Swiss consensus on the role of DHEA in the management of genitourinary syndrome of menopause

Genitourinary syndrome of menopause (GSM) has a significantly negative impact on affected women's lives. However, despite the increasing number of GSM treatment options (e.g. non-hormonal vaginal products, vaginal hormones [estrogens], dehydroepiandrosterone [DHEA; prasterone], vaginal laser therapy, oral ospemifene), many women remain untreated. The goal of the Swiss interdisciplinary GSM consensus meeting was to develop tools for GSM management in daily practice: a GSM management algorithm (personalized medicine); a communication tool for vaginal DHEA (drug facts box); and a communication tool for understanding regulatory authorities and the discrepancy between scientific data and package inserts. The acceptance and applicability of such tools will be further investigated.

Randomised controlled trial on the effect of clomiphene citrate and gonadotropin dose on ovarian response markers and IVF outcomes in poor responders

STUDY QUESTION

Does the gonadotropin (GN) starting dose and the addition of clomiphene citrate (CC) during the early follicular phase influence oocyte yield in poor responders undergoing ovarian stimulation for IVF treatment?

SUMMARY ANSWER

The number of retrieved oocytes was similar regardless of the starting dose of GN (150 versus 450 IU) with or without the addition of CC (100 mg from Day 3 to 7 versus placebo).

WHAT IS KNOWN ALREADY

ART in poor responders is a challenge for patients and clinicians. So far, randomised controlled studies addressing interventions have shown that neither the GN dose nor the addition of oral medication has any significant effect on the clinical outcome of ART in poor responders. There is limited knowledge about the effect of GN starting dose in combination with CC during the early follicular phase of ovarian stimulation on ovarian response markers and ART outcome.

STUDY DESIGN, SIZE, DURATION

This single-centre randomised double-blinded clinical trial was conducted from August 2013 until November 2017. Using the Bologna criteria, 220 of 2288 patients (9.6%) were identified as poor responders and 114 eligible participants underwent ovarian stimulation in a GnRH-antagonist protocol for ART.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The participants were equally randomised to one of four treatment arms: Group A (n = 28) received 100 mg CC (Day 3-7) and a starting dose of 450 IU HMG, Group B (n = 29) received 100 mg CC and a starting dose of 150 IU HMG, Group C (n = 30) received placebo and a starting dose of 450 IU HMG and Group D (n = 27) received placebo and a starting dose of 150 IU HMG. Serum levels of FSH, LH, estradiol and progesterone were measured on Day 1 and 5 and on the day of ovulation induction. Available embryos were cultured up to the blastocyst stage and were always transferred in the same cycle. The primary outcome was the number of oocytes collected after ovarian stimulation. Other outcome measures were response to ovarian stimulation, embryo development and obstetrical outcome.

MAIN RESULTS AND THE ROLE OF CHANCE

All study participants (n = 114) fulfilled at least two of the Bologna criteria for poor responders. Median age of the study population was 38.5 years. There were 109 patients who underwent oocyte retrieval. The number of oocytes retrieved was similar among the groups (±SD; 95% confidence intervals); A: 2.85 (±0.48; 2.04-3.98), B: 4.32 (±0.59; 3.31-5.64); C: 3.33 (±0.52; 2.45-4.54); D: 3.22 (±0.51; 2.36-4.41); P overall = 0.246. However, ovarian stimulation with 150 IU plus CC resulted in a higher number of blastocysts compared to ovarian stimulation with 450 IU plus CC (±SD; 95% confidence intervals); A: 0.83 (±0.15; 0.58-1.2), B: 1.77 (±0.21; 1.42-2.22); P overall = 0.006. Mean FSH serum levels were lower in the groups with a starting dose of 150 IU. Adding CC did not affect mean serum FSH levels. There were no differences in estradiol concentrations among the groups. Endometrial thickness was lower in the groups receiving CC. The overall live birth rate (LBR) was 12.3%, and the cumulative LBR was 14.7%.

LIMITATIONS, REASONS FOR CAUTION

The trial was powered to detect differences in neither the number of blastocysts nor the LBR, which would be the preferable primary outcome of interventional trials in ART.

WIDER IMPLICATIONS OF THE FINDINGS

We found that ovarian stimulation with 150 IU gonadotrophin in combination with 100 mg CC produced more blastocysts. The effect of adding CC to GN on LBR in poor responders remains to be proven in randomised trials. High GN doses (450 IU) resulted in high FSH serum levels but increased neither the estradiol levels nor the number of retrieved oocytes, implying that granulosa cell function is not improved by high FSH serum levels. Lower starting doses of GN lead to a reduction of costs of medication. The small but significant difference in blastocyst formation and the lower FSH levels in the treatment groups receiving less GN may be an indication of better oocyte quality with higher developmental competence.

STUDY FUNDING/COMPETING INTEREST(S)

The costs for the HMG used for ovarian stimulation were provided by IBSA Switzerland. The study was also supported by the Repronatal Foundation, Basel, Switzerland. The authors declare no conflict of interest.

TRIAL REGISTRATION NUMBER

NCT01577472.

TRIAL REGISTRATION DATE

13 April 2012.

DATE OF FIRST PATIENT’S ENROLMENT

August 2013.

The role of the trainer in adapted physical activity for osteoporosis to improve quality of life

Background

Osteoporosis is a major health burden worldwide and require a multi-modal approach including exercise. Fractures have a substantial impact on quality of life (QoL) so exercise programs may to be conducted by trainers able to deal with this condition, because exercise alone, even if in the right dosage, seems to be not enough to improve QoL. A quasi-experimental pilot study performed to determine the feasibility and safety of an Adapted Physical Activity (APA) protocol specifically designed for osteoporotic women with vertebral fractures and its effect on QoL, with a specific focus on trainer's role.

