Phase II study of capecitabine-based concomitant chemoradiation followed by durvalumab as a neoadjuvant strategy in locally advanced rectal cancer: the PANDORA trial

BACKGROUND

This study investigated the efficacy of chemoradiotherapy (CRT) followed by durvalumab as neoadjuvant therapy of locally advanced rectal cancer.

PATIENTS AND METHODS

The PANDORA trial is a prospective, phase II, open-label, single-arm, multicenter study aimed at evaluating the efficacy and safety of preoperative treatment with durvalumab (1500 mg every 4 weeks for three administrations) following long-course radiotherapy (RT) plus concomitant capecitabine (5040 cGy RT in 25-28 fractions over 5 weeks and capecitabine administered at 825 mg/m2 twice daily). The primary endpoint was the pathological complete response (pCR) rate; secondary endpoints were the proportion of clinical complete remissions and safety. The sample size was estimated assuming a null pCR proportion of 0.15 and an alternative pCR proportion of 0.30 (α = 0.05, power = 0.80). The proposed treatment could be considered promising if ≥13 pCRs were observed in 55 patients (EudraCT: 2018-004758-39; NCT04083365).

RESULTS

Between November 2019 and August 2021, 60 patients were accrued, of which 55 were assessable for the study's objectives. Two patients experienced disease progression during treatment. Nineteen out of 55 eligible patients achieved a pCR (34.5%, 95% confidence interval 22.2% to 48.6%). Regarding toxicity related to durvalumab, grade 3 adverse events (AEs) occurred in four patients (7.3%) (diarrhea, skin toxicity, transaminase increase, lipase increase, and pancolitis). Grade 4 toxicity was not observed. In 20 patients (36.4%), grade 1-2 AEs related to durvalumab were observed. The most common were endocrine toxicity (hyper/hypothyroidism), dermatologic toxicity (skin rash), and gastrointestinal toxicity (transaminase increase, nausea, diarrhea, constipation).

CONCLUSION

This study met its primary endpoint showing that CRT followed by durvalumab could increase pCR with a safe toxicity profile. This combination is a promising, feasible strategy worthy of further investigation.

Primary care management strategies and COVID-19 related hospitalization: a population-based study

Background

Due to SARS-CoV-2 rapid mutations, the ending of the pandemic is still proceeding at a slow pace and there is the need to strengthen and invest in health systems that avoid hospital overload and its consequences on patients’ health. Most symptomatic infections have mild to moderate respiratory symptoms and patients are managed in the context of primary care. In Italy, literature on COVID-19 outpatients management by general practitioners (GPs) is scarce. This study explores the effect of GP active care and monitoring on COVID-19-related hospitalization in patients in the province of Modena (Italy) and investigates the possible determinants of GP's management.

Methods

This is a retrospective cohort study of SARS-CoV-2 infected adult outpatients managed by their GPs from March 2020 to April 2021 in the province of Modena (Italy). Data on GPs’ characteristics, management strategies (visits and remote monitoring), patients’ socio-demographic characteristics, and hospitalization were extracted from the GP's electronic medical records and were analyzed using descriptive statistics and multiple logistic regression.

Results

46 GPs agreed to participate, and 5340 patients were included in the analyses. 3014 (56%) patients received active daily remote monitoring and 840 (16%) were visited at home. Remote monitoring and home visits were both associated with a reduction of the probability of hospitalization rate of approximately 50% (respectively OR:0.52, 95%CI:0.33, 0.80 and OR:0.50, 95%CI;0.33, 0.78). Preliminary analysis of determinants showed that GPs’ patient load, setting, age, and sex were significantly associated with management strategies.

Conclusions

Active monitoring performed by GPs was effective in reducing the probability of hospitalization. Primary and hospital care integration can be effective for COVID-19 management. Studies on GPs’ characteristics and patient load and their effect on their ability to care for patients are needed.

Key messages

• Active remote monitoring and visits performed by Italian general practitioners effectively reduced hospitalization for COVID-19.

• Primary and hospital care integration can be effective for COVID-19 management.

Functional recovery in senior adults undergoing surgery for colorectal cancer: Assessment tools and strategies to preserve functional status

Colorectal cancer is a widely-recognized aging-associated disease. Recent advances in the care of senior colorectal cancer patients has led to similar cancer-related life expectancy for older patients when compared to their younger counterparts. Recent data suggests that onco-geriatric patients place as much value on maintenance of functional independence and quality of life after treatment as they do on the potential improvements in survival that a treatment might offer. As a result, there has been significant interest in the geriatric literature surrounding the concept of "functional recovery," a multidimensional outcome metric that takes into account several domains, including physical, physiologic, psychological, social, and economic wellbeing. This review introduces the concept of functional recovery and highlights a number of predictors of post-treatment functional trajectory, including several office-based tools that clinicians can use to help guide informed decision making surrounding potential treatment options. This review also highlights a number of validated metrics that can be used to assess a patient's progress in functional recovery after surgery. While the timeline of each individual's functional recovery may vary, most data suggests that if patients are to return to their pre-operative functional status, this could occur up to 6 months post-surgery. For those patients identified to be at risk for post-operative functional decline this review also delineates strategies for prehabilitation and rehabilitation that may improve functional outcomes.

