The role of laboratory medicine in a value-based healthcare system: the example of heart failure patient management in the Italian context

OBJECTIVE

As of today, healthcare systems worldwide face severe challenges that undermine their sustainability. The value-based healthcare (VBHC) approach has been proposed as a strategic and methodological framework to ensure the delivery of the best patient outcomes with economic efficiency. Through the illustrative example of B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) for heart failure (HF) patient management in the context of the Italian National Healthcare system, this article explores the role that in vitro diagnostics (IVDs) can play in enabling value-based care models.

SUBJECTS AND METHODS

14 healthcare professionals representing the relevant professional figures involved in HF patient management met to revise the current HF patient journey and design a new care pathway that, leveraging on BNP/NT-proBNP, reflects the VBHC principles.

RESULTS

The literature recognizes the dosage of BNP/NT-proBNP as the gold stan-dard for diagnosing HF. However, as of today, these IVDs are not employed at their full potential regarding HF patient management. A new patient journey is proposed so that patients are diagnosed early and properly monitored in the aftermath of hospitalization, improving outcomes at contained costs.

CONCLUSIONS

As testified by the example of HF patient management in Italy, laboratory medicine can represent a lever for adopting value-based care models. Still, large-scale adoption of VBHC will call for structural reforms that revise how healthcare delivery is organized, measured, and reimbursed.

Acute changes in free and extracellular vesicle-associated circulating miRNAs and myokine profile in professional sky-runners during the Gran Sasso d’Italia vertical run

The modification of gene expression profile, a first step in adaptation to exercise, leads to changes in the level of molecules associated with skeletal muscle activity and energy metabolism—such as myokines—as well as those involved in their transcriptional regulation, like microRNA. This study aimed to investigate the influence of strenuous exercise on circulating microRNAs and their possible association with myokine response. Pre-competition and post-competition plasma samples were collected from 14 male athletes participating in a vertical run (+1,000 m gain, 3,600 m length). Circulating total (t-miRNA) and extracellular vesicle-associated (EV-miRNA) miRNAs were extracted from the pooled plasma. Nanoparticle tracking analysis was performed to investigate pre- and post-competition EV concentration and size distribution. A panel of 179 miRNAs was assayed by qPCR and analyzed by Exiqon GenEx v6 normalized on the global mean. t-miRNA and EV-miRNAs whose level was ≥5-fold up- or down-regulated were validated for each single subject. Target prediction on MirWalk v3.0, Gene-Ontology, and pathway enrichment analysis on Panther v17.0 were performed to define the potential biological role of the identified miRNAs. A panel of 14 myokines was assayed in each sample by a multiplex immunoassay. In whole plasma, five miRNAs were upregulated and two were downregulated; in the EV fraction, five miRNAs were upregulated and three were downregulated. Nanoparticle tracking analysis revealed a similar EV size distribution in pre- and post-competition samples and a decreased concentration in post-competition samples related to pre-competition samples. Gene-Ontology and pathway enrichment analysis revealed that the identified t-miRNAs and EV-miRNAs were potentially involved in metabolism regulation in response to exercise. Correlation between fold-change of the post-competition relative to pre-competition plasma level of both t-miRNAs and EV-miRNAs and myokines further confirmed these results. This study provides an example of a systemic response to acute endurance exercise, in which circulating miRNAs play a pivotal role.

Are clinical practice guidelines for low back pain interventions of high quality and updated? A systematic review using the AGREE II instrument

BACKGROUND

Clinical practice guidelines (CPGs) provide recommendations for practice, but the proliferation of CPGs issued by multiple organisations in recent years has raised concern about their quality. The aim of this study was to systematically appraise CPGs quality for low back pain (LBP) interventions and to explore inter-rater reliability (IRR) between quality appraisers. The time between systematic review search and publication of CPGs was recorded.

METHODS

Electronic databases (PubMed, Embase, PEDro, TRIP), guideline organisation databases, websites, and grey literature were searched from January 2016 to January 2020 to identify GPCs on rehabilitative, pharmacological or surgical intervention for LBP management. Four independent reviewers used the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool to evaluate CPGs quality and record the year the CPGs were published and the year the search strategies were conducted.

RESULTS

A total of 21 CPGs met the inclusion criteria and were appraised. Seven (33%) were broad in scope and involved surgery, rehabilitation or pharmacological intervention. The score for each AGREE II item was: Editorial Independence (median 67%, interquartile range [IQR] 31-84%), Scope and Purpose (median 64%, IQR 22-83%), Rigour of Development (median 50%, IQR 21-72%), Clarity and Presentation (median 50%, IQR 28-79%), Stakeholder Involvement (median 36%, IQR 10-74%), and Applicability (median 11%, IQR 0-46%). The IRR between the assessors was nearly perfect (interclass correlation 0.90; 95% confidence interval 0.88-0.91). The median time span was 2 years (range, 1-4), however, 38% of the CPGs did not report the coverage dates for systematic searches.

CONCLUSIONS

We found methodological limitations that affect CPGs quality. In our opinion, a universal database is needed in which guidelines can be registered and recommendations dynamically developed through a living systematic reviews approach to ensure that guidelines are based on updated evidence.

