One year of surgical mask testing at the University of Bologna labs: Lessons learned from data analysis

The outbreak of SARS-CoV-2 pandemic highlighted the worldwide lack of surgical masks and personal protective equipment, which represent the main defense available against respiratory diseases as COVID-19. At the time, masks shortage was dramatic in Italy, the first European country seriously hit by the pandemic: aiming to address the emergency and to support the Italian industrial reconversion to the production of surgical masks, a multidisciplinary team of the University of Bologna organized a laboratory to test surgical masks according to European regulations. The group, driven by the expertise of chemical engineers, microbiologists, and occupational physicians, set-up the test lines to perform all the functional tests required. The laboratory started its activity on late March 2020, and as of the end of December of the same year 435 surgical mask prototypes were tested, with only 42 masks compliant to the European standard. From the analysis of the materials used, as well as of the production methods, it was found that a compliant surgical mask is most likely composed of three layers, a central meltblown filtration layer and two external spunbond comfort layers. An increase in the material thickness (grammage), or in the number of layers, does not improve the filtration efficiency, but leads to poor breathability, indicating that filtration depends not only on pure size exclusion, but other mechanisms are taking place (driven by electrostatic charge). The study critically reviewed the European standard procedures, identifying the weak aspects; among the others, the control of aerosol droplet size during the bacterial filtration test results to be crucial, since it can change the classification of a mask when its performance lies near to the limiting values of 95 or 98%.

Glucose consumption and gene expression in granulosa cells collected before and after in vitro oocyte maturation in the southern white rhinoceros (Ceratotherium simum simum)

CONTEXT

With two northern white rhinos (NWR) remaining, the continued existence of this species relies on studying their relative, the southern white rhino (SWR).

AIMS

(1) Characterise gene expression in granulosa cells (GC) from SWR cumulus oocyte complexes (COCs) prior to (Pre-) and after (Post-) in vitro maturation (IVM), comparing culture media and oocytes from donors treated with or without gonadotropin stimulation prior to ovum recovery; and (2) evaluate COC glucose consumption in spent media.

METHODS

COCs were retrieved from four SWRs. Granulosa cells were collected before and after IVM in SDZ or IZW medium. Total RNA was evaluated by qPCR.

KEY RESULTS

Oocyte maturation was greater in SDZ than IZW media. Expression of genes associated with follicle development increased in Pre-IVM GC. Six genes were differentially expressed in Post-IVM GC from stimulated compared to unstimulated donors. COCs from stimulated animals consumed more glucose. Fifty seven percent of oocytes in SDZ medium consumed all available glucose.

CONCLUSIONS

Gene expression changed upon in vitro maturation and gonadotropin stimulation. Higher glucose availability might be needed during IVM.

IMPLICATIONS

This is the first study examining GC gene expression and COC metabolic requirements in rhinoceros, which are critical aspects to optimise IVM of rhinoceros oocytes.

48 Different chromatin accessibility in murine male and female inner cell mass

Previous research has shown that embryos conceived by IVF show a sexual dimorphic phenotype and different metabolite expression into adulthood. Interestingly, female embryos have a higher apoptotic rate and are more vulnerable to environmental stressors. Our prior studies have examined DNA methylation changes in male and female embryos; however, limited knowledge is available with regard to chromatin accessibility in male and female embryos. The objective of this study was to assess if genome-wide chromatin accessibility changes occur in the inner cell mass (ICM) of the male v. female mouse embryo. For this experiment we utilised expanded blastocysts (CF-1 females×B6D2F1 males) that were obtained by IVF or flushed out of the uterus (FB, control). We performed IVF using KSOM with amino acids and 5% O2. The ICM were isolated from trophectoderm cells utilising immunosurgery and complement. The chromatin status was assessed using an assay for transposase-accessible chromatin status using a sequencing (ATAC seq) protocol modified from Wu et al. (2016 Nature 524, 652-657, DOI: 10.1038/nature18606). Briefly, cells were lysed and nuclei incubated with the Tn5 transposome and tagmentation buffer (Nextera, Illumina Inc., San Diego, CA, USA). After tagmentation, PCR amplification (15 cycles), mitochondrial depletion, and library purification were performed. The sex of the embryo was determined based on MSY (male sex region on the Y chromosome) and total Y chromosome aligning reads. Samples were then divided into 2 groups, male (n=20) and female (n=25), and sequencing was completed using Illumina HiSEqn 2500 (Illumina Inc.). Sequencing was completed using Illumina HiSEqn 2500. MACS2 (https://github.com/taoliu/MACS/) was used for peak identification from the sequencing results and DESEqn 2 (https://www.r-project.org/) was used for statistical analysis and false discovery rate<0.1 was considered significant. GREAT analysis (http://great.stanford.edu/public/html/) was used to identify the top biological processes. Overall, 17,136 regions were identified as more open in males and 19,460 regions were identified as more open in females. Interestingly, of these identified regions, only 28 were considered significant (25 increased and 3 decreased in males). The majority of these regions were located on chromosome Y and most of the regions that were increased in male correlated with gene Gm10352, a gene with an unknown function. While some pathway changes were expected, like the ones involved in sex determination, male gonadal development, and male sexual characteristics, others included histone demethylation, regulation of chromatin silencing, negative regulation of DNA replication, and antigen processing and presentation of peptide antigen. Our data are the first to analyse genome-wide chromatin accessibility changes in the ICM of male and female mouse embryos. Importantly, these data indicate that chromatin differences are already present in the ICM of male and female embryos. Further analysis will provide insights into epigenetic and sexual dimorphic changes present in embryos.

Interleukin-2, Interferon-α and Interleukin-2 plus Interferon-α in Renal Cell Carcinoma. A Randomized Phase Ii Trial

Background

The purpose of the present study was to investigate the therapeutic effectiveness of interleukin-2 (IL-2) and interferon (IFN), either alone or in combination, in comparable groups of patients affected by advanced renal cell carcinoma (RCC).

Patients and methods

In order to limit selection biases, treatment was allocated on a random basis. Patients randomized to IL-2 alone were scheduled to receive eight rIL-2 24-hour i.v. infusion cycles, days 1 to 4, at a daily dose of 18 x 106 IU/m2 for a total of 25 weeks. Patients randomized to IFN alone were scheduled to receive rIFN-α at a daily dose of 6 x 106 IU/m2, days 1, 3 and 5, every week for a total of 52 weeks. Patients randomized to the combination of IFN and IL-2 were given the same drugs at the same daily doses for a total of 24 weeks. Drug dose was modified according to toxicity.

