Pramipexole Augmentation for Treatment-Resistant Unipolar and Bipolar Depression in the Real World: A Systematic Review and Meta-Analysis

BACKGROUND

Pramipexole is a dopamine full agonist approved for the treatment of Parkinson's disease and restless legs syndrome. Its high affinity for the D3 receptor and neuroprotective, antioxidant, and anti-inflammatory activity provides a rationale for the treatment of depression. In this paper, we review studies on the effectiveness and safety of antidepressant pramipexole augmentation in treatment-resistant depression.

METHODS

This comprehensive systematic review and meta-analysis of observational studies on pramipexole-antidepressant augmentation included patients with resistant unipolar and bipolar depression. The primary outcome measure was the treatment response, measured at the study endpoint.

RESULTS

We identified 8 studies including 281 patients overall, 57% women and 39.5% with bipolar disorder and 60.5% with major depressive disorder. The mean follow-up duration was 27.3 weeks (range 8-69). The pooled estimate of treatment response was 62.5%, without significant differences between unipolar and bipolar depression. Safety was good, with nausea and somnolence the most frequent side effects.

CONCLUSIONS

The findings of this systematic review, needing further confirmation, show that off-label use of pramipexole as augmentation of antidepressant treatment could be a useful and safe strategy for unipolar and bipolar treatment-resistant depression.

Italian midwives in Europe: a qualitative study on the experiences of professional migration

Aim

To explore the reasons for Italian midwives' decision to migrate, and their lived professional and emotional experiences.

Methods

A descriptive phenomenological study was conducted recruiting Italian midwives who were working abroad in European countries. We offered a telephone or web interview. Two researchers conducted, audio-recorded, and fully transcribed the interviews and other two researchers, independently, performed a content analysis.

Results

Thirty-two midwives having professional experiences in the UK, Ireland, Germany, Switzerland, and Spain were interviewed. Five themes emerged: 1) Education, 2) Migration decision-making, 3) Professional experience abroad, 4) Midwives' perceptions of their role, 5) Satisfaction versus desire to return. Our findings show a general dissatisfaction with Italian job opportunities in terms both of access to employment and work conditions. This scenario is complicated by the status of the professional midwifery in Italy.

Conclusion

Stakeholders should ensure that the migration of Italian midwives is not synonymous with dispersion but is a channel of professional growth and mutual exchange.

Impact of frailty status on medium-term follow up in patients undergoing percutaneous transcatheter aortic valve implantation in a high-flow referral center with high procedural volumes

Background

Transcatheter strategies to treat aortic stenosis (AS) are an established therapeutic option in older patients not candidate for open heart surgery. Current guidelines recommend the adoption of surgical scores like the Society of Thoracic Surgeons (STS) as tools for risk stratification. However, these scores may have limited predictive value in older patients.

Purpose

To assess the impact of frailty status on a composite endpoint comprising mortality and cardiovascular (CV) events in patients with severe AS evaluated for transcatheter aortic valve implantation (TAVI) in a high-flow and high-volume tertiary care center.

Methods

Consecutive patients >80 years referred to TAVI from January to December 2019 at our tertiary care institution were prospectively screened for frailty through a comprehensive geriatric assessment (CGA) based on physical function and the Multidimensional Prognostic Index (MPI). Physical function was evaluated by the Short Physical Performance Battery (SPPB), a tool exploring balance, gait speed, strength and endurance that produces a score ranging from 0 to 12 (lowest to highest performance). The SPPB <6 is an established strong predictor of mortality and disability.

The MPI is a three-level score used to stratify risk of mortality (low, intermediate or high risk) based on eight key domains for frailty assessment (functional and cognitive status, nutrition, mobility and risk of pressure sores, multimorbidity, polypharmacy and co-habitation).

Data on mortality and CV events at 6 and 12 months were retrieved via administrative records and/or telephone follow-up.

Results

Overall, 134 patients were referred for TAVI (mean age: 84±4 years; >90 years: 12%, women 67%). The average STS risk score was 4.6±3.0 (low risk: 49%; intermediate: 39%, high risk: 12%). Mean SPPB was 6.3±3.7 (SPPB <6: 32%). Ninety-five (71%) patients belonged to the MPI-low risk group, 30 (22%) to the MPI intermediate risk group and nine (7%) to the MPI high risk group. SPPB and MPI scores were moderately correlated with STS (Spearman correlation coefficient: SPPB R=0.31, p=0.01, MPI R=0.29, p=0.03, Figure Panel A and B).

At 12 months, 3 (2.2%) patients died, and 11 (8.2%) were hospitalized for CV events: major bleeding, N=6 (4.5%); stroke: N=4 (3.0%); re-do: N=1 (0.7%). The probability of the composite endpoint was higher for patients at intermediate/high MPI risk (HR intermediate/high risk vs low risk: HR 2.9, 95% CI 1.1–6.8, p=0.031, Figure 1 Panel C), while no association with STS (p=0.332) was found.