LEVEL OF EVIDENCE

1 TRIAL REGISTRATION: REGISTRATION PROSPERO DETAILS: CRD42019127619 .

How the effects of actions become our own

Every day, we do things that cause effects in the outside world with little doubt about who caused what. To some, this sense of agency derives from a post hoc reconstruction of a likely causal relationship between an event and our preceding movements; others propose that the sense of agency originates from prospective comparisons of motor programs and their effects. Using functional magnetic resonance imaging, we found that the sense of agency is associated with a brain network including the pre-supplementary motor area (SMA) and dorsal parietal cortex. Transcranial magnetic stimulation affected the sense of agency only when delivered over the pre-SMA and specifically when time-locked to action planning, rather than when the physical consequences of the actions appeared. These findings make a prospective theory of the sense of agency more likely.

How Task Interactivity Shapes Action Observation

Action observation triggers imitation, a powerful mechanism permitting interpersonal coordination. Coordination, however, also occurs when the partners’ actions are nonimitative and physically incongruent. One influential theory postulates that this is achieved via top-down modulation of imitation exerted by prefrontal regions. Here, we rather argue that coordination depends on sharing a goal with the interacting partner: this shapes action observation, overriding involuntary imitation, through the predictive activity of the left ventral premotor cortex (lvPMc). During functional magnetic resonance imaging (fMRI), participants played music in turn with a virtual partner in interactive and noninteractive conditions requiring 50% of imitative/nonimitative responses. In a full-factorial design, both perceptual features and low-level motor requirements were kept constant throughout the experiment. Behaviorally, the interactive context minimized visuomotor interference due to the involuntary imitation of physically incongruent movements. This was paralleled by modulation of neural activity in the lvPMc, which was specifically recruited during the interactive task independently of the imitative/nonimitative nature of the social exchange. This lvPMc activity reflected the predictive decoding of the partner’s actions, as revealed by multivariate pattern analysis. This demonstrates that, during interactions, we process our partners’ behavior to prospectively infer their contribution to the shared goal achievement, generating motor predictions for cooperation beyond low-level imitation.

Modular implant design affects metal ion release following metal-on-metal hip arthroplasty: a retrospective study on 75 cases

Metal-on-Metal (MoM) total hip arthroplasty (THA) has been associated to wear and metal-ions release, controversially related to a variety of clinical complications. Little is known about the relevant design-dependent parameters involved in this process. The present study investigated the correlation between metal ion release in blood and revision rate as a function of: (i) specific MoM implant modular design parameters, (i.e. acetabular cup and femoral head diameters, taper adapter material and size, femoral neck material and modularity and stem size); (ii) MoM bilaterality. Co and Cr ions concentration levels in blood of 75 patients were retrospectively-evaluated with a mean follow-up of 4.8 years (range: 1.8-6.3). Patients were divided in a unilateral and a bilateral group. Statistical analysis was performed to find any significant difference related to acetabular cup diameter, femoral head diameter, taper adapter material/size, neck material/size and stem size. The bilateral MoM group had 4-times higher metal ion levels in blood than the unilateral one (p=0.017 only Cr), related to a higher revision rate (30% vs 20%): differences were 10-times higher particularly with a 48 mm femoral head diameter (p=0.012) and a Ti-alloy neck (p=0.041). Within the monolateral group using a shorter taper adapter and a shorter neutrally-oriented neck demonstrated higher ion levels (p=0.038 only Cr and p=0.008 only Co, respectively). The aforementioned design-features and MoM bilaterality are important risk-factors for metal-ion release in modular MoM THA.

Hungry brains: A meta-analytical review of brain activation imaging studies on food perception and appetite in obese individuals

The dysregulation of food intake in chronic obesity has been explained by different theories. To assess their explanatory power, we meta-analyzed 22 brain-activation imaging studies. We found that obese individuals exhibit hyper-responsivity of the brain regions involved in taste and reward for food-related stimuli. Consistent with a Reward Surfeit Hypothesis, obese individuals exhibit a ventral striatum hyper-responsivity in response to pure tastes, particularly when fasting. Furthermore, we found that obese subjects display more frequent ventral striatal activation for visual food cues when satiated: this continued processing within the reward system, together with the aforementioned evidence, is compatible with the Incentive Sensitization Theory. On the other hand, we did not find univocal evidence in favor of a Reward Deficit Hypothesis nor for a systematic deficit of inhibitory cognitive control. We conclude that the available brain activation data on the dysregulated food intake and food-related behavior in chronic obesity can be best framed within an Incentive Sensitization Theory. Implications of these findings for a brain-based therapy of obesity are briefly discussed.

Are Diabetic Metabolic Compensation and CA19.9 Really Correlated?

Diabetes has been claimed to be a risk factor for pancreatic carcinoma, but it is probably a consequence of gland invasion from the neoplastic tissue. A link between diabetes and pancreatic carcinoma was suggested by means of biochemical markers of the diseases, namely glycated hemoglobin and CA19.9. Moreover, CA19.9 was proposed as a sensitive and useful marker of the severity of exocrine damage in diabetes, since the mucin decreased when metabolic compensation improved. We examined 64 diabetic patients (36 insulin dependent, 16 non insulin dependent, 12 treated with diet) by measuring CA19.9 using two different immunometric methods and glycemia and glycated hemoglobin. We observed that a correlation between CA19.9 and biochemical markers of metabolic compensation of diabetes was inexistent and no differences between insulin dependent and non insulin dependent patients were found. A high concentration of CA19.9 in a diabetic patient should be interpreted and evaluated in the same manner as for a non diabetic patient.

