Ruxolitinib Adherence in Myelofibrosis and Polycythemia Vera: the "RAMP" Italian multicenter prospective study

Ruxolitinib is beneficial in patients with myelofibrosis (MF) and polycythemia vera (PV). Information on ruxolitinib adherence is scant. The Ruxolitinib Adherence in Myelofibrosis and Polycythemia Vera (RAMP) prospective multicenter study (NCT06078319) included 189 ruxolitinib-treated patients. Patients completed the Adherence to Refills and Medications Scale (ARMS) and Distress Thermometer and Problem List (DTPL) at the earliest convenience, after registration in the study, and at later timepoints. At week-0, low adherence (ARMS > 14) and high distress (DT ≥ 4) were declared by 49.7% and 40.2% of patients, respectively. The main reason for low adherence was difficult ruxolitinib supply (49%), intentional (4.3%) and unintentional (46.7%) non-take. In multivariable regression analysis, low adherence was associated to male sex (p = 0.001), high distress (p < 0.001), and treatment duration ≥ 1 year (p = 0.03). Over time, rates of low adherence and high distress remained stable, but unintentional non-take decreased from 47.9% to 26.0% at week-48. MF patients with stable high adherence/low distress were more likely to obtain/maintain the spleen response at week-24. Low adherence to ruxolitinib represents an unmet clinical need that require a multifaceted approach, based on reason behind it (patients characteristics and treatment duration). Its recognition may help distinguishing patients who are truly refractory and those in need of therapy optimization.

Treatment discontinuation following low-dose TKIs in 248 chronic myeloid leukemia patients: Updated results from a campus CML real-life study

TKIs long-term treatment in CML may lead to persistent adverse events (AEs) that can promote relevant morbidity and mortality. Consequently, TKIs dose reduction is often used to prevent AEs. However, data on its impact on successful treatment-free remission (TFR) are quite scarce. We conducted a retrospective study on the outcome of CML subjects who discontinued low-dose TKIs from 54 Italian hematology centers participating in the Campus CML network. Overall, 1.785 of 5.108 (35.0%) regularly followed CML patients were treated with low-dose TKIs, more frequently due to relevant comorbidities or AEs (1.288, 72.2%). TFR was attempted in 248 (13.9%) subjects, all but three while in deep molecular response (DMR). After a median follow-up of 24.9 months, 172 (69.4%) patients were still in TFR. TFR outcome was not influenced by gender, Sokal/ELTS risk scores, prior interferon, number and last type of TKI used prior to treatment cessation, DMR degree, reason for dose reduction or median TKIs duration. Conversely, TFR probability was significantly better in the absence of resistance to any prior TKI. In addition, patients with a longer DMR duration before TKI discontinuation (i.e., >6.8 years) and those with an e14a2 BCR::ABL1 transcript type showed a trend towards prolonged TFR. It should also be emphasized that only 30.6% of our cases suffered from molecular relapse, less than reported during full-dose TKI treatment. The use of low-dose TKIs does not appear to affect the likelihood of achieving a DMR and thus trying a treatment withdrawal, but might even promote the TFR rate.

Time course of the upper limb motor recovery in subacute stroke patients undergoing conventional or robotic rehabilitation. A preliminary report

Upper limb recovery is a complex process and a strong challenge in the rehabilitation of patients after stroke. Several studies have been conducted to compare the efficacy of conventional and robotic rehabilitation to restore the upper limb motor impairment following a stroke. However, the evolution of the upper limb motor ability during an intervention, as well as the time point when the patient stops improving (the so call plateau), are rarely measured, and never compared between the two approaches. These latter aspects are very important considering the need for an optimization of the economic resources. In this study, the time course of the upper limb motor recovery of 24 subacute stroke patients undergoing a 30-session robotic or conventional treatment was analyzed through the upper extremity portion of the Fugl-Meyer Assessment scale (FMA-UE). The FMA-UE was administered before the treatment, and after 10, 20, and 30 rehabilitation sessions. Statistical analysis showed that, according to the FMA-UE, the time course in the two groups was similar: patients did not change between the baseline and the 10-session assessment, while they improved between 10 and 20 sessions, and between 20 and 30 sessions, with most of the gain observed between 10 and 20 sessions. This result suggests that 30-session robotic or conventional rehabilitation programs induce a similar curve trend in the upper limb motor recovery of patients with subacute stroke, with an important increase in the middle of the program and without reaching a clear plateau in the analyzed time interval.

