Sensorimotor integration is affected by acute whole-body vibration: a coherence study

Introduction: Several whole-body vibration (WBV) effects on performance have been related to potential changes in the neural drive, motor unit firing rate, and sensorimotor integration. In the present paper, motor unit coherence analysis was performed to detect the source of neural modulation based on the frequency domain. Methods: Thirteen men [25 ± 2.1 years; Body Mass Index (BMI) = 23.9 ± 1.3 kg m2; maximal voluntary force (MVF): 324.36 ± 41.26 N] performed sustained contractions of the Tibialis Anterior (TA) at 10%MVF before and after acute WBV. The vibrating stimulus was applied barefoot through a platform to target the TA. High-Density surface Electromyography (HDsEMG) was used to record the myoelectrical activity of TA to evaluate coherence from motor unit cumulative spike-trains (CSTs). Results: Mean coherence showed a significant decrease in the alpha and low-beta bandwidths (alpha: from 0.143 ± 0.129 to 0.132 ± 0.129, p = 0.035; low-beta: from 0.117 ± 0.039 to 0.086 ± 0.03, p = 0.0001), whereas no significant changes were found in the other ones (p > 0.05). The discharge rate (DR) and the Force Covariance (CovF%) were not significantly affected by acute WBV exposure (p > 0.05). Discussion: According to the significant effects found in alpha and low-beta bandwidths, which reflect sensorimotor integration parameters, accompanied by no differences in the DR and CovF%, the present results underlined that possible neural mechanisms at the base of the previously reported performance enhancements following acute WBV are likely based on sensorimotor integration rather than direct neural drive modulation.

Seismic source identification of the 9 November 2022 Mw 5.5 offshore Adriatic sea (Italy) earthquake from GNSS data and aftershock relocation

The fast individuation and modeling of faults responsible for large earthquakes are fundamental for understanding the evolution of potentially destructive seismic sequences. This is even more challenging in case of buried thrusts located in offshore areas, like those hosting the 9 November 2022 Ml 5.7 (M_w 5.5) and M_L 5.2 earthquakes that nucleated along the Apennines compressional front, offshore the northern Adriatic Sea. Available on- and offshore (from hydrocarbon platforms) geodetic observations and seismological data provide robust constraints on the rupture of a 15 km long, ca. 24° SSW-dipping fault patch, consistent with seismic reflection data. Stress increase along unruptured portion of the activated thrust front suggests the potential activation of longer portions of the thrust with higher magnitude earthquake and larger surface faulting. This unpleasant scenario needs to be further investigated, also considering their tsunamigenic potential and possible impact on onshore and offshore human communities and infrastructures.

The acute effects of whole-body vibration on motor unit recruitment and discharge properties

Introduction: several studies have reported improved neuromuscular parameters in response to whole-body vibration (WBV). This is likely achieved by modulation of the central nervous system (CNS). Reduced recruitment threshold (RT), which is the % of Maximal Voluntary Force (%MVF) at which a given Motor Unit (MU) is recruited, may be responsible for the force/power improvements observed in several studies. Methods: 14 men (25 ± 2.3 years; BMI = 23.3 ± 1.5 kg m² MVF: 319.82 ± 45.74 N) performed trapezoidal isometric contractions of the tibialis anterior (TA) at 35-50-70 %MVF before and after three conditions: WBV, STAND (standing posture), and CNT (no intervention). The vibration was applied through a platform for targeting the TA. High-density surface electromyography (HDsEMG) recordings and analysis were used to detect changes in the RT and Discharge Rate (DR) of the MUs. Results: Mean motor unit recruitment threshold (MURT) reached 32.04 ± 3.28 %MVF before and 31.2 ± 3.72 %MVF after WBV, with no significant differences between conditions (p > 0.05). Additionally, no significant changes were found in the mean motor unit discharge rate (before WBV: 21.11 ± 2.94 pps; after WBV: 21.19 ± 2.17 pps). Discussion: The present study showed no significant changes in motor unit properties at the base of neuromuscular changes documented in previous studies. Further investigations are needed to understand motor unit responses to different vibration protocols and the chronic effect of vibration exposure on motor control strategies.

An interpretable machine learning model to explain the interplay between brain lesions and cortical atrophy in multiple sclerosis

Multiple Sclerosis (MS) is the most common cause, (after trauma) of neurological disability in young adults in Western countries. While several Magnetic Resonance Imaging (MRI) studies have demonstrated a strong association between the presence of cortical grey matter atrophy and the progression of neurological impairment in MS patients, the neurobiological substrates of cortical atrophy in MS, and in particular its relationship with white matter (WM) and cortical lesions, remain unknown. The aim of this study was to investigate the interplay between cortical atrophy and different types of lesions at Ultra-High Field (UHF) 7 T MRI, including cortical lesions and lesions with a susceptibility rim (a feature which histopathological studies have associated with impaired remyelination and progressive tissue destruction). We combined lesion characterization with a recent machine learning (ML) framework which includes explainability, and we were able to predict cortical atrophy in MS from a handful of lesion-related features extracted from 7 T MR imaging. This highlights not only the importance of UHF MRI for accurately evaluating intracortical and rim lesion load, but also the differential contributions that these types of lesions may bring to determine disease evolution and severity. Also, we found that a small subset of features [WM lesion volume (not considering rim lesions), patient age and WM lesion count (not considering rim lesions), intracortical lesion volume] carried most of the prediction power. Interestingly, an almost opposite pattern emerged when contrasting cortical with WM lesion load: WM lesion load is most important when it is small, whereas cortical lesion load behaves in the opposite way.Clinical Relevance- Our results suggest that disconnection and axonal degeneration due to WM lesions and local cortical demyelination are the main factors determining cortical thinning. These findings further elucidate the complexity of MS pathology across the whole brain and the need for both statistical and mechanistic approaches to understanding the etiopathogenesis of lesions.