Local Impairment of Immunoreactivity in Hiv-infected Women with Hpv-related Squamous Intraepithelial Lesions of the Cervix

Aims and background

The aim of this study was to compare the local immune response in two groups of patients with high-grade cervical intraepithelial squamous lesions (SIL): one with HIV infection and the other with HPV infection alone.

Materials and methods

16 conization specimens (8 from HIV-infected and 8 from non-HIV-infected patients) of HPV-related, high-grade SIL were selected. The specimens from non-HIV patients were considered as controls. The total number of Langerhans cells, CD4 and CD8 cells present in 10 field areas (3.120 mm2) was recorded in each case. In HIV patients CD4 and CD8 peripheral counts were performed immediately before surgery.

Results

The CD4/CD8 ratio never exceeded 0.71, whereas the lowest ratio in controls was 0.81: this difference was statistically significant (P=0.0009). The mean number of Langerhans cells was markedly reduced in the high-grade SILs in the HIV patients in comparison with controls (P=0.001). The number of CD4 cells and the CD4/CD8 ratio correlated with the peripheral CD4 count (P=0.001 and 0.02).

Conclusions

In our study a marked local impairment of cervical immunoreactivity was observed, which may play a major role in the progression of these lesions in HIV-infected women.

CA 19.9, CA 242 and CEA in the Diagnosis and Follow-up of Pancreatic Cancer

The diagnosis of pancreatic cancer is usually made in the advanced stages of the disease when the prognosis is poor. We compared the behavior of CA19.9, CEA and the newly proposed mucin CA242 in a consecutive series of 42 pancreatic carcinomas. A control group was recruited of 21 patients with benign pancreatic diseases. With the recommended cutoffs (37 U/ml for CA19.9, 20 U/ml for CA242 and 8 ng/ml for CEA) we obtained a specificity of 90% for CA19.9 and of 85% for CA242 and CEA. The sensitivity was 85.7% for CA19.9, 73.8% for CA242 and 26.2% for CEA. CA19.9 and CA242 showed identical behavior in various TNM stages of cancer and in stages HI and TV of the Hermreck classification. Moreover, CA19.9 and CA242 showed identical behavior in 10 patients monitored during the survival period who developed recurrence of disease. ROC curve evaluation demonstrated that CA242 and CA19.9 were very similar. The results of CA242 were better than those of CA19.9 in the false positive range under 10%, whereas CA19.9 had a better performance in the true positive range over 70%. CA242 could be used instead of CA19.9 for diagnosing pancreatic carcinoma.

Small Pore Size Microporous Membrane Oxygenator Reduces Plasma Leakage during Prolonged Extracorporeal Circulation: A Case Report

Plasma leakage has been regarded as the main technical problem during prolonged extracorporeal circulation (ECC) with microporous membrane oxygenators (MMOs). We report the case of a 15 year old male who underwent long term ECC for ARDS and in whom, by using new MMOs with reduced pore size, we were able to achieve prolonged artificial gas exchange efficiency with minimal plasma leakage. We conclude that reduced pore size MMOs might represent a valuable technical advance in extracorporeal oxygenation therapy.

European cardiovascular mortality over the last three decades: evaluation of time trends, forecasts for 2016

BACKGROUND

The circulatory diseases, in particular ischemic heart diseases and stroke, represent the main causes of death worldwide both in high income and in middle and low income countries. Our aim is to provide a comprehensive report to depict the circulatory disease mortality in Europe over the last 30 years and to address the sources of heterogeneity among different countries.

METHODS

Our study was performed using the WHO statistical information system - mortality database - and was restricted to the 28 countries belonging to the European Union (EU-28). We evaluated gender and age time series of all circulatory disease mortality, ischemic heart diseases, cerebrovascular diseases, pulmonary and other circulatory diseases and than we performed forecast for 2016. Mortality heterogeneity was evaluated by countries using the Cochrane Q statistic and the I-squared index.

RESULTS

Between 1985 and 2011 SDR for deaths attributable to all circulatory system diseases decreased from 440.9 to 212.0 x 100,000 in EU-28 and a clear uniform reduction was observed. Heterogeneity among countries was found to be consistent, therefore different analysis were carried out considering geographical area.

CONCLUSIONS

We forecast a reduction in European cardiovascular mortality. Heterogeneity among countries could only in part be explained by both geographical and health expenditure factors.

An overview of different health indicators used in the European Health Systems

INTRODUCTION

In the European Union three different health systems could be defined according to service delivery, financing, and economic policies: Beveridge, Bismarck and Mixed system. Although health systems are hardly to compare, various organizations are developing methods assessing performance. In the present work the performance of the three systems were evaluated using European Community Health Indicators according to Organization for Economic Cooperation and Development.

METHODS

The study has been conducted among the 28 states of the European Union using the following indicators: Standardized death rate for diseases of the circulatory system, standardized death rate of malignant neoplasms, road traffic accidents with injury, life expectancy at birth, incidence of Human Immunodeficiency Virus (HIV), infant deaths, pure alcohol consumption, infants vaccinated against Diphtheria Tetanus Pertussis (DTP), public and total expenditure on health over the period 2001-2010.

RESULTS

The variation of health indicators over the observational time shows similar trend of circulatory system diseases and malignant neoplasms death rates, road accidents with injury, infant deaths, life expectancy at birth, public and total health expenditure. Some differences in the trend of HIV incidence, alcohol intake and DTP vaccination rates arise among systems. Grouping countries by health system paradigm and geographical area, resulted in a relevant heterogeneity (I² ≥ 90%, Pvalue < 0.0001). No clear superiority of a given health delivery system was found with respect to other paradigms.