Box and block test, hand grip strength and nine-hole peg test: correlations between three upper limb objective measures in multiple sclerosis

BACKGROUND AND PURPOSE

Limited data are available in the literature for upper limb impairment in multiple sclerosis (MS). This study aimed to report the distribution of values of hand grip strength (HGS), of the box and block test (BBT) and of the nine-hole peg test (9HPT) correlated with demographic and clinical data in subjects with MS.

METHODS

This study involved five Italian neurological centres. The inclusion criteria were age ≥ 18, MS diagnosis, stable disease phase, right-hand dominance. All subjects underwent HGS, BBT and 9-HPT evaluation.

RESULTS

In all, 202 subjects with MS were enrolled: 137 females; mean age 48.4 years; mean Expanded Disability Status Scale (EDSS) 4.17; mean disease duration 14.12 years; disease course 129 relapsing-remitting, 21 primary progressive and 52 secondary progressive MS subjects; mean right HGS 25.3 kg, left 23.2 kg; mean right BBT 45.7 blocks, left 44.9 blocks; mean right 9-HPT 30.7 s, left 33.4 s. All results were statistically significantly different compared to healthy controls. HGS, BBT and 9-HPT were associated with age, EDSS and disease duration, whilst disease course correlated with BBT and 9-HPT. The BBT and 9-HPT scores significantly differed according to level of disability (EDSS ≤3.0, 3.5-5.5, ≥6.0).

CONCLUSION

Hand grip strength and BBT value distribution in a large MS population is reported. Correlations between HGS, BBT and 9-HPT were generally low.

Nine Hole Peg Test asymmetry in refining upper limb assessment in multiple sclerosis

BACKGROUND

The Expanded Disability Status Scale (EDSS) is the most frequently used scale to measure neurologic impairment and quantify the level of disability in Multiple Sclerosis (MS) even though the scale focuses on ambulation and undervalues upper limb (UL) impairment. The 9-Hole Peg Test (9-HPT) is the gold standard for UL assessment in MS, calculating a mean score from right and left arms, even though subjects with MS often show a lateralization of neurological deficit.

OBJECTIVE

The study aimed to determine whether an interaction exists between mean right-left 9-HPT scores or 9HPT score asymmetry (difference between right and left side) in predicting EDSS in MS subjects.

METHODS

Demographic and disease variables and 9-HPT scores were obtained from medical records of individuals with MS collected in an ad-hoc database. Subjects with 9-HPT score ≤180 s for each arm were included. An asymmetry score was represented as the absolute value of the difference between 9-HPT scores for both arms.

RESULTS

549 subjects were included: 67.8% female, mean age 45±13.14 years, mean EDSS 3.98±2.12, 356 relapsing-remitting, 68 primary and 125 secondary progressive, mean 9-HPT scores: right arm 30.20 ± 19.99 s, left arm 31.80 ± 20.35 s. Mean asymmetry was 9.35±18.20 s. Correlation between mean right-left 9-HPT scores and EDSS was 0.58 (p<.001). Significant interaction between mean right-left 9-HPT scores and 9-HPT asymmetry in predicting EDSS scores was found. Regression slope of EDSS on mean right-left 9-HPT score decreases as asymmetry value increases (non-significance area values ≥ 40.93 s).

CONCLUSIONS

Findings suggest interaction exists between mean right-left 9-HPT scores and asymmetry in predicting EDSS. A consequence of this is that, by disregarding information about asymmetry, studies exploring the association between mean right-left 9-HPT scores and global measures of disability may provide biased results. The bias tends to increase as asymmetry increases, and to be most prevalent among patients with EDSS scores > 6.

How to design a study to evaluate therapeutic drug monitoring in infectious diseases?

BACKGROUND

Therapeutic drug monitoring (TDM) is a tool to personalize and optimize dosing by measuring the drug concentration and subsequently adjusting the dose to reach a target concentration or exposure. The evidence to support TDM is however often ranked as expert opinion. Limitations in study design and sample size have hampered definitive conclusions of the potential added value of TDM.

OBJECTIVES

We aim to give expert opinion and discuss the main points and limitations of available data from antibiotic TDM trials and emphasize key elements for consideration in design of future clinical studies to quantify the benefits of TDM.

SOURCES

The sources were peer-reviewed publications, guidelines and expert opinions from the field of TDM.

CONTENT

This review focuses on key aspects of antimicrobial TDM study design: describing the rationale for a TDM study, assessing the exposure of a drug, assessing susceptibility of pathogens and selecting appropriate clinical endpoints. Moreover we provide guidance on appropriate study design.

IMPLICATIONS

This is an overview of different aspects relevant for the conduct of a TDM study. We believe that this paper will help researchers and clinicians to design and conduct high-quality TDM studies.