Medically assisted suicide in Italy: the recent judgment of the Constitutional Court

Abstract

Medically assisted suicide is considered among the most contro-versial of the current bioethical debate in our Country. In the Italian legal system, we are lacking specific discipline of this practice, as it is covered by the general legal forms applicable to crimes against life. The Constitutional Court, with Decision No. 242/2019, declared the illegitimacy of Art. 580 of the Criminal Code (instigation to suicide), in the part not excluding the punishment of those who facilitates the execution of the intention to commit suicide, independently and freely formed, by a person kept alive by life support and suffering an irreversible disease, source of physical or psychological suffering that the person deems intolerable, but who is fully capable of making free and conscious decisions. The Constitutional Court found that the current regulatory fra-mework concerning the end of life leaves certain situations constitutio-nally worthy of protection and to be balanced with other constitutionally relevant assets without adequate protection. The Court has identified the conditions that can justify third-party assistance in ending the life of a sick person. The judges envisaged the possibility of including this discipline under Law No. 219/2017, but this hypothesis is not shared by the Italian National Bioethics Committee.

Adherence to the three Italian screening in a sample of women (and men) in the Southern Italy

INTRODUCTION

Although scientific evidence shows the numerous benefits of screening programs, in Italy. There is a great disparity between the regional coverage of the North and South despite the screening programs have been activated for several years in all regions even with territorial differences.

OBJECTIVE

The aim of our study was to evaluate the knowledge and adherence to different screenings in the population, the influence exercised by the local health authority the role of the general practitioner in advising and referring patients to screening tests and the main causes of refuse.

MATERIAL AND METHODS

The study was carried out, from December 2019 to May 2020, through the administration of anonymous self-filled "ad hoc" questionnaires to women and men over 26 years old.

RESULTS

in our sample 36% have never performed a breast check and 39% of the interviewees never had a mammogram; for cervical cancer 25% did not ever perform screening and 65% did not have an indication by GP. The worst result was found for colorectal cancer (only 27% of the sample performed the screening). The role of GP was fundamental for and similar to other studies, was fundamental in fact,similar to other studies the most frequent reported reasons for the non-execution of screening were the lack of physicians' advice, follwed by lack of time, the most frequent reported reasons for the non-execution of screening were the lack of physicians' advice, a lack of time, fear of cancer and embarrassment at visiting a gynaecologist.

DISCUSSION AND CONCLUSIONS

the study carried out found that despite the knowledge of the oncological disease and the possibilities of prevention is fairly rooted in the population, adherence to the screening is quite inadequate, especially as regards colorectal cancer.

Impact of the environment on the health: From theory to practice

The Erice 56 Charter titled "Impact of the environment on the health: from theory to practice" was unanimously approved at the end of the 56th course of the "International School of Epidemiology and Preventive Medicine G. D'Alessandro" held from 3rd to November 7, 2019 in Erice - Sicily (Italy) and promoted by the Study Group of "Environment and Health" of the Italian Society of Hygiene, Preventive Medicine and Public Health. The course, that included lectures, open discussions and guided working groups, was aimed to provide a general training on epidemiological and toxicological aspects of the environmental health impact, to be used by public health professionals for risk assessment, without forgetting the risk communications. At the end of the course 12 key points were agreed among teachers and students: they underlined the need of specific training and research, in the perspective of "One Health" and "Global Health", also facing emerging scientific and methodological issues and focusing on communication towards stakeholders. This Discussion highlight the need to improve knowledge of Health and Environment topic in all sectors of health and environmental prevention and management.

The role of angiogenetic single-nucleotide polymorphisms in thymic malignancies and thymic benign lesions

Background

We previously showed that selected single-nucleotide-polymorphisms (SNPs) of genes involved in angiogenesis influence the aggressiveness of thymic epithelial tumors (TETs). This study analyzes their role in TETs and in thymic benign lesions, in order to investigate potential correlation with risk and outcome.

Methods

Genomic DNA was extracted from paraffin-embedded tissue of 92 patients, undergoing surgery at our Institution. We investigated by Real-Time PCR the SNPs of the following genes: platelet-derived growth factor receptor-α (PDGFRα), hypoxia-inducible factor-1α (HIF-1α), vascular endothelial growth factor A (VEGF-A), vascular endothelial growth factor receptor-2 and 3 (VEGF-2, VEGFR-3), excision repair cross-complementation group-1 (ERCC1).

Results

Fifty-seven TETs and 35 thymic benign lesions were included into the study. Frequency of SNPs was as follows: rs2057482 C, rs11158358 C and rs11549465 C polymorphisms of HIF1-a: thymomas < general population (P=0.008, P=0.007, and P=0.044 respectively). HIF1-a alleles: general population > study groups, rs1951795C SNP (P=0.026 for benign lesions and P=0.0007 for thymomas), rs10873142T SNP (P=0.008 and P=0.001 respectively), rs12434438 A SNP (P=0.034 and P=0.0007) and rs2301113A SNP (P=0.027 and P=0.010). rs699947C polymorphism of VEGF-A: benign lesions > general population (P=0.012).

Conclusions

This is the first study investigating the angiogenetic polymorphisms in thymic benign lesions and TETs. SNPs analysis may represent a further asset in identification of patients who could benefit from anti-angiogenetic therapy.

Incidence of major bleeding events and outcome of patients of 80 and 90 years or older with ongoing anticoagulants: five-year survey in northwest Tuscany

Objective

To search for rates of major bleeding events in patients (pts) with age ≥80 or ≥90 years (y.) with ongoing anticoagulants referred to hospital.

Methods

Patients complaining any bleeding events were submitted to propensity score matching for major bleeding and stratified according to age ≥80 or ≥90 y. and warfarin or direct oral anticoagulants (DOACs).