Methods

The Experimental Group (EG) performed APA protocol 1hour twice a week for 6 months, while the Control Group (CG) received standard care. QoL was assessed at baseline and follow-up with ECOS-16 questionnaire and semi structured interviews to understand women perceptions regarding trainer's role. Using mixed-methods quantitative and qualitative data were analyzed using SPSS 5 and NVivo 12, respectively.

Results

40 post-menopausal women (mean age: 67.6±4.6) divided in 2 groups EG = 22 and CG = 18, completed the study. At follow-up, EG improved significantly QoL (EG: -0.5±0.5 vs CG: 0.0±0.3 p = 0.02). The APA intervention had a significant effect on all the components of QoL, as measured by the disease-specific ECOS-16 questionnaire: Physical Component Summary (PCS) (EG: -0.4±0.5 vs CG: 0.0±0.4 p = 0.06) and Mental Component Summary (MCS) (EG: -0.5±0.6 vs CG: 0.1±0.5 p = 0.02). The interviews confirmed this result, emphasizing the key role of the trainer in improving their QoL. The adherence calculated as number of sessions performed compared to the sessions proposed was 75.8%. No injuries were observed.

Conclusions

The feasibility, the safety, and the positive effect of the proposed exercise protocol on QoL confirmed also by the interviews, show that principles of exercise education applied by trainers should be extended also to patients with other chronic condition.

Key messages

Trainers specifically educated, could be a means of achieving the goal improving people’s QoL, as they occupy the role of exercise experts and also an educational, relational and support role. The management of osteoporosis is multi-modal and includes exercise, often recommended as a beneficial non-pharmacological treatment to slow the rate of bone loss and improve quality of life.

Development and validation of the multiple sclerosis questionnaire for the evaluation of job difficulties (MSQ-Job)

OBJECTIVE

Multiple sclerosis (MS) affects young adults of working age. Difficulties in work-related activities are usually ascribed to MS symptoms, while the impact of workplace features is underestimated. This article presents the Multiple Sclerosis Questionnaire for Job Difficulties (MSQ-Job), designed to assess working difficulties due to MS symptoms and workplace features.

METHODS

A sample of employed MS patients completed the MSQ-Job, the WHO-Disability Assessment Schedule (WHODAS 2.0) and the 54-items MS Quality of Life Questionnaires (MSQOL-54); the expanded disability status scale (EDSS) was used to define MS severity. Factor structure was evaluated using principal component extraction and Oblimin rotation; internal consistency was assessed with Cronbach's alpha; construct and discriminant validity using t-test (EDSS 0-2 vs >2; patients self-reporting need for support vs patients reporting no needs; full-time vs part-time employees); and Pearson's correlation with WHODAS 2.0 and MSQOL-54.

RESULTS

The MSQ-Job is a 42-item questionnaire with six scales and an overall factor. Scores range on a 0-100 scale (higher scores indicate more and more severe difficulties); patients with EDSS>2 and self-reporting support needs had worse scores than those with EDSS 0-2 and without needs. Correlations with WHODAS 2.0 and MSQOL-54 were generally significant (P < 0.0007) and below 0.70.

CONCLUSIONS

The MSQ-Job jointly measures the impact of respondents' symptoms and workplace features on work activities and enables to assess the effects of clinical and occupational interventions and better describe the impact of MS indirect costs.

Assessing human exposure to inorganic arsenic in high-arsenic areas of Latium: a biomonitoring study integrated with indicators of dietary intake

BACKGROUND

In Latium (central Italy), arsenic concentrations exceeding the regulatory limit of 10 μg/L for drinking water are present in groundwater from a large area of volcanic origin. At least in part of the area, high arsenic concentrations have been detected also in soil and phytoavailable geogenic arsenic enters the food chain. As a result, local population may be exposed to inorganic arsenic via water and also through consumption of food with higher than background arsenic concentrations.

METHODS

A cross sectional study was conducted to assess inorganic arsenic exposure and metabolism in 269 residents of 27 municipalities in the provinces of Viterbo, Rome and Latina. Total arsenic in toenails and the sum of inorganic arsenic and methylated metabolites in urine, the latter determined by HPLC-ICP-MS, were used as biomarkers of inorganic arsenic exposure. All the subjects involved in the study provided samples of the water(s) used for drinking and cooking as well as detailed information on water use. To get an insight into dietary intake from locally-processed food, inorganic arsenic in bread samples collected in affected municipalities of the three provinces was determined and compared to background levels of samples from reference areas.

RESULTS

30% of the sample used bottled water or resorted to water treatment in order to lower the arsenic content <10 μg/L (Group 1), 51% of the sample drank bottled water and used tap water with an arsenic content exceeding 10 μg/L for cooking only (Group 2), 19% of the sample used tap water with an arsenic content exceeding 10 μg/L for both drinking and cooking (Group 3). Nail arsenic was higher for Group 2 and 3 compared to Group 1, whereas all groups had higher nail arsenic than the reference group. The sum of inorganic arsenic and related metabolites in urine was higher in Group 3 than in the other two groups, and higher in Group 2 compared to Group 1. White bread from the study area showed significantly higher inorganic arsenic levels compared to samples from reference areas.

CONCLUSIONS

Use of toenail arsenic as biomarker of long-term exposure allowed to retrospectively reconstruct exposure irrespective of recent modifications due to changes in water use. In Group 3, urinary concentration of inorganic arsenic and metabolites exceeded the upper limit of the reference concentration range for the Italian population. Inter-individual variability of the efficiency of arsenic metabolism in the study population was substantial indicating that a subgroup of the population is more susceptible to the toxic effects of inorganic arsenic owing to a lower methylation capability.