Results

Twenty-three percent (95% CI: ± 17.5) of patients treated with IL-2 alone showed an objective response to treatment (9% CR). The corresponding figures in patients treated with IFN alone or IFN plus IL-2 were 9% (95% CI: ± 11.9) and 9% (95% CI: ± 11.9), respectively. Complete responses were observed only in patients treated with IL-2. The median duration of response in the IL-2 arm was 18 months (range, 9.5-24). The duration of the two responses achieved by IFN alone was seven and nine, months, respectively. The corresponding figures in the two patients responding to the combination of IFN with IL-2 were 19 and 27 months, respectively. Total IL-2 dose appeared to be a major predictor of response. Only a minority of patients experienced grade 3-4 toxicity, the incidence being higher in those treated with IL-2 or IL-2 plus IFN.

Conclusions

Neither IFN nor IL-2 or the combination of the two appear to be very active in patients with advanced RCC, even when trial entry was restricted to patients with relatively indolent disease. This stresses the need for the development of new approaches.

321 CYTOSKELETAL ALTERATIONS OF EQUINE OOCYTES THAT FAILED TO CLEAVE AFTER INTRACYTOPLASMIC SPERM INJECTION: EVALUATION OF MATERNAL AND CELL AGING

Intracytoplasmic sperm injection (ICSI) is used for assisted fertilization of equine oocytes. However, not all oocytes cleave after ICSI. Maternal aging deleteriously affects fertility in mares and women, with reduced oocyte quality and success of assisted reproductive technologies. In the oocyte, senescence and cell-programmed death begins after maturation; the extent that maternal age affects these events is unknown. We hypothesised that formation of α/β tubulin asters and f-actin bubbles are associated with aging of the oocyte in vitro and/or aging of the oocyte in vivo, in aged donors. In Exp 1, oocytes were collected from ovaries obtained from an abattoir and matured for 28 h and selected for polar body extrusion (0 h). At 0, 24, and 48 h, oocytes (n = 38 total) were fixed in MTSB-XF and transferred into wash solution with 1% BSA and 0.1% Triton X-100 in PBS for immunostaining. For experiment 2, oocytes were collected from preovulatory follicles of mares (9–25 yr) in a clinical ICSI program and injected with sperm from various stallions after extrusion of a polar body. Between 24 to 51 h after ICSI, uncleaved oocytes (n = 52, single cell without evidence of fragmentation or indentation of the oolemma) were fixed. All oocytes were incubated with α/β tubulin and human-anti-centromere antibody-CREST/ACA (1 : 100 each). Following primary incubation, oocytes were washed and incubated with Alexa 488, Alexa 647, Alexa 561-phalloidin, and Hoechst 33258. Images and Z-stacks were acquired on an Olympus IX81 spinning disk confocal microscope. Morphometric and intensity analyses of images were performed using SlideBook software (Denver, CO). Student's t-test, Fisher's exact test, and chi-square analyses were used for statistical comparisons. After aging in vitro (experiment 1), the number of oocytes with tubulin multiasters increased (P < 0.001; 9% at 0 h, 14% at 24 h, 85% at 48 h); however, actin bubbling was observed in only 5/38 (13%) oocytes, with no effect of incubation time. In experiment 2, tubulin multiasters were present in 62% of oocytes that failed to cleave. More multiasters were observed per oocyte from mares ≤13 yr than ≥20 yr (P = 0.03) and fixed at 24 to 28 h than 44 to 51 h (P = 0.04). Actin bubbles were observed in 71% of oocytes that failed to cleave after ICSI, with more actin bubbles in oocytes from mares ≥20 yr than ≤13 yr (P = 0.01) and fixed 44 to 51 h versus 24 to 28 h after ICSI (P = 0.05). The sum intensity and area of the actin bubbles were higher in oocytes fixed at 44 to 51 h than 24 to 28 h (P = 0.01 and P = 0.04). The area occupied by the actin bubbles was larger (P = 0.05) in oocytes from mares ≥20 yr than ≤13 yr. This study demonstrates actin bubbles and tubulin asters are involved in oocyte aging and cytoskeleton remodelling with or without fertilization. Although actin structures were associated with donor age and hours after ICSI, they were not present in unfertilized oocytes aged in vitro. Multiaster formation was associated with cell senescence in oocytes aged in vitro. Although not previously reported for the equine oocyte, multiaster formation appeared to be an initial fertilization event within the oocyte associated with attempted zygote development.

181 CYTOSKELETAL AND CHROMOSOMAL ORGANIZATION IN DEVELOPMENTALLY ARRESTED EQUINE ZYGOTES AFTER INTRACYTOPLASMIC SPERM INJECTION