CONCLUSIONS

In accordance with the evidence of our study, it can be stated that best performances are more likely to be linked to country specific economic factors. In conclusion, it was not possible to identify the best health system model.

Anti-adalimumab antibodies in psoriasis: lack of clinical utility and laboratory evidence

OBJECTIVE

Adalimumab has proven effective in psoriasis; however, secondary failure may result from the drug's immunogenicity. Prevalence data on the immunogenicity of biologicals, and of adalimumab in particular, are highly variable. We investigated the prevalence of anti-adalimumab antibodies and the association with clinical indexes and tumour necrosis factor α (TNFα) serum levels in psoriatic patients.

DESIGN

Case-control, longitudinal.

SETTING

Single centre.

PARTICIPANTS

Patient groups: I (n=20) receiving biological therapies after switching from adalimumab; II (n=30) ongoing adalimumab therapy; III (n=30) novel adalimumab therapy; IV (n=15) biological therapies other than adalimumab.Healthy subjects: (group V; n=15) never treated with immunosuppressants or biologicals.

INTERVENTIONS

All groups were tested at enrolment. Group II was also tested at 12 months, and group III at 1, 3, and 6 months.

PRIMARY AND SECONDARY OUTCOME MEASURES

Standard clinical evaluations (Psoriasis Area Severity Index (PASI)), blood samples and two-site ELISA-based measurement of serum adalimumab trough levels, anti-adalimumab antibodies and TNFα.

RESULTS

The false-positive rate was 23% for adalimumab detection and 22% for anti-adalimumab antibodies in patients naïve to adalimumab. Spurious positivity for anti-adalimumab antibodies (one-time-point positivity in group III during follow-up) accounted for 33% of the total. The prevalence of anti-drug antibodies was highest (87%) in group I patients. No correlations were found between the presence of anti-adalimumab antibodies or adalimumab levels and changes in PASI scores.

CONCLUSIONS

High variability of results, high prevalence of false-positives and lack of association between anti-adalimumab antibodies and TNFα level/PASI score limit this assay's usefulness. Accurate clinical evaluation is key to early identification of treatment failures.

The adult zebrafish as polyhedric model for skeletal studies

In the last decade, several examples have been produced by scientific literature about zebrafish as a model to study human bone diseases. In fish, bone turnover, reparation and remodeling of the adult bone tissue cannot be studied in embryonic or juvenile stages. In addition, fins and scales represent unique anatomical features useful to study adult bone metabolism and diseases. For these reasons, the adult zebrafish represents an innovative and readily available resource for studying the bone metabolism at cellular and molecular level. Although the adult fish is less used than the embryo, several applications have been found in the last years with the production of innovative pathological models in adult zebrafish, helpful to understand the mechanisms of bone physiopathology. The use of mutants, regenerating organs, transgenic fish and scales have increased the power of this model in the last years.

Plasma endocannabinoid behaviour in total knee and hip arthroplasty

Endocannabinoids are a class of lipid mediators involved in a wide range of physiological pathways including pain perception, and immunological defences. In particular, the involvement of endocannabinoids in bone metabolism and bone resorption has recently been studied. Moreover, one study on total knee arthroplasty describes the probable role of endocannabinoids in pain perception after surgery. The aim of the present study was to evaluate variations of endocannabinoid concentrations in patients undergoing total hip or total knee arthroplasty before and after surgery. Sera from 23 patients were collected at three different times: before surgery and at two different times during rehabilitation, and endocannabinoids were quantified by HPLC-MS/MS analysis. Mean values of endocannabinoids in presurgical serum samples were: 6.11±0.5 ng/ml for N-palmitoylethanolamide, 1.39±0.08ng/ml for N-stearoylethanolamide, 4.84±0.04 ng/ml for N-oleoylethanolamide, 0.44±0.03ng/ml for N-arachidonoylethanolamide, 0.84±0.05ng/ml for N-linoleoylethanolamide, 0.17±0.01ng/ml for N-α-linolenoylethanolamide. Statistical analysis showed a significant decrease of all the endocannabinoids after surgery, while there were no remarkable differences between total hip and total knee arthroplasties or between genders. Moreover, the results show no significant correlation between endocannabinoid concentrations and C-reactive protein and Erythrocyte sedimentation rate. The present study shows for the first time a specific and univocal behaviour of six endocannabinoids and N-acylethanolamides in orthopaedic surgery, suggesting the endocannabinoid system as a possible pharmacological target for presurgical therapeutics.

Wnt signaling pathway inhibitors as promising diagnostic serum markers of osteolytic bone metastasis

Despite the clinical importance of bone metastases, we still know little about their onset and progression and current diagnostic tools lack the sensitivity and specificity required for clear early diagnosis. We therefore need to continue studying the pathogenesis of bone metastatic invasion in order to improve diagnosis. The Wnt pathway has been described as having an important role in bone carcinogenesis and metastatic progression. This study investigated the diagnostic potential of the two main Wnt inhibitors, sclerostin and DKK-1, to improve the detection of osteolytic bone metastases. We measured sclerostin and DKK-1, MMP-2 and MMP-9, the bone resorption marker TRAP5b and the metastatic marker survivin in a control group of healthy patients, in patients with primary tumors and in a group with metastasis. Sclerostin and DKK-1 were clearly high in primary tumor patients and even higher in metastatic patients, compared to controls. The close correlations with metastatic markers and bone resorption markers make sclerostin and DKK-1 promising as new biomarkers in the diagnosis of bone osteolytic metastases.