CDH1 POLYMORPHISMS AND LOW EXPRESSION OF E-CADHERIN AND β-CATENIN IN COLORECTAL CANCER PATIENTS

Epithelial-mesenchymal transition (EMT) process has a central role in tumor progression and metastases. Loss of cell-to-cell adhesiveness is a key step in EMT. In particular, E-cadherin and β-catenin, components of the adherens junctions, play a strategic role. Accumulation of β-catenin at cytoplasmic level following adherens junctions disruption, induces its translocation into the nucleus, where it binds to members of the TCF/LEF family of transcription factors. In particular, Lymphoid Enhancer-Binding factor 1 (LEF1) product can target genes involved in EMT. The aim of the present study was to evaluate the influence of CDH1 and CTNNB1 genes, coding for E-cadherin and β-catenin respectively and LEF1 in a sample study of 140 Italian patients affected by colorectal cancer. An association study between four single nucleotide polymorphisms (rs11865026, rs11642413, rs13689, and rs10431923) of CDH1 and the disease did not provide statistically significant results. The gene expression analysis carried out for CDH1, CTNNB1 and LEF1 in 54 paired specimens from 27 patients provided evidence of a reduced expression of the first two in cancer tissues. We believe there may be a sort of cross regulation between the products of these two genes which closely interact in EMT activation and that such hypothesis should be further investigated in a greater number of cases.

Screening for predictors of adverse outcome in onco-geriatric surgical patients: A multicenter prospective cohort study

AIMS

The aim of this study was to investigate the predictive ability of screening tools regarding the occurrence of major postoperative complications in onco-geriatric surgical patients and to propose a scoring system.

METHODS

328 patients ≥ 70 years undergoing surgery for solid tumors were prospectively recruited. Preoperatively, twelve screening tools were administered. Primary endpoint was the incidence of major complications within 30 days. Odds ratios (OR) and 95% confidence intervals (95% CI) were estimated using logistic regression. A scoring system was derived from multivariate logistic regression analysis. The area under the receiver operating characteristic curve (AUC) was applied to evaluate model performance.

RESULTS

At a median age of 76 years, 61 patients (18.6%) experienced major complications. In multivariate analysis, Timed Up and Go (TUG), ASA-classification and Nutritional Risk Screening (NRS) were predictors of major complications (TUG>20 OR 3.1, 95% CI 1.1-8.6; ASA ≥ 3 OR 2.8, 95% CI 1.2-6.3; NRS impaired OR 3.3, 95% CI 1.6-6.8). The scoring system, including TUG, ASA, NRS, gender and type of surgery, showed good accuracy (AUC: 0.81, 95% CI 0.75-0.86). The negative predictive value with a cut-off point >8 was 93.8% and the positive predictive value was 40.3%.

CONCLUSIONS

A substantial number of patients experience major postoperative complications. TUG, ASA and NRS are screening tools predictive of the occurrence of major postoperative complications and, together with gender and type of surgery, compose a good scoring system.

Targeting of ADAMTS5's ancillary domain with the recombinant mAb CRB0017 ameliorates disease progression in a spontaneous murine model of osteoarthritis

OBJECTIVE

ADAMTS5 (aggrecanase-2) has been demonstrated to be crucial in the development of osteoarthritis (OA), by use of several mouse mutants carrying either truncated, catalytically inactive enzymes or aggrecanase-resistant mutant aggrecan. We have selected recombinant monoclonal antibodies directed against ADAMTS5, by using Intracellular Antibody Capture Technology (IACT). CRB0017 revealed very high affinity for the enzyme in Biacore analyses and very good specificity in a panel of binding assays. Therefore, we tested CRB0017 in a relevant spontaneous OA model, the STR/ort mouse.

DESIGN

STR/ort male mice were recruited at 5 months of age, and treated intra-articularly in each knee with CRB0017 1.2 μg, CRB0017 12 μg, or vehicle. After 6 weeks, the intra-articular administration of CRB0017 was repeated with the same doses. After 3 months from recruitment, the animals were sacrificed and the femorotibial joints processed for histology and scored in a blind fashion according to both Mankin's and the OARSI methods.

RESULTS AND CONCLUSIONS

All histological scores were significantly decreased in the CRB0017 12 μg/knee group compared to vehicle, while administration of CRB0017 1.2 μg was associated with a trend to a decrease in the same parameters. Therefore, CRB0017 administered twice in 3 months could modify the course of OA in the STR/ort mouse, by delaying cartilage breakdown as assessed histologically. The procedure of blind scoring of the histological samples clearly showed that knee intra-articular administration of CRB0017, an anti-ADAMTS5 antibody, dose-dependently improved disease progression in a relevant animal model of OA.

