA levels, HBx-binding onto cccDNA by chromatin immunoprecipitation-based quantitative assay, and rate of apoptosis and cell-cycle progression by cytofluorimetry.

RESULTS

F30V was the only HBx mutation correlated with HCC (18.5% (5/27) in HCC patients versus 1.0% (1/96) in non-HCC patients, p 0.002); a result confirmed by multivariate analysis. In vitro, F30V determined a 40% and 60% reduction in pgRNA and core-associated HBV-DNA compared with wild-type (p <0.05), in parallel with a significant decrease of HBx binding to cccDNA and decreased HBx stability. F30V also decreased the percentage of apoptotic cells compared with wild-type (14.8 ± 6.8% versus 19.1 ± 10.1%, p <0.01, without affecting cell-cycle progression) and increased the probability of HBx-Ser-31 being phosphorylated by PI3K-Akt kinase (known to promote anti-apoptotic activity).

CONCLUSIONS

F30V was closely correlated with HBV-induced HCC in vivo, reduced HBV replicative efficiency by affecting HBx-binding to cccDNA and increased anti-apoptotic HBx activity in vitro. This suggests that F30V (although hampering HBV's replicative capacity) may promote hepatocyte survival, so potentially allowing persistent production of viral progeny and initiating HBV-driven hepatocarcinogenesis. Investigation of viral genetic markers associated with HCC is crucial to identify those patients at higher risk of HCC, who hence deserve intensive liver monitoring and/or early anti-HBV therapy.

Thermal evolution of MnxOy nanofibres as catalysts for the oxygen reduction reaction

The present study shows how, starting from green and low-cost precursors, nanostructured manganese oxides with good catalytic efficiencies for the oxygen reduction reaction can be fabricated through the electrospinning technique. The role of the crystalline phase and morphological features, on the electro-catalytic behaviour, is discussed.

Defining the role of nanonetting in the electrical behaviour of composite nanofiber/nets

The electrical behaviour of MWCNT-based composite nanofiber/nets can be tuned by controlling the morphology of the secondary nanoweb.

Healing and Long-Term Viability of Grafts in the Venae Cavae Reconstruction

The need for superior vena cava (SVC) or inferior vena cava (IVC) recon struction is not uncommon: lung cancer, mediastinal tumors, or retroperitoneal neoplasms are the most frequent indications for caval replacement. Since auto genous veins, which represent the most satisfactory venous substitute, have not been applicable to caval replacement, because of the lack of suitable length and caliber, many types of materials have been tested in the venous system. The present study was planned to compare the potential of expanded polytetrafluoroethylene (e-PTFE) and glutaraldehyde-tanned human umbilical vein (HUV) grafts as caval substitutes.

Patch (4 x 5 cm) reconstruction of the SVC was carried out in 10 dogs, tubu lar (3 x 10 mm) reconstruction of the SVC in 5 dogs, and patch (1 x 2 cm) recon struction of the IVC in 8 dogs. In the patch reconstruction groups, HUV grafts were used in half of the cases and 30 μm pore sizes e-PTFE grafts in the other half, while in the tubular SVC replacement group, only e-PTFE grafts were employed. The grafts were removed fifteen to thirty days after IVC patch re construction, thirty to two hundred seventy days after SVC patch reconstruc tion, and thirty-three to forty-one months after SVC tubular replacement. In every instance, specimens were obtained for light microscopy (LM) and scan ning electron microscopy (SEM).