Setting

A General Hospital, northwest Tuscany, five-year survey, 385,650 visits; catchment area 197,722 inhabitants, of whom 18,373 on warfarin and 14,808 on DOACs. Out of DOACs, dabigatran and rivaroxaban were available in the catchment area since 5 y., apixaban 4 y. and edoxaban 3 y; 5,553 pts received rivaroxaban, 4,602 dabigatran, 3,147 apixaban and 1,506 edoxaban.

Endpoint

Primary endpoint was one-week death, and incidence of major bleeding.

Results

Out of 7,474 pts considered, 2504 (33.5%) pts were older than 80 y., of whom 518 (6.8%) were older than 90 y; they were enrolled in the study. Overall, 253 (10.1%) showed history of stroke/TIA, 578 (22.9%) atrial fibrillation, 277 (11.1%) cancer, 177 (7.0%) congestive heart failure, 33 (1.3%) pulmonary thromboembolism.

Of these 7,474 pts 1,040 (41.5%) showed major bleeding: 621 (24.8%) were gastrointestinal of which 258 (10.3%) of the upper tract and 363 (14.5%) of the lower tract; 794 (31.7%) were brain haemorrhage; the remaining patients showed other bleeding.

Overall, 435 (5.8%) pts needed reversal anticoagulation, 325 (4.4%) red blood cell pack, and 2879 (38.5%) admission. Eventually, 127 pts have been readmitted to the hospital for ischemic stroke and 499 for new bleeding event. CHA2D2VASc-score was 2.5±1.5 and Charlston Comorbidity Index was 3.4±2.3.

Out of 2,504 patients older than 80 y., 367 (14,7%) received anticoagulants (including heparin) of which 134 (5.4%) received warfarin versus 63 (2.5%) DOACs (p&lt;0.001); 24 dabigatran, 19 rivaroxaban, 17 apixaban, and 3 edoxaban. Overall 88 (3.5%) needed reversal anticoagulation, 128 pts (5.1%) red blood cell pack, and 825 (32.9%) pts admission.

One-week mortality rate as follows: anticoagulants 35 (1.4%) versus DOACs 6 (0.2%), p&lt;0.001; dabigatran 0, rivaroxaban 2, apixaban 2, edoxaban 2.

Out of 518 patients older than 90 y., 98 (18.9%) received anticoagulants (including heparin) of whom 44 (8.5%) received warfarin; 11 (2.1%) DOACs (p&lt;0.001); 4 dabigatran, 2 rivaroxaban, 4 apixaban, and 1 edoxaban. Overall 24 (4.6%) needed reversal anticoagulation, 50 (9.7%) red blood cell pack, and 203 (39.2%) admission.

One-week mortality rate as follows: anticoagulants 10 (1.9%) versus DOACs 1 (0.2%), p&lt;0.001; dabigatran 0, rivaroxaban 0, apixaban 1 (0.2%), edoxaban 0.

Conclusion

Patients of 80 y. and even 90 y. or older, with ongoing warfarin, showed higher percentage of major bleeding events and mortality rate versus DOACs. Within DOACs, edoxaban was more likely to show lower rate of major bleeding events, without differences in death rate.

Funding Acknowledgement

Type of funding source: None

Systemic Treatment for Metastatic Hormone Sensitive Prostate Cancer: A Comprehensive Meta-Analysis Evaluating Efficacy and Safety in Specific Sub-Groups of Patients

BACKGROUND AND OBJECTIVES

Several systemic treatments are available for metastatic hormone sensitive prostate cancer (mHSPC) including docetaxel (D), abiraterone and prednisone (A + P) and new anti-androgens (NA). In our study we performed a systematic review and meta-analysis assessing efficacy outcomes (survival and radiological-free survival), safety and survival on specific subgroups of patients.

METHODS

Outcomes of interest were: (i) Risk of death, biochemical and radiological progression among all patients. (ii) Risk of death according to different pathological/clinical features. (iii) Evaluation of the relative risk (RR) and risk difference of serious toxicity defined as adverse events (AEs) with grade ≥ 3 specific AEs. Hazard ratios (HRs) and RR were measures adopted for endpoints 1-3.

RESULTS

Overall, eight randomized trials were included in meta-analysis for a total of 9987 patients. Administration of D, A + P and NA resulted in improved overall survival (OS) and radiological progression-free survival (rPFS). Survival benefit was not confirmed in patients receiving NA and previously exposed to docetaxel (HR 0.948, 95% CI 0.671-1.338). Patients with visceral metastases and high lactate dehydrogenase (LDH) did not benefit from NA treatment, while it seems that patients with low Gleason score do not benefit from A + P. NA showed the more favorable safety profile.

CONCLUSION

NA may not provide survival benefit when adopted subsequently or in concomitant to D. Specific subgroups of patients may benefit more from A + P, D or NA. Safety profiles significantly differ among agents evaluated.

Dermatologists and SARS-CoV-2: the impact of the pandemic on daily practice

Since the first case of 'pneumonia of unknown aetiology' was diagnosed at the Wuhan Jinyintan Hospital in China on 30 December 2019, what was recognized thereafter as 'severe acute respiratory syndrome coronavirus 2' (SARS-CoV-2) has spread over the four continents, causing the respiratory manifestations of coronavirus disease-19 (COVID-19) and satisfying the epidemiological criteria for a label of 'pandemic'. The ongoing SARS-CoV-2 pandemic is having a huge impact on dermatological practice including the marked reduction of face-to-face consultations in favour of teledermatology, the uncertainties concerning the outcome of COVID-19 infection in patients with common inflammatory disorders such as psoriasis or atopic dermatitis receiving immunosuppressive/immunomodulating systemic therapies; the direct involvement of dermatologists in COVID-19 care for patient assistance and new research needs to be addressed. It is not known yet if skin lesions and derangement of the skin barrier could make it easier for SARS-CoV-2 to transmit via indirect contact; it remains to be defined if specific mucosal or skin lesions are associated with SARS-CoV-2 infection, although some unpublished observations indicate the occurrence of a transient varicelliform exanthema during the early phase of the infection. SARS-CoV-2 is a new pathogen for humans that is highly contagious, can spread quickly, and is capable of causing enormous health, economic and societal impacts in any setting. The consequences may continue long after the pandemic resolves, and new management modalities for dermatology may originate from the COVID-19 disaster. Learning from experience may help to cope with future major societal changes.