WITHDRAWN: Assessment of the inter-laboratory repeatability of gait analysis measurements in patients with multiple sclerosis

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Retrospective Analysis of 156 Cases of Metastatic Renal Cell Carcinoma: Evaluation of Prognostic Factors and Response to Different Treatments

Background

Metastatic renal cell carcinoma is a “capricious” tumor. Many prognostic factors have been evaluated, treatment is still controversial, and results are not coincident.

Methods

We reviewed 156 patients with metastatic renal cell carcinoma. Survival from the time of diagnosis was the end point of the study. The influence on survival of age, sex, nephrectomy, disease-free interval, performance status, site and number of metastases was analyzed. Univariate and multivariate analysis were done. Survival according to different therapies was also evaluated.

Results

In our study, no nephrectomy, a disease-free interval < 24 months, > 2 metastatic sites and a performance status > 2 proved to be risk factors. According to the number of risk factors, 3 groups of patients were identified (low, intermediate and high risk). We observed 3 kinds of responses to treatments: 1) in untreated patients (n = 48), median overall survival was 6 months, and the 24-month survival rate was 8%; 2) in patients treated with hormone therapy and/or chemotherapy (n = 73), median overall survival was 13 months, and the 24-month survival rate was 24%; 3) in patients treated with interferon and/or interleukin-2 (n = 35), median overall survival was 16 months and the 24-month survival rate was 34%.

Conclusions

Our results are only partially in accordance with those observed by other authors. Risk factors and treatment must be determined in more defined and selected studies.

[Conscience clause in end-of-life care.]

The article proposes a critical reflection on issues that appeal to the conscience clause as part of end of life care can produce and what can guarantee freedom of conscience, self-determination of those involved and respect for the dignity of the sick person. After a philosophical and normative analysis, the article is organized on the basis of two important documents for discussion: a position paper of Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI) signed by several scientific societies "Grandi insufficienze d'organo end stage: cure intensive o cure palliative?" and the Design of Law currently being debated "Norme in materia di consenso informato e di disposizioni anticipate di trattamento". In particular, the conscience clause has been discussed in the light of advance care planning (ACP), which represents the instrument to guarantee the shared planning of care and the shared-decision making. In this context, recourse to the clause of conscience brings out critical ethical and deontological issues that the article discusses, using the position paper SIAARTI and the text of law currently being debated, both built on the assumptions of a shared care relationship, where patient has a key-role in medical decisions.

The predictive value of ABCB1, ABCG2, CYP3A4/5 and CYP2D6 polymorphisms for risperidone and aripiprazole plasma concentrations and the occurrence of adverse drug reactions

We investigated in ninety Caucasian pediatric patients the impact of the main polymorphisms occurring in CYP3A, CYP2D6, ABCB1 and ABCG2 genes on second-generation antipsychotics plasma concentrations, and their association with the occurrence of adverse drug reactions. Patients with the CA/AA ABCG2 genotype had a statistically significant lower risperidone plasma concentration/dose ratio (Ct/ds) (P-value: 0.007) and an higher estimated marginal probability of developing metabolism and nutrition disorders as compared to the ABCG2 c.421 non-CA/AA genotypes (P-value: 0.008). Multivariate analysis revealed that the ABCG2 c.421 CA/AA genotype was found associated to a higher hazard (P-value: 0.004) of developing adverse drug reactions classified as metabolism and nutrition disorders. The ABCB1 2677TT/3435TT genotype had a statistically significant lower aripiprazole Ct/ds if compared with patients with others ABCB1 genotypes (P-value: 0.026). Information obtained on ABCB1 and ABCG2 gene variants may result useful to tailor treatments with these drugs in Caucasian pediatric patients.

Splanchnic vein thrombosis in myeloproliferative neoplasms: risk factors for recurrences in a cohort of 181 patients

We retrospectively studied 181 patients with polycythaemia vera (n=67), essential thrombocythaemia (n=67) or primary myelofibrosis (n=47), who presented a first episode of splanchnic vein thrombosis (SVT). Budd–Chiari syndrome (BCS) and portal vein thrombosis were diagnosed in 31 (17.1%) and 109 (60.3%) patients, respectively; isolated thrombosis of the mesenteric or splenic veins was detected in 18 and 23 cases, respectively. After this index event, the patients were followed for 735 patient years (pt-years) and experienced 31 recurrences corresponding to an incidence rate of 4.2 per 100 pt-years. Factors associated with a significantly higher risk of recurrence were BCS (hazard ratio (HR): 3.03), history of previous thrombosis (HR: 3.62), splenomegaly (HR: 2.66) and leukocytosis (HR: 2.8). Vitamin K-antagonists (VKA) were prescribed in 85% of patients and the recurrence rate was 3.9 per 100 pt-years, whereas in the small fraction (15%) not receiving VKA more recurrences (7.2 per 100 pt-years) were reported. Intracranial and extracranial major bleeding was recorded mainly in patients on VKA and the corresponding rate was 2.0 per 100 pt-years. In conclusion, despite anticoagulation treatment, the recurrence rate after SVT in myeloproliferative neoplasms is high and suggests the exploration of new avenues of secondary prophylaxis with new antithrombotic drugs and JAK-2 inhibitors.

