Second-line treatment strategies for RAS wild-type colorectal cancer: A systematic review and Network Meta-analysis (NMA)

BACKGROUND

The optimal strategy for second-line (IIL) treatment in KRAS wt metastatic colorectal cancer (mCRC) is not determined yet.

METHODS

A random-effect NMA of phase II/III RCTs was conducted to evaluate IIL treatment for all-RAS wt mCRC, comparing anti-EGFR or anti-VEGF, and chemotherapy (CT).

RESULTS

Overall, 11 RCTs (3613 patients) were included. In KRAS wt patients, PFS was improved with anti-VEGF (HR 0.43) and anti-EGFR (HR 0.63) vs CT. However, anti-VEGF based therapy had the highest likelihood of being ranked as the best treatment in terms of PFS (SUCRA 99.3%) and OS (SUCRA 99.4%). Bevacizumab-based treatment is most likely to be the best treatment in terms of PFS (SUCRA 89.1%) and OS (SUCRA 86.7%).

CONCLUSIONS

Second line treatment with anti-VEGF and anti-EGFR improved PFS in mCRC patients, however, anti-VEGF based therapy, particularly CT plus bevacizumab, is the best treatment according to SUCRA in terms of PFS and OS.

Bone metastases in biliary cancers: A multicenter retrospective survey

•Natural history of biliary cancers metastatic to bone•The role of skeletal events in patients with biliary cancer•Biliary cancer and bone metastases: role of bisphosphonates.

Alexithymia partly predicts pain, poor health and social difficulties in patients with temporomandibular disorders

Temporomandibular disorders (TMD) are functional diseases of the masticatory system; their symptoms are clicking, difficulty opening the mouth wide, ear pain, facial pain and headaches. The relationships among distress, emotional factors and TMD are well known. It was shown that patients with TMD have little awareness of their inner states and emotions, and it was found that those reporting oro-facial pain presented higher alexithymia than did asymptomatic people. Other authors confirmed that alexithymia was higher in the painful TMD group than controls. This study was aimed to evaluate whether alexithymia and its components can be considered as predisposing factors for pain severity, poor health and greater social difficulties in patients with TMD. One hundred thirty-three patients received a diagnosis of TMD and completed the 20-item Toronto Alexithymia Scale. Multiple stepwise regressions showed that alexithymia and age explained 10% of the pain and 31% of poor health and also that alexithymia explained 7% of social difficulty. A direct comparison of patients with TMD based on alexithymia revealed a higher presence of pain in alexithymic patients with TMD than in those characterised by moderate or no alexithymia. In conclusion, alexithymia partly predicts pain, poor health and social difficulties in patients with TMD. Furthermore, alexithymic patients have more pain than those with moderate or low alexithymia.

Old and new targets for innovative antimalarial compounds: the different strategies of the Italian Malaria Network

Clinical treatment-failures to affordable drugs encouraged new investigation for discovery and development of new prophylactic and therapeutic interventions against malaria. The Drug Discovery Cluster (DDcl) of the Italian Malaria Network gathers several highly integrated and complementary laboratories from different Italian Institutions to identify, synthesise, screen in vitro and in vivo new antimalarial molecules directed against the intraerythrocytic stage of P. falciparum parasites and/or with transmission blocking activity to select lead compounds for further development. Complementary research activities, both in vitro and in the clinics, aim at investigating the pathogenetic mechanisms of severe malaria anaemia and the different manifestations of the disease in malaria-HIV co-infected patients to identify new therapies and improve survival.

