Increased risk of tumor seeding after percutaneous radiofrequency ablation for single hepatocellular carcinoma

Radiofrequency (RF) ablation is an alternative to percutaneous ethanol injection (PEI) for single nonsurgical hepatocellular carcinoma (HCC) and is currently used as adjuvant therapy before liver transplantation. This phase II study assesses the treatment-related complications and response rate of RF for the treatment of single HCC < or = 5 cm. Percutaneous RF was performed under conscious sedation and ultrasound (US) guidance with an electrical generator connected to a single cooled-tip electrode. Neoplastic cells in peripheral blood (reverse transcription-polymerase chain reaction for alpha fetoprotein [AFP] messenger RNA) were analyzed before and after RF. Treatment response was assessed by spiral computed tomography (CT) at 1 month and every 3 months by US or spiral CT thereafter. Thirty-two patients (20 men; age 67 +/- 4 years; 78% hepatitis C virus; 24 Child-Pugh A) with a mean tumor size of 2.8 cm (25 patients < or = 3 cm) were treated by RF (1.25 sessions; mean time, 22.1 +/- 2 minutes). Adjuvant PEI was performed in 9 cases. Complete response was achieved in 21 patients (65%), being significantly higher for HCC < or = 3 cm (76% vs. 29%, P = .03). After a median follow-up of 10 months, 8 patients showed treatment-related morbidity. Four of them (12.5%) showed biopsy-proven needle-track seeding detected between 4 to 18 months. Neoplastic seeding was related to subcapsular location (P = .009), poor differentiation degree (P = .02), and baseline AFP levels (P = .02). Thus, RF ablation with cooled-tip needle for HCC is associated with a high risk of neoplastic seeding. Iatrogenic dissemination was related to subcapsular location or an invasive tumoral pattern, and has to be considered when selecting curative treatments for HCC or adjuvant therapies before liver transplantation.

Cortical networks for visual reaching: physiological and anatomical organization of frontal and parietal lobe arm regions

The functional and structural properties of the dorsolateral frontal lobe and posterior parietal proximal arm representations were studied in macaque monkeys. Physiological mapping of primary motor (MI), dorsal premotor (PMd), and posterior parietal (area 5) cortices was performed in behaving monkeys trained in an instructed-delay reaching task. The parietofrontal corticocortical connectivities of these same areas were subsequently examined anatomically by means of retrograde tracing techniques. Signal-, set-, movement-, and position-related directional neuronal activities were distributed nonuniformly within the task-related areas in both frontal and parietal cortices. Within the frontal lobe, moving caudally from PMd to the MI, the activity that signals for the visuo-spatial events leading to target localization decreased, while the activity more directly linked to movement generation increased. Physiological recordings in the superior parietal lobule revealed a gradient-like distribution of functional properties similar to that observed in the frontal lobe. Signal- and set-related activities were encountered more frequently in the intermediate and ventral part of the medial bank of the intraparietal sulcus (IPS), in area MIP. Movement-and position-related activities were distributed more uniformly within the superior parietal lobule (SPL), in both dorsal area 5 and in MIP. Frontal and parietal regions sharing similar functional properties were preferentially connected through their association pathways. As a result of this study, area MIP, and possibly areas MDP and 7m as well, emerge as the parietal nodes by which visual information may be relayed to the frontal lobe arm region. These parietal and frontal areas, along with their association connections, represent a potential cortical network for visual reaching. The architecture of this network is ideal for coding reaching as the result of a combination between visual and somatic information.

Specific structural determinants are responsible for the antioxidant activity and the cell cycle effects of resveratrol

Resveratrol (3,4',5-trihydroxy-trans-stilbene) is a natural phytoalexin found in grapes and wine, which shows antioxidant and antiproliferative activities. In this study we have investigated whether these properties are dependent on similar or different structural determinants of the molecule. To this purpose, resveratrol derivatives, in which all or each single hydroxylic function were selectively substituted with methyl groups, were synthesized. Analogues with the stilbenic double bond reduced or with the stereoisometry modified were also investigated. The antioxidant activity of these compounds was evaluated by measuring the inhibition of citronellal thermo-oxidation, or the reduction of 2,2-diphenyl-1-picrylhydrazyl radical. In addition, the protection against lipid peroxidation was determined in rat liver microsomes, and in human primary cell cultures. The antiproliferative activity was evaluated by a clonogenic assay, and by analysis of cell cycle progression and DNA synthesis. The results showed that the hydroxyl group in 4' position is not the sole determinant for antioxidant activity. In contrast, the presence of 4'-OH together with stereoisometry in the trans-conformation (4'-hydroxystyryl moiety) was absolutely required for inhibition of cell proliferation. Enzymatic assays in vitro demonstrated that inhibition of DNA synthesis was induced by a direct interaction of resveratrol with DNA polymerases alpha and delta.