[Improving dietary habits in the effective prevention of excess weight and obesity]

The new research survey "Okkio alla salute", conducted in children in the 3rd year of elementary school, has confermed the worrisome phenomenon of the high number of obese and overweight children. Therefore, it is necessary, also in light of the few available resources, to fight back against this phenomenon that has been demonstrated to be a cause of disabling illnesses in adults. There must therefore be collaboration between Departments of Prevention and Hygiene and Nutrition services (SIAN) to build valid and efficient pathways. In this presentation we describe some national projects carried out by various local health agencies to address this health problem.

Gene expression profile of human colon cancer cells treated with cross-reacting material 197, a diphtheria toxin non-toxic mutant

Cross-Reacting Material 197 (CRM197) is a diphtheria toxin non-toxic mutant that has shown antitumor activity in mice and humans. It is still unclear whether this anti-tumorigenic effect depends on its strong inflammatory-immunological property, its ability to inhibit heparin-binding epidermal growth factor (HB-EGF), or even its possible weak toxicity. CRM197 is utilized as a specific inhibitor of HB-EGF that competes for the epidermal growth factor receptor (EGFR), overexpressed in colorectal cancer and implicated in its progression. In this study we evaluate the effects of CRM197 on HT-29 human colon cancer cell line behaviour and, for CRM197 recognized ability to inhibit HB-EGF, its possible influence on EGFR activation. In particular, while HT-29 does not show any reduction of viability after CRM197 treatment (MTT modified assay), or changes in cell cycle distribution (flow cytometry), in EGFR localization, phospho-EGFR detected signals (immunohistochemistry) or in morphology (scanning electron microscopy, SEM) they show a change in the gene expression profile by microarray analysis (cDNA microarray SS-H19k8). The overexpression of genes like protein phosphatase 2, catalytic subunit, alpha isozyme (PPP2CA), guanine nucleotide-binding protein G subunit alpha-1(GNAI1) and butyrophilin, subfamily 2, member A1 (BTN2A1) has been confirmed with real-time-qPCR. This is the first study where the CRM197 treatment on HT-29 shows a possible scarce implication of endogenous HB-EGF on EGFR expression and cancer cell development. At the same time, our results show the alteration of a specific and selected number of genes.

Training the teachers for improving primary schoolchildren's fruit and vegetables intake: a randomized controlled trial

Effectiveness comparison of different school-based nutrition education interventions to improve fruit and vegetable (F&V) consumption in schoolchildren not yet well researched. We evaluated the effectiveness of two school-based interventions promoting fruit and vegetable intake among Italian schoolchildren. In this randomized intervention trials, the first intervention was conducted by schoolteachers who attended a nutritionist-led training course (group-1), the second intervention conducted by schoolteachers who performed a self-training course (group-2). Thirty-two second to fifth-grade elementary classes enrolling 96 schoolteachers and 813 schoolchildren were randomized, and assigned to the two different nutrition education interventions. 804 students completed the study. By the end of the study, the group-1 (n = 409) followed by the teachers who attended a nutritionist-led course successfully increased the consumption of fruit and vegetables: in 183 (44.7%) and 157 (38.3%) schoolchildren respectively; the group-2 (n = 395) with teachers who performed a self-training course reported an increased consumption of fruit and vegetables in 81 (20.5%) and 76 (19.2%), respectively. This study indicates that a school-based nutrition education conducted by teachers who attended a nutritionist-led training course has a significant impact on primary school-age children's F&V intake.

15-week long school-based nutritional education program to promote Italian primary schoolchildren's fruit and vegetable intake

A short-version (15-week long) of school-based nutrition education program called "Bring Fruit to School" to enhance primary schoolchildren's fruit and vegetable (F&V) intake was evaluated. We recruited 199 primary schoolchildren from 8 classes (grade 2-5). The primary end-point was an increase in the children's F&V intake. The intervention period lasted 15 weeks, and was divided into three phases: weeks 1-5, weeks 6-10 and weeks 11-15. The F&V intake of the schoolchildren was also monitored in a subsequent follow-up period (16th-32nd week). By week 15, 92 (46.2%, P < .001) schoolchildren increase fruit intake and 91 (45.7%, P < .001) increase vegetable intake. The F&V intake increased during the intervention period and was constant in follow-up. The BFtS program is an effective means to promote primary schoolchildren's F&V intake, and was implemented in Italy by the Food and Nutrition Service of Foggia's Local Health Authority. It could be extended to many other countries by local nutrition agencies, such as associations for nutrition.

Pilot study: the use of sulfasalazine for the treatment of acute pouchitis

BACKGROUND

Acute pouchitis, an idiopathic inflammatory condition of the ileal pouch anal anastomosis, is the most frequent complication after proctocolectomy for ulcerative colitis.