Reduced sympathetic outflow and adrenal secretory activity during a 40-day stay in the Antarctic

Human adaptation to unknown and extreme environments requires changes in the psychological and physical homeostasis. We previously reported a significant decrease of anterior pituitary and adrenal hormonal levels and a significant modification of psychophysiological correlates of stress, such as galvanic skin response, after exposure to Antarctica, suggesting a possible decrease of individual arousal. The latter was hypothesized to be correlated with a modification of autonomic balance, mainly represented by a possible reduction of adrenergic output. The aim of the present study was to assess the patterns of hormonal circadian rhythms and the autonomic nervous system balance by means of spectral analysis of heart rate variability (HRV). These parameters were evaluated during 3 sessions (baseline, session 1 and session 2), before, at the beginning and after a 40-day stay in Antarctica (Station of Terra Nova Bay; average temperature in the study period: -11 degrees C, 24 h of light, sea level). In each of the sessions, 6 healthy male subjects underwent a 24-h electrocardiogram and blood sampling (08.00, 12.00, 16.00, 20.00, 24.00 and 08.00 h) for hormonal determinations. The data showed a remarkable decrease of hormonal levels without significant changes in circadian rhythms. Spectral analysis of HRV showed an imbalance of the autonomic nervous system with a relative significant decrease of the low frequency band (0.1 Hz) in session 1 and 2 compared to baseline, which can be functionally interpreted as a relative decrement of the sympathetic component. In conclusion, the exposure to a cold and extreme environment seems to affect autonomic balance over a 40-day period. This is followed by a significant reduction of the anterior pituitary and adrenal hormonal secretory patterns with preserved hormonal circadian rhythms (within the same time period of 40 days). This pattern is suggestive of a trophotropic neurovegetative adaptive process.

Modified autonomic balance in offsprings of diabetics detected by spectral analysis of heart rate variability

This study was performed to evaluate the influence of family history for non-insulin-dependent diabetes mellitus (NIDDM) on autonomic balance. The latter was assessed by spectral analysis of heart rate variability (SA-HRV) and by analyzing the relative contribution of low-frequency (LF) and high-frequency (HF) components. Twenty glucose normotolerant offsprings of NIDDM parents and 20 controls underwent a 1-hour continuous electrocardiogram (ECG). LF and HF (mean +/- SEM in normalized units [NU]), respectively increased and decreased in offspring versus controls. The LF/HF ratio (mean +/- SEM) significantly increased (LF/HF = 3.25 +/- 0.7 v 1.45 +/- 0.5, P <.0001 offsprings v controls). To test a stimulated response, a passive tilting (+ 90 degrees ) after 30 minutes of bed rest (0 degrees ) was performed in a subsample of subjects (10 offsprings v 10 controls). During bed rest, we found significantly higher values of the LF/HF ratio in offsprings versus controls (1.93 +/- 0.3 v 1.08 +/- 0.2, P <.05), whereas in the head-up position, the LF/HF ratio value increased to the same levels in the 2 groups (6.48 +/- 1.3 v 6.89 +/- 1.4, not significant [NS]). NIDDM family history is characterized in the basal condition by an imbalance of the autonomic system, which, compared with controls, is expressed by a higher weight of sympathetic and a lower weight of parasympathetic components. No significant differences can be found under stimulated conditions.

Sleepiness: evaluating and quantifying methods

The aim of this literature review is to analyze the methods mainly used for evaluating and quantifying the complex phenomenon of sleepiness. The most common distinction is between subjective measures or self-evaluations, performance decrement measures, measures for evaluating sleep propensity and measures of arousal decrease. Techniques mainly used in specialized literature will be briefly presented and commented upon, evaluating their sensitivity, advantages and limitations. We conclude that: (a) different measures inevitably are differently sensitive to sleepiness fluctuations; (b) the amount of prior sleep is strongly relevant in quantifying sleepiness levels; (c) subjective and behavioral measures show a higher level of vulnerability to external and motivational factors.

Auditory arousal thresholds after selective slow-wave sleep deprivation

OBJECTIVES

The aim of this study is to assess Auditory Arousal Thresholds (AATs) three times during an undisturbed baseline night and to compare them to AATs during the recovery night that follows two consecutive nights of selective SWS deprivation. The presence of a time-of-night effect on AATs will also be assessed.