HUV patches implanted in the SVC showed hemorrhagic foci at their central portion and marked constriction at the anastomotic regions. On the contrary, the inner surface of e-PTFE patch grafts was covered with a uniform and glis tening neointima. By LM, e-PTFE patches showed a smooth and regular lumi nal surface, while the inner surface of HUV patches was irregular, with hemorrhagic areas in the underlying layers. By SEM, e-PTFE patches revealed a more rapid and orderly endothelialization of their inner surface than HUV patches did. Tubular SVC reconstruction showed the good long-term viability of the e-PTFE neointima (as long as forty-one months after grafting). Only spotty areas revealed neointima alterations, such as fibrinoid degeneration, fo cal necrosis, or minor thrombotic foci. In the IVC patch reconstruction model, HUV grafts showed an exuberant fibrin deposition on their inner surface and delayed endothelialization patterns, as compared with e-PTFE grafts. Since rapid healing with rapid endothelialization is accepted as the most important factor providing the graft luminal surface with the best antithrombotic proper ties, the present study demonstrated that e-PTFE is a more suitable material than HUV for SVC and IVC reconstruction.

Long-Term Evaluation of Human Umbilical Vein as Small-Caliber Arterial Substitute

Since 1977, 61 arterial reconstruc tions using glutaraldehyde-tanned human umbilical vein (HUV) grafts were carried out in 56 patients (51 males, 5 females) with unsuitable au togenous saphenous vein. Their mean age was 69 ± 14 years. Limb salvage was the primary indication for sur gery.

HUV grafts were used to perform 44 femoropopliteal, 4 composite aor topopliteal (with a direct end-to-end anastomosis between an aortofe moral Dacron graft and a femoropo pliteal HUV graft), 5 femorotibial, and 6 axillofemoral bypasses, and 1 femorofemoral and 1 iliopopliteal by pass. Ten-year cumulative patency rates were 31 % for all HUV recon structions, 36% for femoropopliteal bypasses, and 32% for femoropopli teal bypasses carried out for limb sal vage only. Four of the 5 femorotibial reconstructions failed during the first month following surgery. Two of the 6 axillofemoral and 3 of the 4 com posite aortopopliteal bypasses throm bosed within one and three years after surgery respectively. In conclu sion, the study evidenced long-term durability of HUV grafts, supporting their use for femorodistal reconstruc tions in patients with limb-threaten ing ischemia and inadequate autoge nous saphenous vein.

Novel cross talk between IGF-IR and DDR1 regulates IGF-IR trafficking, signaling and biological responses

The insulin-like growth factor-I receptor (IGF-IR), plays a key role in regulating mammalian development and growth, and is frequently deregulated in cancer contributing to tumor initiation and progression. Discoidin domain receptor 1 (DDR1), a collagen receptor tyrosine-kinase, is as well frequently overexpressed in cancer and implicated in cancer progression. Thus, we investigated whether a functional cross-talk between the IGF-IR and DDR1 exists and plays any role in cancer progression.

Using human breast cancer cells we found that DDR1 constitutively associated with the IGF-IR. However, this interaction was enhanced by IGF-I stimulation, which promoted rapid DDR1 tyrosine-phosphorylation and co-internalization with the IGF-IR. Significantly, DDR1 was critical for IGF-IR endocytosis and trafficking into early endosomes, IGF-IR protein expression and IGF-I intracellular signaling and biological effects, including cell proliferation, migration and colony formation. These biological responses were inhibited by DDR1 silencing and enhanced by DDR1 overexpression.

Experiments in mouse fibroblasts co-transfected with the human IGF-IR and DDR1 gave similar results and indicated that, in the absence of IGF-IR, collagen-dependent phosphorylation of DDR1 is impaired.

These results demonstrate a critical role of DDR1 in the regulation of IGF-IR action, and identify DDR1 as a novel important target for breast cancers that overexpress IGF-IR.

Electrochemical and impedance characterization of Microbial Fuel Cells based on 2D and 3D anodic electrodes working with seawater microorganisms under continuous operation

A mixed microbial population naturally presents in seawater was used as active anodic biofilm of two Microbial Fuel Cells (MFCs), employing either a 2D commercial carbon felt or 3D carbon-coated Berl saddles as anode electrodes, with the aim to compare their electrochemical behavior under continuous operation. After an initial increase of the maximum power density, the felt-based cell reduced its performance at 5 months (from 7 to 4 μW cm(-2)), while the saddle-based MFC exceeds 9 μW cm(-2) (after 2 months) and maintained such performance for all the tests. Electrochemical impedance spectroscopy was used to identify the MFCs controlling losses and indicates that the mass-transport limitations at the biofilm-electrolyte interface have the main contribution (>95%) to their internal resistance. The activation resistance was one order of magnitude lower with the Berl saddles than with carbon felt, suggesting an enhanced charge-transfer in the high surface-area 3D electrode, due to an increase in bacteria population growth.