Intracytoplasmic sperm injection (ICSI) has been developed as a clinical procedure in the equine industry. Not all sperm-injected oocytes develop into embryos; however, the causes of developmental failure after equine ICSI have not been studied. Our objective was to use confocal microscopy to evaluate sperm-injected equine oocytes from young and old mares that did not cleave in a clinical ICSI program, to study the hypothesis that cleavage failure is associated with cytoskeletal and chromosomal alterations and affected by mare age. Oocytes were collected from the dominant follicles of young (Y; 5–15 years old) and old (O; 20–24 years old) oestrous mares approximately 24 h after administration of deslorelin and hCG. At approximately 44 h after deslorelin and hCG administration, oocytes were injected using frozen-thawed sperm from various stallions. Injected oocytes (n = 15) that failed to cleave by 24 to 48 h were fixed in microtubule stabilization buffer extraction fixative (MTSB-XF) and stained for DNA, α/β tubulin, acetylated α-tubulin, and f-actin. Confocal z-stacks were obtained using a Zeiss LSM 5 microscope (Carl Zeiss Microscopy LLC, Thornwood, NY), and images were assessed for cytoskeletal structures and chromosome organisation using the Zeiss LSM image browser. Potential zygotes (Y: n = 6 and O: n = 9) were categorized for (1) 2 sets of chromosomes, (2) misaligned chromosomes, (3) oversized spindles (approximately twice the size of an MII spindle), and (4) actin bubbling. The number of zygotes in each category for Y and O mares were compared by Fisher's exact test. Some samples were included in more than 1 morphological category. Two separate sets of chromosomes were observed in 1 of 6 and 4 of 9 injected oocytes from Y and O mares, respectively (P = 0.58), with development stopping before fusion of male and female pronuclei. Misaligned chromosomes were present in 2 of 6 and 7 of 9 oocytes from Y and O mares, respectively (P = 0.14). Oversized spindles were observed in more Y than O potential zygotes (5 of 6 and 2 of 9, respectively, P = 0.04), representing fusion of male and female pronuclei before developmental arrest. Multiasters were associated with the oversized spindles in potential zygotes from Y (2 of 6) and O (2 of 9) mares (P = 1), with microtubule activity potentially associated with the first mitotic division. Structures associated with actin bubbling tended (P = 0.12) to be higher in uncleaved zygotes from Y than O mares (5 of 6 and 3 of 9, respectively). Of the 15 injected oocytes, 10 arrested after fusion of male and female pronuclei. We have previously observed a high incidence of chromosomal misalignment in metaphase II oocytes from old mares. In the small number of potential zygotes that were studied, chromosomal misalignment tended (P = 0.14) to be higher for old mares. Other observations, such as oversized spindles and actin bubbling, appeared to be more prevalent in the potential zygotes of Y than O mares; these observations could be associated with normal development or post-ovulatory aging of the oocyte. Additional work will focus on the roles of actin and microtubules in remodelling the cytoplasm and organizing the chromosomes after fertilization in the horse and on the role of maternal aging in fertilization failure.

Nutritional status of patients undergoing ileal pouch-anal anastomosis

The nutritional consequences of total colectomy and ileal pouch-anal anastomosis (IPAA) were assessed by evaluating 36 patients at the end of the defunctionalised stage (DS group) and 18 patients with recanalised IPAA (IPAA group). The changes in protein-calorie and zinc status occurring after the closure of the diverting ileostomy were evaluated also in 11 patients assessed both during the DS and the IPAA stage. The results were compared with those observed in 14 patients who underwent a Brooke-type permanent ileostomy (PI group). In the DS group there were protein-calorie malnutrition in 50% of cases characterised by body weight, TSF and AMC values lower than normal associated with normal serum protein levels; severe salt and water depletion with secondary aldosteronism in 90%; normal calcium-phosphorus balance in all but few cases, low values of parameters related to vitamin D and K, Fe, Zn and Cu status in 6-25% of cases and normal folate status. In the IPAA group all the anthropmetric parameters improved significantly after the closure of the protective ileostomy, but muscle mass (AMC) remained lower than normal in 40% of cases; mild salt depletion (urinary Na K ratio between 1 and 2) was observed in 1 3 of cases and of severe degree (urinary Na K < 1 ) in 20%; lower serum Zn occurred in 60% of patients probably due to greater requirements of the metal, secondary to increased muscle protein synthesis; parameters of calcium-phosphorus balance, vitamin D and K, folate, Fe and Cu status, were normal in almost all the cases. In the PI group, protein-calorie and salt and mineral nutritional status were similar to those of the IPAA group, whereas Zn status was normal in all the patients and erythrocytes folate levels and prothrombin time were significantly lower than in the IPAA group. These last two results might be explained by the different characteristics of the small bowel flora occurring in the two types of ileostomy.

Effect of vitrification of feline ovarian cortex on follicular and oocyte quality and competence

Cryopreservation of ovarian cortex has important implications in the preservation of fertility and biodiversity in animal species. Slow freezing of cat ovarian tissue resulted in the preservation of follicular morphology and in the follicular development after xenografting. Vitrification has been recently applied to ovarian tissues of different species, but no information is available on the effect of this method on feline ovarian cortex. Moreover, meiotic competence of fully grown oocytes isolated from cryopreserved tissue has not been reported. The aim of this study was to evaluate the effect of vitrification of feline ovarian cortex on follicular morphology and oocyte integrity, as well as meiotic competence. A total of 352 fragments (1.5-2 mm(3) ) were obtained from ovarian cortical tissues: 176 were vitrified and 176 were used fresh as control. Histological evaluation of fresh and vitrified fragments showed intact follicles after cryopreservation procedures with no statistically significant destructive effect from primordial to antral follicles. After IVM, oocytes collected from vitrified ovarian fragment showed a higher proportion of gametes arrested at germinal vesicle (GV) stage compared to those isolated from fresh control tissue (33.8% vs 2.9%; p < 0.001). However, oocytes isolated from vitrified tissues were able to resume meiosis, albeit at lower rate than those collected from fresh tissues (39.8% vs 85.9%; p < 0.00001). Vitrification induced changes in the organization of cytoskeletal elements (actin microfilaments and microtubules) of oocytes, but significantly only for actin network (p < 0.001). Finally, chromatin configuration within the GV was not affected by the cryopreservation procedure. Our study demonstrated that vitrification preserves the integrity of ovarian follicles and that oocytes retrieved from cryopreserved tissue maintain the capability of resuming meiosis. To our knowledge, this has not previously been reported in the cat.

Gene expression as a predictive marker of outcome for high-risk transitional-cell carcinoma (TCC) of the bladder in patients (pts) randomized to adjuvant chemotherapy with cisplatin-gemcitabine (PG) or observation (OBS) after radical cystectomy