COVID-19 and dermatology: a comprehensive guide for dermatologists

Linked articles: COVID‐19 SPECIAL FORUM. J Eur Acad Dermatol Venereol 2020; 34: e291–e310.

Association between increased plasma ceramides and chronic kidney disease in patients with and without ischemic heart disease

AIM

Plasma levels of certain ceramides are increased in patients with ischemic heart disease (IHD). Many risk factors for IHD are also risk factors for chronic kidney disease (CKD), but it is currently uncertain whether plasma ceramide levels are increased in patients with CKD.

METHODS

We measured six previously identified high-risk plasma ceramide concentrations [Cer(d18:1/16:0), Cer(d18:1/18:0), Cer(d18:1/20:0), Cer(d18:1/22:0), Cer(d18:1/24:0) and Cer(d18:1/24:1)] in 415 middle-aged individuals who attended our clinical Cardiology and Diabetes services over a period of 9 months.

RESULTS

A total of 97 patients had CKD (defined as e-GFR_CKD-EPI<60ml/min/1.73m² and/or urinary albumin-to-creatinine ratio≥30mg/g), 117 had established IHD and 242 had type 2 diabetes. Patients with CKD had significantly (P=0.005 or less) higher levels of plasma Cer(d18:1/16:0), Cer(d18:1/18:0), Cer(d18:1/20:0), Cer(d18:1/22:0), Cer(d18:1/24:0), and Cer(d18:1/24:1) compared to those without CKD. The presence of CKD remained significantly associated with higher levels of plasma ceramides (standardized beta coefficients ranging from 0.124 to 0.227, P<0.001) even after adjustment for body mass index, smoking, hypertension, diabetes, prior IHD, plasma LDL-cholesterol, hs-C-reactive protein levels and use of any lipid-lowering medications. Notably, more advanced stages of CKD and abnormal albuminuria were both associated (independently of each other) with increased levels of plasma ceramides. These results were consistent in all subgroups considered, including patients with and without established IHD or those with and without diabetes.

CONCLUSION

Increased levels of plasma ceramides are associated with CKD independently of pre-existing IHD, diabetes and other established cardiovascular risk factors.

[Giant parathyroid adenoma: a rare cause of severe hypercalcemia]

We report the case of a 37-year-old woman that developed severe hypercalcemia due to a parathyroid gland mass. After the initial medical treatment, only a minimal reduction of calcemia was observed and her clinical condition worsened; thus, she required continuous renal replacement therapy (CRRT) that resulted in the normalization of calcium serum level. She then underwent a left thyroid lobectomy with exeresis of the associated parathyroid glands; the histological diagnosis revealed a giant parathyroid adenoma (GPA). CRRT, initially recommended only in case of severe refractory hypercalcemia poorly responsive to pharmacological approaches, is now being evaluated in the first line treatment of life-threatening cases, with or without associated acute kidney injury (AKI).

Gender Differences and Outcomes in Melanoma Patients

INTRODUCTION

Melanoma is one of the most common cancers in younger people. The incidence of cutaneous melanoma is increasing in patients of both sexes, with female patients generally living longer than their male counterparts. The aim of this retrospective study was to evaluate and confirm the sex-based difference in survival of melanoma patients and the relationship of this difference with pathological features.

METHODS

A total of 1023 patients who had been treated at the Department of Medical Oncology, Università Politecnica Marche (Ancona, Italy) and the INRCA-IRCCS Department of Dermatology (Ancona, Italy) between 1987 and 2014 were enrolled in the study.

RESULTS

In terms of stage of disease at onset, there was a significant difference in disease-free survival (DFS) and overall survival (OS) in favor of female patients in disease stage I (P  = 0.001 and P  = 0.01, respectively) and II (P  = 0.02 and P  = 0.009, respectively). Female patients also showed a significant improvement in 12-year DFS and 12-year OS adjusted for pathological features (Breslow thickness, ulceration, "absent" tumor-infiltrating lymphocyte (TIL) melanomas, "non-brisk" TIL pattern). Globally, female patients had an advantage over with male patients in both DFS and OS (P  < 0.001).

CONCLUSIONS

Our results show that women have a survival benefit over with men after adjustment for many variables that can reduce mortality risk in female melanoma patients. In a future investigation we wish to examine possible biological sex differences in tumor-host interactions.

Reduced betweenness centrality of a sensory-motor vestibular network in subclinical agoraphobia

Agoraphobic patients feel dizzy in crowded open spaces and respond to this symptom with excessive fear and avoidance. These clinical features show great similitude with the newly defined syndrome of persistent postural perceptual dizziness (PPPD). Patients with PPPD show decreased activity and connectivity in regions of the vestibular cortex. Due to the great overlap between these two conditions, we hypothesized that individuals with sub-clinical agoraphobia would show reduction in the connectivity features of these regions. We selected a group of healthy individuals from the Human Connectome Project that self-reported agoraphobia episodes, and compared it with a control group. We accurately matched the two groups for psychological measures and personality traits in order to study the neural correlates of vestibular symptoms independently of possible psychiatric vulnerabilities. We found that the agoraphobia group showed reduced betweenness centrality of a network encompassing key regions of the vestibular cortex. Dysfunctions of the vestibular cortex may explain the dizziness symptom for a disorder previously labelled as psychogenic.