Early Integration of Palliative Care in Oncology Practice: Results of the Italian Association of Medical Oncology (AIOM) Survey

BACKGROUND

Early integration of palliative care in oncology practice ("simultaneous care", SC) has been shown to provide better care resulting in improved quality-of-life and also survival. We evaluated the opinions of Italian Association of Medical Oncology (AIOM) members.

PATIENTS AND METHODS

A 37-item questionnaire was delivered to 1119 AIOM members. Main areas covered were: social, ethical, relational aspects of disease and communication, training, research, organizational and management models in SC. Three open questions explored the definition of Quality of Life, Medical Oncologist and Palliative Care.

RESULTS

Four hundred and forty-nine (40.1%) medical oncologists returned the questionnaires. Forty-nine percent stated they address non-curability when giving a diagnosis of metastatic tumor, and 43% give the information only to patients who clearly ask for it. Fifty-five percent say the main formative activity in palliative medicine came from attending meetings and 90% agree that specific palliative care training should be part of the core curriculum in oncology. Twenty-two percent stated they consulted guidelines for symptom management, 45% relied upon personal experience and 26% make a referral to a palliative care specialist. Seventy-four percent were in favor of more research in palliative medicine. An integration between Units of Oncology and Palliative Care Services early in the course of advanced disease was advocated by 86%. Diverse and multifaceted definitions were given for the concepts of Quality of Life, Palliative Care and Medical Oncologist.

CONCLUSION

SC is felt as an important task, as well as training of medical oncologists in symptom management and research in this field.

Comparison of upright balance in stroke, Parkinson and multiple sclerosis

OBJECTIVE

Multiple sclerosis (MS), Parkinson's disease (PD) and stroke (ST) subjects show balance impairments due to damage of the balance control system. The objective of the study was to assess the impact of MS, PD and ST on upright posture in eyes open condition and when visual and/or proprioceptive inputs are altered.

MATERIALS AND METHODS

A total of 188 subjects with MS (n = 80), PD (n = 58) and ST (n = 50), mean age (SD), 57.9 (14.6) years, and 32 healthy subjects (HS) aged 53.7 (15.7) years were assessed by a stabilometric platform in a cross-sectional study.

RESULTS

Compared to HS, MS showed large deviations from normal performances with respect to magnitude (P < 0.001) and regularity (P < 0.05) of body sway irrespective of the altered sensory information. Similarly to MS, PD showed large and abnormal levels of body sway (P < 0.001) and postural tremor (P < 0.05), while ST was the least impaired except for an asymmetrical distribution of body weight between legs (P < 0.001). Finally, the MS group compared to PD and ST showed the largest body instability after eye closure (P < 0.05) and when visual and proprioceptive inputs were removed (P < 0.05). PD showed instability mainly after the alteration of proprioceptive inputs (P < 0.05), while ST showed the smallest increase of body instability when sensory inputs were reduced.

DISCUSSION

Objective assessment revealed pathology-specific balance disorders and showed the differential impact of MS, PD and ST on the ability to use sensory information for balance control.

Clinical and stabilometric measures predicting falls in Parkinson disease/parkinsonisms

OBJECTIVES

Clinical predictors of falls in patients with Parkinson disease (PD) are fairly inaccurate. Stabilometric measures appear useful in investigating the relationship between balance, sensory disturbance, and falls. The aim of the study was to identify the best combination of clinical and stabilometric tests to predict falls prospectively.

MATERIALS & METHODS

Fifty-three consecutive subjects with PD or parkinsonisms at risk of falls were included and followed for 6 months. Clinical variables were used as fall predictors: the Unified Parkinson Disease's Rating Scale (motor section) and the Longitudinal Aging study Amsterdam Physical Activity Questionnaire (LAPAQ). Variables from stabilometric platform underwent a principal component analysis. Multivariate logistic models were used to predict fallers using fall status (fallers: 1 + falls; recurrent fallers: 2 + falls) as dependent variable.