Burden and cost of neurological diseases: a European North-South comparison

OBJECTIVES

To address the relationship between years lived with a disability (YLDs), prevalence and cost of neurological diseases, and to test whether there is a European North-South gradient for national health expenditure, disability, costs and prevalence of neurological diseases.

MATERIALS AND METHODS

Information on costs, prevalence and YLDs referred to 2010 were taken from the Study on the Cost of Disorders of the Brain and from the Global Burden of Disease study; data on health expenditure were taken from OECD reports. Selected conditions were as follows: brain tumours, stroke, dementia, Parkinson's disease, epilepsy, multiple sclerosis, migraine and tension-type headache; selected countries were from North (Denmark, Finland, Norway, Sweden) and South (Greece, Italy, Portugal, Spain) Europe. The association between the variables for each condition was tested using Spearman's correlation; Wilcoxon signed ranks test was used to test North-South Europe differences.

RESULTS

Correlations were largely non-significant (except for stroke). YLDs and cost were generally lower in South-European countries, and prevalence was lower in North-European countries, but no significant differences were found.

CONCLUSIONS

Health expenditure, YLDs, costs and prevalence of neurological conditions were generally not correlated across the eight countries. A clear North-South gradient was found for health expenditures, and partially for YLDs, costs and diseases' prevalence. We hypothesized that this is a consequence of the expansion of morbidity of neurological conditions connected to ageing, that health and welfare systems of selected countries were not prepared to face.

Determinants of disability using count-based approaches to ICF-based definition of neurological disability

INTRODUCTION

The aim of this study was to explore the most relevant determinants of severe disability in a heterogeneous sample of patients with neurological conditions.

OBJECTIVES

We used data from previous studies on patients with myasthenia gravis (MG), migraine, Parkinson's disease (PD), multiple sclerosis, traumatic brain injury (TBI), stroke and epilepsy (349 patients, aged 18-74 years; mean 48.0, SD 11.7). We calculated count-based extension indexes to address severe disability, and hierarchical logistic regression to assess the association between severe disability, sociodemographic and health status information.

CONCLUSIONS

Results show that sociodemographic variables played a minor role, while health state information was a stronger determinant of severe disability. Compared to the reference value of TBI patients, those with MG, PD and epilepsy had higher odds to have severe difficulties undertaking daily activities despite the presence of environmental factors. Our results contrast with those of previous studies, mostly derived from general populations, showing the different impact of clinical and sociodemographic variables.

Do diagnostic differences between vegetative state and minimally conscious state patients correspond to differences in functioning and disability profiles? Results from an observational multi-center study on patients with DOC

BACKGROUND

Patients in vegetative (VS) and minimally conscious state (MCS) have different degrees of consciousness recovery but both display severe levels of disability.

AIM

To describe and compare VS and MCS patients' functioning and disability according to ICF model (International Classification of Functioning, Disability and Health).

DESIGN

Observational cross-sectional multi-center study involving sixty-nine Italian centers.

SETTING

Patients recruited in post-acute, long-term care facilities and at home in Italy.

POPULATION

Adult patients in VS and MCS.

METHODS

ICF Functioning profiles were completed and, for each ICF chapter and domain, extension and severity indexes were developed. Indexes have been compared between VS and MCS patients with Mann Whitney U test. Descriptive statistics have been applied to describe the most relevant categories that had a percentage of missing below 25% and that were reported as a problem by at least 50% of patients.

RESULTS

A total of 564 patients were enrolled: 396 in VS (mean age 56.8), 168 in MCS (mean age 54.2). Fifty-eight ICF categories were selected: of them, 24 were from Activity and Participation (A&P). Few differences between patients in VS and MCS were reported in Body Functions (BF), mostly referred to mental, sensory and digestive functions; among A&P, differences were found only in learning chapter. For VS patients less environmental barriers were reported than MCS patients.

CONCLUSION

Patients in VS and MCS have similar functioning and disability profiles and similar needs thus levels of care and assistance should not be different across the two conditions.

CLINICAL REHABILITATION IMPACT

An ICF-based methodology of data collection enables to describe VS and MCS patients' functioning and disability: this is helpful when rehabilitation programs based on the features of single patients with DOC need to be planned.

Disability and quality of life in headache: where we are now and where we are heading

Headache disorders determine relevant personal and societal burden, and thus the use of patient-reported outcome measures (PROMs) investigating the level of disability and health-related quality of life (HRQoL) have been increasingly used in headache research. The aim of this review was to address the status of research on disability and HRQoL, by addressing results from recently published clinical trials as well as in longitudinal observational studies on headache patients. PubMed has been searched for papers in which measures of HRQoL and/or disability were used as primary or secondary outcome on adult subjects with primary headache, and published in 2010-2012. Among the 70 records retrieved, 12 papers were selected for narrative synthesis. They included data on 2,621 patients with episodic migraine with and without aura, chronic daily headache, and/or chronic migraine with and without medication overuse. The selected trials investigated the efficacy of different pharmacological prophylaxis, of some surgical approaches, of education programmes and osteopathic manipulative treatment; two studies reported longitudinal observations of patients currently under treatment. Overall, the results of our review showed that headache frequency as well as HRQoL and disability were positively impacted by treatment interventions; positive outcomes were less evident in two studies, and similar results were found in the two observational studies. Our findings confirmed that the most commonly used PROMs, including disease-specific tools to assess disability and HRQoL and SF-36, are sensitive to the beneficial effects occurring over time in functioning and quality of life domains in headache patients. They also suggest that the personal and societal costs of headache disorders are likely to be reduced when headache patients receive appropriate treatments and when continuity of care is offered. In terms of future directions, we note that the systematic use of appropriate PROMs should be encouraged both in the clinical practice and in the research field, as they offer a valid option to assess the global effect of treatments on patient-perceived sense of well-being and quality of performance.