Topical treatment of basal cell carcinoma with tazarotene: a clinicopathological study on a large series of cases

BACKGROUND

Basal cell carcinoma (BCC) is the most common cancer in humans. Medical treatment modalities offer cost reductions and clinical advantages in selected cases such as low-risk areas, surgically inaccessible sites, patients with multiple neoplasms, and older, infirm or anticoagulated subjects. Tazarotene has been proposed for the treatment of BCC; however, data on its efficacy are lacking.

OBJECTIVES

To investigate the efficacy of tazarotene in a large series of BCCs, better to define the clinical advantages and the mechanisms of action in vivo.

METHODS

Tazarotene 0.1% gel was applied daily for 24 weeks to 154 small superficial and nodular BBCs. Clinicopathological changes were followed during the therapy by dermoscopic and histological examination. Proliferation, retinoic acid receptors and apoptosis were investigated by immunohistochemistry and terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick-end labelling on biopsies.

RESULTS

At 24 weeks of therapy, 70.8% of the BCCs showed > 50% clinical and dermoscopic regression, and 30.5% healed without recurrences after 3 years of follow-up. At 12 weeks, biopsies showed that regression was associated with reduced proliferation and increased apoptosis of basaliomatous cells. Most unresponsive tumours displayed a keratotic differentiation.

CONCLUSIONS

Tazarotene was effective in the majority of superficial and nodular undifferentiated BCCs treated, possibly by antiproliferative and proapoptotic actions in vivo. Keratotic BCCs were the major type among the unresponsive tumours, and were characterized by overexpression of p53 and cellular retinol binding protein-1 in comparison with undifferentiated tumours. Topical tazarotene represents an alternative medical choice for selected cases of BCC.

Risk of lipodystrophy in HIV-1-infected patients treated with protease inhibitors: a prospective cohort study

BACKGROUND

Risk factors for lipodystrophy in patients infected with HIV-1 treated with highly active antiretroviral therapy (HAART) containing HIV-1 protease inhibitors are poorly understood. We aimed to identify the risk factors for lipodystrophy in antiretroviral-naive HIV-1-infected adults on HAART.

METHODS

Moderate or severe body-fat changes were clinically assessed and categorised as subcutaneous lipoatrophy, central obesity, or both, in all consecutive antiretroviral-naïve HIV-1-infected adults who began HAART with two nucleoside reverse transcriptase inhibitors plus at least one protease inhibitor from October, 1996, to September, 1999. A person-years analysis was used to calculate the incidence of types of lipodystrophy, and Cox proportional hazards models were used to describe the univariate and multivariate factors associated with progression to any lipodystrophy.

FINDINGS

After a median follow-up of 18 months, 85 (17%) of the 494 patients developed some type of lipodystrophy. The incidences of any lipodystrophy, lipodystrophy with subcutaneous lipoatrophy, and lipodystrophy with central obesity were 11.7 (95% CI 9.2-14.2), 9.2 (7.0-11.4), and 7.7 (5.7-9.7) per 100 patient-years. An increased risk for any lipodystrophy was found among women as compared with men (relative hazard 1.87 [1.07-3.28]), heterosexuals (2.86 [1.50-5.48]), and homosexuals (2.17 [1.07-4.42]) as compared with intravenous drug users, with increasing age (1.33 per 10 years older [1.08-1.62]), and with the duration of exposure to antiretroviral therapy (1.57 per 6 months extra [1.30-1.88]) but not with any individual antiretroviral agent. The factors associated with an increased risk for lipodystrophy with subcutaneous lipoatrophy or lipodystrophy with central obesity were very similar to those associated with any lipodystrophy. The duration of indinavir use may represent an additional contribution for the development of lipodystrophy with central obesity (1.26 per 6 months extra [0.99-1.60]); p=0.064).

INTERPRETATION

Risk factors associated with development of any lipodystrophy, lipodystrophy with subcutaneous lipoatrophy, and tipodystrophy with central obesity in patients infected with HIV-1 who were receiving HAART containing protease inhibitors are multifactorial and overlapping, and cannot be exclusively ascribed to the duration of exposure to an particular antiretroviral agent.