Real-World Data on Cabozantinib in Previously Treated Patients with Metastatic Renal Cell Carcinoma: Focus on Sequences and Prognostic Factors

Cabozantinib is approved for the treatment of renal cell carcinoma (RCC). However, prognostic factors are still lacking in this context. The aim of this study was to evaluate prognostic factors in RCC patients treated with second- or third-line cabozantinib. A multicenter retrospective real-world study was conducted, involving 32 worldwide centers. A total of 237 patients with histologically confirmed clear-cell and non-clear-cell RCC who received cabozantinib as second- or third-line therapy for metastatic disease were included. We analyzed overall survival (OS), progression-free survival (PFS) and time-to-strategy failure (TTSF) using Kaplan–Meier curves. Cox proportional models were used at univariate and multivariate analyses.The median PFS and OS of cabozantinib were 7.76 months (95% CI 6.51–10.88) and 11.57 months (95% CI 10.90–not reached (NR)) as second-line and 11.38 months (95% CI 5.79–NR) and NR (95% CI 11.51–NR) as third-line therapy. The median TTSF and OS were 11.57 and 15.52 months with the sequence of cabozantinib–nivolumab and 25.64 months and NR with nivolumab–cabozantinib, respectively. The difference between these two sequences was statistically significant only in good-risk patients. In the second-line setting, hemoglobin (Hb) levels (HR= 2.39; 95% CI 1.24–4.60, p = 0.009) and IMDC (International Metastatic Renal Cell Carcinoma Database Consortium) group (HR = 1.72, 95% CI 1.04–2.87, p = 0.037) were associated with PFS while ECOG-PS (HR = 2.33; 95%CI, 1.16–4.69, p = 0.018) and Hb levels (HR = 3.12; 95%CI 1.18–8.26, p = 0.023) correlated with OS at multivariate analysis, while in the third-line setting, only Hb levels (HR = 2.72; 95%CI 1.04–7.09, p = 0.042) were associated with OS. Results are limited by the retrospective nature of the study.This real-world study provides evidence on the presence of prognostic factors in RCC patients receiving cabozantinib.

Targeted therapy for solid tumors and risk of hypertension: a meta-analysis of 68077 patients from 93 phase III studies

Objective: Hypertension is a common adverse event with targeted agents in cancer patients and can lead to serious and sometimes lethal cardiovascular complications. The authors performed a meta-analysis of clinical trials aiming to evaluate the incidence and Relative Risk (RR) of developing all-grade and high-grade Hypertension Events (HE) in patients with solid tumors receiving targeted therapy.Methods: A review of citations from PubMed was performed and studies were selected based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The search was limited to randomized phase III trials published in English focused on the efficacy and safety of targeted agents in cancer patients, reporting data on HE. Incidence, RR and relative 95% CIs were analyzed using random or fixed-effects models. Overall incidences were calculated and further compared with the chi-squared test for proportions.Results: Ninety-three phase III trials were included, with a total of 68,077 patients. Prostate cancer was the most represented (18.9%), followed by breast cancer (17.3%) and colorectal cancer (16.4%). The incidence of all- and high-grade HE was 23.47% and 8.57%, respectively, with the highest incidence of serious HE reported by adjuvant Sunitib/Sorafenib (29.03%). The highest RR of high-grade HE was observed with Bevacizumab in patients with advanced cervical cancer. By drug category, the highest RR of high-grade HE was reported by VEGFR/EGFR TKIs.Conclusion: According to these data, monitoring this class of toxicities is of primary importance to avoid hypertension worsening and, thus, the risk of major cardiovascular events.

P657Anticoagulation strategies based on warfarin or direct oral anticoagulants compared to major hemorrhagic events: the relevance of patients aged 75 years or older

Objective

To evaluate rates of major bleeding (mBleed) associated with anticoagulant treatments in patients (pts) with age ≥75 years (y), referred to hospital in northwest Tuscany.

Methods

We analysed 4-y survey; 302,687 visits; catchment area 197,722 inhabitants, of whom 15,267 on Warfarin (W) and 10,397 on direct oral anticoagulants (DOACs). DOACs were available in the catchment area since 4 y (dabigatran and rivaroxaban), 3 y (apixaban), and 2 y (edoxaban). Overall, 3,373 pts received dabigatran, 4,046 rivaroxaban, 2,141 apixaban, and 839 edoxaban. Pts with hemorrhage were submitted to propensity score matching for mBleed and stratified according to age ≥75 y, and W or DOACs. Primary endpoint was one-month death in pts with age ≥75 y.

Results

Out of 1,919 mBleed enrolled, those of pts aged ≥75 y were 1,127 (59%) versus (vs) 792 (41%) aged <75 y, with 77 (4.0%) one-month death vs 20 (1.0%), respectively; p<0.0001.

Patients on W showed higher rate of mBleed (n=175; 9.1%) compared to DOACs (n=53; 2.8%); p<0.0001. One-month death accounted for 14 (0.7%) vs 1 (0.1%), respectively; p=0.0019. Pts aged ≥75 years were more likely to show female gender and comorbidities including atrial fibrillation; p<0.01. Among DOACs, edoxaban presented the lowest absolute rate of hospital admission for mBleed and dabigatran the highest, although without statistical differences within DOACs (p=0.6454). Interestingly, in the subset of pts aged ≥75 y, within DOACs, we found no statistical difference in one-month mortality, although edoxaban showed one death due to brain mBleed; conversely, we found statistical significance in rate of mBleed. Indeed, edoxaban vs dabigatran showed p=0.0008, edoxaban vs apixaban p=0.0242, edoxaban vs rivaroxaban p=0.0058, apixaban vs rivaroxaban p=0.7093, apixaban vs dabigatran p=0.2279, rivaroxaban vs dabigatran p=0.5087.