Usefulness of ICF-CY to define functioning and disability in very low birth weight children: a retrospective study

BACKGROUND

Preterm birth is associated with variable degrees of brain injury, adverse neurodevelopmental outcomes and continuing special health care needs.

STUDY AND AIMS

This observational, retrospective and cross-sectional study aims to describe the functional features of VLBW infants using the ICF-CY classification and to identify the association between gender, twinship, birth weight, gestational age, adjusted age and functioning as defined by the ICF biopsychosocial model.

SAMPLE

56 VLBW infants (corrected age of 12-24 months) were consecutively enrolled.

INSTRUMENTS

Three assessment tools were used: a neuro-functional assessment (NFA); the Griffiths Mental Development Scales-Revised: Birth to 2 years (Griffiths 0-2) to evaluate psychomotor development and the ICF-CY questionnaire for ages 0-3.

RESULTS

A two-step cluster component analysis with the Bayesian information criterion was conducted based on NFA and Griffiths 0-2 scores and four groups of infant's functioning (very low, low, intermediate, high) emerged. Study findings demonstrate that the traditional assessment tools tend to poorly evaluate the interaction between the person's functioning and environment factors (EF), even thought EF results to be relevant for VLBW infants. The higher number of symptoms, more difficulties in activities and participations and the higher number of environmental facilitators maximize the difference between infants with very low and those with intermediate or higher functioning. The distribution of gender or the presence of siblings is not significantly associated to any group.

CONCLUSION

This study shows that a more complete evaluation of functioning of VLBW children, based on the biopsychosocial approach, is needed and can be successfully implemented in the follow-up routine through ICF-CY questionnaire.

Physical and mental health, anxiety and depressive symptoms in caregivers of patients in vegetative state and minimally conscious state

Caregivers of patients in vegetative state and minimally conscious state play a crucial role in the process of taking care and, as previous studies reported, they can suffer of high burden and negative health outcomes. The aim of this national cross-sectional study was to assess whether physical and mental health of caregivers, considering gender differences, is related to the presence of depressive symptoms, anxiety, age and patient's disease duration. Four-hundred and eighteen caregivers, 294 women and 124 men, completed the State Trait Anxiety Inventory-Y, Beck Depression Inventory, second version and Short Form-12. Hierarchical multiple regression analyses were performed to evaluate to which extent depressive and anxiety symptoms predict physical and mental health. Men reported higher levels of mental health state, whereas physical health was not different across gender. High levels of anxiety symptoms were associated to negative mental health outcomes in both genders, whereas depressive symptoms were found to impact on female's mental and physical health only. A comprehensive and cost-effective screening of anxiety and depressive symptoms may help to identify determinants of health worsening in order to plan, when necessary, caregivers' support.

KEY PRACTITIONER MESSAGES

Female caregivers of patients in vegetative state and minimally conscious state have poorer levels of mental health, whereas physical health is similar to men's. Anxiety symptoms are related to negative mental health outcomes in both male and female caregivers, whereas depressive symptoms are found to impact on female mental and physical health only. It is essential to consider and assess depressive and anxiety symptoms as they may contribute to caregivers' health worsening. This knowledge can lead to plan more comprehensive and tailored caregivers' supports and a better care for patients.

Burden of caregivers of patients in Vegetative state and minimally conscious state

OBJECTIVES

To assess differences in the burden of caregivers of patients in Vegetative state (VS) and minimally conscious state (MCS).

MATERIALS AND METHODS

The Family Strain Questionnaire, Coping Orientations to Problem Experiences, Caregiver Needs Assessment, Short Form-12, Beck Depression Inventory and State-Trait Anxiety Inventory were used. Differences in psychological condition between caregivers of VS and MCS patients, with different disease duration and hosting facility were assessed with Kruskall-Wallis test and factors associated with the overall levels of burden with UNIANOVA.

RESULTS

In total, 487 participants were enrolled. Daily hours of care-giving is significantly associated with the overall level of burden perceived by caregivers (F = 4.099; P = 0.018). Strain, needs and frequency of use of coping strategies are substantially similar regardless of the patient's condition and distance from the acute event. Caregivers of post-acute patients reported low scores in mental health (median = 33.8; IQR = 23.1-47.6) and higher state of anxiety (median = 54; IQR = 45-62), whereas caregivers of long-term patients expressed more needs in social involvement (median = 19; IQR = 15-22).

CONCLUSIONS

Burden and distress were high for all caregivers of VS and MCS patients. As care-giving is a long-term commitment process, support to the caregiver should be guaranteed throughout the duration of the relative's disease despite the patient's diagnosis or place where the patient is hosted.

Absence of cardiovascular disease risk factors in restless legs syndrome

OBJECTIVE

Restless legs syndrome (RLS) might represent a condition at risk of cardiovascular (and cerebrovascular) disease; the role of sleep periodic leg movements, sleep deprivation, and presence of common risk factors for heart disease in these patients remains to be determined. The aim of this study was to evaluate the eventual presence of risk factors for cerebrovascular disease in RLS.

MATERIALS & METHODS

Eighty-seven consecutive patients affected by idiopathic RLS were included in this study together with 81 controls. Blood count, chemistry, and kidney function tests were obtained. We detected subjects suffering from diabetes mellitus, kidney diseases, heart diseases, disk herniation, neuropathy, blood diseases, liver diseases, artery diseases, dyslipidemia, or hypertension. Polysomnography was recorded in 66 patients, and cerebral neuroimaging was obtained in 59 patients with RLS.