METHODS

Ten male Ss slept in the laboratory for 6 consecutive nights. The first two nights were undisturbed. The 3rd night was considered as baseline. During the 4th and 5th nights, selective SWS deprivation was obtained by means of acoustic stimulation. The 6th night was a recovery. In the last 4 nights Ss were awakened three times, after 2, 5 and 7.5 h of sleep, respectively. All the awakenings were carried out from stage 2 (after at least 5 consecutive min of stage 2), by means of 1000 Hz ascending tone series. The AAT determination was based on EEG-EMG criteria: at least 10-s of clear alpha rhythm and/or a 10 s movement arousal.

RESULTS

During both deprivation nights, SWS amount was close to zero. In the ensuing recovery night a significant SWS rebound was found, accompanied by a significant increase of AATs with respect to the baseline. Furthermore, there was a significant linear decrease of AATs during the night. Finally, the individual correlations between AATs and SWS amount were significant in 4 out of 10 Ss.

CONCLUSIONS

These results confirm that AATs are a reliable index of sleep depth by showing that the SWS rebound following selective SWS deprivation is paralleled by a significant AAT enhancement. The experimental paradigm also allows us to claim that AATs show a decreasing linear trend during the night, having excluded any procedural bias. Finally, AATs can be directly related to SWS amount that preceded the awakening, although the individual correlations between AATs and SWS have to be considered with caution, given the high inter-subject variability and the small number of observations.

Assessing nighttime vigilance through a three-letter cancellation task (3-LCT): effects of daytime sleep with temazepam or placebo

Nocturnal sleepiness is a common complaint suffered by night-shift workers, especially in conditions of an abrupt shift of the wake-sleep cycle. Alertness management strategies can minimize the adverse effects of sleep loss and circadian rhythm desynchronization and promote optimal vigilance in operational settings. Within these strategies. one possibility is to use short periods of "prophylactic sleep" (before long periods of work), which can be facilitated by hypnotics. Vigilance can be evaluated by means of several tests which, sometimes, imply procedures and devices not easily employable in operational settings. In such conditions pencil and paper tests of vigilance can be very useful in the assessment of attentional performance degradation due to sleep loss and/or inversion of the sleep-wake cycle. In this study we evaluated the sensitivity of a three-Letter Cancellation Task (3-LCT) in revealing nighttime variations of vigilance in a laboratory simulation of acute night shift, after a diurnal sleep with placebo (PLC) or temazepam (TMZ). Nocturnal levels of vigilance were also assessed using the Maintenance of Wakefulness Test (MWT) and the Multiple Sleep Latency Test (MSLT). All tests were administered four times at 2-h intervals during nighttime after a daytime sleep. Results show that the 3-LCT is sensitive to variations of vigilance occurring during a laboratory simulation of acute night shift. We also found some effects of TMZ, which in the first nocturnal session caused a slowing down of visuoattentive performance. Nocturnal variations of vigilance detected through the 3-LCT were similar to those revealed by means of MSLT, while the ability to maintain wakefulness was substantially spared during the night.

Endocrine and psychophysiological aspects of human adaptation to the extreme

Human beings need to adapt to any extreme, unknown, or isolated environment. This adaptation requires changes in the normal regulation of psychophysiological homeostasis, as described in terms of stress reaction. The aim of the present study was to monitor the processes of human adaptation to cold and isolated areas in Antarctica during the 12th expedition of the Italian National Research Program. Nine healthy subjects (experimental subjects), members of the expedition, and nine controls in Italy, were studied over a period of 2 months. Anterior pituitary hormone secretion, insulin, and melatonin, plus routine blood test, blood pressure, and ECG were performed. In addition, psychophysiological correlates were also recorded before and after the expedition period. In experimental subjects results of metabolic data suggested the presence of an increased peripheral insulin sensitivity at the end of the permanence in the station and a significant increased of total cholesterol. Hematocrit also significantly increased due to the conditions of hypobaric hypoxia. Results of endocrine data showed a significant decrease (p < 0.05) of hormone levels, which was associated with a significant decrement of the Galvanic Skin Response (GSR) activity to a standardized cognitive stress. No significant differences were reported in the controls. The data suggest that the exposure to the extreme environment develops a possible psychophysiological mechanism(s) that decreases the individual arousal.