Transferrin receptor induction by hypoxia. HIF-1-mediated transcriptional activation and cell-specific post-transcriptional regulation

The tight relationship between oxygen and iron prompted us to investigate whether the expression of transferrin receptor (TfR), which mediates cellular iron uptake, is regulated by hypoxia. In Hep3B human hepatoma cells incubated in 1% O(2) or treated with CoCl(2), which mimics hypoxia, we detected a 3-fold increase of TfR mRNA despite a decrease of iron regulatory proteins activity. Increased expression resulted from a 4-fold stimulation of the nuclear transcription rate of the TfR gene by both hypoxia and CoCl(2). A role for hypoxia-inducible factor (HIF-1), which activates transcription by binding to hypoxia-responsive elements in the activation of TfR, stems from the following observations. (a) Hypoxia and CoCl(2)-dependent expression of luciferase reporter gene in transiently transfected Hep3B cells was mediated by a fragment of the human TfR promoter containing a putative hypoxia-responsive element sequence, (b) mutation of this sequence prevented hypoxic stimulation of luciferase activity, (c) binding to this sequence of HIF-1alpha, identified by competition experiments and supershift assays, was induced in Hep3B cells by hypoxia and CoCl(2). In erythroid K562 cells, the same treatments did not affect iron regulatory proteins activity, thus resulting in a stimulation of TfR gene expression higher than in hepatoma cells.

Kinematic determinants of human locomotion

1. The aim of this study was to find kinematic patterns that are invariant across the normal range of locomotion speeds. Subjects walked at different, freely chosen speeds ranging from 0.9 to 2.1 m s-1, while motion and ground reaction forces on the right side of the body were recorded in three-dimensional space. 2. The time course of the anatomical angles of flexion-extension at the hip and ankle was variable not only across subjects, but even from trial to trial in the same subject. By contrast, the time course of the changes in the angles of elevation of each limb segment (pelvis, thigh, shank and foot) relative to the vertical was stereotyped across subjects. 3. To compare the waveforms across speeds, data were scaled in time relative to gait cycle duration. The pattern of ground reaction forces was highly speed dependent. Several distinct families of curves could be recognized in the flexion-extension angles at the hip and ankle. Instead, the waveforms of global length and elevation of the limb, elevation angles of all limb segments and flexion-extension at the knee were invariant with speed. 4. When gait trajectories at all speeds are plotted in the position space defined by the elevation angles of the limb segments, they describe regular loops on a plane. The statistical characteristics of these angular covariations were quantified by means of principal component analysis. The first two principal components accounted together for > 99% of the total experimental variance, and were quantitatively comparable in all subjects. 5. This constraint of planar covariation of the elevation angles is closely reminiscent of that previously described for the control of posture. The existence of laws of intersegmental co-ordination, common to the control of posture and locomotion, presumably assures the maintenance of dynamic equilibrium during forward progression, and the anticipatory adaptation to potentially destabilizing factors by means of co-ordinated kinematic synergies of the whole body.

Representing spatial information for limb movement: role of area 5 in the monkey

How is spatial information for limb movement encoded in the brain? Computational and psychophysical studies suggest that beginning hand position, via-points, and target are specified relative to the body to afford a comparison between the sensory (e.g., kinesthetic) reafferences and the commands that generate limb movement. Here we propose that the superior parietal lobule (Brodmann area 5) might represent a substrate for a body-centered positional code. Monkeys made arm movements in different parts of 3D space in a reaction-time task. We found that the activity of area 5 neurons can be related to either the starting point, or the final point, or combinations of the two. Neural activity is monotonically tuned in a body-centered frame of reference, whose coordinates define the azimuth, elevation, and distance of the hand. Each spatial coordinate tends to be encoded in a different subpopulation of neurons. This parcellation could be a neural correlate of the psychophysical observation that these spatial parameters are processed in parallel and largely independent of each other in man.

Motor patterns for human gait: backward versus forward locomotion

Seven healthy subjects walked forward (FW) and backward (BW) at different freely chosen speeds, while their motion, ground reaction forces, and electromyographic (EMG) activity from lower limb muscles were recorded. We considered the time course of the elevation angles of the thigh, shank, and foot segments in the sagittal plane, the anatomic angles of the hip, knee, and ankle joints, the vertical and longitudinal ground reaction forces, and the rectified EMGs. The elevation angles were the most reproducible variables across trials in each walking direction. After normalizing the time course of each variable over the gait cycle duration, the waveforms of all elevation angles in BW gait were essentially time reversed relative to the corresponding waveforms in FW gait. Moreover, the changes of the thigh, shank, and foot elevation covaried along a plane during the whole gait cycle in both FW and BW directions. Cross-correlation analysis revealed that the phase coupling among these elevation angles is maintained with a simple reversal of the delay on the reversal of walking direction. The extent of FW-BW correspondence also was good for the hip angle, but it was smaller for the knee and ankle angles and for the ground reaction forces. The EMG patterns were drastically different in the two movement directions as was the organization of the muscular synergies measured by cross-correlation analysis. Moreover, at any given speed, the mean EMG activity over the gait cycle was generally higher in BW than in FW gait, suggesting a greater level of energy expenditure in the former task. We argue that conservation of kinematic templates across gait reversal at the expense of a complete reorganization of muscle synergies does not arise from biomechanical constraints but may reflect a behavioral goal achieved by the central networks involved in the control of locomotion.