RESULTS

None of the differences in blood test parameters was statistically significant; however, hypertension was found to be more frequent in controls and dyslipidemia was more frequent in patients with RLS, but this was explained by its higher frequency in patients also affected by obstructive sleep apnea. A diagnosis of cerebrovascular disease was posed for 14 patients with RLS (16.1%), but no predictive factor for its presence was found at the binomial logistic regression.

CONCLUSION

Our findings argue against the presence of an altered lipid metabolism as a risk factor for the development of cerebrovascular disease in patients with RLS, even if they do support the idea that cerebrovascular disease might be frequent in this condition.

Children in vegetative state and minimally conscious state: patients' condition and caregivers' burden

Caring for children in vegetative state (VS) or minimally conscious state (MCS) challenges parents and impacts on their well-being. This study aims to evaluate caregivers' health condition, coping, anxiety and depression levels, and how these issues relate to children's disability. 35 children with VS and MCS were administered the disability rating scale (DRS) and 35 caregivers completed the Coping Orientations to Problem Experiences, Short Form-12, Beck Depression Inventory, and the Spielberger State-Trait Anxiety Inventory-Y. Children were mainly males (68.6%), hosted at domicile (77.1%), and diagnosed with VS (60%), with anoxic aetiology (45.7%). Caregivers were mainly mothers (85.7%), married (82.9%), and housewives (51.4%); 60% declared financial difficulties, and 82.9% provided full-time assistance. 57.2% reported depressive symptoms, poor mental health, and high level of state and trait anxiety. “Problem-oriented” (P < 0.001) and “emotional-oriented” (P < 0.001), were more adopted than “potentially dysfunctional” ones. DRS scores (mean = 22.0; SD = 1.9) did not significantly correlate to any psychological measure. Rehabilitative programs for children with SV and SMC should also provide interventions on surrounding systems: improving the network of psychological support and social assistance may decrease the burden of caregivers and, in turn, improve caring abilities and children quality of life.

Evidence that muscle cells do not express the histidine-rich glycoprotein associated with AMP deaminase but can internalise the plasma protein

Histidine-rich glycoprotein (HRG) is synthesized by liver and is present at relatively high concentration in the plasma of vertebrates. We have previously described the association of a HRG-like molecule to purified rabbit skeletal muscle AMP deaminase (AMPD). We also provided the first evidence for the presence of a HRG-like protein in human skeletal muscle where a positive correlation between HRG content and total determined AMPD activity has been shown. In the present paper we investigate the origin of skeletal muscle HRG. The screening of a human skeletal muscle cDNA expression library using an anti-HRG antibody failed to reveal any positive clone. The RT-PCR analysis, performed on human skeletal muscle RNA as well as on RNA from the rhabdomyosarcoma (RD) cell line, failed to show any mRNA specific for the plasma HRG or for the putative muscle variant. When the RD cells were incubated with human plasma HRG, a time-dependent increase of the HRG immunoreactivity was detected both at the plasma membrane level and intracellularly. The internalisation of HRG was inhibited by the addition of heparin. The above data strongly suggest that skeletal muscle cells do not synthesize the muscle variant of HRG but instead can actively internalise it from plasma.

Sleep disorders in neurodegenerative diseases

The aim of this review is to provide data on sleep disturbances in three categories of neurodegenerative disorders: synucleinopathies, tauopathies, and other diseases (this heterogeneous group includes also spinocerebellar degeneration and amyotrophic lateral sclerosis). Analysing and knowing sleep disorders in neurodegenerative diseases may offer important insights into the pathomechanism of some of these diseases and calls attention to the still insufficiently known 'sleep neurology'. The identification of sleep disorders in some neurodegenerative conditions may make their diagnosis easier and earlier; for example, rapid eye movements sleep behaviour disorder may precede any other clinical manifestation of synucleinopathies by more than 10 years.

A calpain-like proteolytic activity produces the limited cleavage at the N-terminal regulatory domain of rabbit skeletal muscle AMP deaminase: evidence of a protective molecular mechanism

On storage at 4 degrees C, rabbit skeletal muscle AMP deaminase undergoes limited proteolysis with the conversion of the native 85-kDa enzyme subunit to a 75-kDa core that is resistant to further proteolysis. Further studies have shown that limited proteolysis of AMP deaminase with trypsin, removing the 95-residue N-terminal fragment, converts the native enzyme to a species that exhibits hyperbolic kinetics even at low K+ concentration. The results of this report show that a 21-residue synthetic peptide, when incubated with the purified enzyme, is cleaved with a specificity identical to that reported for ubiquitous calpains. In addition, the cleavage of a specific fluorogenic peptide substrate by rabbit m-calpain is inhibited by a synthetic peptide that corresponds to residues 10-17 of rabbit skeletal muscle AMP deaminase; this peptide contains a sequence (K-E-L-D-D-A) that is present in the fourth subdomain A of rabbit calpastatin, suggesting that the N-terminus of AMP deaminase shares with calpastatin a regulatory sequence that might exert a protective role against the fragmentation-induced activation of AMP deaminase. These observations suggest that a calpain-like proteinase present in muscle removes from AMP deaminase a domain that holds the enzyme in an inactive conformation and which also contains a regulatory region that protects against unregulated proteolysis. We conclude that proteolysis of AMP deaminase is the basis of the large ammonia accumulation that occurs in skeletal muscle subjected to strong tetanic contraction or passing into rigor mortis.