AIM

To test the hypothesis that sulfasalazine (SASP) might have a synergistic beneficial effect in acute pouchitis, by combining the anti-inflammatory activity of 5-aminosalicylic Acid and the bacteriostatic effect of sulphapyridine.

METHODS

Twenty two patients were investigated for acute pouchitis; the Pouchitis Disease Activity Index (PDAI) was calculated and 11 patients with acute pouchitis (PDAI >7) were included in an open study, after obtaining their informed consent. Patients were treated with SASP 500 mg tablets, two tablets three times per day (3000 mg daily), for 2 months. Pouch endoscopy with biopsies was performed at the entry and at the end of the study.

RESULTS

According to the PDAI score, 8/11 patients (73%) improved their clinical condition and 7/11 (63%) were in remission at the end of the treatment. At 8 weeks, the median PDAI index decreased from 11.2 +/- 2.3 to 6.6 +/- 4.7 P < 0.01. No adverse events or toxicity were reported and all patients completed the study.

CONCLUSIONS

Despite the limitations of the current study, sulfasalazine seems to be a potential treatment for acute pouchitis.

Can elderly patients with colorectal cancer tolerate planned surgical treatment? A practical approach to a common dilemma

AIM

Analysing the effectiveness of a surgical procedure is mandatory in every modern health-care system. The aging of the population stresses the need for a good standard of care. This study tests the hypothesis that porthsmouth-physiologic operative severity score for enumeration of morbidity and mortality (P-POSSUM) and colorectal-POSSUM (CR-POSSUM) would be useful clinical auditing tools in colorectal cancer surgery for aged patients.

METHOD

One hundred and seventy-seven consecutive patients over 70 years of age underwent emergency or elective surgery from January 2003 to December 2005. Demographic, clinical and surgical information, score systems' prediction, complications and 30-day mortality data were prospectively entered in a comprehensive database. The observed over expected morbidity and mortality rate was calculated.

RESULTS

Thirty-day observed mortality was 10.3% (19/177) while P-POSSUM and CR-POSSUM expected mortality were, respectively, 11.21% (P = NS) and 13.08% (P = NS). Overall observed morbidity was 42.7%, P-POSSUM prediction was 59.3% (P = 0.002). Morbidity and mortality data were analysed for specific subgroups of patients (resection and anastomosis/resection and stoma/palliative; emergency/elective).

CONCLUSION

P-POSSUM and CR-POSSUM are useful tools to predict mortality in elderly patients. P-POSSUM significantly overestimated the risk of complications. A more accurate tool for preoperative assessment for aged patients is probably needed to predict the post-surgical outcome.

[Bring fruit at school: promotion of healthy food habit in primary school-children]

The many nutrition education guidelines formulated by different organizations and institutions are the frames for the program actions targeting nutrition awareness in the school-age population. But while the guidelines represent a solid starting block they still need to be backed up by programs giving concrete form to the guiding principles, a program whose efficacy is demonstrated by specific applications studies. The aim of the "Bring Fruit at School" nutrition education program is to encourage elementary school children to change their eating habits for the better. And in particular to eat more fruit, vegetables, legumes, and fish and to cut down on junk-food and sugar-sweetened drink.

Sarcomatoid anaplastic carcinoma of the small bowel in cardiac transplant bearer

Sarcomatoid carcinoma is a rare form of primitive carcinoma of the small bowel; it is considered a variant of adenocarcinoma, histologically characterized by a typical biphasic pattern with epithelial- and mesenchymal-like cells. Twenty-one cases have been described in the literature, presenting as small bowel obstructions (twenty cases) or superior vena cava syndrome (one case). The authors report the case of a 56 year-old man on immunosuppressive therapy for a heart transplant, who underwent surgery after a history of repeated episodes of melena, anemization and bowel obstruction. The operation brought to light an intraluminal occlusive mass in the distal ileum, associated with other intraluminal neoplasms of different sizes throughout the small bowel. No evidence of mesenteric adenopathies or hepatic metastases were found. Histological examination and immunohistochemical stain showed an anaplastic sarcomatoid carcinoma. The tumor cells showed strong positivity for cytokeratin and vimentin, and negativity for CD117 and CD34, as well as for all other characteristic markers of mesenchymal tumors. Early diagnosis is usually very difficult, due to the lack of any stereotyped clinical expression and the difficult to study the small bowel. Small-bowel barium follow-through or video capsule endoscopy can be helpful. In most cases, an emergency surgical operation is performed without a clear preoperative diagnosis. The case report is completed by a review of the literature.