15502

Background: A randomized phase III trial comparing PG vs OBS in muscle-invasive TTC of the bladder is currently ongoing. ERCC1 and RRM1 genes are involved in the nucleotide excision repair pathways, and their up-regulation by tumor has been clearly related to resistance of cisplatin and gemcitabine, respectively. Preliminary correlations in patients with bladder cancer randomized to PG were already presented (Proc ASCO 2005, Abstract No: 4589). In the present study, we have examined the predictive value of ERCC1 and RRM1 as markers of tumor progression, as well as their potential correlation with other known prognostic factors also in patients randomized to OBS. Methods: Thirty-nine paraffin-embedded TTC samples of a subset of patients entered the trial were collected. The characteristics were: pT2 23%, pT3 54%, pT4a 23%, pN1–2 46%; G3–4 98%; M/F 10%/90%, median age: 65 years (range 53–74); PG/OBS: 49%/51%. Analysis consisted of real time RT-PCR quantification of mRNA levels of ERCC1 and RRM1. Results: After a median follow-up of 25 months (range 12–51), 17 patients relapsed and 10 deceased. A good correlation was found between mRNA expression levels of both genes. Three-year disease-free survival (DFS) was 74% vs 33% for patients with low and high ERCC1 expression (p=0.03), and 64% vs 22% for those with low and high RRM1 expression (p=0.26), respectively. Comparable result in favour of patients showing lower ERCC1 mRNA levels was found in both groups of patients randomized to PG or obs. Multivariate analysis demonstrated that only the presence of N1–2 and low expression level of ERCC1 were significant prognostic factor for better DFS (HR 4.358, 2.775 and p value = 0.006 and 0.046, respectively). Conclusions: Determination of ERCC1 mRNA expression level in muscle-invasive bladder cancer can make a contribution as an independent predictor of DFS after radical cystectomy. It’s still unclear if quantification of ERCC1 gene expression level could interact with adjuvant chemotherapy. Longer follow-up will help to address this issue (Supported by CNR-MIUR grants 02.00447, 03.00387-ST97).

No significant financial relationships to disclose.

Prevalence of home artificial nutrition in Italy in 2005: A survey by the Italian Society for Parenteral and Enteral Nutrition (SINPE)

AIM

To determine the prevalence (cases per million inhabitants) of home artificial nutrition (HAN), enteral (HEN) and parenteral (HPN), in Italy, grouped according to administrative regions, patient age and primary disease, and to analyze the impact both of the presence of an HAN regional regulation and of demographic characteristics.

METHODS

In April 2005, the Regional Coordinators of the Italian Society for Parenteral and Enteral Nutrition (SINPE) recorded all the ongoing cases of HAN using a structured questionnaire and were asked to estimate the representativeness of the collected sample with respect to the total expected HAN.

RESULTS

A total of 6955 cases of HAN (93.5% adults, 6.5% pediatric patients < or = 18 years) were recorded in 16 of the 20 Italian regions (80% of the Italian population; sample representativeness 78%). HAN prevalence 152.6 (83.9% HEN, 16.1% HPN); the HAN range among the regions was: prevalence 28.1-519.8; oncological disease 13.8-75.7%, neurological disease 15.5-79.9%, intestinal failure 1.3-14.0%. An HAN regulation was present in 11 regions. A positive association (P=0.012) was found between the number of years since the regulation was issued and the HAN prevalence, and also between the % neurological patients and the population density (P=0.130) and the % inhabitants > or = 75 years (P=0.040).

CONCLUSIONS

The need for HAN regards a great number of patients throughout the country; there are substantial differences between the regions with respect to both the prevalence and the use of HAN in various disease categories. A specific regulation may favor the development of HAN.

Pilot study of capecitabine combined with celecoxib (CapCel) as second-line treatment for advanced pancreatic (P) and biliary tree (BT) cancer

14055

Background: COX-2 is overexpressed during cancer progression in several solid tumors, including P and BT, and constitutes an attractive therapeutic target. Selective COX-2 inhibitors, such as celecoxib, have been successfully combined with fluoropyrimidine-based regimens, resulting in a lower-than-expected hematologic, GI, and skin toxicity rate. Methods: Advanced P or BT patients (pts), progressing after first-line treatment, were eligible for the study. Capecitabine was administered at 1000 mg/m2 b.i.d. on days 1–14 q3 weeks; celecoxib was administered at 200 mg b.i.d. continuously starting on day 1. PFS was the primary endpoint. ORR, toxicity, OS, clinical benefit (CB), and QoL were secondary endpoints. Assuming that a rate of PFS >15% at 3 mos would be considered of interest in this pt population, an accrual of 28 pts was planned according to the exact single-stage phase II design described by A’Herne. Results: To date, 25 pts have been accrued (M/F: 11/14; median age: 64 yrs, range 39–75; P/BT: 18/7; PS 0–1/2–3: 19/6). All pts completed at least 1 treatment cycle (median: 3, range 1–9). Twenty-three pts are currently evaluable for response: 1 PR and 1 MR (duration: 33 and 27+ wks) were observed, both in pts with P; 5 additional pts showed SD (duration: 10+, 21, 22+, 27, and 42 wks); the remaining 16 pts had PD. All pts and 83 cycles are evaluable for toxicity. Hematological toxicity was negligible; only 4 pts experienced G3 non-hematological toxicities: diarrhea (2 pts, 2 cycles), skin toxicity (1 pt, resolved with treatment delay), asthenia (1 pt, 2 cycles), and GI bleeding (1 pt, requiring treatment interruption after cycle 1). To date, 19 pts have progressed and 15 pts have died: median PFS is 11 wks (range 3–42) and median OS is 16 wks (range 4–54). Nineteen pts had elevated CA19.9 serum levels at baseline, which decreased of > 25% during treatment in 7 pts, remained stable in 3 pts, and increased in 9 pts. The evaluation of CB and QoL is ongoing. Conclusions: CapCel is a feasible and well-tolerated, fully oral, treatment regimen for advanced P and BT patients, which shows activity, albeit modest, even in a second-line setting. Further evaluation of this therapeutic strategy is warranted.

No significant financial relationships to disclose.

Current status of targeted agents in advanced pancreatic cancer (APC): A pooled analysis of 2,361 patients (pts) enrolled in six phase III trials

4126

Background: Molecular targeting of pathways that are deregulated in pancreatic cancer is a promising approach aimed at improving the dismal prognosis of APC pts. However, the clinical impact of novel “biological” drugs (ND) remains to be defined. Methods: All prospective phase III trials comparing single-agent Gemcitabine (G) with either a ND or a combination of ND and G (ND+G) were considered eligible. A pooled analysis was performed and event-based relative risk ratios (RR) with 95% CI were derived through both a fixed- and a random-effect model approach, exploring OS as the primary outcome and PFS and ORR as secondary outcomes. Heterogeneity between different trials was also taken into account. Results: Six trials involving 2361 pts were identified; ND tested included: FTI inhibitors (1 trial), MMP inhibitors (3 trials), EGFR inhibitors (1 trial), and anti-gastrin vaccine (1 trial). The analysis was conducted considering three different subgroups: 1) overall population (2361 patients, 6 trials), 2) ND+G vs G (1879 patients, 4 trials), and 3) ND vs G (482 patients, 2 trials). As shown in the table, no significant differences in either the primary outcome (OS) or the secondary outcome of PFS were observed in the overall population as well as in ND+G vs G trials, while a significant negative trend for ND was found in ND vs G trials with regard to both endpoints. Conversely the evaluation of the secondary endpoint of ORR significantly favored G in the overall population as well as in ND vs G trials, while a not significant negative trend for ND was observed in ND+G vs G trials. Conclusions: G remains the treatment of choice in APC pts. The ND tested, either alone or combined with G, do not seem to add any benefit over G. A better understanding of pancreatic cancer biology and further clinical evaluation of new agents and is needed to improve prognosis in APC pts.