Prevalence and clinical correlates of sarcopenia in community-dwelling older people: application of the EWGSOP definition and diagnostic algorithm

BACKGROUND

Muscle impairment is a common condition in older people and a powerful risk factor for disability and mortality. The aim of this study was to apply the European Working Group on Sarcopenia in Older People criteria to estimate the prevalence and investigate the clinical correlates of sarcopenia, in a sample of Italian community-dwelling older people.

METHODS

Cross-sectional analysis of 730 participants (74% aged 65 years and older) enrolled in the InCHIANTI study. Sarcopenia was defined according to the European Working Group on Sarcopenia in Older People criteria using bioimpedance analysis for muscle mass assessment. Logistic regression analysis was used to identify the factors independently associated with sarcopenia.

RESULTS

Sarcopenia defined by the European Working Group on Sarcopenia in Older People criteria increased steeply with age (p < .001), with 31.6% of women and 17.4% of men aged 80 years or older being affected by this condition. Higher education (odds ratio: 0.85; 95% CI: 0.74-0.98), lower insulin-like growth factor I (lowest vs highest tertile, odds ratio: 3.89; 95% CI: 1.03-14.1), and low bioavailable testosterone (odds ratio: 2.67; 95% CI: 1.31-5.44) were independently associated with the likelihood of being sarcopenic. Nutritional intake, physical activity, and level of comorbidity were not associated with sarcopenia.

CONCLUSIONS

Sarcopenia identified by the European Working Group on Sarcopenia in Older People criteria is a relatively common condition in Italian octogenarians, and its prevalence increases with aging. Correlates of sarcopenia identified in this study might suggest new approaches for prevention and treatment of sarcopenia.

Effects of novelty and habituation on acetylcholine, GABA, and glutamate release from the frontal cortex and hippocampus of freely moving rats

The involvement of the forebrain cholinergic system in arousal, learning and memory has been well established. Other neurotransmitters such as GABA and glutamate may be involved in the mechanisms of memory by modulating the forebrain cholinergic pathways. We studied the activity of cortical and hippocampal cholinergic, GABAergic and glutamatergic systems during novelty and habituation in the rat using microdialysis. After establishing basal release of the neurotransmitters, the animals were transferred to a novel environment and allowed to explore it twice consecutively for 30 min (60 min apart; exploration I and II). The motor activity was monitored. Samples were collected throughout the experiment and the release of acetylcholine (ACh), GABA and glutamate was measured. During the two consecutive explorations of the arena, cortical and hippocampal, ACh release showed a significant tetrodotoxin-dependent increase which was higher during exploration I than II. The effect was more pronounced and longer-lasting in the hippocampus than in the cortex. Cortical GABA release increased significantly only during exploration II, while hippocampal GABA release did not increase during either exploration. Motor activity was higher during the first 10 min of exploration I and II and then gradually decreased during the further 20 min. Both cortical and hippocampal ACh release were positively correlated with motor activity during exploration II, but not during I. During exploration II, cortical GABA release was inversely correlated, while hippocampal GABA release was positively correlated to motor activity. No change in cortical and hippocampal glutamate release was observed. In summary, ACh released by the animal placed in a novel environment seems to have two components, one related to motor activity and one related to attention, anxiety and fear. This second component disappears in the familiar environment, where ACh release is directly related to motor activity. The negative relationship between cortical GABA levels and motor activity may indicate that cortical GABAergic activity is involved in habituation.

A novel inward-rectifying K+ current with a cell-cycle dependence governs the resting potential of mammalian neuroblastoma cells

1. Human and murine neuroblastoma cell lines were used to investigate, by the whole-cell patch-clamp technique, the properties of a novel inward-rectifying K+ current (IIR) in the adjustment of cell resting potential (Vrest), which was in the range -40 to -20 mV. 2. When elicited from a holding potential of 0 mV, IIR was completely inactivated with time constants ranging from 13 ms at -140 mV to 4.5 s at -50 mV. The steady-state inactivation curve (h(V)) was found to be independent of [Na+]o and [K+]o (2-80 mM) and could be fitted to a Boltzmann curve with a steep slope factor of 5-6, and a V1/2 around Vrest. Divalent ion-free extracellular solutions shifted h(V) to the left by about 28 mV. 3. Peak chord conductance, whose maximal value was approximately proportional to the square root of [K+]o, could be fitted to a Boltzmann curve independently of [K+]o, with a V1/2 value around -48 mV and a slope factor of 18. Extracellular Cs+ and Ba2+ blocked the IIR in a concentration- and voltage-dependent manner, but Ba2+ was less effective than it is on classical inward-rectifier channels. 4. Under control culture conditions the values of Vrest and V1/2 of h(V) varied widely among cells. The knowledge of V1/2 proved crucial or the theoretical prediction of Vrest. After cell synchronization in the G0-G1 phase of the cell cycle, or at the G1-S boundaries, the cells reduced their variability of h(V). The same occurred after cell synchronization in G1 by treatment with retinoic acid. 5. The experimental data could be fitted to a classical model of an inward rectifier, after removing the dependence of conductance activation on (V-EK), and incorporating an inactivation with an intrinsic voltage dependence. Moreover, the model predicts, for this novel inward rectifier and in contrast with the classical inward rectifier, the incapacity of maintaining, in physiological media, a Vrest more negative than -35 to -40 mV, which is an important feature of cancer cells.