Warfarin or DOACs and outcomes Major Bleeding (pts ≥75 y) p value versus pts <75 y p value within group One-month death (pts ≥75 y) p value versus pts <75 y p value within group n=1,127 n=77 Warfarin 175 (9.1%) 0.0001 <0.0001 14 (1.2%) 0.514 0.0019 DOACS 53 (2.8%) 0.0001 1 (0.1%) 0.256 Dabigatran 21 (1.1%) 0.026 0.0088 0 (0%) 0.391 0.8012 Rivaroxaban 16 (0.8%) 0.121 0 (0%) 0.619 Apixaban 13 (0.7%) 0.033 0 (0%) 1 Edoxaban 3 (0.2%) 0.647 1 (0.1%) 0.191 Patients: pts; direct oral anticoagulants: DOACs; p value Yates' correction: p value.

Patients with age >75 years and bleeding

Conclusion

In pts with age ≥75 y, rate of mBleed and short-term mortality were significantly higher than in pts aged <75 y In those pts, DOACs showed significantly lower rate of mBleed, and short-term death. Within DOACs, edoxaban was more likely to show lower rate of mBleed.

P4636Major gastrointestinal haemorrhage of patients with ongoing anticoagulants presented to the emergency department of a community hospital: four-year survey

Objective

To look for outcomes of patients (pts) with major gastrointestinal haemorrhage (mGIH) and ongoing anticoagulants out of four-year survey of community hospital with catchment area 197,722 inhabitants, of whom 15,267 with Warfarin (W) and 10,397 with direct oral anticoagulants (DOACs). DOACs were available for prescription in the catchment area since 4 years (dabigatran and rivaroxaban), 3 years (apixaban), and 2 years (edoxaban).

Methods

Haemorrhage (n=1,919) were submitted to propensity score matching for major bleeding; mGIH were enrolled and stratified according to ongoing W or DOACs. Primary endpoint was one-month death.

Results

Out of 476 mGIH, 73 pts received anticoagulants; 22 DOACs and 51 W; p=0.0006. Of note mGIH on W accounted for 2.7% (51/1,919) per year of pts, and 0.08% (51/15,267) of the catchment area. Conversely, mGIH on DOACs accounted as follows: dabigatran (n=10/476) 0.53%, rivaroxaban (n=6/476) 0.32%, apixaban (n=5/476) 0.35%, and edoxaban (n=1/476) 0.11% per year of pts; p=0.117. Rate of mGIH and DOACs versus (vs) rate of mGIH and W as follows: less than (−) 5 fold (2.7x100/0.53) of dabigatran vs W, p=0.004; −8 fold (2.7x100/0.32) of rivaroxaban vs W, p=0.0002; −7 fold (2.7x100/0.35) of apixaban vs W; p=0.ehz745.10188, and −25 fold (2.7x100/0.11) of edoxaban vs W; p=0.ehz745.101801. However no difference versus the catchment area per year (0.723): 0.07% (10/3,373) dabigatran, 0.04% (6/4,046) rivaroxaban, 0.08% (5/2,141) apixaban, 0.06% (1/839) edoxaban.

Overall, one-month death accounted for 10/476 (2.1%). Of note 236 mGI were from the upper tract and 240 from the lower tract. Among upper tract, 10 pts received DOACs (4 dabigatran, 4 rivaroxaban, 2 apixaban, and 0 edoxaban) and 21 received W. One-month death was 0/10 DOACs versus 1/21 W, p=0.483. Among lower tract, 12 pts received DOACs (6 dabigatran, 2 rivaroxaban, 3 apixaban, and 1 edoxaban) and 30 pts received W; one-month death was 0 for every groop. Anticoagulant reversal treatment was given to 6/22 (27%) pts with DOACs versus 18/51 (35%) with W, p=0.014; transfusion to 6/22 (27%) versus 11/51 (22%), respectively, p=0.306; admission 19/22 (86%) versus 42/51 (82%), respectively, p=0.004. Sensitivity/specificity ratio of variables and biomarkers for aggressive pharmacological approach were obtained by area under ROC curve (AUC) >0.50. PTT value >37 sec (AUC 0.57) showed sensitivity 15%, specificity 90%; INR value >1.4 (0.50), sens 15%, spec 80%. In addition, warfarin (0.49) sens 15%, spec 80%; age ≥75 years (0.48) sen 60%, spec 40%.

Gastrointestinal bleeding: flow-chart.

Conclusion

Out of four-year survey, pts with ongoing DOACs were less likely to have mGIH when compared to W.

Patients with W were more likely to receive reversal tratment; pts with DOACs were more likely to undergo admission. Short-term mortality of pts with W was higher than DOACs. Aggressive pharmacological approach should be driven by PTT, INR, ongoing warfarin, and older age.

EARLY FETAL HYDROPIC CHANGES ARE ASSOCIATED WITH MODERATE DILATATION OF THE BRAIN VENTRICULAR SYSTEM: A CLUE TO A POSSIBLE LINK BETWEEN CERVICAL LYMPHATIC ENGORGEMENT AND VENTRICULAR DILATATION?