[Table: see text]

No significant financial relationships to disclose.

Gemcitabine-based polychemotherapy for advanced pancreatic cancer (APC): Is it ready for prime time? A pooled analysis of 3,682 patients (pts) enrolled in 12 phase III trials

4118

Background: Since the introduction of gemcitabine (G), attempts have been made to develop G-based combination regimens to improve the dismal outcome of APC pts. Results of randomized trials, however, have been conflicting and single-agent G presently remains the standard of care for such pts. Methods: All prospective phase III trials comparing single-agent G with G-based polychemotherapy regimens (poly-G) were considered eligible. A pooled analysis was performed and event-based relative risk ratios (RR) with 95% CI were derived through both a fixed- and a random-effect model approach, exploring OS as the primary outcome and PFS and ORR as secondary outcomes. Heterogeneity between different trials was also taken into account. Results: Twelve trials involving 3682 pts were identified. The analysis was conducted considering three different subgroups: 1) overall population (3682 patients, 12 trials), 2) platinum-containing poly-G (PG) vs G (768 pts, 5 trials), and 3) fluoropyrimidine-containing poly-G (FG) vs G (1640 pts, 4 trials). As shown in the table, no significant differences in the primary outcome (OS) were observed in any of the three groups analyzed. Conversely, a significant advantage for poly-G was evident with regard to both PFS and ORR in the overall population as well as in the PG vs G subgroup, although with some heterogeneity. A heterogeneous non-significant trend towards a better PFS and ORR outcome was also observed in the FG vs G subgroup. Conclusions: Single-agent G remains the treatment of choice in APC pts. However, the addition of platinum compounds to G appears to significantly improve PFS and ORR, possibly justifying the use of platinum-based poly-G in younger and fit patients.

[Table: see text]

No significant financial relationships to disclose.

Fixed dose-rate gemcitabine infusion as first-line treatment for advanced-stage carcinoma of the pancreas and biliary tree: series of 106 consecutive patients

14099

Background: Our group recently published a phase II trial of GEM infused at fixed dose-rate of 10 mg/m2/min over 100 min in patients with advanced PDAC and BTC. (Cancer September 15,2005). Given the promising results obtained in the first 40 pts, we expanded the cohort under an observational protocol and this is the report of such experience. Methods: From April 2002 to September 2005, 106 advanced PDAC (n = 75) or BTC (n = 31) pts (median age: 63 yrs, range 28–82; M/F: 48/58; PDAC/BTC: 75/31; LA/Met: 36/70; PS 0/1/2/3: 31/53/17/5) were treated with GEM 1000 mg/m2 at the fixed dose-rate of 10 mg/m2/min for 7 consecutive wks and weekly × 3 q4 wks thereafter (FDR-GEM). All patients and 1154 treatment weeks were evaluable for toxicity, 100 were evaluable for response, 87 patients were evaluable for clinical benefit response (CBR) according to Burris criteria, and 56 patients had elevated CA19.9 serum levels at entry. Results: From April 2002 to September 2005, 106 advanced PDAC (n = 75) or BTC (n = 31) pts (median age: 63 yrs, range 28–82; M/F: 48/58; PDAC/BTC: 75/31; LA/Met: 36/70; PS 0/1/2/3: 31/53/17/5) were treated with GEM 1000 mg/m2 at the fixed dose-rate of 10 mg/m2/min for 7 consecutive wks and weekly × 3 q4 wks thereafter (FDR-GEM). All patients and 1154 treatment weeks were evaluable for toxicity, 100 were evaluable for response, 87 patients were evaluable for clinical benefit response (CBR) according to Burris criteria, and 56 patients had elevated CA19.9 serum levels at entry. Conclusions: The results obtained with FDR-GEM in a series of 106 consecutive pts confirm previous results obtained in smaller series and suggest that pharmacokinetically rationale GEM scheduling may improve its therapeutic index. FDR-Gem may constitute a viable alternative to standard Gem infusion as first-line treatment in advanced PDAC and BTC.

No significant financial relationships to disclose.

Hormonal adjuvant treatment plus radiotherapy versus exclusive radiotherapy in locally advanced prostate cancer: Pooled analsys of 6 randomized trials

4642

Background: The magnitude of the benefit of adding adjuvant hormonal treatment to radiotherapy for locally advanced prostate cancer is still unclear. We performed a pooled-analysis of phase III trials, to quantify the eventual benefit in recurrence decrease. Methods: All prospective phase III trials were considered eligible. A pooled analysis was accomplished, and event-based relative risk ratios (RR) with 95% confidence interval (CI) were derived through both a fixed- (FEM) and a random-effect model (REM) approach. Significant differences in primary outcome (recurrence rate), and secondary outcomes (overall survival), were explored. Magnitude outcome measures were: absolute benefits and number of patients needed to treat (NNT) for 1 patient to benefit. Heterogeneity test was applied as well. Results: Six trials designed to look if hormonal treatment plus radiotherapy decreases recurrence rate (3,571 patients) were gathered. In the primary outcome, the combined approach significantly improves the recurrence rate when applying the FEM (RR 0.72, 95% CI 0.68, 0.77, p < 0.0001), with an absolute benefit of 10.7%. The NNT was 9 patients. Although significant heterogeneity was found (p = 0.00001), the benefit remains significant at the REM as well (RR 0.67, 95% CI 0.54, 0.82, p < 0.0001). Although significant at FEM (RR 0.93, 95% CI 0.86, 1.00, p = 0.039) but heterogeneous (p = 0.0007), the overall survival demonstrated a not-significant trend in favour of the combined strategy at REM (RR 0.90, 95% CI 0.75, 1.10, p = 0.263). Conclusions: Considered all the available phase III trials, the combination of adjuvant hormonal treatment with radiotherapy over standard exclusive radiotherapy significantly decreases the recurrence rate in patients affected by localized prostate cancer. The significant heterogeneity in the analysis underscores the existing difference in patient’ characteristics. No significant benefit in overall survival was found.

