Botulinum Neurotoxin A Intravesical Injections in Interstitial Cystitis/Bladder Painful Syndrome: A Systematic Review with Meta-Analysis

Botulinum neurotoxin A (BoNT/A) appears to be one of the best intravesical treatments for interstitial cystitis/bladder painful syndrome (IC/BPS). We aimed to point out what the evidence is regarding the effects of BoNT/A intravesically injected in patients with IC/BPS. We performed a systematic review of all randomized controlled trials (RCTs) assessing BoNT/A for IC/BPS by using Medline, EMBASE, CINAHL, CENTRAL and MetaRegister of Controlled Trials. Standardized mean differences (SMD) were extracted from the available trials and combined in a meta-analysis applying a random effect model, including heterogeneity of effects. Twelve trials were identified. Significant benefits from BoNT/A injections were detected in: Interstitial Cystitis Symptom Index and Problem Index (ICSI, ICPI) (small to medium effect size: SMD = -0.302; p = 0.007 and -0.430, p = 0.004, respectively); Visual Analog Scale (VAS) for pain and day-time urinary frequency (medium effect size: SMD = -0.576, p < 0.0001 and -0.546, p = 0.013, respectively). A great effect size was detected for post-void residual volume (PVR, SMD = 0.728; p =0.002) although no clinically relevant in most cases. Great heterogeneity was observed in treatments' methodologies and symptoms assessment. Overall, BoNT/A intravesical injections significantly improve some of the most relevant symptoms affecting IC/BPS patients.

Bladder and bowel dysfunction, adaptive behaviour and psychiatric profiles in adults affected by autism spectrum disorders

AIMS

Bladder and bowel dysfunction (BBD) have been recognized in children affected by autism spectrum disorder (ASD), but no consistent information exist in adults with the condition. We evaluated the prevalence of BBD and the impact of psychiatric and behavioural profiles in adults affected by ASD.

METHODS

Twenty-two adults and 13 children/teens with ASD and a matched group of typically developing subjects (TD) were prospectively studied. Patients and TD subjects underwent the evaluation of urinary incontinence (UI: diurnal, continuous or intermittent), nocturnal enuresis (NE), and bowel disturbances with the 3-day voiding and bowel diary. In addition, assessment of intellectual disability (ID) and psychiatric and adaptive behaviours with the Neuropsychiatric Inventory Scale (NPI) and the Vineland Adaptive Behaviour Scale 2nd Edition (Vineland-II), was performed.

RESULTS

In adults, any type of incontinence was observed in 81.8% of cases, and NE and intermittent UI in 59.0% and 36.3% of patients, respectively. Faecal incontinence and constipation were detected 36.3% and in 68.1% of cases, respectively. ID was severe in 2 cases and profound in 18; NPI and Vineland-II items most affected were "Irritability/Lability," "Motor Activity," and "Agitation," and IQ-Socialization and IQ-Communication. Significant relationships were identified between intermittent UI and greater ID (P < .02) and high "anxiety" (P < .05), and between NE and high "euphoria/elevated mood" (P < .05). These results were similar to those observed in children/teens.

CONCLUSIONS

Adults with ASD, and greater ID and mood disorders, present with a high prevalence of BBD. A shared pathogenetic mechanism could underlie the co-occurrence of ASD, mood disorders, and BBD.

Obstetric and psychosocial risk factors associated with maternity blues

AIM

To identify risk factors for maternity blues (MB) and to evaluate the impact of obstetric factors on MB prevalence.

MATERIALS AND METHODS

194 mothers have completed the Edinburgh Postnatal Depression Scale (EPDS) 2 days after delivery. Bivariate and multivariate logistic regression models were used to identify the predictors of MB.