Role of muscle mass and muscle quality in the association between diabetes and gait speed

OBJECTIVE

Older people with type 2 diabetes are at high risk of mobility disability. We investigated the association of diabetes with lower-limb muscle mass and muscle quality to verify whether diabetes-related muscle impairments mediate the association between diabetes and low walking speed.

RESEARCH DESIGN AND METHODS

We performed a cross-sectional analysis of 835 participants (65 years old and older) enrolled in the InCHIANTI (Invecchiare in Chianti, aging in the Chianti area) population-based study. Total, muscular, and fat cross-sectional areas of the calf and relative muscle density were measured using peripheral quantitative computerized tomography. Indicators of muscle performance included knee-extension torque, ankle plantar flexion and dorsiflexion strength, lower-extremity muscle power, and ankle muscle quality (ratio of ankle strength to the muscle area [kilograms per centimeters squared]). Gait performance was assessed by 4- and 400-m walking speed. Diabetes was ascertained by standard American Diabetes Association criteria.

RESULTS

Prevalence of diabetes was 11.4%. After adjustment for age and sex, participants with diabetes had lower muscle density, knee and ankle strength, and muscle power and worse muscle quality (all P < 0.05). Diabetic participants were also slower on both 4-m (β: -0.115 ± 0.024 m/s, P < 0.001) and 400-m (β:-0.053 ± 0.023 m/s, P < 0.05) walking tests. In multivariable linear regression models, lower-limb muscle characteristics accounted for 24.3 and 15.1% of walking speed difference comparing diabetic and nondiabetic subjects in the 4- and 400-m walks, respectively.

CONCLUSIONS

In older persons, diabetes is associated with reduced muscle strength and worse muscle quality. These impairments are important contributors of walking limitations related to diabetes.

Conversion from clinically isolated syndrome to multiple sclerosis: A large multicentre study

Background and objective:

We explored which clinical and biochemical variables predict conversion from clinically isolated syndrome (CIS) to clinically definite multiple sclerosis (CDMS) in a large international cohort.

Methods:

Thirty-three centres provided serum samples from 1047 CIS cases with at least two years’ follow-up. Age, sex, clinical presentation, T2-hyperintense lesions, cerebrospinal fluid (CSF) oligoclonal bands (OCBs), CSF IgG index, CSF cell count, serum 25-hydroxyvitamin D3 (25-OH-D), cotinine and IgG titres against Epstein-Barr nuclear antigen 1 (EBNA-1) and cytomegalovirus were tested for association with risk of CDMS.

Results:

At median follow-up of 4.31 years, 623 CIS cases converted to CDMS. Predictors of conversion in multivariable analyses were OCB (HR = 2.18, 95% CI = 1.71–2.77, p < 0.001), number of T2 lesions (two to nine lesions vs 0/1 lesions: HR = 1.97, 95% CI = 1.52–2.55, p < 0.001; >9 lesions vs 0/1 lesions: HR = 2.74, 95% CI = 2.04–3.68, p < 0.001) and age at CIS (HR per year inversely increase = 0.98, 95% CI = 0.98–0.99, p < 0.001). Lower 25-OH-D levels were associated with CDMS in univariable analysis, but this was attenuated in the multivariable model. OCB positivity was associated with higher EBNA-1 IgG titres.

Conclusions:

We validated MRI lesion load, OCB and age at CIS as the strongest independent predictors of conversion to CDMS in this multicentre setting. A role for vitamin D is suggested but requires further investigation.