Use of rabies virus as a transneuronal tracer of neuronal connections: implications for the understanding of rabies pathogenesis

In neurosciences, rabies virus (CVS strain) has become a very powerful tool for studying multisynaptic neuronal connections, due to its ability to function as a self-replicating marker and to propagate exclusively between connected neurons by transneuronal transfer, which is strictly time-dependent. In this laboratory, transneuronal tracing studies of rabies virus propagation in primates and rodent models during the asymptomatic period have provided valuable information on rabies pathogenesis. We have shown that rabies virus propagates by fast axonal transport at similar speeds in primates and rodents, after inoculation into the peripheral or central nervous system (CNS). Intracellulartransport of rabies virus is preferentially addressed to neuronal dendrites rather than axons, since transneuronal transfer occurs only retrogradely, i.e., from dendrites of first infected neurons to presynaptic terminals of connected neurons. Rabies virus propagation occurs at chemical synapses, but not via gap junctions or local spread. The results of our studies show that rabies virus receptors have a ubiquitous distribution on neurons within the CNS. Conversely, in the peripheral nervous system, rabies virus receptors are present only on motor endings, since uptake is restricted to motor endplates and axons, whereas sensory and autonomic endings are not infected. Thus, after peripheral inoculations, motoneurons are the only gateway for rabies virus transmission to the CNS. Infection of sensory and autonomic neurons requires longer incubation times, since it reflects centrifugal propagation of rabies virus from the CNS to the periphery, i.e., it is the result of retrograde transneuronal transfer to sensory and autonomic terminals within the CNS.

Prognostic markers in stage II/III rectal cancer after neoadjuvant 5-fluorouracil-based chemoradiotherapy

14514

Background: The aim of this study was to evaluate the prognostic value of histologic tumor regression grade (TRG) and pathological biomarkers after neoadjuvant chemoradiotherapy (CT/RT) in rectal cancer pts. Methods: Pts entering the study had rectal adenocarcinoma and stage uT3-T4 N-/+ with location <12 cm from the anal margin. CT consisted of 5-fluorouracil (5FU) 225 mg/m2/die continuous infusion IV d1–38 with/without oxaliplatin (OXA) 60 mg/m2 weekly infusion IV for 6 times. RT was delivered up to a dose of 50.4 Gy in daily fractions of 1.8 Gy. Rectal surgery with TME was performed 6–8 weeks after neoadjuvant therapy. Eight courses of adjuvant CT (LV5FU2) were given after surgery. Immunohistochemical determination of Ki67, p53, bcl2, TS, EGFR, MLH1, MSH2 was performed in pre-treatment biopsy and operative specimen; TRG (Dworak) response (0=none, 1=low, 2–3= intermediate, 4=complete) and circumferential resection margin (CRM) were evaluated on surgical specimens. Results: Between March 2002 and December 2006, 56 pts had completed the integrated treatment. Pt characteristics were: 39M/17F; stage uT3N- 32(57.1%), uT3N+ 15(26.8%), uT3Nx 4(7.1%), uT4N+ 4(7.1%), uT4Nx 1(1.8%). CT was 5FU in 15(26.8%) pts, 5FU/OXA in 41(73.2%) pts. Pathological downstaging was achieved in 31(55.4%) pts, including 9(16.1%) pCR. After a median follow-up of 28.5(6–58) months, 7(12.5%) pts had disease recurrence. TRG evaluation was: no TRG0, 9(16.1%) TRG1, 21(37.5%) TRG2, 17(30.4%) TRG3, 9(16.1%) TRG4. CRM was negative in 91% of pts. By means of univariate analysis, TRG was found to be significantly correlated with DFS (estimated median DFS was 23 months in TRG1 pts, not achieved in TRG2–4 pts; p<0.0001). Other factors correlating significantly with a better DFS by univariate analysis included ypT0–2 (p=0.013) and pN- (p=0.002) categories, CRM- (p=0.024) and lower Ki67 expression post-CT/RT (p=0.012). Using multivariate analysis, we found that TRG2–4 was the strongest DFS prognostic factor (HR=0.0312; 95% CI: 0.003–0.40, p=0.008). Conclusions: In this analysis complete (TRG4) and intermediate (TRG2+3) pathological response produced improved DFS. Significant favorable prognostic factors were the ypT0–2/pN- categories, CRM- status and lower Ki67 expression after CT/RT.

No significant financial relationships to disclose.

Fitz-Hugh-Curtis-syndrome mimicking acute cholecystitis: value of new ultrasound findings in the differential diagnosis

Fitz-Hugh-Curtis is a rare syndrome characterised by perihepatitis following pelvic inflammatory disease. We report the case of a patient with a right ovarian teratoma, abnormal liver tests and pain in the right abdomen and shoulder, initially attributed to an acalculous cholecystitis. Before gynaecological surgery, a repeat ultrasound scan found several small avascular peritoneal masses at the upper dome of the liver, not reported in the initial examination. This prompted laparoscopic exploration of the subdiaphragmatic space, and the final diagnosis of Fitz-Hugh-Curtis-syndrome was made. Such ultrasound finding appears to be a new diagnostic feature of this syndrome.