RESULTS

Seven patients were lost to follow up, leaving 46 evaluable subjects. Of these, 32 (70%) were fallers and 22 (48%) were recurrent fallers. The only variable predicting fallers was the LAPAQ (odd ratio [OR] 0.99 (95% confidence interval [CI] 0.98-1.00); accuracy 71.7%; sensitivity 87.5%; specificity 35.7%). For recurrent fallers, Factor 2 (body sway velocity) (OR 2.37; 95% CI 1.01-5.58) and, in part, LAPAQ (OR 0.99; 95% CI 0.98-1.00) retained significance in the multivariate model, showing an accuracy of 76.9%, a sensitivity of 77.8%, and a specificity of 76.2%.

CONCLUSIONS

A combination of clinical and instrumental tools is useful to identify fallers in PD or parkinsonisms. Body sway velocity and ability to perform the activities of daily living are the best predictors of recurrent falls.

Automatic knowledge extraction from chemical structures: the case of mutagenicity prediction

This work proposes a new structure-activity relationship (SAR) approach to mine molecular fragments that act as structural alerts for biological activity. The entire process is designed to fit with human reasoning, not only to make the predictions more reliable but also to permit clear control by the user in order to meet customized requirements. This approach has been tested on the mutagenicity endpoint, showing marked prediction skills and, more interestingly, bringing to the surface much of the knowledge already collected in the literature as well as new evidence.

Expression of DNA repair genes in ovarian cancer samples: biological and clinical considerations

The purpose of this study was to investigate retrospectively the mRNA expression of genes involved in different DNA repair pathways implicated in processing platinum-induced damage in 171 chemotherapy-naïve ovarian tumours and correlate the expression of the different genes with clinical parameters. The expression of genes involved in DNA repair pathways (PARP1, ERCC1, XPA, XPF, XPG, BRCA1, FANCA, FANCC, FANCD2, FANCF and PolEta), and in DNA damage transduction (Chk1 and Claspin) was measured by RT-PCR in 13 stage I borderline and 77 stage I and 88 III ovarian carcinomas. ERCC1, XPA, XPF and XPG genes were significantly less expressed in stage III than in stage I carcinoma; BRCA1, FANCA, FANCC, FANCD2 gene expressions were low in borderline tumours, higher in stage I carcinomas and lower in stage III samples. High levels of ERCC1, XPA, FANCC, XPG and PolEta correlated with an increase in Overall Survival (OS) and Progression Free Survival (PFS), whilst high BRCA1 levels were associated with PFS on univariate analysis. With multivariate analyses no genes retained an association when adjusted by stage, grade and residual tumour. A tendency towards a better PFS was observed in patients with the highest level of ERCC1 and BRCA1 after platinum-based therapy than those given both platinum and taxol. The expression of DNA repair genes differed in borderline stage I, stage I and stage III ovarian carcinomas. The role of DNA repair genes in predicting the response in ovarian cancer patients seems far from being established.

Expression of DNA repair genes in ovarian cancer samples: biological and clinical considerations

The purpose of this study was to investigate retrospectively the mRNA expression of genes involved in different DNA repair pathways implicated in processing platinum-induced damage in 171 chemotherapy-naïve ovarian tumours and correlate the expression of the different genes with clinical parameters. The expression of genes involved in DNA repair pathways (PARP1, ERCC1, XPA, XPF, XPG, BRCA1, FANCA, FANCC, FANCD2, FANCF and PolEta), and in DNA damage transduction (Chk1 and Claspin) was measured by RT-PCR in 13 stage I borderline and 77 stage I and 88 III ovarian carcinomas. ERCC1, XPA, XPF and XPG genes were significantly less expressed in stage III than in stage I carcinoma; BRCA1, FANCA, FANCC, FANCD2 gene expressions were low in borderline tumours, higher in stage I carcinomas and lower in stage III samples. High levels of ERCC1, XPA, FANCC, XPG and PolEta correlated with an increase in Overall Survival (OS) and Progression Free Survival (PFS), whilst high BRCA1 levels were associated with PFS on univariate analysis. With multivariate analyses no genes retained an association when adjusted by stage, grade and residual tumour. A tendency towards a better PFS was observed in patients with the highest level of ERCC1 and BRCA1 after platinum-based therapy than those given both platinum and taxol. The expression of DNA repair genes differed in borderline stage I, stage I and stage III ovarian carcinomas. The role of DNA repair genes in predicting the response in ovarian cancer patients seems far from being established.