Evidence for a cardiac ion channel mutation underlying drug-induced QT prolongation and life-threatening arrhythmias

The aim of this study was to test the hypothesis that some cases of drug-induced arrhythmias depend on genetic predisposition. Excessive prolongation of the QT interval and life-threatening arrhythmias (torsades de pointes or ventricular fibrillation) may occur in response to a variety of cardiac and noncardiac drugs, with detrimental effects on patient safety and the investments made by the pharmaceutical industry. Moss and Schwartz hypothesized that some drug-induced arrhythmias might represent cases of "forme fruste" of the congenital long QT syndrome (LQTS). The availability of molecular screening techniques for LQTS genes allowed us to test this hypothesis. An elderly female patient with documented cardiac arrest related to cisapride, a prokynetic drug that blocks I(Kr), and transiently prolonged QT interval underwent mutational analysis of the known LQTS-related genes performed by single-strand conformational polymorphism and DNA sequencing. Double-electrode voltage clamp in Xenopus oocytes as the expression system was used to study the in vitro cellular phenotype caused by the genetic defect in coexpression with the wild-type (WT) gene. Molecular analysis revealed a heterozygous mutation leading to substitution of a highly conserved amino acid in the pore region of KvLQT1. This mutation was present not only in the patient with ventricular fibrillation but also in her two adult asymptomatic sons who have a normal QT interval. In vitro expression of the mutated KvLQT1 protein showed a severe loss of current with a dominant negative effect on the WT-KvLQT1 channel. Our findings demonstrate that some cases of drug-induced QT prolongation may depend on a genetic substrate. Molecular screening may allow identification among family members of gene carriers potentially at risk if treated with I(Kr) blockers. Evolving technology may lead to rapid screening for mutations of candidate genes that cause drug-induced life-threatening arrhythmias and allow early identification of individuals at risk.

Tele-assistance in chronic respiratory failure patients: a randomised clinical trial

Chronic respiratory patients requiring oxygen or home mechanical ventilation experience frequent exacerbations and hospitalisations with related costs. Strict monitoring and care have been recommended. The aim of the present study was to primarily evaluate reduction in hospitalisations and, secondly, exacerbations, general practitioner (GP) calls and related cost-effectiveness of tele-assistance (TA) for these patients. A total of 240 patients (101 with chronic obstructive pulmonary disease (COPD)) were randomised to two groups: an intervention group entered a 1-yr TA programme while controls received traditional care. No anthropometric and clinical differences were found between groups both in baseline and in mortality (18% for TA, 23% for controls). Compared with controls, the TA group experienced significantly fewer hospitalisations (-36%), urgent GP calls (-65%) and acute exacerbations (-71%). Only COPD patients, as a separate group, had fewer hospitalisations, emergency room admissions, urgent GP calls or exacerbations. Each patient referred to staff a mean+/-sd 36+/-25 times. After deduction of TA costs, the average overall cost for each patient was 33% less than that for usual care. In chronic respiratory failure patients on oxygen or home mechanical ventilation, a nurse-centred tele-assistance prevents hospitalisations while it is cost-effective. The chronic obstructive pulmonary disease group seems to have a greater advantage from tele-assistance.

Randomized controlled trial of interferon treatment for advanced hepatocellular carcinoma

The aim of this randomized controlled trial was to assess the efficacy of interferon alfa-2b (IFN) for the treatment of advanced hepatocellular carcinoma (HCC). Fifty-eight patients with HCC who were not suitable for resection, transplantation, ethanol injection, or arterial embolization were stratified according to their Okuda stage and randomized to receive IFN (3 x 10(6), 3 times a week, for 1 year) (n = 30) or symptomatic treatment (n = 28). Both groups were identical in terms of age, sex, performance status, presence of constitutional syndrome, Child-Pugh class, Okuda stage, multinodularity, portal thrombosis, and extrahepatic spread. Adhesion to IFN treatment was adequate in 27 patients, with a mean duration of treatment of 8 +/- 3 months. However, IFN treatment was associated with side effects in 23 patients, leading to treatment discontinuation in 13 patients. Two of the 30 patients (6.6%) presented a partial response with greater than 50% size reduction and normalization of alpha-fetoprotein levels. The survival at 1 and 2 years according to intention to treat was not different between the 2 groups (58% and 38% vs. 36% and 12%, respectively, Breslow P =. 19, log rank P =.14) and the absence of difference was maintained when dividing patients according to their Okuda stage. The probability of presenting tumor progression (P =.17), or deterioration of Child-Pugh class (P =.37), performance status (P =. 07), or Okuda stage (P =.44) was not modified by IFN treatment. These results indicate that IFN is not properly tolerated in patients with cirrhosis and advanced HCC and that its administration prompts no benefit in terms of tumor progression rate and survival.