Conclusions

In a prospectively enrolled cohort of TAVI candidates, frailty indices stratified short- and medium-term prognosis. The integrated frailty assessment could be a useful tool for early detection of patients at risk of disability, and potentially, for preventing the futility of the TAVI procedure.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Learning via variably scaled kernels

We investigate the use of the so-called variably scaled kernels (VSKs) for learning tasks, with a particular focus on support vector machine (SVM) classifiers and kernel regression networks (KRNs). Concerning the kernels used to train the models, under appropriate assumptions, the VSKs turn out to be more expressive and more stable than the standard ones. Numerical experiments and applications to breast cancer and coronavirus disease 2019 (COVID-19) data support our claims. For the practical implementation of the VSK setting, we need to select a suitable scaling function. To this aim, we propose different choices, including for SVMs a probabilistic approach based on the naive Bayes (NB) classifier. For the classification task, we also numerically show that the VSKs inspire an alternative scheme to the sometimes computationally demanding feature extraction procedures.

A one-generation reproductive toxicity study of the mycotoxin ochratoxin A in Fischer rats

Ochratoxin A (OTA) is a mycotoxin produced by Aspergillus and Penicillium molds. Grain-based foods account for most human dietary exposures to OTA. OTA is a teratogen, but its reproductive and developmental effects are poorly understood. A one-generation reproductive toxicity study was conducted with groups of 16 male and 16 female Fischer rats exposed to 0, 0.026, 0.064, 0.16, 0.4 or 1.0 mg OTA/kg in diet. Dams exposed to 1.0 mg OTA/kg diet had statistically significant F1 pup losses between implantation and postnatal day (PND 4). Delays in preputial separation (PPS) and vaginal opening (VO) were indicative of delayed puberty in F1 rats. Mild renal lesions in nursing pups indicated that exposure prior to weaning impacted the kidneys. The developing kidney was more susceptible to OTA than the adult kidney. Significant increases in multi-oocyte follicles (MOFs) and proportional changes in resting and growing follicles were observed in F1 female ovaries. Plasma testosterone was reduced in F0 males, and there were negative effects on sperm quality in F0 and F1 male rats. The results confirm that continuous dietary exposure to OTA causes post-implantation fetotoxicity in dams, and renal and reproductive toxicity in their male and female offspring.

Psycho-social characteristics in patients with discopathy: Quality of Life, coping strategy and mood state

The pathologies of the musculoskeletal apparatus are the most common cause of chronic diseases, with a huge impact on people and society. Scientific literature has discovered how experiencing chronic pain directly affects peoples' well-being, lifestyle, social relationships and can also cause psychological distress. The present study aims to investigate pain experience in patients with hernias or protrusions of the cervical and lumbosacral tract on a sample of 120 patients, recruited from patients of Poliambulatorio Oberdan, medical centre in Brescia (Italy) specialized in physical rehabilitation and CT-guided oxygen ozone therapy. In a bio-psychosocial perspective, the research aimed to investigate how the perception of pain, the mood state associated with it, the coping strategies adopted and the quality of life differ according to each patient's gender and to the more or less prolonged use of pain medication. The data were collected by means of medical and psychological anamnestic interviews and self-report tests (WHOQOL-BREF, COPE-NVI, POMS). The quantitative analysis, carried out through SPSS 25 (2017) software, showed how functional impairment of one's autonomy (walking, driving) affects mood states. In particular, the female sample expressed a more deflected mood, despite the greater use of relational and/or transcendent support (coping strategies) compared to men. The study suggests that the greater impairment of the moods of women can be attributed both to the caregiving role they play, which often results in a greater fatigue and difficulties in redefining this role following the algic condition, and more general differences in the expression of suffering, which, on a cultural level, sees men emotionally coerced. The analysis also shows how taking pain medication for a long period of time has a negative impact on the quality of life. The results suggest that the patients treated with analgesic therapy tend to adopt avoidant coping styles, which usually escalate into postponement of the time when dealing with a stressful situation and, if used in the long run, may lead to worsening health condition.

Discovering human germ cell mutagens with whole genome sequencing: Insights from power calculations reveal the importance of controlling for between-family variability

Mutations in germ cells pose potential genetic risks to offspring. However, de novo mutations are rare events that are spread across the genome and are difficult to detect. Thus, studies in this area have generally been under-powered, and no human germ cell mutagen has been identified. Whole Genome Sequencing (WGS) of human pedigrees has been proposed as an approach to overcome these technical and statistical challenges. WGS enables analysis of a much wider breadth of the genome than traditional approaches. Here, we performed power analyses to determine the feasibility of using WGS in human families to identify germ cell mutagens. Different statistical models were compared in the power analyses (ANOVA and multiple regression for one-child families, and mixed effect model sampling between two to four siblings per family). Assumptions were made based on parameters from the existing literature, such as the mutation-by-paternal age effect. We explored two scenarios: a constant effect due to an exposure that occurred in the past, and an accumulating effect where the exposure is continuing. Our analysis revealed the importance of modeling inter-family variability of the mutation-by-paternal age effect. Statistical power was improved by models accounting for the family-to-family variability. Our power analyses suggest that sufficient statistical power can be attained with 4-28 four-sibling families per treatment group, when the increase in mutations ranges from 40 to 10% respectively. Modeling family variability using mixed effect models provided a reduction in sample size compared to a multiple regression approach. Much larger sample sizes were required to detect an interaction effect between environmental exposures and paternal age. These findings inform study design and statistical modeling approaches to improve power and reduce sequencing costs for future studies in this area.