[Alcohol and work. Consensus Document of the La.R.A. (Workers representing a risk for others) group]

AIM

Current Italian legislation obliges employers to prevent workers who are occupationally at risk or who perform jobs that may be hazardous for the safety or health of third parties from consuming alcohol. The LaRA Group undertook to assess whether the law fully safeguards the health and safety of both workers and third parties, without impinging upon the civil rights of workers.

METHOD

A written document expressing agreement was produced following discussions between doctors, lawyers, bioethicists and social partners.

RESULTS

There are gaps and inconsistencies in current laws; the differences in local and regional provisions prevent authorities from applying a single strategy at national level. There should be a change in existing rules under which the employer's obligation to enforce the ban on consumption alcohol in the workplace is enacted solely by the "competent" physician whose institutional role is to safeguard and promote health. Some occupational categories that are subject to a ban on alcohol consumption do not currently under-go health surveillance. For example, if road transport drivers are not exposed to a specific occupational risk foreseen under another law, they can be placed under health surveillance only in those regions where the local laws contemplate this type of control. In other cases, the practice of assessing the risk to third parties and providing for compulsory health surveillance in the Risk Assessment Document, is considered by some jurists to be a "consuetudo praeter legem" and therefore acceptable in a field not yet covered by a specific law, but to be "contra legem" or unlawful by other jurists. Moreover, the competent physician who uses a breathanalyser or tests for alcohol addiction faces an ethical dilemma, since by communicating the results to an employer or authorities responsible for the issuing of licenses, he may be violating his professional oath of secrecy. Furthermore, the emphasis placed on testing has induced companies and inspectors to overlook educational and rehabilitation aspects. It is essential to involve general practitioners, educators and specialist services in addressing the problems of alcohol abuse so as to inform/train, recover and rehabilitate. The few studies available indicate that the rules are poorly enforced and that non-compliance may go unobserved.

CONCLUSIONS

The Group urges all employers to assess the risk for third parties caused by alcohol abuse and to devise a policy on alcohol. Controlling alcohol-related risks in the workplace calls for a better definition of the roles of Vigilance Bod-ies and Company Physicians together with a shift from a reactive to a proactive attitude of all the parties involved.

Metformin inhibits androgen-induced IGF-IR up-regulation in prostate cancer cells by disrupting membrane-initiated androgen signaling

We have previously demonstrated that, in prostate cancer cells, androgens up-regulate IGF-I receptor (IGF-IR) by inducing cAMP-response element-binding protein (CREB) activation and CREB-dependent IGF-IR gene transcription through androgen receptor (AR)-dependent membrane-initiated effects. This IGF-IR up-regulation is not blocked by classical antiandrogens and sensitizes cells to IGF-I-induced biological effects. Metformin exerts complex antitumoral functions in various models and may inhibit CREB activation in hepatocytes. We, therefore, evaluated whether metformin may affect androgen-dependent IGF-IR up-regulation. In the AR(+) LNCaP prostate cancer cells, we found that metformin inhibits androgen-induced CRE activity and IGF-IR gene transcription. CRE activity requires the formation of a CREB-CREB binding protein-CREB regulated transcription coactivator 2 (CRTC2) complex, which follows Ser133-CREB phosphorylation. Metformin inhibited Ser133-CREB phosphorylation and induced nuclear exclusion of CREB cofactor CRTC2, thus dissociating the CREB-CREB binding protein-CRTC2 complex and blocking its transcriptional activity. Similarly to metformin action, CRTC2 silencing inhibited IGF-IR promoter activity. Moreover, metformin blocked membrane-initiated signals of AR to the mammalian target of rapamycin/p70S6Kinase pathway by inhibiting AR phosphorylation and its association with c-Src. AMPK signals were also involved to some extent. By inhibiting androgen-dependent IGF-IR up-regulation, metformin reduced IGF-I-mediated proliferation of LNCaP cells. These results indicate that, in prostate cancer cells, metformin inhibits IGF-I-mediated biological effects by disrupting membrane-initiated AR action responsible for IGF-IR up-regulation and suggest that metformin could represent a useful adjunct to the classical antiandrogen therapy.