HIF-1-mediated activation of transferrin receptor gene transcription by iron chelation

Treatment with iron chelators mimics hypoxic induction of the hypoxia inducible factor (HIF-1) which activates transcription by binding to hypoxia responsive elements (HRE). We investigated whether HIF-1 is involved in transcriptional activation of the transferrin receptor (TfR), a membrane protein which mediates cellular iron uptake, in response to iron deprivation. The transcription rate of the TfR gene in isolated nuclei was up-regulated by treatment of Hep3B human hepatoma cells with the iron chelator desferrioxamine (DFO). The role of HIF-1 in the activation of TfR was indicated by the following observations: (i) DFO-dependent activation of a luciferase reporter gene in transfected Hep3B cells was mediated by a fragment of the human TfR promoter containing a putative HRE sequence; (ii) mutation of this sequence prevented stimulation of luciferase activity; (iii) binding to this sequence of HIF-1alpha, identified by competition experiments and supershift assays, was induced by DFO. Furthermore, in mouse hepatoma cells unable to assemble functional HIF-1, inducibility of TfR transcription by DFO was lost and TfR mRNA up-regulation was reduced. These results, which show the role of HIF-1 in the control of TfR gene expression in conditions of iron depletion, give insights into the mechanisms of transcriptional regulation which concur with the well-characterized post-transcriptional control of TfR expression to expand the extent of response to iron deficiency.

The Predictive Value of the EWGSOP Definition of Sarcopenia: Results From the InCHIANTI Study

BACKGROUND

Sarcopenia is associated with increased risk of adverse outcomes in older people. Aim of the study was to explore the predictive value of the European Working Group on Sarcopenia in Older People (EWGSOP) diagnostic algorithm in terms of disability, hospitalization, and mortality and analyze the specific role of grip strength and walking speed as diagnostic criteria for sarcopenia.

METHODS

Longitudinal analysis of 538 participants enrolled in the InCHIANTI study. Sarcopenia was defined as having low muscle mass plus low grip strength or low gait speed (EWGSOP criteria). Muscle mass was assessed using bioimpedance analysis. Cox proportional and logistic regression models were used to assess risk of death, hospitalization, and disability for sarcopenic people and to investigate the individual contributions of grip strength and walking speed to the predictive value of the EWGSOP's algorithm.

RESULTS

Prevalence of EWGSOP-defined sarcopenia at baseline was 10.2%. After adjusting for potential confounders, sarcopenia was associated with disability (odds ratio 3.15; 95% confidence interval [CI] 1.41-7.05), hospitalization (hazard ratio [HR] 1.57; 95% CI 1.03-2.41), and mortality (HR 1.88; 95% CI 0.91-3.91). The association between an alternative sarcopenic phenotype, defined only by the presence of low muscle mass and low grip strength, and both disability and mortality were similar to the association with the phenotypes defined by low muscle mass and low walking speed or by the EWGSOP algorithm.

CONCLUSIONS

The EWGSOP's phenotype is a good predictor of incident disability, hospitalization and death. Assessment of only muscle weakness, in addition to low muscle mass, provided similar predictive value as compared to the original algorithm.

The incidence of sarcopenia among hospitalized older patients: results from the Glisten study

BACKGROUND

New evidence is emerging on the importance of lean body mass during periods of illness and recovery. The preservation of lean body mass during such periods of intense stress impacts both patient and treatment outcomes. However, data concerning the incidence of sarcopenia among older people during hospitalization are scarce. The objective of this study was to evaluate the development of sarcopenia in a sample of hospitalized older subjects.

METHODS

We used data of 394 participants from the multicentre Italian Study conducted by the Gruppo Lavoro Italiano Sarcopenia-Trattamento e Nutrizione (GLISTEN) in 12 Acute Care Wards (Internal Medicine and Geriatrics) of University Hospitals across Italy. This study was designed to determine the prevalence of sarcopenia at hospital admission and the change in muscle mass and strength during hospitalization. Sarcopenia was defined as low skeletal mass index (kg/m² ) along with either low handgrip strength or slow walking speed [European Working Groups on Sarcopenia in Older People (EWGSOP) criteria]. Estimation of skeletal muscle mass was performed by bioelectrical impedance analysis (BIA).

RESULTS

The mean age of the 394 enrolled patients (including 211 females who accounted for 53% of the sample) was 79.6 ± 6.4 years. Among those without sarcopenia at hospital admission, 14.7% of the study sample met the EWGSOP sarcopenia diagnostic criteria at discharge. The incidence of sarcopenia during hospitalization was significantly associated with the number of days spent in bed but was not correlated with the total length of hospital stay. In particular, patients who developed sarcopenia spent an average of 5.1 days in bed compared with 3.2 days for those with no sarcopenia at discharge (P = 0.02). Patients with sarcopenia showed a significantly lower body mass index compared with non-sarcopenic peers (25.0 ± 3.8 kg/m² vs. 27.6 ± 4.9 kg/m² , respectively; P < 0.001). Similarly, the skeletal mass index at admission was significantly lower among patients who developed sarcopenia during hospital stay.

CONCLUSIONS

Incident sarcopenia during hospital stay is relatively common and is associated with nutritional status and the number of days of bed rest.