No significant financial relationships to disclose.

The surgical treatment of fecal incontinence with artificial anal sphincter implant. Preliminary clinical report

BACKGROUND/AIMS

Fecal incontinence has a serious impact upon patients' quality of life. Several treatment methods are possible according to the pathophysiology of the disease.

METHODOLOGY

Between March 1999 and February 2002 eight artificial anal sphincters (American Medical System - AMS) were implanted in seven patients affected with severe fecal incontinence; in one case the device was positioned in a patient who had previously undergone a Miles' resection. All cases were carefully selected according to appropriate diagnostic evaluation. The follow-up varies between 3 and 40 months.

RESULTS

The prosthesis had to be removed in two cases; in one patient infection of the implant area occurred, while in the other case persistent perianal pain due to the presence of the device could not be tolerated by the patient. In the six patients that could be successfully treated with the artificial anal sphincter implant, it dramatically improved their quality of life.

CONCLUSIONS

The success of the procedure allows the consideration that the artificial anal sphincter implant is the best treatment for severe fecal incontinence that cannot be solved with conservative therapy.

Incidence of intentional poisoning of dogs in the Abruzzo region of Italy

Toxicological assays done between 1997 and 2000 on 105 presumed baits of the baits and poisonings in 408 dogs are reported. Of the baits, 54.4% were positive for organophosphates and 27.5% for strychnine. In 31.1% of the dog cases, analysis confirmed the presence of toxic concentrations of organophosphate pesticides (43.3%) and strychnine (44.1%).

[Endoluminal pressure: risk factor for anastomotic dehiscence in rectal carcinoma. Preliminary results]

The aim of this work was to evaluate the risk factors for anastomotic leakage with particular reference to endoluminal pressures in patients undergoing surgery for colorectal cancer between february 1998 and september 2000. In this preliminary report a total of 120 patients were identified; 96 patients were treated with a total mesorectal excision (with anastomosis less than 10 cm from the anal margin) for rectal cancer and 33 with a partial mesorectal excision (with anastomosis of the superior rectum) for rectosigmoid carcinoma. The leakages were observed in 10.4% of patients and the incidence of this complication was 15.6% in patients with rectal cancer. Using a transanal tube (7 x 2 cm) which reduces endoluminal pressure close to the anastomosis, a significant reduction in the number of leakages was observed. The authors suggest that the transanal tube represents a useful aid in resolving the problem of anastomotic leakage in rectal cancer and stress the importance of this simple, cheap surgical technique.

[Fournier syndrome: report of a clinical case]

The case of a Fournier's syndrome in a 58 years old patient is reported from the Authors that describe the ethiopathogenetic and therapeutic aspects. They analyse the importance of an early surgical treatment associated with antibiotic therapy and later a riparation of the lesions with a myocutaneous skin flap of TLF.

[Incidental diagnosis of seminoma in male infertility: report of a clinical case]

The aims of the study were to evaluate the association between male infertility and risk of developing testis cancer and to establish guidelines for the early diagnosis of testis neoplasia in subfertile men. 32-year-old infertile man. The patient underwent random testicular biopsy to establish the exact cause of infertility. An incidental diagnosis of seminoma was made and the patient then underwent right testis excision. Anatomopathologic macroscopic examination revealed two nodules, the sizes of which were 0.8 x 0.4 and 0.3 x 0.2 cm, respectively. Histologic examination confirmed the diagnosis of typical seminoma, pT1, with copious lymphocytic struma infiltration. There appears to be a correlation between male infertility and occurrence of seminoma. Diagnosis of testis cancer is often incidental and sometimes occurs in men undergoing testicular biopsy to investigate infertility. Since the biopsy was not specifically targeted in our case, the diagnosis of seminoma was casual. This suggests the need for a careful follow-up, including testicular ultrasonography as a screening test to achieve an early diagnosis of testis cancer in all infertile men, because of their higher risk of developing testis cancer than the normal population.

Bone turnover in short-term and long-term home parenteral nutrition for benign disease

6 mo afterward. Long-HPN was assessed only at baseline. In short-HPN, there was a hyperkinetic turnover at baseline. At follow-up, OC was similar to baseline, whereas cross-links, urinary calcium and magnesium decreased (P < 0.03), and parathyroid hormone increased (P < 0.001). The variation of urinary calcium correlated with that of cross-links (r = 0.73, P < 0.04). In long-HPN, OC was low or low-normal in almost all the patients, and cross-links were normal. Mean OC was lower than that of short-HPN both at baseline (P < 0. 003) and at follow-up (P < 0.002). The results suggest that in the early period of HPN bone metabolism improved from a hyperkinetic turnover to a positive balance. A low bone-formation rate appeared to be a characteristic feature of long-term HPN.

Lipid peroxidation and antioxidant status in adults receiving lipid-based home parenteral nutrition

BACKGROUND

Infusion of lipid emulsions rich in polyunsaturated fatty acids (PUFAs) may increase lipid peroxidation, which is counteracted mainly by superoxide dismutase (SOD) (a zinc-, copper-, and manganese-dependent enzyme), selenium-dependent glutathione peroxidase (Se-GSHPx), and alpha-tocopherol.

OBJECTIVE

We investigated lipid peroxidation and antioxidant status in patients receiving home parenteral nutrition (HPN) providing variable amounts of a lipid emulsion rich in PUFAs, and alpha-tocopherol, zinc, copper, and manganese as recommended by the American Medical Association, and no selenium.

DESIGN

Serum malondialdehyde, plasma alpha-tocopherol, selenium, Se-GSHPx, PUFAs, and red blood cell Se-GSHPx and SOD were evaluated in 12 patients and in 25 healthy control subjects. Malondialdehyde was also assessed in a group of 40 healthy control subjects.