Smooth pursuit and saccadic eye movements as possible indicators of nighttime sleepiness

Sleepiness is associated with specific variations of spontaneous oculomotor activity. During nocturnal sleep onset periods and also during the Multiple Sleep Latency Test (MSLT) a reduction of both rapid eye movements and blinks are recorded. In many operational contexts it might be even more relevant to assess whether and to what extent voluntary visual ocular control is affected by sleepiness due to sleep deprivation and time-of-day effects. In this study we evaluated, in a laboratory simulation of a sudden inversion of the sleep-wake cycle, the nocturnal modifications of smooth pursuit (SP) and saccadic (SAC) eye movements as possible indicators of sleepiness. Levels of sleepiness were objectively measured by means of MSLT and Maintenance of Wakefulness Test (MWT); subjective ratings of sleepiness were also obtained. After a diurnal sleep, five subjects underwent four nocturnal test sessions, each one comprising an SP and a SAC trial. Both the SP variables considered (velocity gain and phase) showed a trend similar to that one of MWT latencies, being significantly impaired only in the last nocturnal trial, when levels of sleepiness were maximal. Saccadic accuracy showed the same trend, being negatively affected by sleepiness only in the last nocturnal session. In addition, percentage of rejected (inappropriate) saccades showed a linear increase during the night, paralleling the shortening of sleep latency at MSLT and the linear increase of subjective ratings of sleepiness. These results, suggesting that saccadic performance, unlike SP, seems to be more sensitive to increasing levels of sleepiness, encourage further research on this topic.

Sleepiness, alertness and performance during a laboratory simulation of an acute shift of the wake-sleep cycle

Monitoring the presence of sleepiness on the job and its effects on performance is of primary importance for improving schedule systems of shiftworkers. Shiftworkers, often involved in night-time operations and irregular work schedules, frequently complain of nocturnal sleepiness especially in conditions of abrupt shift of the wake-sleep cycle. In this study, the authors evaluated the effects of a laboratory simulation of acute night-shift changes on sleepiness, vigilance and performance, using Maintenance of Wakefulness Test, Multiple Sleep Latency Test and three pencil and paper tests: Digit Symbol Substitution Test, 'Deux Barrages' Test and a 3-Letter Cancellation Task. All of the tests were administered four times at 2-hourly intervals during the night after daytime sleep. Results showed that the ability to maintain wakefulness and to perform simple visuo-attentive tasks is substantially spared during the night. On the other hand, sleep tendency and performance on a more complex and monotonous task (Letter Cancellation Task) reveal, respectively, increasing sleepiness and degrading performance.

Actigraphic motor asymmetries during sleep

Much evidence indicates that during sleep there is a repatterning of motor asymmetries with a relative advantage of the left hand (i.e., the left hand moves more than the right). This could be due to the ability of the right hemisphere in operating at levels of reduced arousal (arousal hypothesis) or to its superior spatial abilities (motor specificity hypothesis), or it could indicate a greater need for sleep in the left hemisphere (homeostatic hypothesis). Since only the latter hypothesis predicts that the repatterning should be present in the first part of sleep (i.e., when the homeostatic processes are more pronounced), the present study evaluated whether actigraphic data are consistent with this prediction. Sixteen right-handed college students wore actigraphs (AMI 16K) on both upper and lower limbs for about 56 hours. Factorial ANOVAS were carried out on side (left vs right) and part (first vs second) of the recording period during sleep and waking. During waking, the right hand showed more intense motor activity as compared to the left. During sleep, in the first part of the night, the right hand lost this advantage, while in the second part of the night it regained its superiority. Since this repatterning was specific for hand movements and no difference was found in overall motor activity and in arousal between the two parts of the sleep period, the results are interpreted as consistent with the homeostatic hypothesis.