Italian guidelines on the systemic treatments of moderate-to-severe plaque psoriasis

Psoriasis is a common disease, which has a considerable impact on the healthcare system. Therefore, appropriate use of therapeutic resources is very important. Management of psoriasis in daily clinical practice is highly variable because many issues are still debated and not definitely addressed by the evidence-based medicine. Moreover, the different availability and reimbursability of drugs in each country justifies national guidelines. Expert consensus can provide helpful guidelines for optimizing patient care. A total of 20 dermatologists from different areas of Italy and with large experience in the treatment of psoriasis agreed to participate in the guidelines expert panel who aimed to reach consensus on the factors influencing psoriasis severity, the indications for systemic treatments, the parameters to be considered in the choice of treatment, and the factors to be considered in the choice of biological treatment. The recommendations for the use, screening and monitoring of systemic therapies were based on the 2015 S3 European Dermatology Forum/European Academy of Dermatology and Venereology psoriasis guidelines. Recommendations on the treatment of psoriasis in special patient populations were also agreed. The final document was discussed in a meeting moderated by a facilitator with participation of the entire group and adopting a nominal group technique to reach consensus. A statement was regarded as consented when agreement was achieved by at least 75% of the voting experts according to the Delphi procedure.

Long-term effectiveness of pulmonary rehabilitation in patients with chronic airway obstruction

The aim of this study was to evaluate the long-term outcome of an outpatient pulmonary rehabilitation programme (PRP) in patients with chronic airway obstruction (CAO). In 61 CAO patients (35 asthmatics and 26 chronic obstructive pulmonary disease (COPD)) lung and respiratory muscle function, exercise tolerance (by symptom limited cycloergometer and walking tests), dyspnoea (Borg scale, visual analogue scale (VAS), baseline and transitional dyspnoea index (BDI and TDI, respectively)) and quality of life (St George's Respiratory Questionnaire (SGRQ)) were assessed at baseline (to), at discharge (t1) and 12 months postdischarge (t2). Preprogramme and post-programme hospital admissions and exacerbations of disease were also recorded. In comparison with baseline, no significant change was observed in lung function tests in either diagnostic group, either at t1 or at t2. In both groups improvements in respiratory muscle strength, exercise tolerance, Borg scale and VAS reported at t1 were partially reduced at t2. Analysis of variance showed that these changes over time were similar in the two groups. Mean values of SGRQ and BDI/TDI improved at t1, and, unlike exercise tolerance, did not worsen at t2. However, a clinically relevant difference in SGRQ between t2 and to was reported only in 56% of asthmatics and 52% of COPD patients. Compared with the preceding 2 yrs, in the year following PRP, hospital admissions and disease exacerbations decreased significantly in both diagnostic groups. Regardless of diagnosis, patients with chronic airway obstruction who underwent an outpatient pulmonary rehabilitation programme maintained an improved quality of life 12 months postdischarge despite a partial loss of the improvement in exercise tolerance.

Kinematic coordination in human gait: relation to mechanical energy cost

Twenty-four subjects walked at different, freely chosen speeds (V) ranging from 0.4 to 2.6 m s-1, while the motion and the ground reaction forces were recorded in three-dimensional space. We considered the time course of the changes of the angles of elevation of the trunk, pelvis, thigh, shank, and foot in the sagittal plane. These angles specify the orientation of each segment with respect to the vertical and to the direction of forward progression. The changes of the trunk and pelvis angles are of limited amplitude and reflect the dynamics of both right and left lower limbs. The changes of the thigh, shank, and foot elevation are ample, and they are coupled tightly among each other. When these angles are plotted one versus the others, they describe regular loops constrained on a plane. The plane of angular covariation rotates, slightly but systematically, along the long axis of the gait loop with increasing V. The rotation, quantified by the change of the direction cosine of the normal to the plane with the thigh axis (u3t), is related to a progressive phase shift between the foot elevation and the shank elevation with increasing V. As a next step in the analysis, we computed the mass-specific mean absolute power (Pu) to obtain a global estimate of the rate at which mechanical work is performed during the gait cycle. When plotted on logarithmic coordinates, Pu increases linearly with V. The slope of this relationship varies considerably across subjects, spanning a threefold range. We found that, at any given V > 1 m s-1, the value of the plane orientation (u3t) is correlated with the corresponding value of the net mechanical power (Pu). On the average, the progressive rotation of the plane with increasing V is associated with a reduction of the increment of Pu that would occur if u3t remained constant at the value characteristic of low V. The specific orientation of the plane at any given speed is not the same in all subjects, but there is an orderly shift of the plane orientation that correlates with the net power expended by each subject. In general, smaller values of u3t tend to be associated with smaller values of Pu and vice versa. We conclude that the parametric tuning of the plane of angular covariation is a reliable predictor of the mechanical energy expenditure of each subject and could be used by the nervous system for limiting the overall energy expenditure.