Cytokine-regulated expression of collagenase-2 (MMP-8) is involved in the progression of ovarian cancer

Matrix metalloproteinases (MMPs) have been implicated in ovarian cancer progression. Among them, MMP-8 that degrades type I collagen may play a crucial role. The aim of our study was to determine MMP-8 expression and regulation in ovarian cancer and its association with other MMPs and tissue inhibitors of metalloproteinases (TIMPs). Tissue microarrays (TMAs) containing tissue cylinders from 302 patients were used for immunohistochemical studies. In addition, MMP-8 expression in vitro was analysed by a specific immunoassay and PCR-analysis. MMP-7 (81%), MMP-8 (95%), MT3-MMP (100%), TIMP-2 (100%), and TIMP-3 (96%) were expressed in all the OVCAs, but the staining intensities varied. MMP-3 (6%), MMP-9 (57%) and TIMP-1 (43%) expressions were more rarely detected. Only MMP-8 expression levels correlated with tumour grade (P<0.01), tumour stage (P<0.01), and a poor prognosis (P<0.05). MMP-8 protein and gene expression in vitro was found to be significantly upregulated by interleukin-1beta (IL-1beta, P<0.01). The data indicate that MMP-8 overexpression in OVCAs is regulated by IL-1beta and that pro-inflammatory cytokines may promote the invasive potential of ovarian cancer.

From durum wheat to pasta: effect of technological processing on the levels of arsenic, cadmium, lead and nickel--a pilot study

A study was undertaken to investigate the effect of technological processing in pasta-making on the content of arsenic, cadmium, lead and nickel. Milling of durum wheat as well as further processing were carried out in a pilot plant. Commercial pasta samples purchased from the local market were also included for comparison. Furthermore, the effect of cooking was investigated to gain information on the actual content of the selected elements in the final ready-to-eat product. Analyte concentrations in whole grain, semolina, pasta and cooked pasta were determined by inductively coupled plasma-mass spectrometry. Milling reduced the element content in the order nickel > arsenic > cadmium > lead. In the experimental conditions of this study, slight contamination by atmospheric lead in milling/pasta-making and release of nickel during pasta-making were observed. These issues have evidently been effectively dealt with in industrial processing given that remarkably lower levels of lead and nickel were found in commercial pastas compared with the experimental samples. On the whole, commercial pasta samples showed low average levels of all the elements included in this study. Cooking caused a significant decrease of the element content in all pasta samples, with average losses of 50-60% on a dry weight basis.

Influence of laboratory homogenization procedures on trace element content of food samples: an ICP-MS study on soft and durum wheat

Sample contamination as a consequence of abrasion of grinding tools during the homogenization of food materials to be analysed for trace elements was addressed. The possible release of 15 trace elements (Al, As, Cd, Co, Cr, Cu, Fe, Mn, Mo, Ni, Pb, Se, Sn, V, Zn) from six different grinding and milling devices, operating either continuously or discontinuously, was evaluated. All the devices were commercially available and were representative of models usually employed in food and agricultural laboratories. Wheat grains belonging to one soft and one durum cultivar were used as test material. The determination of the analyte concentrations in subsamples submitted to the different preparation treatments was performed by quadrupole inductively coupled plasma mass spectrometry (Q-ICP-MS). Accordingly, a suitable digestion method was developed and the ArC+ interference affecting Cr determination was evaluated and corrected. Statistical differences with respect to the control were detected for 10 elements (Al, Cd, Co, Cr, Cu, Fe, Mn, Mo, Ni, Pb) and in most cases contamination of the samples was traced back to the composition of the grinding equipment. None of the investigated devices was contamination-free with respect to all of the quantified elements. Abrasion of the grinding tools was higher with durum wheat than with soft wheat as a consequence of their different hardiness.

Regulation of skeletal muscle AMP deaminase: lysine residues are critical for the pH-dependent positive homotropic cooperativity behaviour of the rabbit enzyme

Reaction of rabbit skeletal muscle AMP deaminase with a low molar excess of trinitrobenzene sulfonic acid (TNBS) results in conversion of the enzyme into a species with about six trinitrophenylated lysine residues per molecule which no longer manifests positive homotropic cooperativity at pH 7.1 or at the optimal pH value of 6.5 in the presence of low K+ concentrations. Substitution of the reactive thiol groups with 5,5'-dithiobis-(2-nitrobenzoic acid) does not protect the enzyme from the TNBS-induced changes of the catalytic properties, indicating that cysteine residues modification is not at the basis of the effects of TNBS treatment on AMP deaminase and strongly suggesting the obligatory participation of lysine residues to the constitution of a regulatory anionic site to which AMP must bind to stimulate the enzyme at alkaline pH. The TNBS-treated enzyme is also completely desensitized to inhibition by ATP, but not to inhibition by GTP and stimulation by ADP. This observation suggests a connection between the operation of the hypothesized anionic activating site, responsible for positive homotropic cooperativity, and the inhibition exerted by anionic compounds that compete for the same site, among them the most efficient metabolite being probably ATP.

Presence in human skeletal muscle of an AMP deaminase-associated protein that reacts with an antibody to human plasma histidine-proline-rich glycoprotein

Histidine-proline-rich glycoprotein (HPRG) is a protein that is synthesized by parenchimal liver cells. The protein has been implicated in a number of plasma-specific processes, including blood coagulation and fibrinolysis. We have recently reported the association of an HPRG-like protein with rabbit skeletal muscle AMP deaminase (AMPD). The results of the immunological analysis reported here demonstrate that an antibody against human plasma HPRG reacts with an AMPD preparation from human skeletal muscle. To probe the localization of the putative HPRG-like protein in human skeletal muscle, serial sections from frozen biopsy specimens were processed for immunohistochemical and histoenzymatic stains. A selective binding of the anti-HPRG antibody to Type IIB muscle fibers was detected, suggesting a preferential association of the novel protein to the AMPD isoenzyme contained in the fast-twitch glycolytic fibers.