Effects of bioactive fatty acid amide derivatives in zebrafish scale model of bone metabolism and disease

The endocannabinoid system (which includes fatty acid derivatives, receptors, and metabolizing enzymes) is involved in a variety of physiological processes, including bone metabolism in which it regulates the function of osteoblasts and osteoclasts, as well as differentiation of their precursors. The zebrafish (Danio rerio) provides a useful animal model for bone research since zebrafish bones develop rapidly and are anatomically similar to mammalian bones. Putative orthologues and paralogs of endocannabinoid genes have recently been identified in zebrafish, demonstrating the presence of cannabinoid type 1 (CB1) and type 2 (CB2) receptors with affinity to endocannabinoid ligands. To identify therapeutic molecules potentially useful in bone-related diseases, we evaluated the in vivo effects of exposure to long-chain fatty acid amides in adult zebrafish. Using a well-established zebrafish scale model, we found that anandamide and N-linoleoylethanolamine are able to stimulate bone formation by increasing alkaline phosphatase activity in physiological conditions. In addition, they prevent the alteration of bone markers in a prednisolone-induced osteoporosis model in adult zebrafish scales, whereas their esterified forms do not. These data suggest that long-chain fatty acid amides are involved in regulating bone metabolism in zebrafish scales and that the CB2 receptor is a key mediator in this process.

Perisurgical and intra-rehabilitative salivary steroid hormone profiles in bicompartmental arthroplasty

Sex hormones play a role in pain perception, a key variable in evaluating the progression and treatment of osteoarthritis. The aim of this study was to determine the relationship between salivary concentrations of four steroid hormones and functional/clinical outcomes after hip and knee arthroplasty. Saliva samples were collected from 24 otherwise healthy patients with osteoarthritis before surgery, on admission to rehabilitation, and at hospital discharge. Salivary concentrations of testosterone, 17β-estradiol, dehydroepiandrosterone (DHEA), and cortisol were immunoassayed. Changes in hormone levels were compared with clinical outcomes, as assessed by functional independence measure (FIM®), Barthel Index (BI), and visual analog scale for pain (VAS) scores. Changes in testosterone levels were significantly inversely correlated with VAS (r= -0.53, p=0.043) and FIM® and BI scores in all patients (r= -0.30, p= 0.043, and r= -0.35, p=0.031, respectively). The testosterone to cortisol ratio was inversely correlated with BI scores in all patients (r= -0.30, p=0.040), and in the men (r= -0.55, p=0.005) and the women (r= -0.28, p=0.042) when analyzed separately. Changes in salivary testosterone concentrations closely correlated with clinical outcome measurements for total hip and knee arthroplasty. Clinical outcome after arthroplasty was generally better among the men.

Predictors of renal survival in ANCA-associated vasculitis. Validation of a histopatological classification schema and review of the literature

OBJECTIVES

In 2010 a histopathological classification of ANCA-associated glomerulonephritis was proposed to predict the outcomes at diagnosis. Our aim was to validate the proposed classification in our cohort of patients and to compare the studies already published.

METHODS

The data of 93 patients who underwent kidney biopsy in a single Italian centre within 15 years were retrospectively collected.

RESULTS

The 10-year renal and patients' survival were 60% and 81%, respectively. Biopsies were classified as 21% focal, 30% crescentic, 39% mixed and 10% sclerotic. Survival without ESRD at 5 years was 82% in focal, 37% in crescentic, 81% in mixed and 51% in sclerotic group. The Kaplan-Meier analysis highlights that renal survival was not different between sclerotic and crescentic groups (p=0.9) but both had a significantly worse prognosis than focal (p=0.04 and 0.015 respectively) and mixed groups (p=0.05 and 0.03 respectively). Focal and mixed groups had the same renal survival (p=0.7). At multivariate analysis the independent predictors of end-stage renal disease were less than 20% of normal glomeruli at kidney biopsy (p=0.022), high serum creatinine (p=0.009) and arterial hypertension at presentation (p= 0.006).

CONCLUSIONS

In our cohort, the proposed histological classification was not predictive of renal prognosis. The focal and the mixed classes had the same prognosis and a significantly better renal outcome than both the crescentic and the sclerotic classes. At multivariate analysis among the histological features only less than 20% of normal glomeruli defines the renal prognosis together with renal function and arterial hypertension at baseline.

Modifications of biochemical parameters related to protein metabolism and renal function in male soccer players after a match

AIM

The impact of a soccer match on parameters related to protein catabolism and renal function was evaluated in male players.

METHODS

Blood was collected before and immediately after a 90 minutes soccer match from 19 athletes of two first division teams in Brazil. Red blood cells (RBC), hemoglobin (Hb), hematocrit (Ht), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH) and mean corpuscular hemoglobin concentration (MCHC), ammonia, uric acid, urea and creatinine were analyzed. The modification of plasma volume was calculated, and biochemical values were corrected for this change. Urea/creatinine ratio and equations to estimate the glomerular filtration rate (eGFR) were used to assess kidney function.