Sensory impairments in quiet standing in subjects with multiple sclerosis

Balance disorders and falls are frequently observed in subjects with multiple sclerosis (MS). Along with motor impairment, sensory disorders and integration deficits of sensory inputs lead to inadequate motor responses. The assessment of these sensory disorders in an every day tasks, such as upright stance, increases our knowledge of postural control in this pathology, thus promoting more effective treatments. The aim of the study was to describe sensory impairments and sensory strategies in different sensory conditions. A stabilometric assessment was carried out in a consecutive convenience sample of 53 subjects. The age of the sample was 52.7 (21.1) years; the onset of pathology was 27.20 (14.5) years before the assessment. Balance was assessed in six sensory conditions. The impact of pathology on balance control was shown by the high percentage of abnormal scores: 75% of subjects with MS showed abnormal scores even in the eyes open condition. The alteration of a single sensory input led to an increase of abnormal scores in up to 82% of subjects. Almost all subjects showed abnormal scores in the vestibular conditions where 22% of them fell. The pattern of the subjects' performance in the six sensory conditions suggests that balance control may be more correlated to the number of reliable sensory inputs than the nature of the sensory input itself.

Pharmacogenetics of immunosuppressants: progress, pitfalls and promises

Most of the immunosuppressants used in organ transplantation are characterized by a narrow therapeutic index, whereby underdosing is associated with increased risk of rejection episodes and overdosing may exacerbate drug-related toxicity. Pharmacogenetics--complementary to pharmacokinetics--holds the potential to allow individualized dosing of immunosuppressive agents to optimize their therapeutic actions while minimizing adverse effects. Most of the studies have focused on polymorphisms of genes involved in drug metabolism and distribution, but as of now, only thiopurine-S-methyltransferase and cytochrome P 450 3A5 genotypes appear to have sufficiently large influence to have potentialities in guiding drug dosing. This may reflect the fact that available information from other polymorphisms derives almost exclusively from retrospective observations or from studies with important methodological biases. Active investigations aimed at identifying allelic variants of gene encoding for the pharmacologic targets are now ongoing. Recent studies have demonstrated that also donor genotype may play a significant role in immunosuppressive drug pharmacokinetics and pharmacodynamics. As one of the main future tasks, it is mandatory to develop mathematical models able to incorporate multiple gene polymorphisms with pharmacokinetic data and other critical information, providing algorithms able to individualize the best immunosuppressive therapy for each patient before transplantation.

Effects of balance exercises on people with multiple sclerosis: a pilot study

OBJECTIVE

To evaluate the effects of balance retraining in a sample of people with multiple sclerosis.

DESIGN

Randomized controlled trial.

SETTING

Rehabilitation unit.

SUBJECTS

A consecutive sample of 44 subjects was randomized into two experimental groups and one control group. The inclusion criteria were: ability to stand independently more than 30 seconds, ability to walk for 6 m.

INTERVENTIONS

Group 1 received balance rehabilitation to improve motor and sensory strategies. Group 2 received balance rehabilitation to improve motor strategy. Group 3 received treatments not specifically aimed at improving balance.

MAIN OUTCOME MEASURE

Berg Balance Scale, Dynamic Gait Index and fall frequency were used to assess balance impairments. Dizziness Handicap Inventory and Activities-specific Balance Confidence were used to assess handicap and the level of balance confidence.

RESULTS

Frequency of falls post treatment was statistically different among groups (P=0.0001); The Berg Balance Scale showed an overall statistically significant difference (P=0.0008) among groups. Change pre-post scores were 6.7, 4.6 and 0.8 points for groups 1, 2 and 3. Dynamic Gait Index showed an overall near statistically significant difference among groups (P=0.14), with change pre-post scores of 3.85, 1.6 and 1.75 points for groups 1, 2 and 3; after the exclusion of drop-outs a statistically significant difference was observed (P=0.04). The self-administered tests (Activities-specific Balance Confidence and Dizziness Handicap Inventory) did not show clinically relevant improvements.

CONCLUSIONS

Balance rehabilitation appeared to be a useful tool in reducing the fall rate and improving balance skills in subjects with multiple sclerosis. Exercises in different sensory contexts may have an impact in improving dynamic balance.

DeltaNp63 expression is associated with poor survival in ovarian cancer

BACKGROUND

P63 belongs to the 'p53 family' whose role in cancer progression has been recently revisited in light of the plethora of splicing variants that are generated. We analyzed the expression of the full-length TAp63 gene and its dominant-negative form deltaNp63 in ovarian cancer biopsies to correlate their expression with clinical outcome.

MATERIALS AND METHODS

Real-time RT-PCR analysis was used to determine the levels of TAp63 and deltaNp63 in 83 stage I and in 86 stage III ovarian cancer biopsies and in seven human ovarian cancer cell.