End to side mucomucosal Wirsung jejunostomy after pancreaticoduodenectomy: immediate results and long term follow-up

BACKGROUND/AIMS

Pancreatico-duodenectomy (PD) is nowadays a widely performed operation which still carries a risk of some morbidity and mortality due to leakage of the Pancreatico-jejunostomy. The aim of the present paper is to describe critically the experience of a surgical team with a large number of consecutive non-selective PDs, where the same surgical procedure was adopted in all cases to manage the pancreatic stump.

METHODOLOGY

Sixty six Whipple/Child PDs and 4 Traverso-Longmire (Duodenum Preserving PD) were performed between 1974 and 1993, by the same surgical team in our surgical department. The management of the pancreatic stump was always the same: a hand-made end-to-side mucomucosal Wirsung-jejunostomy, completed by a second layer between pancreatic capsula and jejunal sero-muscular wall.

RESULTS

The overall mortality was 7.1% (5 cases). Only one death could be ascribed to pancreatico-jejunostomy related complications (post-operative acute pancreatitis). Specific morbidity was 12.6% (9 cases). Only one complication was related to the Wirsung-jejunostomy (leakage of the anastomosis, treated by a "sleeve" end-to-end pancreato-jejunostomy). Long-term patency of the anastomosis was shown by ERCP.

CONCLUSIONS

Even if this anastomotic technique requires a little more time and attention by the surgeon, we think that the low incidence of pancreatico-jejunal anastomosis related complications represents a validation of the method, and a motivation to adopt this anastomotic technique. The long-term patency of the muco-mucosal Wirsung-jejunostomy is another valid argument that supports this kind of management of the pancreatic stump after PD.

Sleep and alertness during alternating monophasic and polyphasic rest-activity cycles

People involved in shift work often have to face altered patterns of sleep and wakefulness. This is particularly true for schedules involving night shifts and/or fragmentation of duty periods throughout the 24-hr day. In such conditions, it can be difficult to obtain satisfactory periods of sleep, and sleepiness on duty is a frequent and dangerous occurrence. The aim of this study was to evaluate sleep and wakefulness periods of subjects whose work schedule was characterized by an alternation of 2 hours of activity and 4 hours of rest (sleep allowed), repeated 4 times throughout the 24-hr day. This schedule was alternated with 24 hours off duty. Nine healthy male volunteers were monitored by means of ambulatory polysomnography while attending their 24-hr rest-activity schedule. Sleep periods were visually scored according to standard criteria. Wake periods were visually scored using both 30 s and 5 s epochs in order to reveal episodes of drowsiness and/or microsleep. Results showed that total sleep time was substantially reduced as compared to the usual 7-8 hour monophasic nocturnal sleep. Subjects did not sleep during the first rest period (11.00-15.00). Time in sleep linearly increased in the course of the 3 remaining rest periods. Normal sleep stage distribution was substantially spared only in the last rest period (3.00-7.00 a.m.). With regard to duty periods, only a few microsleeps were detected and their number did not significantly vary across the four 2-hr activity periods. In conclusion, this rest-activity schedule, despite the considerable sleep reduction, allowed maintaining good levels of vigilance as shown by the virtual absence of EEG microsleeps. Whether future research will prove that this regimen does not cause an impairment of performance, it should be a suitable strategy for the management of continuous operations.

Acutely shifting the sleep-wake cycle: nighttime sleepiness after diurnal administration of temazepam or placebo

HYPOTHESIS

Sleepiness on the job is a common problem suffered by people involved in night shift work, especially in conditions of abrupt reversal of the sleep-wake cycle, such as emergencies and combat air operations. It is well known that sleepiness can severely affect alertness and performance. One of the most useful countermeasures is to take a prophylactic nap before working at irregular hours. To induce and maintain sleep in the "forbidden zones for sleep" during the day, it is possible to use suitable benzodiazepine hypnotics such as temazepam (TMZ). However, it is then necessary to monitor sleepiness and performance the night following the diurnal intake of the drug in order to evaluate possible side effects.

METHODS

In this study, sleepiness was subjectively and objectively measured during the night after a daytime administration of TMZ 20 mg in soft gelatine capsules or placebo to obtain a prophylactic sleep.