RESULTS

Plasma volume decreased from pre- to post-match. Post-match values higher than the pre-match ones were observed for RBC, Hb and Ht, as a consequence of plasma volume decrease. An increase in ammonia and creatinine concentrations post-match in comparison with pre-match values was registered, without changes in uric acid and urea levels. A reduction in urea/creatinine ratio and in eGFR was observed post-match, suggesting a decrease of renal function.

CONCLUSION

A soccer match induced alterations in parameters linked to renal function and protein metabolism in male athletes. Particular attention should be paid in the monitoring of the ammonia concentration as an indicator of metabolic activity and energy requirement during prolonged exercise.

Is Minimally Invasive Spine Surgery Also Minimally Pro-Inflammatory? Muscular Markers, Inflammatory Parameters and Cytokines to Quantify the Operative Invasiveness Assessment in Spine Fusion

Over the last decades, minimally invasive surgery (MIS) techniques entered in the surgical routine due to their major advantage in reducing the unnecessary exposure of tissue and, thus, the trauma. Even in the context of orthopedics and spine surgery these practices have been widely developed and applied. Besides the clinical outcome of the patients, few studies have quantitatively assessed the traumatic and inflammatory effects of a specific surgical technique. Indeed, currently, a universally accepted biological outcome measure, such as a panel of biochemical markers, to define the success of MIS approach is still lacking. We reviewed the literature to collect the published data regarding the quantitative analysis of trauma induced by either conventional or minimally invasive surgery with the aim of highlighting evidence useful to guide future studies. Previous publications show some evidence in support of the hypothesis that MIS approaches are less traumatic, and possibly less pro-inflammatory, than conventional ones. Creatin kinase (as a marker of muscular damage) and C-reactive protein (as a marker of systemic inflammation) seem to reproducibly follow different trends in minimally invasive surgery compared to conventional procedures. Moreover, cytokines, such as interleukin (IL)-6 and IL-10 are also promising markers in this context.

Salivary steroid hormone response to whole-body cryotherapy in elite rugby players

Saliva represents a low stress, not-invasively collected matrix that allows steroid hormone monitoring in athletes by reflecting type, intensity and duration of exercise. Whole body cryotherapy (WBC) consists of short whole-body exposures to extremely cold air (-110° to -140°C) which, despite being initially used to treat inflammatory diseases, is currently acquiring increasing popularity in sports medicine. Cryostimulation practice is now widely accepted as an effective treatment to accelerate muscle recovery in rugby players. The aim of this work was to study the changes of steroid hormones in saliva of rugby players after both 2 and 14 consecutive WBC sessions, in order to investigate the effects of the treatment on their salivary steroid hormonal profile. Twenty-five professional rugby players, belonging to the Italian National Team, underwent a 7-day cryotherapy protocol consisting of 2 daily sessions. Saliva samples were taken in the morning prior to the start of the WBC, in the evening after the end of the second WBC, and in the morning of the day after the last WBC session. The samples were analyzed for cortisol, DHEA, testosterone and estradiol using competitive enzyme-linked immunosorbent assays. Cortisol and DHEA showed a reduction already after the 2 WBC sessions of the first day; after 14 consecutive WBC sessions cortisol, DHEA, and estradiol levels decreased, while testosterone increased as did the testosterone to cortisol ratio. These results were confirmed by the fact that the majority of subjects showed variations exceeding the critical difference (CD). In conclusion, we found that WBC acutely affects the salivary steroid hormone profile, and the results are evident already after only one twice-daily session. Most significantly, after one-week of consecutive twice-daily WBC sessions, all the hormones were modified. This is the first experimental report that links changes in the hormonal asset to WBC.

Progressive improvement of patient and renal survival and reduction of morbidity over time in patients with lupus nephritis (LN) followed for 20 years

Whether the long-term patient and renal survival of those diagnosed with lupus nephritis (LN) has improved over the decades is still debated. Eighty-nine patients diagnosed between 1968 and 1990 entered this study and their outcome was evaluated after 20 years. At presentation 54% of patients had class IV LN, 39.3% had renal insufficiency and 59.5% had nephrotic syndrome. Patients were divided into two groups: Group 1 consisted of 30 patients diagnosed between 1968 and 1980; Group 2 consisted of 59 patients diagnosed between 1981 and 1990. In Group 1 patient survival at 20 years was 84% versus 95% in Group 2 ( p = 0.05). Survivals without end-stage renal failure were respectively 75% and 84% at 20 years ( p = 0.05). Survivals without severe infection at 20 years were 44% in Group 1 and 66.5% in Group 2 ( p = 0.02). Survivals without cardiovascular events at 20 years were: 53% in Group 1 and 90% in Group 2 ( p = 0.005). At presentation, patients in Group 1 had higher serum creatinine (1.96 vs 1.15 mg/dl, p = 0.01), higher activity index (8 vs 5.5, p = 0.01), lower hematocrit (31% v s6%, p = 0.008) and lower serum C4 levels ( p = 0.04) than Group 2 patients. Patients in Group 1 also received less frequent methylprednisolone pulses (43% v s81%, p = 0.0006). In Italian patients with LN, long-term life expectancy and renal survival progressively improved over the decades, while morbidity progressively declined. An earlier referral and refinement of therapy achieved this goal.