Oculomotor areas of the primate frontal lobes: a transneuronal transfer of rabies virus and [14C]-2-deoxyglucose functional imaging study

We used the [14C]-2-deoxyglucose method to study the location and extent of primate frontal lobe areas activated for saccades and fixation and the retrograde transneuronal transfer of rabies virus to determine whether these regions are oligosynaptically connected with extraocular motoneurons. Fixation-related increases of local cerebral glucose utilization (LCGU) values were found around the fundus of the inferior limb of the arcuate sulcus (AS) just ventral to its genu, in the dorsomedial frontal cortex (DMFC), cingulate cortex, and orbitofrontal cortex. Significant increases of LCGU values were found in and around both banks of the AS, DMFC, and caudal principal, cingulate, and orbitofrontal cortices of monkeys executing visually guided saccades. All of these areas are oligosynaptically connected to extraocular motoneurons, as shown by the presence of retrogradely transneuronally labeled cells after injection of rabies virus in the lateral rectus muscle. Our data demonstrate that the arcuate oculomotor cortex occupies a region considerably larger than the classic, electrical stimulation-defined, frontal eye field. Besides a large part of the anterior bank of the AS, it includes the caudal prearcuate convexity and part of the premotor cortex in the posterior bank of the AS. They also demonstrate that the oculomotor DMFC occupies a small area straddling the ridge of the brain medial to the superior ramus of the AS. Our results support the notion that a network of several interconnected frontal lobe regions is activated during rapid, visually guided eye movements and that their output is conveyed in parallel to subcortical structures projecting to extraocular motoneurons.

[Treatment of complicated peptic ulcer: personal experience]

BACKGROUND

The availability of drugs which can effectively inhibit gastric secretion allowed the control of the peptic disease in almost all the patients, but the incidence of complications is substantially unchanged.

METHODS

In the present study, we performed a retrospective evaluation of 153 patients treated for complicated peptic ulcer (hemorrhage and perforation) in the last 6 years. Hemor-rhage is a common onset of the peptic disease and it rarely requires a surgical treatment, because medical and endoscopic therapies are successful in a high number of patients.

RESULTS

Surgery was necessary in 17.2% of the cases in the group of patients studied.

CONCLUSIONS

Our experience confirms the high operative mortality in the patients who underwent surgery for hemorrhage related to complicated peptic ulcer because of the frequent presence of several risk factors. Surgical therapy is the main procedure of treatment of perforated peptic ulcer and in the group of patient examined all the cases of perforation underwent surgical operation. In conclusion, despite the progress of pharmacological and endoscopic therapies, surgical treatment is the best therapy of complicated peptic ulcer.

[Peripheral nervous system involvement in HCV-related mixed cryoglobulinemia]

In HCV-related mixed cryoglobulinemia (MC) a peripheral neuropathy (PN) may occur. To evaluate the prevalence and the characteristics of PN, 133 consecutive patients with HCV-MC (117 type II, 16 type III) were studied. Neurologic evaluation was performed according to the guidelines of Italian Group for the Study of Cryoglobulinemias, using a neurological disability score and a neurological symptom score. In 52/133 patients an electrophysiologic study (ENG) of ulnar, peroneal and sural nerves was performed. For 27/52 patients ENG data registered at different times (interval 12-96 months) were available. In 11 patients a sural nerve biopsy was obtained. An overt PN, mostly as sensory asymmetrical or symmetrical nerve impairment, was found in 107/133 patients (80.4%). ENG abnormalities-reduction or absence of sensory and sometimes of motor action potential, normal or slightly impaired nerve conduction velocity, consistent with axonal damage- were detected in 48/52 patients (92.3%). In 26 out of the 27 patients observed at different times an evolution of PN was found. Nerve biopsies showed a prevalent axonal damage, swollen endothelial cells in epi- and perineurial vessels and scarce mononuclear perivascular infiltrates. No leukocytoclastic vasculitis was observed. Immunoglobulins and complement in sub-perineurial vessel wall were detected. CONCLUSIONS: In HCV-MC a PN is frequent. It is mostly a sensory and progressively worsening axonopathy. Different mechanisms may be involved in the pathogenesis of this disorder and a direct role of HCV cannot be excluded.