RESULTS

57 women (29.4%) were positive at screening. Comparing the two groups, no statistically significant difference was found in age (p = .536), nationality (p = .065) and BMI before pregnancy (p = .224). Interestingly, no significant differences were highlighted in terms of assisted reproduction technology or spontaneous pregnancies and the presence of labor analgesia, while MB was significantly more frequent in case of cesarean section (CS) (p = .035). Statistical differences have been found in previous CS (p = .022), previous voluntary interruption of pregnancy (p = .021), number of previous pregnancies (p = .007), Apgar 5' (p = .026), lower level of education (p = .009), and previous postpartum depression (PPD) (p = .026). A logistic regression analysis was realized according to a multivariate model incorporating all the variables with a p-value ≤.25 in bivariate analysis. In the final model vaginal delivery (OR 0.451, 95% CI [0.224-0.911], p = .026) resulted to be MB protective factor, while a lower level of education (OR 3.657, 95% CI [1.482-9.023], p = .005) as well as previous PPD (OR 4.714, 95% CI [1.273-17.458], p = .020) were identified as independent risk factors.

CONCLUSION

This study showed that a lower education level and a previous PPD resulted to be important risk factors for MB development, while natural delivery was revealed as a protective factor. These results could be used to develop a better and more accurate prevention program after delivery.

Effect of Short Term Intensive Lifestyle Intervention on Hepatic Steatosis Indexes in Adults with Obesity and/or Type 2 Diabetes

Background: Non-alcoholic fatty liver disease (NAFLD) has an estimated prevalence of 20–30% in the general population and even higher in individuals with metabolic risk factors. The aim of this study was to evaluate the effect of a lifestyle intervention program on surrogate markers of hepatic steatosis in obesity and/or type 2 diabetes patients, enrolled in the C.U.R.I.A.Mo. (Centro Universitario di Ricerca Interdipartimentale Attività Motoria) trial. Methods: 102 subjects (56 females and 46 males, aged between 23 and 78) with type 2 diabetes, obesity or a BMI of at least 25 kg/m² with comorbidities, participated in the intensive phase of a multidisciplinary lifestyle intervention program at the Healthy Lifestyle Institute of the University of Perugia (C.U.R.I.A.Mo.). Six indices related to NAFLD (Visceral Adiposity Index, Fatty Liver index, Non-Alcoholic Fatty Liver Disease liver fat score and liver fat equation, hepatic steatosis index and TyG index) were calculated before and after a three-month multidisciplinary lifestyle intervention. Results: The intervention improved the anthropometric and clinical parameters in the total population, the obese and/or diabetics. Data showed a significant weight loss, a reduced waist circumference, triglycerides, and an improvement in Mediterranean diet adherence. Hepatic steatosis indices were significantly reduced in the total population and in different subgroups (males, females, obesity and diabetes).

Celiac Disease Prevalence is Increased in Primary Sjögren's Syndrome and Diffuse Systemic Sclerosis: Lessons from a Large Multi-Center Study

Association of celiac disease (CD) with systemic autoimmune diseases (ADs) remains controversial. Awareness of CD in these patients is important to prevent complications, including lymphoproliferative disorders. We evaluated previously diagnosed CD prevalence in systemic lupus erythematosus (SLE), primary Sjögren’s syndrome (pSS) and systemic sclerosis (SSc) patients in comparison to 14,298 matched controls. All patients were screened for subclinical CD. Data from 1458 unselected consecutive SLE (580), pSS (354) and SSc (524) patients were collected. Previously biopsy-proven CD diagnosis and both CD- and AD-specific features were registered. All patients without previous CD were tested for IgA transglutaminase (TG). Anti-endomysium were tested in positive/borderline IgA TG. Duodenal biopsy was performed in IgA TG/endomysium+ to confirm CD. CD prevalence in AD was compared to that observed in 14,298 unselected sex- and age-matched adults who acted as controls. CD was more prevalent in pSS vs controls (6.78% vs 0.64%, p < 0.0001). A trend towards higher prevalence was observed in SLE (1.38%, p = 0.058) and SSc (1.34%, p = 0.096). Higher CD prevalence was observed in diffuse cutaneous SSc (4.5%, p ≤ 0.002 vs controls). Subclinical CD was found in two SLE patients and one pSS patient. CD diagnosis usually preceded that of AD. Primary SS and SSc–CD patients were younger at AD diagnosis in comparison to non-celiac patients. Autoimmune thyroiditis was associated with pSS and CD. CD prevalence is clearly increased in pSS and diffuse SSc in comparison to the general population. The association of CD with diffuse but not limited SSc may suggest different immunopathogenic mechanisms characterizing the two subsets. CD screening may be considered in pSS and diffuse SSc in young patients, particularly at the time of diagnosis.