Behaviour of perioperative values of haemoglobin, haematocrit and red blood cells in elderly patients undergoing lower limb arthroplasty: a retrospective cohort study on non-transfused patients

Little is known on how elderly patients recover pre-operative haemoglobin, haematocrit and red blood cell levels after total hip and knee arthroplasties. In this study we aimed to evaluate blood loss and recovery blood levels in relation to gender, type of surgery and preoperative haemoglobin values. We conducted a retrospective cohort study on 187 patients over 65 years of age who underwent total knee or total hip arthroplasty between January 2008 and December 2009. Preoperative blood analysis was carried out within 40 days prior to intervention followed by a 15-day postoperative follow-up. Haemoglobin recovery values in anaemic patients versus healthy patients was also estimated. All tested values decreased significantly during the first 3-5 postoperative days. Haemoglobin levels decreased statistically significantly more in males than in females, while no significant differences were observed for haematocrit and erythrocytes. Recovery of haemoglobin values did not differ significantly between healthy patients and patients with preoperative haemoglobin below 120 g/L. Furthermore, our data showed a higher blood loss in total hip arthroplasty, whilst recovery rates showed to be higher after a total knee arthroplasty procedure. In conclusion, the type of intervention and gender played an important role in blood loss and recovery rates in total joint arthroplasty.

Reciprocal regulation of calcium-/phosphate-regulating hormones in cyclists during the Giro d'Italia 3-week stage race

Calcium and phosphate are essential for cell functions, and their serum concentrations result from the balance between intestinal absorption, bony storage, and urinary excretion. Fibroblast growth factor 23 (FGF23), expressed by osteocytes and osteoblasts, acts in the kidney, leading to hypophosphatemia and low 1,25-dihydroxycholecalciferol synthesis, but suppresses parathyroid function. The aim of this study was to explore the effects of a high-energy demanding cycling race on this bone-kidney-parathyroid axis. We studied nine cyclists during the 2011 Giro d'Italia stage race. Pre-analytical and analytical phases followed academic and anti-doping recommendations. Serum parathyroid hormone (PTH), 25(OH)D, total calcium, inorganic phosphorus, and plasma FGF23 were measured on days -1, 12, and 22 and corrected for changes in plasma volume. Dietary calcium and phosphorus, anthropometric parameters (height, weight, and body mass index) and indexes of metabolic effort (net energy expenditure, power output) were recorded. Dietary calcium and phosphorus intakes were kept at the same levels throughout the race. Twenty-five (OH)D, PTH, and calcium concentrations remained stable. FGF23 increased 50% with a positive correlation with the indexes of metabolic effort and, consequently, phosphorous decreased, although only in the first half. The strong metabolic effort acts on the bone-kidney-parathyroid system, and the rise in FGF23 plasma concentration might be aimed at maintaining calcium and phosphorus homeostasis.

Influence of age and physical exercise on sirtuin activity in humans

Sirtuins are NAD+-dependent lysine deacetylases. Sirtuins acquired worldwide attention because of their ability to increase yeast, flies, worms and mice lifespan. Recently, this assumption has been challenged. However, their beneficial role on the quality of ageing is widely accepted. In this work we aimed to study how and if sirtuins expression and activity levels varies in function of age and, in the case of young subjects, of exercise. Fifteen blood donors of different ages and fifteen athletes of the Italian rowing male team were enrolled and peripheral blood mononuclear cells (PBMCs) isolated from blood samples. Our results show that sirtuins deacetylases activity measured in PBMCs increases from 18 to 40 years of age and then decreases during the following 20 years. Moreover, physical exercise in professional athletes can upregulate sirtuin activity. Thus, for the first time in humans, we demonstrate that sirtuin activity is a function of age and can be altered through physical exercise.

Growth hormone variants: a potential avenue for a better diagnostic characterization of growth hormone deficiency in children

Human GH (hGH) is a heterogeneous protein hormone consisting of several isoforms. This heterogeneity is the consequence of multiple hGH genes, mRNA splicing, post-translational modifications, and peripheral metabolism, and it represents one important reason for the disparity among GH assay results from different laboratories. However, other factors are involved: a) interference from endogenous GH binding proteins; b) different specificities of anti- GH (monoclonal and polyclonal) antibodies; c) different matrix effects among the calibrators; d) the use of different calibrators. The measurement of GH levels in response to provocative testing is an essential part of the diagnosis of GH deficiency. For this purpose, an accurate, reproducible and universally valid GH measurement would be highly desirable, but, despite a huge number of efforts in clinical biochemistry, this goal remains elusive.

Osteoprotegerin, RANK and RANKL are not modified by acute exercise in elite rugby players

AIM

The OPG-RANK-RANKL system is a new family of bone metabolism biomarkers belonging to the immune system. In this study, were evaluated these biomarkers in professional rugby players after a single-bout of training session.

METHODS

The study has been performed on 30 professional male rugby players during a training camp of the Italian National Team, in July, before the start of the competitive season. Blood drawings were performed before and after training in the same day. Levels of soluble OPG, RANKL RANK in serum specimens were measured by commercially available according to the manufacturers' protocols.

RESULTS

All the bone markers examined displayed no significative changes after training session.

CONCLUSION

Short exercise is insufficient for modifying serum concentrations of these osteoimmunologic markers, as previously indicated for commonly used bone metabolism markers. Future studies will be conducted over an entire competition season in order to define a common profile of bone markers in rugby players.