RESULTS

TAp63 levels were comparable in stage I and stage III, but deltaNp63 levels increased 77-fold in stage III, independently of the p53 status. Patients with high deltaNp63 expression had the worst overall survival (OS); patients with a deltaNp63/TAp63 ratio >2 had a poor OS. Patients with a high deltaNp63/TAp63 ratio were those with a poor response to platinum-based therapy.

CONCLUSIONS

Data indicate a role for deltaNp63 as a potential biomarker to predict patient's outcome and tumor progression in ovarian cancer. This would have particularly clinical relevance in ovarian cancer where the high rate of mortality reflects our lack of knowledge of molecular mechanisms underlying cell progression toward malignancy.

Influence of co-medication with sirolimus or cyclosporine on mycophenolic acid pharmacokinetics in kidney transplantation

The pharmacokinetics of mycophenolic acid (MPA)--the active metabolite of mycophenolate mofetil (MMF)--is significantly influenced by co-medications. The impact of sirolimus on daily MPA exposure, however, has not been investigated so far. As a part of the study aimed at investigating the efficacy of Campath-1H induction therapy in a steroid-free regimen in kidney transplantation, MPA plasma levels were serially measured in 21 patients treated with low-dose sirolimus (SRL) or low-dose CsA both in addition to low-dose MMF over 12 months post-operatively. Full pharmacokinetic profiles were compared at month 6 and 12 post-surgery. Mean dose-adjusted MPA trough levels were 4.4-fold higher in patients on combined SRL and MMF than in those given CsA and MMF. Pharmacokinetic studies demonstrated that mean MPA C(max) and T(max) were comparable in the two groups, while mean MPA AUC(0-12) was higher in SRL than CsA treated patients. The pharmacokinetic profile of SRL- but not of CsA-group showed a second peak consistent with the enterohepatic recirculation of MPA. These findings suggest that SRL and CsA have different effects on MPA metabolism and/or excretion eventually affecting its immunosuppressive property and/or toxicity. CsA, but not SRL, inhibits MPA enterohepatic recirculation, reducing MPA daily exposure.

Blood Cyclosporine Level Soon After Kidney Transplantation is a Major Determinant of Rejection: Insights From the Mycophenolate Steroid-Sparing Trial

Target organs express antigens directly recognized by antigen-specific T cells, thereby precipitating rejection. When early T-cell activation is inhibited, there is a low risk of rejection. We sought to determine the predictive values of serial posttransplant blood cyclosporine trough (C(0)) concentrations to minimize the risk for a first rejection episode compared with 2-hour postdose (C(2)) drug concentrations. The final aim of the study was to identify a concentration range for the best predictive pharmacokinetic parameter that should be targeted to reduce the risk of rejection. This possibility was explored in 334 de novo kidney transplant recipients who participated in the prospective, multicenter Mycophenolate Steroid-Sparing Trial. Among measurements performed during the first 6 months postsurgery, cyclosporine C(0) levels measured early after transplantation were the strongest predictor of acute graft rejection. Levels within 300 to 440 ng/mL were associated with the lowest risk of rejection, while patients with levels lower than 300 ng/mL showed a more than double risk. Cyclosporine trough values predicted allograft rejection with an accuracy of 74%, while C(2) levels had no predictive value. These findings underline the need to target cyclosporine therapy early posttransplant to modulate T-cell activation.

Nephrotoxic aspects of cyclosporine

Over the last 20 years cyclosporine (CsA) has improved the survival of kidney, heart, and liver transplants. However, with increasing use, evidence has accumulated that CsA therapy carries a variety of side effects, the most important being renal toxicity. CsA can lead to a wide spectrum of renal function impairments, including a marked and rapidly reversible decrease in renal hemodynamics (acute CsA nephrotoxicity), and a chronic form of renal damage that potentially progress irreversibly to end-stage renal disease (chronic CsA nephrotoxicity). All these manifestations are the consequence of the drug toxic effects on renal vessels and the tubulointerstitium. A proper diagnosis of CsA toxicity at early stages, the combination of low CsA doses with non-nephrotoxic immunosuppressants, and the development of more feasible strategies to monitor daily CsA exposure may contribute to a better CsA management, improve quality of life of transplant recipients, and prolong graft survival.