Modern concepts of brainstem anatomy: from extraocular motoneurons to proprioceptive pathways

The extraocular muscles, unlike the skeletal muscles, contain non-twitch muscle fibers. Recent experiments have located the non-twitch motoneurons. They lie around the periphery of the oculomotor, trochlear and abducens nuclei, separate from the more usual twitch motoneurons that cluster within the boundaries of the classical motor nuclei. The premotor inputs to non-twitch neurons were traced by the injection of rabies virus into the distal tip of the lateral rectus muscle. Retrogradely labeled cells were found in areas associated with the neural integrator, vergence and smooth pursuit premotor areas, but not the saccadic premotor burst neurons or the direct vestibulo-ocular pathways. The rabies tracing emphasizes for the first time that the central mesencephalic reticular formation (cMRF) and the supraoculomotor area exert direct premotor control over the non-twitch motoneurons. Because the two sets of motoneurons do not receive the same afferents, they must have different functions; these are not yet clarified. These results are not compatible with the concept of a single final common pathway from motoneurons to eye muscles. Putative sensory receptors, palisade endings, are located at the tips of non-twitch muscle fibers reminiscent of an inverted muscle spindle, which would make the non-twitch motoneurons, gamma-motoneurons. We propose that twitch motoneurons are the major source of tension used for eye movements, whereas non-twitch motoneurons are more important for fine alignment of the eyes. Furthermore, the non-twitch motoneurons could be controlled through sensory feedback networks (including perhaps proprioceptive signals from the palisade endings) that are relayed through the superior colliculus and via cMRF to the non-twitch motoneurons. The clinical repercussions of these hypotheses are discussed.

Expression profile of epidermal differentiation complex genes in normal and anal cancer cells

Anal cancer originates from a peculiar histological region and provides a useful model for investigating alterations in proliferation and/or differentiation of neoplastic keratinocytes. Epidermal differentiation complex (EDC) genes, which form one of the major gene clusters in the human genome, are involved in the terminal differentiation of epithelial cells and in many instances have been implicated in epithelial tumours. We constructed a DNA macroarray capable of characterising the expression profiles of the entire EDC gene complex in normal mucosa and anal cancer biopsies of seven unrelated patients. Brain tissue and cultured keratinocytes were used as controls. All anal cancer samples showed expression profiles in which none of the EDC genes was silent, as evaluated by phosphor-imager analysis. Variance analysis showed significantly lower expression of SPRR2 with respect to SPRR1 or SPRR3, and significantly higher expression of S100A8 than of other S100A subfamily members. At hierarchical clustering analysis, the four basaloid anal cancer cases conglomerated in the top five positions. The macroarray method used by us provides the first demonstration of the expression profile of the EDC gene family in anal cancer, and is capable of producing significant information on the subgrouping of epithelial tumours such as anal cancer.

Peripheral neuropathy in chronic alcoholism: a retrospective cross-sectional study in 76 subjects

A consecutive sample of 76 chronic alcoholic patients was studied clinically, biochemically and electrophysiologically to assess clinical and/or subclinical signs of alcohol-related neuropathy as well as the most important and disputed risk factors for neuropathy such as age, parental history of alcoholism, nutritional status, alcoholic disease duration and total lifetime dose of ethanol (TLDE). The results show that alcohol-related neuropathy, especially when subclinical, seems to be frequent and mostly characterized by axonal degeneration of peripheral nerve fibres with earlier and more frequent involvement of sensory fibres and lower limbs. Moreover, positive family history of alcoholism, but above all alcoholic disease duration and TLDE, could be more important factors than malnutrition in determining neuropathy.

The neuronal microtubule-associated protein tau is a substrate for caspase-3 and an effector of apoptosis

We have identified a class of tau fragments inducing apoptosis in different cellular contexts, including a human teratocarcinoma-derived cell line (NT2 cells) representing committed human neuronal precursors. We have found a transition point inside the tau molecule beyond which the fragments lose their ability to induce apoptosis. This transition point is located around one of the putative caspase-3 cleavage sites. This is the only site that can be effectively used by caspase-3 in vitro, releasing the C-terminal 19 amino acids of tau. These results establish tau as a substrate for an apoptotic protease that turns tau itself into an effector of apoptosis. Accordingly, tau may be involved in a self-propagating process like what has been predicted for the pathogenesis of different neurodegenerative disorders.

Expression analysis and mutational screening of the epithelium-specific ets gene-1 (ESE-1) in patients with squamous anal cancer

To investigate whether ESE-1 gene abnormalities are involved in alterations of epithelial cell differentiation in squamous anal cancer ESE-1 expression and structure were screened in six patients by reverse transcriptase-polymerase chain reaction (RT-PCR) and automated sequence analysis. The complete cDNA of isoform ESE-1b was always expressed and correctly spliced, with single nucleotide polymorphism being observed in two cases. Presence of ESE-1b point mutations was excluded. Expression of SPRR2A and ENDOA/CK8, two epithelium-specific ESE-1 target genes, were revealed by RT-PCR in all cases. This first report of expression of ESE-1, and of SPRR2A and ENDOA/CK8 (both related to terminal differentiation in different types of epithelia lining) in anal cancer excludes the hypothesis that these genes influenced carcinogenesis in our patients. Despite selecting of patients without clinical evidence of HPV infection, PCR consistently revealed HPV-16 DNA, highlighting the importance of HPV infection in anal cancer.

Neuronal propagation of HSV1 from the oral mucosa to the eye

PURPOSE

To identify possible neuronal pathways leading to herpetic ocular disease after primary oral infection in mice.