Presence in human skeletal muscle of an AMP deaminase-associated protein that reacts with an antibody to human plasma histidine-proline-rich glycoprotein

Histidine-proline-rich glycoprotein (HPRG) is a protein that is synthesized by parenchimal liver cells. The protein has been implicated in a number of plasma-specific processes, including blood coagulation and fibrinolysis. We have recently reported the association of an HPRG-like protein with rabbit skeletal muscle AMP deaminase (AMPD). The results of the immunological analysis reported here demonstrate that an antibody against human plasma HPRG reacts with an AMPD preparation from human skeletal muscle. To probe the localization of the putative HPRG-like protein in human skeletal muscle, serial sections from frozen biopsy specimens were processed for immunohistochemical and histoenzymatic stains. A selective binding of the anti-HPRG antibody to Type IIB muscle fibers was detected, suggesting a preferential association of the novel protein to the AMPD isoenzyme contained in the fast-twitch glycolytic fibers.

Association of purified skeletal-muscle AMP deaminase with a histidine-proline-rich-glycoprotein-like molecule

Denaturation of rabbit skeletal-muscle AMP deaminase in acidic medium followed by chromatography on DEAE-cellulose in 8 M urea atpH 8.0 allows separation of two main peptide components of similar apparent molecular mass (75-80 kDa) that we tentatively assume correspond to two different enzyme subunits. Whereas the amino acid composition of one of the two peptides is in good agreement with that derived from the nucleotide sequence of the known rat and human AMPD1 cDNAs, the second component shows much higher contents of proline, glycine and histidine. N-Terminal sequence analysis of the fragments liberated by limited proteolysis with trypsin of the novel peptide reveals a striking similarity to the fragments produced by plasmin cleavage of the rabbit plasma protein called histidine-proline-rich glycoprotein (HPRG). However, some divergence is observed between the sequence of one of the fragments liberated from AMP deaminase by a more extensive trypsinization and rabbit plasma HPRG in the region containing residues 472-477. A fragment with a blocked N-terminus, which was found among those liberated by proteolysis with pepsin of either whole AMP deaminase or the novel component of the enzyme, shows an amino acid composition quite different from that of the N-terminus of the known subunit of AMP deaminase. By coupling this observation with the detection in freshly prepared AMP deaminase of a low yield of the sequence (LTPTDX) corresponding to that of HPRG N-terminus, it can be deduced that in comparison with HPRG, the putative HPRG-like component of AMP deaminase contains an additional fragment with a blocked N-terminus, which is liberated by a proteolytic process during purification of the enzyme. The implications of the association to rabbit skeletal-muscle AMP deaminase of a HPRG-like protein species are discussed.

Regulation of skeletal-muscle AMP deaminase: involvement of histidine residues in the pH-dependent inhibition of the rabbit enzyme by ATP

Reaction of rabbit skeletal-muscle AMP deaminase with a low molar excess of diethyl pyrocarbonate results in conversion of the enzyme into a species with one or two carbethoxylated histidine residues per subunit that retains sensitivity to ATP at pH 7.1 but, unlike the native enzyme, it is not sensitive to regulation by ATP at pH 6.5. This effect mimics that exerted on the enzyme by limited proteolysis with trypsin, which removes the 95-residue N-terminal region from the 80 kDa enzyme subunit. These observations suggest involvement of some histidine residues localized in the region HHEMQAHILH (residues 51-60) in the regulatory mechanism which stabilizes the binding of ATP to its inhibitory site at acidic pH. Carbethoxylation of two histidine residues per subunit abolishes the inhibition by ATP of the proteolysed enzyme at pH 7.1, suggesting the obligatory participation of a second class of histidine residues, localized in the 70 kDa subunit core, in the mechanism of the pH-dependent inhibition of the enzyme by ATP. At a slightly acidic pH, these histidine residues would be positively charged, resulting in a desensitized form of the enzyme similar to that obtained with the carbethoxylation reaction.

Evidence of a species-differentiated regulatory domain within the N-terminal region of skeletal muscle AMP deaminase

Rabbit skeletal muscle AMP deaminase was submitted to limited proteolysis by trypsin that converts the native 80 kDa enzyme subunit to a stable product of approx. 70 kDa, which, in contrast to the native enzyme, is not sensitive to regulation by ATP at pH 6.5. Tryptic peptide mapping indicates that proteolysis is confined to the N-terminal region of the molecule, identifying in this region of AMP deaminase a non-catalytic, 95 residue regulatory domain that stabilises the binding of ATP to a distant site in the molecule. Protein sequence analysis reveals a marked degree of divergence between rat and rabbit skeletal muscle AMP deaminases in the regions containing residues 7-12 and 51-52, giving molecular basis to the hypothesis of the existence of isoenzymes of AMP deaminase in the mature skeletal muscle of the mammals.

Regulation of skeletal-muscle AMP deaminase. Evidence for a highly pH-dependent inhibition by ATP of the homogeneous derivative of the rabbit enzyme yielded by limited proteolysis

Limited proteolysis of rabbit skeletal-muscle AMP deaminase (AMP aminohydrolase, EC 3.5.4.6) with trypsin results in conversion of the enzyme into a species which over the pH range 6.5-7.1 exhibits hyperbolic kinetics at low K+ concentration even in the absence of ADP, but shows a 20% decrease in activity at saturating substrate concentration. Analysis by sedimentation-equilibrium techniques reveals the proteolysed enzyme to be homogeneous and to have a molecular mass of 222,000 Da, indicative of a trimeric structure with a subunit molecular mass of 72,000 Da, in contrast with the tetrameric structure of the native enzyme, composed of four 79,000-Da subunits. These observations suggest a role of the 7,000-Da fragment which is removed by proteolysis in the maintenance of the three-dimensional structure of the subunit that causes the enzyme at low K+ concentration to show homotropic positive co-operativity. Study of the influence of pH, isolated from that of K+, on the kinetics of AMP deaminase reveals a highly pH-dependent inhibitory effect by ATP which is completely absent at acid pH values and abruptly manifests itself just above neutrality. This phenomenon may have significance in the metabolism of exercising muscle, in connection with the pH-dependent interaction of AMP deaminase with the thick filament.