The aim of this study is to assess whether early cervical lymphatic obstruction is associated with a sonographically detectable dilatation of the ventricular system in the 1st trimester of pregnancy. In particular, the objective is to assess whether fetuses with non-immune hydrops fetalis (NIHF), cystic hygroma, or enlarged nuchal translucency (NT) have a greater atrial width/biparietal diameter (AW/BPD) ratio than normal at time of the combined first trimester screening scan. This retrospective study included 96 first trimester fetuses (33 normal and 63 with various degree of cervical lymphatic engorgement). Inclusion criteria were CRL in the 45-84 mm range and availability of one or more three-dimensional volume datasets of the fetal head, acquired from the BPD plane. Each three-dimensional volume dataset was opened and multiplanar correlation employed to align the three orthogonal planes. The ratio between the atrial width and the BPD (AW/BPD ratio) was used to evaluate the possible presence of increased amount of cerebrospinal fluid. Abnormal cases were placed into 4 categories: 1)enlarged non-septated NT 2.5-3.9 mm, no hydrops; 2) grossly enlarged non-septated NT/ edema &gt;3.9 mm; 3) cystic hygroma and/or NIHF; 4) major anomalies with NT &lt;2.5 mm. Presence of dilatation of the latero-cervical jugular lymphatic sacs, karyotype and presence of congenital anomalies were also recorded. The One-way ANOVA test was used to compare means. Intra- and inter-observer variability were also assessed. The AW/BPD ratio was found to be significantly higher in fetuses with grossly enlarged NT/nuchal edema and NIHF/septated cystic hygroma than in normal (p &lt;0.05 and p &lt;0.01, respectively). Also, the AW/BPD ratio was significantly higher in NIHF/septated cystic hygroma than in enlarged NT 2.5-3.9 mm (p &lt;0.05). In case of enlarged NT (2.5-3.9 mm), the AW/BPD ratio is significantly higher in presence of JLS (p &lt;0.01). At the end of the first trimester, presence of cervical lymphatic engorgement, in terms of grossly enlarged NT, nuchaledema, septated cystic hygroma, and NIHF, is statistically associated with a moderate dilatation of the ventricular system. Of note, among fetuses with moderately enlarged NT, those with evidence of dilatation of the JLS show a statistically significant increase in the AW/BPD ratio.

Comparison of Propofol Consumption and Recovery Time in Caucasians from Italy, with Chinese, Malays and Indians from Malaysia

Differences in sensitivity to anaesthetic drugs may exist among different ethnic groups. Allelic variants for drug metabolizing isoenzymes and pharmacokinetic differences may account for a variable response to some anaesthetic drugs. This study was designed to compare propofol consumption and recovery characteristics in four ethnic groups: Chinese, Malays, and Indians in Malaysia and Caucasians in Italy.

Patients undergoing total intravenous anaesthesia with propofol and fentanyl were evaluated for propofol consumption and recovery time. The Bispectral Index (BIS) was used to maintain the same anaesthesia depth in all patients. The BIS value, the response to verbal stimuli and eye-opening time were used to assess recovery. After propofol discontinuation the BIS values returned to baseline in 11±4.2 min for Caucasians, in 12.5±5.1 min for Chinese, 15.9±6.3 min for Malays and 22.1±8.1 for Indians. Time to eye-opening was 11.63±4.2 min in Caucasians, 13.23±4.9 min in Chinese, 16.97±5.2 min in Malays and 22.3±6.6 min in Indians. The propofol consumption was significantly lower in Indians compared to the other three groups (P<0.01).

The recovery of Indians was much slower compared to Chinese, Malays and Caucasians. The recovery time of Malays is significantly slower compared to Chinese and Caucasians. Differences in propofol consumption and recovery time were not significant between Chinese and Caucasians, but the ratio recovery time/propofol consumption was significantly lower in Caucasians compared to all the other groups.

Cervical margin relocation: case series and new classification system

PURPOSE

The present clinical study aimed to investigate the safety and feasibility of cervical marginal relocation (CMR) procedures in cases of deep caries involving supracrestal tissue attachment (STA).

MATERIALS AND METHODS

Fifteen patients were selected from those attending the Studio Ghezzi Dental Clinic, Settimo Milanese, Milan, Italy. After following an oral hygiene program with specific counseling sessions, the selected patients were included in a periodic supportive periodontal therapy program. Depending on the treatment they received, the patients were divided into three groups according to a new classification system: a) Class 1: Nonsurgical CMR; b) Class 2a: Surgical CMR (gingival approach); c) Class 2b: Surgical CMR (osseous approach). The primary and secondary outcomes were pocket depth (PD) on probing and residual bleeding on probing (BOP) after 1 year.

RESULTS

No differences were found among the three CMR approaches for PD (overall mean value after 1 year: 2.5 ± 0.64 mm; overall mean value after 5.7 years: 2.3 ± 0.49 mm) or residual BOP (40% of the cases after 1 year).

CONCLUSION

Based on the study results, the authors can conclude that CMR procedures do not negatively affect the periodontal health status of patients when the connective compartment of the STA is not violated.

Early fetal hydropic changes are associated with moderate dilatation of the brain ventricular system: A clue to a possible link between cervical lymphatic engorgement and ventricular dilatation?

The aim of this study is to assess whether early cervical lymphatic obstruction is associated with a sonographically detectable dilatation of the ventricular system in the 1st trimester of pregnancy. In particular, the objective is to assess whether fetuses with non-immune hydrops fetalis (NIHF), cystic hygroma, or enlarged nuchal translucency (NT) have a greater atrial width/biparietal diameter (AW/BPD) ratio than normal at time of the combined first trimester screening scan. This retrospective study included 96 first trimester fetuses (33 normal and 63 with various degree of cervical lymphatic engorgement). Inclusion criteria were CRL in the 45-84 mm range and availability of one or more three-dimensional volume datasets of the fetal head, acquired from the BPD plane. Each three-dimensional volume dataset was opened and multiplanar correlation employed to align the three orthogonal planes. The ratio between the atrial width and the BPD (AW/BPD ratio) was used to evaluate the possible presence of increased amount of cerebrospinal fluid. Abnormal cases were placed into 4 categories: 1) enlarged non-septated NT 2.5-3.9 mm, no hydrops; 2) grossly enlarged non-septated NT / edema >3.9 mm; 3) cystic hygroma and/ or NIHF; 4) major anomalies with NT <2.5 mm. Presence of dilatation of the laterocervical jugular lymphatic sacs, karyotype and presence of congenital anomalies were also recorded. The One-way ANOVA test was used to compare means. Intra- and inter-observer variability were also assessed. The AW/BPD ratio was found to be significantly higher in fetuses with grossly enlarged NT/nuchal edema and NIHF/septated cystic hygroma than in normal (p <0.05 and p <0.01, respectively). Also, the AW/BPD ratio was significantly higher in NIHF/septated cystic hygroma than in enlarged NT 2.5-3.9 mm (p <0.05). In case of enlarged NT (2.5-3.9 mm), the AW/BPD ratio is significantly higher in presence of JLS (p <0.01). At the end of the first trimester, presence of cervical lymphatic engorgement, in terms of grossly enlarged NT, nuchal edema, septated cystic hygroma, and NIHF, is statistically associated with a moderate dilatation of the ventricular system. Of note, among fetuses with moderately enlarged NT, those with evidence of dilatation of the JLS show a statistically significant increase in the AW/BPD ratio.