[Functional loss of the transplanted kidney: immunological and non-immunological factors]

During the past few years, the short-term graft survival after kidney transplantation has improved dramatically, a phenomenon not paralleled by an increase in the long-term graft survival. This is due to the progressive renal injury and dysfunction known as chronic transplant nephropathy or 'chronic rejection', a process that involves both immune and non-immune factors. Immunological factors include T- and B-cell recognition of alloantigens, cytomegalovirus infection, and endothelial cell activation followed by vascular smooth cells proliferation. Among nonimmune mechanisms, proteinuria and hypertension play a relevant role. Moreover, the reduced number of functioning nephrons may trigger an inflammatory process that, eventually, contributes to the loss of the graft. Several studies have documented the efficacy of blocking the renin-angiotensin system (RAS) in reducing proteinuria and preventing renal function deterioration in experimental models of chronic rejection. Early results are promising. However, available clinical trials are rather limited in terms of number of patients enrolled, consequently they cannot be considered definitive. Since several pathogenetic factors are involved in the progression of chronic transplant nephropathy, a multidrug approach with specific immunosuppressants and RAS-blocking drugs has been proposed to control/prevent chronic injury and progressive renal deterioration. Preliminary results in experimental models are promising. Data from prospective clinical trials are, however, mandatory to confirm the efficacy of a polypharmacological strategy in preventing chronic rejection.

Do static or dynamic AFOs improve balance?

OBJECTIVE

To verify if partial or total limitation of degrees of freedom at ankle joints could help patients with balance disorders in standing and walking.

DESIGN

A cross-over design was chosen. Patients with multiple sclerosis (MS) were tested in three experimental conditions: barefooted, wearing ankle foot orthoses (AFOs), and wearing AFOs that allowed plantar flexion.

SETTING

Neurorehabilitation unit in a rehabilitation centre.

SUBJECTS

Fourteen patients suffering from MS with mild strength problems and balance disorders that required them to use walking aids outside.

MAIN OUTCOME MEASURES

Tests inferring static and dynamic skills were carried out in the three experimental conditions described above.

RESULTS

Improvements were obtained in static balance tests especially wearing dynamic AFOs; the number of patients who were able to pass tasks on balance in upright position such as 'standing with feet together, head extended' increased from three to nine. Dynamic balance was impaired especially with static AFOs; the time spent walking 10 metres with these orthoses increased by 172% with respect to barefoot; less difference (113%) has been reported wearing dynamic AFOs.

CONCLUSION

Static and dynamic AFOs improved static balance, while dynamic balance was impaired especially by static AFOs; less negative influence on dynamic balance has been found while wearing dynamic AFOs.

Pharmacokinetics help optimizing mycophenolate mofetil dosing in kidney transplant patients

BACKGROUND

Mycophenolic acid (MPA), the active metabolite of mycophenolate mofetil (MMF), is now routinely used as immunosuppressant in solid organ transplantation in a fixed daily dose regimen (2 g/d) in association with cyclosporine (CsA) and steroids. However, no correlation has been shown between fixed MMF dose and clinical outcome.

METHODS

Here we examined the possibility of optimizing MMF dosing by drug pharmacokinetic monitoring in 46 stable kidney transplant recipients. MPA plasma concentration profiles were measured by a reverse-phase high-performance liquid chromatography method 6-9 months after transplantation and related with routine laboratory analysis tests. Since MPA is extensively bound to serum albumin and only the free fraction is pharmacologically active, in a subgroup of 23 patients free plasma MPA was also determined.

RESULTS

Despite a comparable MMF dose, a large interindividual variability in both MPA area under the curve (AUC) from 0 to 12 h (range 10.1-99.8 microg/mL. h) and in trough levels (range 0.24-7.04 microg/mL) was found. Patients with AUC >40 microg/mL. h showed a better (p<0.05) renal function than patients with lower AUC (creatinine clearance 85.7+/-23.2 versus 64.5+/-17.5 mL/min), despite no difference in CsA dose, CsA AUC and blood CsA trough level. The percentage of free plasma MPA but not total MPA correlated with the red blood cell and leukocyte count.

CONCLUSIONS

Therapeutic MMF drug monitoring might contribute to a better management of kidney transplant recipient with the goal of optimizing drug dosing and limiting the risk of MMF-related toxicity.

Computerized system to improve voluntary control of balance in neurological patients

The treatment of acquired impairments of balance is one of the most elusive problems that rehabilitative medicine faces. Computerized systems to measure how patients control their balance in static conditions were introduced long ago into clinical practice and proved to be useful; we have designed and developed a computerized system called "BioGP," which combines features of a classic stabilometric platform with those of a retraining device based on visual feedback The aim of this study was to identify homogeneous groups of patients and to provide objective proof of effectiveness for the rehabilitation of patients with balance disorders. The findings confirm that the new equipment provides clinically valid and sensitive information concerning subjects' ability to control voluntary shifts of center of pressure (COP) while standing. The information is relevant to applications using basically the same approach (1) and are encouraging for possible use of the system as a rehabilitation instrument.