Skin toxicity after chest wall/breast plus level III-IV lymph nodes treatment with helical tomotherapy

INTRODUCTION

To evaluate the incidence of toxicity in breast cancer with helical tomotherapy (HT).

MATERIALS AND METHODS

51 patients with breast cancer were assigned to postoperative radiotherapy by means of HT to the chest wall/breast plus draining nodes. During HT treatment, toxicity was monitored and were assessed using the Common Terminology Criteria for Adverse Events 4.0 scale.

RESULTS

Acute skin G3 toxicity observed in 1.9% cases. No acute or late G4 toxicity was observed. At a median follow-up of 21 months 2 patients have late G1 toxicity.

CONCLUSIONS

HT was associated with a low incidence of low-grade skin toxicity.

Efficacy and safety of adalimumab after failure of other anti-TNFα agents for plaque-type psoriasis: clinician behavior in real life clinical practice

Introduction: During treatment with biologic agents for psoriasis (Pso) in a number of patients a failure may occur and discontinuation with transitioning to another drug or an optimization strategy, consisting in a dose-adjustment or a co-medication with a traditional systemic agent, represent two possible alternatives. Objective: The SAFARI study objective was a retrospective observation of adalimumab efficacy and safety profile after switching from other anti-TNFα agents related to clinician behavior after the failure of the first-line agent. Results: The retrospective multicenter observation demonstrated that after a first-line anti-TNFα failure adalimumab efficacy was consistent at week-12 and 24 with a further significant improvement at week-48 with a proportion of patients achieving PASI75/PASI90/PASI100 of 83.3, 71.6, and 56.9.%, respectively. Clinician strategies to extend drug-survival after first-line anti-TNFα failure, such as co-medication or dose-adjustment, were irrelevant to future drug effectiveness. Conclusions: Adalimumab profile was excellent in this 5-year retrospective observation, showing the clinical validity of interclass transitioning among anti-TNFα options.

Hypofractionated whole breast radiotherapy with or without hypofractionated boost in early stage breast cancer patients: a mono-institutional analysis of skin and subcutaneous toxicity

BACKGROUND

Our study evaluated skin and subcutaneous toxicity analyzing its correlation with patient- and treatment-related factors in a large mono-institutional series of women with early stage breast cancer treated with adjuvant hypofractionated whole breast radiotherapy (WBRT) with or without a sequential hypofractionated boost (HB).

METHODS

Two hundred and nineteen patients, median age 62 years, received adjuvant hypofractionated WBRT in 16 fractions to a total dose of 42.4 Gy. Patients with negative prognostic factors received a HB of 2.65 Gy for 4 or 5 (patients with focal positive surgical margins) fractions. Systemic adjuvant treatments were hormonal therapy (HT) and/or chemotherapy (CHT) and/or Trastuzumab. Toxicities were assessed using the Common Terminology Criteria for Adverse Events (CTCAE 4.03) scale at 5th, 10th, 16th, 20th day from the start of radiotherapy (RT) and 1, 6 and 12 months after the end of RT. Univariate and multivariate analysis estimated toxicity predictive factors.