Risk of fatigue in cancer patients treated with anti programmed cell death-1/anti programmed cell death ligand-1 agents: a systematic review and meta-analysis

AIM

We aimed to assess the incidence and relative risk (RR) of fatigue in cancer patients treated with anti programmed cell death-1 (PD-1) and anti programmed cell death ligand-1 (PD-L1) agents.

PATIENTS & METHODS

Eligible studies were selected according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Incidence, RR and 95% CIs were calculated using random or fixed-effects models.

RESULTS

Thirty-eight studies were included in this analysis, with a total of 11,719 patients. The incidences were 23.4 and 2.1% for all- and high-grade fatigue, respectively. The highest incidence of high-grade fatigue was reported by the combination of nivolumab and ipilimumab. Overall RR of high-grade fatigue with anti-PD-1/PD-L1 compared with chemotherapy or targeted therapy was 0.48.

CONCLUSION

Treatment with anti-PD-1/PD-L1 agents correlates with lower incidence and RR of fatigue compared with standard therapies.

Emerging Biomarkers in Bladder Cancer Identified by Network Analysis of Transcriptomic Data

Bladder cancer is a very common malignancy. Although new treatment strategies have been developed, the identification of new therapeutic targets and reliable diagnostic/prognostic biomarkers for bladder cancer remains a priority. Generally, they are found among differentially expressed genes between patients and healthy subjects or among patients with different tumor stages. However, the classical approach includes processing these data taking into consideration only the expression of each single gene regardless of the expression of other genes. These complex gene interaction networks can be revealed by a recently developed systems biology approach called Weighted Gene Co-expression Network Analysis (WGCNA). It takes into account the expression of all genes assessed in an experiment in order to reveal the clusters of co-expressed genes (modules) that, very probably, are also co-regulated. If some genes are co-expressed in controls but not in pathological samples, it can be hypothesized that a regulatory mechanism was altered and that it could be the cause or the effect of the disease. Therefore, genes within these modules could play a role in cancer and thus be considered as potential therapeutic targets or diagnostic/prognostic biomarkers. Here, we have reviewed all the studies where WGCNA has been applied to gene expression data from bladder cancer patients. We have shown the importance of this new approach in identifying candidate biomarkers and therapeutic targets. They include both genes and miRNAs and some of them have already been identified in the literature to have a role in bladder cancer initiation, progression, metastasis, and patient survival.

Autophagic Gene Polymorphisms in Liquid Biopsies and Outcome of Patients with Metastatic Clear Cell Renal Cell Carcinoma

BACKGROUND/AIM

Autophagy has been shown to be involved in cancer development and response to cancer therapy. In this study, genotypes of autophagic genes were analyzed to assess their correlation with the risk of clear cell renal cell carcinoma (ccRCC) and the outcome of patients treated with pazopanib for metastatic ccRCC.

MATERIALS AND METHODS

Single nucleotide polymorphisms (SNPs)were selected in the following genes: ATG4A (rs7880351), ATG4B (rs6709768), ATG4C (rs2886770, rs6670694, rs6683832), ATG5 (rs9373839, rs3804333, rs490010), ATG16L1 (rs6752107), ATG16L2 (rs10751215) and IRGM (rs10059011). The Kaplan-Meier method and log-rank test were used to evaluate differences between groups.

RESULTS

Forty patients with metastatic ccRCC treated with pazopanib were included in the analysis. ATG16L2rs10751215 was significantly less frequent in patients with ccRCC compared to the general population, suggesting its potential protective role, while ATG4Ars7880351, ATG4C rs6670694 and rs6683832 and ATG5 rs490010 were correlated with the progression-free survival (PFS) of patients treated with pazopanib.

CONCLUSION

Our results suggest, for the first time, that autophagic gene SNPs are associated with ccRCC risk and patient outcome.

Immunotherapy in renal cell carcinoma: latest evidence and clinical implications

Advances in understanding the mechanisms of tumour-induced immunosuppression have led to the development of immune-checkpoint inhibitors in cancer patients, including those with renal cell carcinoma (RCC). The optimal combination between immunotherapy and targeted agents (as well as the possible favourable sequential therapy of these two classes of drugs) remains an open question at this moment. Several trials are currently underway to assess the combination of anti-programmed-death 1 (PD-1) or anti-PD-ligand(L)1 agents with other immunotherapies or with anti-vascular endothelial growth factor receptor (VEGFR) tyrosine kinase inhibitors (TKIs). In this editorial, we described the results of the most recent clinical trials on the use of immunotherapies in RCC and the emerging data on the research for reliable biomarkers of tumour response in this setting. In addition, we have focused on the role of the gut microbiome and tumour microenvironment in the development of future therapeutic strategies for RCC patients.