RESULTS AND DISCUSSION

Results showed the effectiveness of TMZ for inducing and maintaining diurnal sleep. This lengthening of total sleep time did not cause a decrease of sleepiness during the night, but no significant carry over effect of TMZ was present for nighttime sleep tendency. Both polygraphic and subjective measures of sleep latency decreased during the night. Finally, no significant relationship between the Stanford Sleepiness Scale and the Multiple Sleep Latency Test measures was found.

Performance, ability to stay awake, and tendency to fall asleep during the night after a diurnal sleep with temazepam or placebo

Sleep loss and increased sleepiness on the job are among the most prevalent problems encountered by people involved in night shift work, especially in cases of abrupt shift of the wake-sleep cycle. In such conditions, detrimental effects on performance are well documented. In these situations, to avoid decrements of performance at night, one possibility is to use hypnotics for improving the quality and quantity of daytime sleep. In this study, we evaluated the effects of 20 mg of temazepam on daytime sleep, the subsequent levels of nocturnal alertness/sleepiness, and performance in a laboratory simulation of acute night shift. For evaluating alertness, sleepiness, and performance we used, respectively, the maintenance of wakefulness test (MWT), the multiple sleep latency test (MSLT), and two pencil and paper tests: digit symbol substitution test (DSST) and deux barrages test (DBT). All tests were administered four times at 2-hour intervals during the nighttime after daytime sleep. Results showed that the ability to maintain wakefulness (MWT) and to perform some visuo-attentive tasks were substantially maintained during the night. On the other hand, sleep tendency (MSLT) linearly increased during the night. Temazepam resulted in being an effective diurnal hypnotic, increasing total sleep time with no residual detrimental effects on sleepiness and performance and with an increase in the ability to stay awake.

Assessing vigilance through a brief pencil and paper letter cancellation task (LCT): effects of one night of sleep deprivation and of the time of day

Behavioural effects of the lack of sleep in normal subjects have been investigated mostly by experimenter-paced choice reaction times in prolonged stimulus detection tasks. However, length and procedure complexity of these tasks limit their use in research on larger numbers of subjects. The aim of the present study was to assess the effectiveness of a brief subject-paced pencil and paper performance task, i.e. letter cancellation task (LCT) in revealing the effects of one night of sleep deprivation. In addition, the authors evaluated sleep loss and time of day effects on six Visual Analogue Scales (VAS) measuring subjective activation-deactivation. Results show that a LCT is sensitive in revealing the effects of time of day and of 24 h of sleep deprivation. Effects of sleep deprivation were also revealed by VAS data. Sleepiness, tiredness and energy scales on the VAS were also affected by time of day. Despite the sensitivity of both the LCT and VAS, there was little correspondence between performance and subjective measures.

A finger-tapping task and a reaction time task as behavioral measures of the transition from wakefulness to sleep: which task interferes less with the sleep onset process

The aim of this study was to assess whether a finger-tapping task (FTT), in which normal subjects repeatedly tap on a button while falling asleep, could be less disturbing and provide comparable information on the sleep onset period (SOP) with respect to a reaction-time task (RTT) to acoustic stimuli, in which the onset of sleep can be delayed by the arousing effect of the acoustic stimuli. Twelve subjects slept at their homes and six slept in a sleep laboratory for four consecutive nights. After one adaptation night and one baseline night, subjects were required to fall asleep in the third and fourth nights, bimanually performing either a RTT or a FTT. The results indicate that the FTT interfaces less with the SOP compared to the RTT and suggest that the FTT provides further advantages as a behavioral measure of the transition from wakefulness to sleep. In fact, the tapping task is associated with significantly shorter behavioral and polysomnographic sleep onset latencies and with a greater proportion of slow-wave sleep (SWS) during the transition from wakefulness to sleep compared with the RTT. Furthermore, correlations among subjective, behavioral, and electroencephalograph (EEG) latencies confirm the validity of the finger-tapping task as a behavioral measure of sleep onset.