Anti-angiogenic therapies in the treatment of Waldenstrom's Macroglobulinemia

Bone marrow microenvironment has been shown to play a crucial role in supporting the pathogenesis and the progression of several B-cell malignancies, including Waldenstrom's Macroglobulinemia (WM). Among the different cell types within the bone marrow milieu, endothelial cells have been proven to support WM cells growth. Based on the understanding of bone marrow neo-angiogenesis in plasma cell dyscrasias, a number of anti-angiogenic molecules are now available for the treatment of these diseases. Indeed, anti-angiogenic drugs, such as proteasome-, proteins kinase-C (PKC)-, phosphatidylinositol 3-kinase/mammalian target of rapamycin (mTOR)-, and histone deacetylase (HDAC)- inhibitors are now available, playing a key role in the treatment of WM both in the preclinical settings and as part of clinical trials.

[Working parents and welfare in Italy]

This paper considers parents empoyment laws in Italy, starting with the very first one in 1902. The legislative development is comparised with Italian history in twentieth and twenty-first centuries, with a particular attention to the Mussolinian age (1922-1943), the Constitution and 1975 Family Law. Social environment is also analyzed in this complex situation.

Proinsulin binds with high affinity the insulin receptor isoform A and predominantly activates the mitogenic pathway

Proinsulin is generally regarded as an inactive prohormone because of its low metabolic activity. However, proinsulin appears to regulate embryo development in animal models. In this study, we evaluated whether proinsulin may differentially bind to and activate the two insulin receptor (IR) isoforms (IR-A and IR-B), because IR-A is a relatively low-specificity receptor that is prevalent in fetal and cancer cells and is able to mediate the growth effects of IGF-II. Mouse R(-) fibroblasts devoid of IGF-I receptor (IGF-IR) and stably transfected with cDNA encoding either human IR-A or IR-B (R(-) /IR-A and R(-) /IR-B cells) were used. Three human cancer cell lines were also studied. We found that proinsulin stimulated phosphorylation of IR-A with an EC(50) of 4.5 ± 0.6 nm and displaced [(125)I]insulin from IR-A with a similar EC(50). In contrast, proinsulin EC(50) values for stimulation of IR-B phosphorylation and for [(125)I]insulin displacement from IR-B were approximately 7-fold higher. Proinsulin did not bind or activate IGF-IR or IR/IGF-IR hybrids. Via IR-A, proinsulin activated the ERK/p70S6K pathway to a similar degree as insulin but elicited a weaker Akt response. Despite its low metabolic activity, proinsulin was almost equipotent as insulin in inducing cell proliferation and migration in cells expressing various IR-A levels. In conclusion, proinsulin is a selective IR-A ligand and may induce biological effects through this IR isoform.

[Radon in workplaces, a review]

Radon is a chemical radioactive element. It occurs naturally as the decay product of radium; it's responsible for the majority of the mean public exposure to ionizing radiation. It is often the single largest contributor to an individual's background radiation dose, and is the most variable from location to location. Radon gas from natural sources can accumulate in buildings, especially in confined areas such as attics, and basements. Breathing in radon is a cause of lung cancer. In Italy, high levels of radon should be found in underground spaces such as wineries, historical buildings, hot springs or mushrooms farms, and it's a hazard all this workplaces. To ensure the health and safety of employees and others who have access to their work environment, the occupational physician can program inexpensive surveys (with dosemeters) and develop an information plan.