RESULTS

No case of treatment interruption and no acute or late G3 toxicities occurred. In the univariate analysis HB administration resulted a risk factor for acute toxicity, while CHT administration and number of excised lymph nodes ≥ 10 resulted a risk factor for late toxicity. In the multivariate analysis none of the evaluated factors emerged a risk factor for acute and/or late toxicity.

CONCLUSIONS

Our results confirmed that hypofractionated WBRT even followed by a HB resulted safe and well tolerated. Longer follow-up is warranted to estimate late toxicity and treatment outcomes.

Treatments of 1242 bulbar urethral strictures: multivariable statistical analysis of results

PURPOSE

We investigated the success rate of different surgical techniques for bulbar stricture repair.

METHODS

Retrospective study of patients with bulbar urethral strictures treated using different techniques. The primary outcome of the study was to evaluate the overall results of treatment (success vs. failure); the secondary outcome was to evaluate the outcome according to any surgical technique. Cysto-urethrography was performed 1 month following surgery. Patients underwent clinical evaluation, uroflowmetry and residual urine measurement every 6 months for 2 years after surgery and later once on year. When patient showed obstructive symptoms, Q_max < 12 ml/s, the urethrography was repeated. Patients who underwent further treatment for recurrent stricture were classified as failures. A bivariable and multivariable statistical analysis was performed.

RESULTS

Overall, 1242 patients were included in the study with mean age 40 years (range 12-84). Median stricture length was 4 cm (range 1-8). The median follow-up was 103 months (range 12-362). Over 1242 patients, 916 (73.8%) were success and 326 (26.2%) failures. Fourteen different surgical techniques showed a success rate ranging from 87.5 to 14.3%. The multivariable analysis showed that stricture length was an independent predictor factors for failure: p < 0.0001 CI 1146-1509. End-end anastomosis and oral mucosa graft urethroplasty are independent predictor factor of success after internal urethrotomy failure.

CONCLUSIONS

Our results showed that treatment of bulbar urethral stricture is satisfactory on 73.8% of patients, but with a wide range of success rate (from 14.3 to 87.5%) using different techniques. Oral mucosa is greatly superior to the skin as substitute material.

Metabolic Profile and Myocardial Performance of Renal Transplant Recipients Participating in Unsupervised Physical Exercise as a Prescription Program

INTRODUCTION

Renal transplant recipients (RTRs) are at high cardiovascular risk (CV) compared to the general population, especially after surgical treatment. The literature supports the role of supervised exercise intervention; however no data are available regarding the effects of unsupervised exercise programs. We investigated whether a home exercise program could reduce CV risk in RTR based on possible changes in renal and cardiometabolic parameters and myocardial performance measured by echocardiography.

METHODS

From a large cohort of 60 RTRs, 30 RTRs (12 females and 18 males 48.3 ± 12.3 years) participated in individualized and unsupervised training programs for 6 months, at moderate intensity. Cardiometabolic risk factors, anthropometric parameters, lipid and glycemic blood sample profiles were studied as was myocardial performance from the 2D echo examination at T0, and T6 months.

RESULTS

The lipid profile remained in the range of a low level of risk, although there was no significant improvement, whereas myocardial performance, in particular the EF, was significantly improved.

CONCLUSIONS

A home exercise program for at least 6 months produces positive effects on myocardial function and helps maintain a low cardiovascular risk profile. The trend supports the importance of highlighting the role of a correct reconditioning of lifestyle in RTR, from the exercise program without supervision to moderate intensity, where well tolerated.

Acute Toxicity Profiles of Hypofractionated Adjuvant and Salvage Radiation Therapy After Radical Prostatectomy: Results of a Prospective Study

PURPOSE

Hypofractionated radiation therapy (RT) is controversial after radical prostatectomy (RP). In this interim analysis, our prospective observational study assessed acute genitourinary (GU) and gastrointestinal (GI) toxicity after hypofractionated adjuvant and salvage RT, as delivered by helical tomotherapy (HT), in patients with prostate cancer.