RESULTS

Patients had significantly higher concentrations of malondialdehyde and SOD and lower alpha-tocopherol concentrations and selenium nutritional status. Linear regression analysis showed that malondialdehyde was associated with the daily PUFA load (r=0.69, P< 0.03) and with plasma alpha-tocopherol (r=-0.59, P< 0.05), but stepwise multiple regression analysis confirmed only the association between malondialdehyde and alpha-tocopherol; plasma alpha-tocopherol was associated with the daily PUFA load (r=-0.65, P< 0.04) and with the duration of HPN (r=-0.74, P< 0.02).

CONCLUSIONS

In HPN patients, the peroxidative stress due to lipid emulsions rich in PUFAs is counteracted primarily by alpha-tocopherol. The dosages of alpha-tocopherol, zinc, copper, and manganese recommended by the American Medical Association appear sufficient to sustain SOD activity but inadequate to maintain alpha-tocopherol nutritional status. HPN formulations should be supplemented with selenium.

Bioavailability of Desmin, a low molecular weight dermatan sulfate, after subcutaneous administration to healthy volunteers

The bioavailability of two different s.c. doses of Desmin (a new low molecular weight dermatan sulfate) was evaluated in 12 healthy volunteers (6 men, 6 women aged 22-45 years) who were injected, on 3 separate days and with a wash-out period of at least 21 days between each administration, with 200 and 300 mg of Desmin by the s.c. route and 200 mg by the i.v. route. Immediately before injection and at various times thereafter (after 15 min and 30 min for i.v. only and after 1, 2, 3, 4, 6, 8, 12, and 24 h for both s.c. and i.v. dosing), blood samples were drawn to investigate bioavailability by measuring several coagulation parameters: activated partial thromboplastin time, thrombin time, inhibition of factor Xa, Heptest, and heparin cofactor II. Furthermore the local tolerance of the s.c. and i.v. injections were investigated. The s.c. administration of the two Desmin doses had a negligible effect on the activated partial thromboplastin time and a very small effect on the thrombin time, measured with human thrombin; in contrast, Heptest, heparin cofactor II, and anti-Xa activities increased, with a good drug bioavailability (more than 100%). The plasma effects of Desmin were dose dependent only when measured by Heptest, which also gave a greater response after the s.c. administrations. There were no symptoms of intolerance or pain at the injection site after single i.v. and s.c. Desmin administration.

Home artificial nutrition in advanced cancer

Attitudes to home artificial nutrition (HAN) in cancer vary greatly from country to country. A 6-year prospective survey of the practice of HAN in advanced cancer patients applied by a hospital-at-home programme in an Italian health district was performed to estimate the utilization rate, to evaluate efficacy in preventing death from cachexia, maintaining patients at home without burdens and distress and improving patients' performance status, and to obtain information about costs. Patients were eligible for HAN when all the following were present: hypophagia; life expectancy 6 weeks or more, suitable patient and family circumstances; and verbal informed consent. From July 1990 to June 1996, 587 patients were evaluated; 164 were selected for HAN (135 enteral and 29 parenteral) and were followed until 31 December 1996. The incidence of HAN per million inhabitants was 18.4 in the first year of activity and 33.2-36.9 in subsequent years, being 4-10 times greater than rates reported by the Italian HAN registers. On 31 December 1996, 158 patients had died because of the disease and 6 were on treatment. Mean survival was 17.2 weeks for those on enteral nutrition and 12.2 weeks for those on parenteral nutrition. Prediction of survival was 72% accurate. 95 patients had undergone 155 readmissions to hospital, where they spent 15-23% of their survival time. Burdens due to HAN were well accepted by 124 patients, an annoyance or scarcely tolerable in the remainder. The frequency of major complications of parenteral nutrition was 0.67 per year for catheter sepsis and 0.16 per year for deep vein thrombosis. Karnofsky performance score increased in only 13 patients and body weight increased in 43. The fixed direct costs per patient-day (in European Currency Units) were 14.2 for the nutrition team, 18.2 for enteral nutrition and 61 for parenteral nutrition. The results indicate that definite entry criteria and local surveys are required for the correct use of HAN in advanced cancer patients, that HAN can be applied without causing additional burdens and distress, and that its costs are not higher than hospital costs.

Bone turnover in patients on home parenteral nutrition: alongitudinal observation by biochemical markers

In order to characterize biochemical markers of bone turnover in home parenteral nutrition(HPN) patients, 8 adult patients on HPN for benign intestinal failure were studied at 0, 6 and 12 months by evaluating serum osteocalcin (bone formation marker), urinary hydroxylysyl pyridinoline, lysyl pyridinoline and beta-galactosyl hydroxylysine (bone resorption markers), serum PTH, Calcitonin, 25 vitD, 1-25vitD, serum and urinary minerals, body weight, rehabilitation degree and HPN characteristics. Three patients entered the study 2-3 months after the beginning of HPN. Their features of bone turnover were homogeneous, characterized by increased resorption associated with normal or increased formation, at baseline, and normalization of resorption associated with an increase or a parallel decrease of formation, at 6 months. At 12 months, the patterns were similar to those observed at 6 months. The patients were not of the same sex and age and had different underlying diseases and types of intestinal failure, HPN composition and serum vitamin D levels. They had weight gain that was already present at baseline and the positive outcomes of the rehabilitation and clinical status in common. Five patients entered the study more than 1 year after the beginning of HPN. They showed heterogeneous features of bone turnover that were stable throughout the study, characterized by increased resorption associated with low or normal formation in two cases, low normal resorption associated with low or normal formation in three. In one patient, who had increased resorption and low formation, the bone turnover appeared to be explained by the nutritional and clinical outcomes, which were negative. These results appeared consistent with those obtained in previous studies by bone histomorphometry, indicating that bone turnover of short-term HPN patients differed from that of long-term patients, and suggesting that the early months of HPN were associated with increased bone resorption.