Platelet rich plasma therapy: inflammatory molecules involved in tissue healing

Inflammation represents a fundamental aspect of the healing process. Besides their primary role in hemostasis, platelets play an active role in the immunological and inflammatory aspect of tissue healing. Indeed , they can be directly involved in the inflammatory response by the production and release of several inflammatory mediators, including a variety of cytokines, such as TGF-beta, IL-1 beta, CD40L, and chemokines, such as CXCL7, CXCL4, CXCL4L1, CCl5, CXCL1, CXCL8, CXCL5, CXCL12, CCL2, CCL3. Platelet are not only a source of several chemokine involved in the inflammatory response and tissue healing, but they also express chemokine receptors, in particular CCR1 CCR3 CCR4 and CXCR4, thus being able to being able to regulate the inflammatory response associated to the healing process. However, this local inflammation must be taken under control, and platelets can prevent the excess of leukocytes recruitment by anti-inflammatory cytokines, such as TGF-beta. For this biological properties of platelets, platelet rich plasma therapy (PRP) is considered an innovative and promising approach that has been extended to many field of medicine, ranging from non-union defects, bone fractures, spinal fusion, bone implant and osteointegration, joint arthroplasty, to the treatment of several traumatic or degenerative pathologies of tendons, cartilage and ligaments.

Growth factor content in PRP and their applicability in medicine

This paper reviews available reports on the advantages and possibilities of clinical use of platelet-rich plasma preparations, with particular emphasis on platelet growth factors. Platelets, an important reservoir of growth factors in the body, play an important role in many processes such as coagulation, immune response, angiogenesis and the healing of damaged tissues. Numerous proteins are contained in the alpha-granules of platelets: platelet-derived growth factor (PDGF), transforming growth factor (TGF), platelet factor interleukin (IL), platelet-derived angiogenesis factor (PDAF), vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), insulin-like growth factor IGF and fibronectin. The development of methods and systems for blood and cell sorting (e.g. CAPSS - compact advanced platelet sequestration system Elektromedics 500, PCCS - platelet concentrate collection system Curasan) have made it possible to obtain significant concentrations of platelets (even by 338 percent) and high concentrations of growth factors, in a form of sterile mass that can be used immediately for clinical purposes. Platelet-rich plasma (PRP; autologous platelet-rich plasma - APRP) are platelet concentrates made of autogenous blood with a high number of platelets in a small volume of plasma. The clinical efficacy of platelet concentrates depends mainly on the number of platelets and the concentration of their growth factors, which act as transmitters in most processes in tissues, particularly in healing where they are responsible for proliferation, differentiation, chemotaxis and tissue morphogenesis. They operate as part of autocrine, paracrine and endocrine mechanisms. Growth factors derived from centrifuged blood were first used in patients with chronic skin ulcers. The clinical use of PRP for a wide variety of applications has been reported mostly in oral and maxillo-facial surgery, orthopedic surgery, treatment of soft tissue diseases and injuries, treatment of burns, hard-to-heal wounds, tissue engineering and implantology.

Sclerostin concentrations in athletes: role of load and gender

Bone mass is the net product of formation and resorption, which are closely regulated by the equilibrium between endogenous/exogenous factors. Sclerostin inhibits the Wnt canonical signaling and is considered an anti-anabolic factor. We compared sclerostin serum concentrations between genders in athletes belonging to different sport disciplines, characterized by a different weight-bearing, and in their sedentary counterparts in order to study the possible link between bone metabolism in athletes and its peripheral concentration. We also compared sclerostin levels with bone alkaline phosphatase activity, a marker of bone formation. Sixty-one elite athletes, belonging to weight-bearing (15 male rugby players, 11 male enduro racers, 8 female basketball players), high-impact (6 male tennis players, 8 female ice skaters), non weight-bearing sports (13 male cyclists) and 16 sedentary controls were enrolled. Higher levels of sclerostin were found in females. Sclerostin was higher in weight-bearing than in non-weight-bearing disciplines in males. Significant inverse age-related correlation was found. Higher bone alkaline phosphatase activity was observed in females. The young adult elite athlete represents a peculiar physiologic model for studying sclerostin behavior: the applied load increased the marker concentrations, testifying a high bone turnover rate; however, a gender effect is evident.

Effects of cold-water immersion and contrast-water therapy after training in young soccer players

AIM

Recent studies have investigated the importance of recovery strategies after training session, including hydrotherapy and cryotherapy. However, only a few studies have focused on cold-water immersion (CWI) treatments in team sport disciplines. The present study investigates the effects of CWI and contrast-water therapy (CWT) on the performance of young male soccer players during a week of training.

METHODS

Eighteen young soccer players participated in the present study (age 15.5±1.0 years, weight 61.8±3.0 Kg, height 175.5±4.0 cm and training experience 8.1±1.0 years). They were involved in a four-day study with recovery using CWI or with CWT after each training session by using performance tests and small-sided games. We measured uric acid concentration, leukocytes, haemoglobin, reticulocytes and creatine kinase changes in the blood, axillary temperature, rating of perceived exertion after a training session, heart rate during exercise, performance tests (counter movement jump, repeated sprint ability and 5' shuttle run).

RESULTS

No significant difference were reported between groups when different physiological tests were used; CWI and CWT did not negatively influence the performances of the athletes. The principal effect of CWI was a reduced perception of fatigue after the training session. The use of active recovery protocols based on cold water or cold/thermoneutral water did not induce modifications of inflammatory and haematological markers in young soccer players.

CONCLUSION

The beneficial effect of a reduced perception of fatigue can improve training and competitions in young soccer players.