METHODS AND MATERIALS

After undergoing RP with or without pelvic lymph node dissection, 112 patients were enrolled. Hypofractionated adjuvant RT (2.25 Gy daily for 29 fractions; total 65.25 Gy) was administered to 40 patients with high-risk features. Hypofractionated salvage RT (2.25 Gy daily for 32 or 33 fractions; total 72-74.25 Gy) was prescribed for 72 patients (24 with biochemical relapse, 48 with local relapse). Toxicity was graded according to the Common Terminology Criteria for Adverse Events version 4.02. The impact of RT on urinary flow was assessed by uroflowmetry.

RESULTS

Acute GU toxicity occurred in 41 of 112 patients (36%) (G1 31, G2 10). Acute GI toxicity was observed in 55 (49%) patients (G1 44, G2 11). Uroflowmetry showed that only salvage RT reduced maximum flow significantly (maximum, 68 vs 50 mL/s; P = .003), perhaps because a higher RT dose had been administered.

CONCLUSIONS

After RP, moderate hypofractionated adjuvant and salvage RT were associated with acceptable incidences of slight-to-moderate acute GU and GI toxicity and had little impact on urinary flow. Prospective trials are warranted with longer follow-up in larger cohorts to confirm these findings.

Induction of the apoptotic pathway by oxidative stress in spontaneous preterm birth: Single nucleotide polymorphisms, maternal lifestyle factors and health status

The purpose of the present study was to search for associations between spontaneous preterm birth (sPTB), single nucleotide polymorphisms (SNPs) associated with the apoptotic pathway as triggered by oxidative stress, maternal lifestyle and health status. SNP genotyping [rs7560 for c-Jun N-terminal kinase (JNK), rs9517320 for mammalian STE20-like protein kinase 3 (MST3), rs1049216 for caspase 3 (CASP3)] in the placenta and maternal blood of 300 controls with at-term birth and 43 cases of sPTB was performed. No association was identified in genotype frequencies or combinations of foetal/maternal genotypes between single SNPs and sPTB. The risk of sPTB was significantly reduced by physical activity and significantly increased by current hypertensive diseases, premature rupture of membranes (PROM) or preterm PROM (P-PROM) and previous sPTB. The TT/GA genotype of JNK/CASP3 in maternal blood and maternal health status (current hypertensive diseases, current PROM/P-PROM, previous sPTB) were independently associated with sPTB. The present findings suggested that, independently of other maternal factors, pregnant women carrying the TT/GA genotype of JNK/CASP3 were more susceptible to sPTB than women bearing the GT/GA (our reference) genotype; that the apoptotic pathway triggered by oxidative stress was involved; and that genetic and non-genetic factors contributed to sPTB. Knowledge of these aspects may aid to improve the management of pregnancies by indicating the lifestyle to be adopted on the basis of sPTB susceptibility.

Terlipressin-induced modifications of Doppler ultrasound signals of systemic arteries in preterm infants with vasoactive-resistant patent ductus arteriosus: A pilot study

PURPOSE

To study the effects of terlipressin (TP) infusion on systemic perfusion, estimated with pulsed-wave Doppler ultrasonography of systemic arteries, in a population of extremely low birth-weight (ELBW) preterm infants with vasoactive-resistant ductus arteriosus.

METHODS

This prospective, observational cohort included, during five years, 12 ELBW infants with hemodynamically significant patent ductus arteriosus and absent or reversed diastolic flow at Doppler ultrasonography of systemic arteries, despite treatment and high-dose vasoactive support. We measured flow velocity of the anterior cerebral, right renal, and superior mesenteric arteries before and after TP infusion. Changes were evaluated by Spearman's rho coefficient analysis, Wilcoxon signed-rank, and Friedman test.

RESULTS

Time-averaged mean velocity of the renal artery (P = .028) increased, while renal pulsatility (P = .010) and resistance (P = .004) indexes, and cerebral artery resistance index (P = .021) decreased after TP infusion. Time-averaged mean velocity of the anterior cerebral artery proportionately increased with dopamine dose (rho = 0.678; P = .015), but showed opposite shifts after TP (rho = -0.662; P = .024).