METHODS

The SC16 strain of herpes simplex virus (HSV)-1 (10(6) plaque-forming units) was injected into the mucocutaneous border of the left upper lip. Animals were killed 2 to 10 days postinoculation (DPI). Spread of the virus in neural structures was studied by immunochemistry.

RESULTS

HSV1 first replicated at the site of inoculation and then at the superior cervical ganglion (at 2 DPI). The trigeminal ganglion and the facial nerve fibers were infected by 4 DPI. Infection of the ciliary body and iris occurred at 6 DPI, together with several brain stem nuclei belonging to the autonomic or sensory pathways. Between 8 and 10 DPI, the neural infection gradually cleared up, except for the ipsilateral sympathetic ganglion, and ipsilateral keratitis appeared in some animals.

CONCLUSIONS

The pattern of viral dissemination in this mouse model suggests that infection of iris and ciliary body results from transfer of virus in the superior cervical ganglion from sympathetic neurons innervating the lip to neighboring neurons innervating the anterior uvea. Later, zosteriform spread of virus from the trigeminal system may have contributed to the clinical and histologic findings.

Gender and peripheral neuropathy in chronic alcoholism: a clinical-electroneurographic study

In some alcohol-related pathologies of chronic alcoholism women are more vulnerable than men. A consecutive sample of 62 chronic alcoholics was studied, 18 females and 44 males, aged between 28 and 69 years to assess the incidence and distribution of peripheral neuropathy with regard to gender. All patients underwent clinical and neurological observations, laboratory tests, and electroneurography. Total lifetime dose of ethanol (TLDE) and other risk factors for neuropathy (disease duration, age, nutritional status) were calculated and correlated to sural nerve sensory-evoked potential (SEP) amplitude. In 42 patients (67.7%), we observed the presence of clinical and/or infraclinical neuropathy, mostly axonal, in 29 males (65.9%) and 13 females (72.2%). In women, compared to men, TLDE and disease duration were significantly inversely correlated to sural nerve SEP amplitude, i.e. in women, SEP amplitude is significantly reduced in relation to TLDE and disease duration increase. These data indicate a higher sensitivity of females towards the toxic effects of ethanol, other than malnutrition, on peripheral nerve fibres.

Alzheimer-like neurodegeneration in aged antinerve growth factor transgenic mice

Neurotrophin nerve growth factor (NGF) has been suggested to be involved in age-related neurodegenerative diseases, but no transgenic model is currently available to study this concept. We have obtained transgenic mice expressing a neutralizing anti-NGF recombinant antibody, in which the levels of antibodies are three orders of magnitude higher in adult than in newborn mice [F.R., S. C. , A.C., E. Di Daniel, J. Franzot, S. Gonfloni, G. Rossi, N. B. & A. C. (2000) J. Neurosci., 20, 2589-2601]. In this paper, we analyze the phenotype of aged anti-NGF transgenic mice and demonstrate that these mice acquire an age-dependent neurodegenerative pathology including amyloid plaques, insoluble and hyperphosphorylated tau, and neurofibrillary tangles in cortical and hippocampal neurons. Aged anti-NGF mice also display extensive neuronal loss throughout the cortex, cholinergic deficit in the basal forebrain, and behavioral deficits. The overall picture is strikingly reminiscent of human Alzheimer's disease. Aged anti-NGF mice represent, to our knowledge, the most comprehensive animal model for this severe neurodegenerative disease. Also, these results demonstrate that, in mice, a deficit in the signaling and/or transport of NGF leads to neurodegeneration.

Neuronal pathways for the propagation of herpes simplex virus type 1 from one retina to the other in a murine model

Herpetic retinitis in humans is characterized by a high frequency of bilateral localization. In order to determine the possible mechanisms leading to bilateral retinitis, we studied the pathways by which herpes simplex virus type 1 (HSV-1) is propagated from one retina to the other after intravitreal injection in mice. HSV-1 strain SC16 (90 p.f.u.) was injected into the vitreous body of the left eye of BALB/c mice. Animals were sacrificed 1, 2, 3, 4 and 5 days post-inoculation (p.i.). Histological sections were studied by immunochemical staining. Primary retinitis in the inoculated eye (beginning 1 day p.i.) was followed by contralateral retinitis (in the uninoculated eye) starting at 3 days p.i. Infected neurons of central visual pathway nuclei (lateral geniculate nuclei, suprachiasmatic nuclei and pretectal areas) were detected at 4 days p.i. Iris and ciliary body infection was minimal early on, but became extensive thereafter and was accompanied by the infection of connected sympathetic and parasympathetic pathways. The pattern of virus propagation over time suggests that the onset of contralateral retinitis was mediated by local (non-synaptic) transfer in the optic chiasm from infected to uninfected axons of the optic nerves. Later, retinopetal transneuronal propagation of the virus from visual pathways may have contributed to increase the severity of contralateral retinitis.