Structure-function relationships in cardiac troponin T

Regions of rabbit and bovine cardiac troponin T that are involved in binding tropomyosin, troponin C and troponin I have been identified. Two sites of contact for tropomyosin have been located, situated between residues 92-178 and 180-284 of troponin T. A cardiac-specific binding site for troponin I has been identified between residues 1-68 of cardiac troponin T, within a region of the protein that has previously been shown to be encoded by a series of exons that are expressed in a tissue-specific and developmentally regulated manner. The binding site for troponin C is located between residues 180-284 of cardiac troponin T. When isolated from fresh bovine hearts, cardiac troponin T contained 0.21 +/- 0.11 mol phosphate per mol; incubation with phosphorylase kinase increased the phosphate content to approx. 1 mol phosphate per mol. One site of phosphorylation was identified as serine-1; a second site of phosphorylation was located within peptide CB3 (residues 93-178) and has been tentatively identified as serine-176. Addition of troponin C to cardiac troponin T does not inhibit the phosphorylation of this latter protein that is catalysed by phosphorylase b kinase.

Regulatory properties of AMP deaminase isoenzymes from rabbit red muscle

We examined the kinetic and regulatory properties of the two isoenzymes of red muscle AMP deaminase, forms A and B, corresponding respectively to the single isoenzymes present in the heart and white skeletal muscle. At the optimal pH value, 6.5, both enzymes show hyperbolic substrate-velocity curves and are inhibited by GTP, inducing sigmoid kinetics. An effect similar to that of GTP is exerted on form B by ATP, whereas form A is almost insensitive to this nucleotide. At pH 7.1 both enzymes follow sigmoid kinetics. ATP enhances the sigmoidicity of the substrate-velocity curve of form B, but it stimulates form A, reverting sigmoidal to hyperbolic kinetics shown by the enzyme at optimal pH. At pH 7.1, form A is also less sensitive to the inhibitory action of Pi and GTP. These results suggest that, owing to the presence of form A, AMP deamination occurs in red muscle also at moderate work intensity. A possible role of this process in counteracting the production of adenosine by 5'-nucleotidase is hypothesized.

Interaction with troponin T from white skeletal muscle restores in white skeletal muscle AMP deaminase those allosteric properties removed by limited proteolysis

Limited proteolysis of rabbit skeletal muscle AMP deaminase (AMP aminohydrolase, EC 3.5.4.6) with trypsin results in conversion of the enzyme to a form which is no longer inhibited by ATP and exhibits hyperbolic kinetics even at low K+ concentration and in the absence of ADP. The interaction with troponin T from white skeletal muscle or with the phosphorylated 42-residue N-terminal peptide of troponin T restores in the trypsin-treated AMP deaminase the sensitivity to adenine nucleotides and increases the KA for K+ activation of the enzyme from 1 mM to 12 mM, this effect being diametrically opposite to that exerted by limited proteolysis on the native enzyme. Treatment of the N-terminal peptide of troponin T with alkaline phosphatase abolishes the modulating properties of the peptide, suggesting that phosphorylation-dephosphorylation processes may be involved in the regulation of the enzyme.

Effect of pH and KCl on aggregation state and sulphydryl groups reactivity of rat skeletal muscle AMP deaminase

The effects of pH and KCl on sedimentation properties and SH groups reactivity of rat skeletal muscle AMP deaminase have been investigated. The values obtained for apparent molecular weight are consistent with an association of AMP deaminase subunits in response to increasing KCl concentration. Increasing pH value from 6.0 to 8.0 causes a reduction in the apparent molecular weight of the enzyme at high KCl concentration, which can be interpreted as due to a deprotonation-induced isomerization process. Removal of Zn2+ from AMP deaminase has effect similar to alkalinization in modifying the sedimentation properties of the enzyme. In the native enzyme at high K+ concentration about 7, 9 and 12 SH groups can be titrated with Nbs2, approximately 1, 2 and 4 SH groups reacting as fast sets, at pH 6.0, 7.0 and 8.0, respectively. Substitution of the 12 SH groups reactive with Nbs2 at pH 8.0 has no effect on the pH-dependent allosteric behaviour of the enzyme. Removal of K+ causes considerable changes in the reactivity of AMP deaminase towards Nbs2, unmasking a class of additional SH groups, so that the total number of titratable SH groups approaches that of 30 determined in denaturing conditions. In the enzyme previously treated with N-ethylmaleimide to alkylate the fast reacting class of SH groups, the class of additional SH groups are substituted by Nbs2 at basic pH, but not at acidic pH, with a concomitant reduction of the enzyme activity.

[Vojta's seven postural reactions in the detection of neuromotor disorders in infants. Experience with 2382 subjects]

The Authors examined 2.382 babies who were between 4 and 6 weeks old using the seven postural reactions proposed by Vojta for neuromotor screening. They followed the progress of 2.295 (96,35%) babies up to the age of 1 year. 100% of the babies judged to be normal after the first visit were normal after a year. The Authors describe the evolution of the babies who were abnormal at the first visit, and clarify the results obtained with early physiotherapeutic treatment.