Morphologic and cytoproliferative patterns of duodenal mucosa in two patients after long-term total parenteral nutrition: changes with oral refeeding and relation to intestinal resection

The morphologic and cytoproliferative patterns of the duodenal mucosa of two adult patients, one of whom had a short bowel, were evaluated after more than 2 months of postoperative total parenteral nutrition and 2 and 12 months after the resumption of oral alimentation. Morphometric analysis was performed on routinely processed duodenal biopsies. Cell proliferation was evaluated by means of in vitro bromodeoxyuridine uptake. The results were compared with those obtained in five healthy controls. After parenteral nutrition, patients showed significantly lower villus height and crypt depth than those of controls and a normal bromodeoxyuridine labeling index. After 2 months of refeeding, villus and crypt returned to normal, and the labeling index was increased. After 12 months of oral refeeding, labeling index, villus height, and crypt depth were similar to those of controls. The patient with the short bowel showed a number of cells per unit length of villus and crypt significantly greater than those of the controls and of the patient who underwent shorter intestinal resection. In human duodenal mucosa, (1) hypoplasia develops after long-term total parenteral nutrition; (2) mucosal recovery occurs through an increased cell proliferation after oral refeeding; and (3) extensive small bowel resection determines the development of relative hyperplasia.

[Transcervical electric resection in submucous myomas]

Twenty-five patients underwent hysteroscopic resection of large symptomatic intrauterine fibroids. Patients were divided into one of three groups: those with pedunculated myomas (G0), those with intramural extension less than 50% (G1), and those with fibroids with intramural extension more than 50% (G2). In the first group (7 patients) the age ranged from 42-52 years (mean age 48 years), the operating time ranged from 15-60 min. (mean time 27 minutes), and the amount of fluid used for irrigation ranged from 1000-10000 ml (mean fluid 4400 ml). Four of the seven patients had concomitant endometrial polyps. Follow-up ranged from 3-32 months (mean 21 months), one patient was lost, and the success rate in 6 was 100%. In the second group (9 patients) the age ranged from 30-54 years (mean age 43.5 years), the operating time ranged from 35-90 minutes (mean time 62 minutes), and the amount of fluid used ranged from 2800-12500 ml (mean fluid 7150 ml). In one case endometrial ablation was associated. Two patients (45 and 54 years) had histopathological diagnosis of malignancy (endometrial stromal nodule and stromal myoma) and required hysterectomy. No residual stromal nodule was found in the uterus following hysteroscopy resection in one case. Follow-up ranged from 6-38 months (mean 20 months), two patients was lost and one had repeat hysteroscopic procedure. Four of the nine patients had a successful outcome.(ABSTRACT TRUNCATED AT 250 WORDS)

Morphologic and cytoproliferative patterns of duodenal mucosa in two patients after long-term total parenteral nutrition: changes with oral refeeding and relation to intestinal resection

The morphologic and cytoproliferative patterns of the duodenal mucosa of two adult patients, one of whom had a short bowel, were evaluated after more than 2 months of postoperative total parenteral nutrition and 2 and 12 months after the resumption of oral alimentation. Morphometric analysis was performed on routinely processed duodenal biopsies. Cell proliferation was evaluated by means of in vitro bromodeoxyuridine uptake. The results were compared with those obtained in five healthy controls. After parenteral nutrition, patients showed significantly lower villus height and crypt depth than those of controls and a normal bromodeoxyuridine labeling index. After 2 months of refeeding, villus and crypt returned to normal, and the labeling index was increased. After 12 months of oral refeeding, labeling index, villus height, and crypt depth were similar to those of controls. The patient with the short bowel showed a number of cells per unit length of villus and crypt significantly greater than those of the controls and of the patient who underwent shorter intestinal resection. In human duodenal mucosa, (1) hypoplasia develops after long-term total parenteral nutrition; (2) mucosal recovery occurs through an increased cell proliferation after oral refeeding; and (3) extensive small bowel resection determines the development of relative hyperplasia.

Home parenteral nutrition for the management of chronic intestinal failure: a 34 patient-year experience

Home parenteral nutrition (HPN) was used for the treatment of 18 patients with chronic intestinal failure (CIF): short bowel syndrome (9), extensive intestinal disease (4), motility disorder (4), entero-enteric fistulas (1). The underlying diseases were: chronic inflammatory (7), mesenteric vascular (4), scleroderma (2), pseudo-obstruction (2), malignancy (2), radiation enteritis (1). HPN was more effective on protein-calorie nutritional status than on fluid and electrolyte balances. About two-thirds of the patients achieved full or partial social rehabilitation. During the 6 months before HPN, there were 20 hospitalizations (mean stay: 55 days). During HPN (mean length of treatment: 22 months/patient) there were 16 hospitalizations (mean stay: 22 days), 8 of which were caused by HPN complications (sepsis and deep vein thrombosis; overall incidence of catheter-related complications: 0.411 per patient-year). Bone demineralization, liver abnormalities and biliary stones developed, respectively, in 57%, 28% and 11% of the cases. The underlying intestinal condition played a role in their pathogenesis. The annual cost of HPN ranged from 40 (Hospital Pharmacy Service) to 80 (commercial firm) million lire per patient. To sum up, HPN improves the nutritional status and the quality of life of patients with CIF, and the risk of complications is acceptable. The medical and social advantages are considered to offset the cost of the technique.

Fat-induced ileal brake in humans: a dose-dependent phenomenon correlated to the plasma levels of peptide YY

BACKGROUND

Upper gastrointestinal motility is regulated by the presence of nutrients in the distal gut. The present study evaluated whether lipid-induced ileal brake on gastric emptying (1) can be elicited by low fat concentrations; (2) is a dose-dependent phenomenon; and (3) is related to gastrointestinal peptide release.

METHODS

Seven patients were studied in the defunctionalized stage of total colectomy, on three separate occasions. On each study day, patients ate a meal labeled in the solid component; 30 minutes later, one of the following solutions was randomly infused into the ileal pouch: 0.9% saline, 2% oleic acid, and 20% oleic acid. Plasma concentrations of peptide YY (PYY), enteroglucagon, neurotensin, and motilin were measured.

RESULTS

Both oleic acid solutions slowed gastric emptying compared with saline (P < 0.001), the effect being dose dependent (P < 0.001). Ileal infusions did not modify neurotensin and enteroglucagon levels but induced a dose-dependent increase of PYY (P < 0.01) and a borderline decrease of motilin (P = 0.05) levels. Slower rates of gastric emptying were related to increased plasma concentrations of PYY (r = 0.615; P < 0.05).

CONCLUSIONS

This study shows that (1) the ileal brake on gastric emptying can be evoked by low doses of lipids in the distal ileum; (2) the delay of gastric emptying is related to the release of PYY; and (3) both phenomena are dose dependent.