Substrate elasticity regulates skeletal muscle stem cell self-renewal in culture

Stem cells that naturally reside in adult tissues, such as muscle stem cells (MuSCs), exhibit robust regenerative capacity in vivo that is rapidly lost in culture. Using a bioengineered substrate to recapitulate key biophysical and biochemical niche features in conjunction with a highly automated single-cell tracking algorithm, we show that substrate elasticity is a potent regulator of MuSC fate in culture. Unlike MuSCs on rigid plastic dishes (approximately 10(6) kilopascals), MuSCs cultured on soft hydrogel substrates that mimic the elasticity of muscle (12 kilopascals) self-renew in vitro and contribute extensively to muscle regeneration when subsequently transplanted into mice and assayed histologically and quantitatively by noninvasive bioluminescence imaging. Our studies provide novel evidence that by recapitulating physiological tissue rigidity, propagation of adult muscle stem cells is possible, enabling future cell-based therapies for muscle-wasting diseases.

Impact of alcohol consumption on winter sports-related injuries

INTRODUCTION

This study was carried out to evaluate data about trauma-related winter sports, including risk factors such as high speed, gender, age, alcohol consumption, details about the accident and snow conditions.

METHODS

A retrospective review was conducted to determine the injury patterns and crash circumstances in holiday skiers and snowboarders. The data recorded were obtained from the database of the Pre-Hospital Emergency Registry of six skiing areas in the Dolomite mountains during the winter seasons November 2004-May 2009, injury data for major traumas from Ski Patrol Injury reports (helicopter, ambulance or ski slopes' patrol reports), and intrahospital Emergency Department data. Alcohol concentration in blood was detected in 200 individuals suffering from major trauma.

RESULTS

A total of 4550 injured patients, predominantly male (69%), mean age 22 years (range 16-72), were included in the observational analysis. Knee, wrist and shoulder injuries were frequently associated with major thoracic, abdominal or head traumas (64% of cases). Suboptimal technical level, high speed, low concentration, snow or weather conditions, faulty equipment and protective devices were among the various causes of accidents. The analysis revealed that high alcohol blood concentration was present in 43% of 200 patients.

CONCLUSIONS

Even though the major causes of accidents were excessive speed, excessive fatigue, technical errors and bad weather conditions, alcohol abuse was often discovered. Random sampling and a non-systematic detection of alcohol blood levels likely led to an underestimation of alcohol consumption-related injuries. It is recommended that investigations into alcoholic intoxication in injured skiers should be carried out on a large scale.

Intrinsic porosity of calcium phosphate cements and its significance for drug delivery and tissue engineering applications

One key point in the field of tissue engineering and drug delivery is to provide materials with an adequate porosity. Many events, including nutrient and waste exchange in scaffolds for tissue engineering, as well as the drug-loading capacity and control of the release rate in drug delivery systems, are controlled by the size, shape and distribution of the pores in the material. Calcium phosphate cements (CPCs) possess an intrinsic porosity that is highly suited for these applications, and this porosity can be controlled by modifying some processing parameters. The objective of this work was to characterize and control the intrinsic porosity of alpha-tricalcium phosphate (alpha-TCP) cements, and to investigate its role against adsorption of bovine serum albumin (BSA). Cements with different percentages of open porosity (35-55%) were prepared by modifying the liquid-to-powder ratio. In addition, two different TCP particles were used to yield cements with specific surface areas of approximately 20 and approximately 37m(2)g(-1). Mercury porosimetry analysis on the set cements showed in most cases a bimodal pore size distribution which varied with the processing parameters and affected differently the adsorption and penetration of BSA. The peak occurring at larger pore dimensions controlled the penetration of BSA and was ascribed to the voids generated in between crystal aggregates, while the peak appearing at lower pore sizes was believed to be due to the intercrystallite voids within aggregates. It was found that, at the concentrations studied, the high intrinsic porosity in CPC does not ensure protein penetration unless there is an adequate pore size distribution.