CONCLUSIONS

These changes suggest that TP may improve systemic perfusion in the ELBW infants with vasoactive-resistant ductus arteriosus.

[Phisycal activity and primary prevention: lifestyle analysis in young people]

OBJECTIVES

to assess physical activity and overweight in a young population as factors associated with well-being.

DESIGN

cross-sectional study.

SETTING AND PARTICIPANTS

data collection was performed in primary and secondary schools of a district located in Florence (Tuscany Region, Central Italy) by a validated questionnaire; 1,776 subjects were enrolled.

MAIN OUTCOME MEASURES

physical activity levels and overweight.

RESULTS

an overweight or obese condition in 14,4% of the study population was observed. Vigorous physical activity prevailed in normal weight children, while the time spent in a sitting position was higher in overweight subjects.

CONCLUSIONS

physical activity levels do not follow the guidelines for youth people. Educational programmes, also at schools, are recommended in order to prevent the risk of developing chronic diseases in adulthood.

Design of a Type-1 Diabetes Vaccine Candidate Using Edible Plants Expressing a Major Autoantigen

Type-1 diabetes (T1D) is a metabolic disease involving the autoimmune destruction of insulin-producing pancreatic beta cells. It is often diagnosed by the detection of autoantibodies, typically those recognizing insulin itself or the 65-kDa isoform of glutamic acid decarboxylase (GAD65). Oral insulin can be used to induce systemic immunological tolerance and thus prevent or delay the onset of T1D, suggesting that combination treatments with other autoantigens such as GAD65 could be even more successful. GAD65 has induced oral tolerance and prevented T1D in preclinical studies but it is difficult to produce in sufficient quantities for clinical testing. Here we combined edible plant systems, namely spinach (Spinacia oleracea cv Industra) and red beet (Beta vulgaris cv Moulin Rouge), with the magnICON^® expression system to develop a safe, cost-effective and environmentally sustainable platform for the large-scale production of GAD65. The superior red beet platform was extensively characterized in terms of recombinant protein yields and bioequivalence to wild-type plants, and the product was tested for its ability to resist simulated gastric digestion. Our results indicate that red beet plants are suitable for the production of a candidate oral vaccine based on GAD65 for the future preclinical and clinical testing of T1D immunotherapy approaches.

Urological dysfunction in young women: an inheritance of childhood?

OBJECTIVE

To investigate the correlation of a history of lower urinary tract symptomatology during childhood with lower urinary tract dysfunction in young adult women.

SUBJECTS AND METHODS

This was a multicentre, prospective, case-control study conducted between April 2013 and November 2015. A total of 300 women, aged 18-40 years, participated. The case group comprised women attending urogynaecology clinics for various lower urinary tract complaints and the control group was recruited from a healthy population. Exclusion criteria were designed to avoid common causes of lower urinary tract dysfunction and symptoms and included diabetes mellitus, neurological disease and pelvic inflammatory disease. All women completed a self-administered 77-item questionnaire, exploring childhood urological and bowel history, as well as current urological, bowel and sexual symptoms. Statistical analysis was performed using chi-squared and Fisher's exact tests to compare categorical variables. Multivariate logistic regression models were fit for the prediction of the adult outcomes, incorporating as explanatory variables all those that showed a significant P value in bivariate analysis. P values < 0.05 were considered statistically significant.

RESULTS

Women with childhood urinary voiding and storage symptoms had a higher prevalence of these symptoms in adult life compared with women without such history. Women with urinary tract infections (UTIs) during childhood had a higher incidence of adult UTIs compared with women without this problem in childhood.

CONCLUSIONS

Lower urinary tract dysfunction in childhood seems to 'persist' in young adult life but the implications of this finding in clinical practice need to be defined in future studies.