Differential signaling activation by insulin and insulin-like growth factors I and II upon binding to insulin receptor isoform A

A variety of human malignancies overexpresses isoform A of the insulin receptor (IR-A) and produces IGFs (IGF-I and/or IGF-II). IR-A binds IGF-II with high affinity (although 4-fold lower than that for insulin), whereas it binds IGF-I with low affinity (approximately 30-fold lower than that for insulin). However, in engineered cells expressing only the IR-A, but not IGF-I receptor (R(-)/IR-A cells), IGF-II is a more potent mitogen than insulin. Herein, we investigated downstream signaling of IGF-II, IGF-I, and insulin in R(-)/IR-A cells to better understand their role in cell growth. We found that despite inducing a lower IR-A autophosphorylation than insulin, IGF-II was more potent than insulin for activating p70S6 kinase (p70S6K) and approximately equally potent in activating the early peaks of ERK1/2 and Akt. However, ERK1/2 activation persisted longer after IGF-II, whereas Akt activation persisted longer after insulin. Therefore, cells stimulated with IGF-II had a higher p70S6K/Akt activation ratio than cells stimulated with insulin. Remarkably, IGF-I also elicited a similar signaling pattern as IGF-II, despite inducing minimal IR-A autophosphorylation. ERK1/2 and protein kinase C seem to be involved in the preferential stimulation of p70S6K by IGFs. In conclusion, our study has identified a novel complex role of IR-A, which not only elicits a unique signaling pattern after IGF-II binding but also induces substantial downstream signaling upon binding to the low-affinity ligand IGF-I. These results underline the role of IR-A in physiology and disease.

MicroRNAs 15a and 16–1 regulates tumor proliferation in multiple myeloma

e14640

Background: MicroRNAs (miRNAs) are non-coding RNAs that act as negative regulators of gene expression. They have been described to play roles in solid tumors and hematologic malignancies. However the role of miRNAs in multiple myeloma (MM) has not been yet fully described. Methods: We performed miRNA-profiling of primary bone marrow-derived CD138+ MM cells, compared to their normal cellular counterparts and validated data by qRT-PCR. In vitro and in vivo functional studies were performed on miRNA-15a- and -16–1-precursors-transfected MM cells. Effect of miRNA-15a and -16–1 on signaling cascades have been evaluated by western blot and immunofluorescence. NF-kB activity has been studied using the Active Motif TransAM kit. In vivo MM cell growth has been evaluated by either using an in vivo imaging model or bioluminescence. Angiogenesis has been studied both in vitro and in vivo using the chorioallantoic membrane model. Results: We identified a MM-specific miRNA signature characterized by down-expression of miRNA-15a, -16–1 and over-expression of miRNA-222/-221/-382/-181a/-181b (P<0.01). Data were confirmed by qRT-PCR on matched samples. Predicted targets for the decreased miRNAs in MM patients included pro-angiogenic cytokines, oncogenes, cell cycle regulators, NFkB activators. Conversely, predicted targets for the increased miRNAs included cell cycle inhibitors, suppressors of cytokine signaling, and pro-apoptotic factors. We demonstrated that miRNA-15a and - 16–1 regulate proliferation and growth of MM cells. Indeed, transfected cells showed decreased DNA synthesis; decreased cyclinD1/cyclinD3/CDC25a/pRb protein expression; phase G1 cell cycle arrest. Moreover, transfected cells showed inhibition of NFkB pathway as shown by reduced p65-/p50-/p52-NFkB activities; downregulation of p-p65/p50/p52 nuclear protein level; upregulation of cttosolic phospho-IkB; and inhibited translocation of p-p65 from the cytolplasm to the nucleus. Similarly, inhibition of MM cell growth was confirmed in vivo; and anti-angiogenic properties of miRNA-15a and -16–1 were demonstrated both in vitro and in vivo. Conclusions: These data indicate that miRNAs play a pivotal role in the biology of MM; providing the basis for the development of new miRNA-based targeted therapies in this disease.

No significant financial relationships to disclose.