Haemodynamic CHIVA correction surgery versus compression for primary venous ulcers: first year results

Objective: To compare two different treatments for primary venous ulcers: a minimally invasive surgical technique for the haemodynamic correction of reflux, versus a traditional compression treatment.

Method: From a cohort of 87 lower extremities affected by the first episode of venous ulcers, 45 mobile patients affected by primary chronic venous insufficiency were randomized to receive either the haemodynamic correction procedure (CHIVA) or compression treatment.

Results: Mean follow up lasted one year. The rate of healing in the surgical group was 100% in a mean time of 29 days with a velocity of 2.86 mm2/day,and in the conservative group the rate was 96% in 61 days, with a velocity of 1.66 mm2/day ( P<0.02). All air plethysmographic parameters, with the exception of ejection fraction, significantly improved at six months in the surgical group. Finally, quality of life significantly improved in both groups, but in the surgical group the following domains were significantly different compared with the compression group: RP, role limitations due to physical problems; VT, energy/vitality; SF, social functioning; RE, role limitations due to emotional problems; and MH, mental health.

Conclusions: Surgical haemodynamic correction of reflux has been demonstrated to improve venous function, time to ulcer healing and quality of life when compared with compression treatment.

A ruthenium derivative of quercetin with enhanced cholesterol-lowering activity

A ruthenium(ii)p-cymene derivative of quercetin was synthesized and functionally tested for cholesterol-lowering abilityviadirect 3-hydroxy-3-methyl-glutaryl-CoA reductase (HMGR) inhibition.

Estimated costs attributable to events of "out-of-temperature" in the stockpiling of hexavalent vaccines occurring in Italy

BACKGROUND

Antigens contained in vaccines are inherently unstable biologically; such a characteristic is conferred by their three-dimensional structure. Preserving the ability of the vaccines to protect against disease is necessary to ensure the supervision and monitoring of all steps of the cold chain. DTPa-HBV-IPV/Hib vaccine (Infanrix hexaTM, GSK Vaccines, Belgium) is designed to prevent disease due to diphtheria, tetanus, pertussis (DTP), hepatitis B virus (HBV), poliomyelitis and Haemophilus influenzae type b (Hib); it was first licensed for use in Europe in 2000 and is currently licensed in at least 95 countries. Since October 2013, more than 102 million doses of GSK's DTPa-HBV-IPV/Hib vaccine have been distributed globally, with nearly 15 million doses distributed in Italy. DTPa-HBV-IPV/Hib components are stable up to a temperature of 25°C for 72 hours. Lacking of officially approved stability data may generate some concern in case of cold chain accidents.

METHODS

An analysis based on collected data was carried out to estimate potential costs attributable to events of "out-of-temperature" in the stockpiling of hexavalent vaccines occurring in Italy in 2014.

RESULTS

The analysis, based on real data, documented that the loss for the National Health Service (NHS) was in the range of 100,000 - 400,000 euros in one year. However, the amount of money that in principle could have been lost would have ranged between nearly half and one million euros/year.

CONCLUSIONS

A substantial loss of money was avoided thanks to the availability of officially approved stability data for GSK's DTPa-HBV-IPV/Hib vaccine.

Synthesis of novel lanthanide acylpyrazolonato ligands with long aliphatic chains and immobilization of the Tb complex on the surface of silica pre-modified via hydrophobic interactions

Immobilization of a Tb acylpyrazolonato complex on silica surfaces via hydrophobic interactions.

Efficacy and safety of oral ketamine for the relief of intractable chronic pain: A retrospective 5-year study of 51 patients

BACKGROUND

This work summarizes the efficiency, failures and adverse effects of oral administration of ketamine at home for intractable pain.

METHODS

This 5-year retrospective study involved testing ketamine by intravenous in-hospital administration, then a conversion to an oral route, or oral treatment directly administered at home. The daily intravenous dose was increased by steps of 0.5 mg/kg to attain an effective daily dose of 1.5-3.0 mg/kg. Pain was evaluated on a numeric scale from 0 to 10, and evidence of adverse effects was collected every day. The effective daily dose was delivered orally (three to four intakes). If effective, ketamine was continued for 3 months. Short infusions or direct oral treatment began with a 0.5-mg/kg dose, then the daily ketamine dose was increased in 15- to 20-mg increments.

RESULTS

Among 55 cases (51 patients, neuropathic pain 60%), the mean effective oral dose was 2 mg/kg. Ketamine was effective in 24 patients (44%, mean pain reduction 67 ± 17%), partially effective in 20% (mean pain reduction 30 ± 11%), with a mean opioid sparing of 63 ± 32%, and failure in 22%. Half of the patients experienced adverse effects, but only eight had to stop treatment. For patients with opioid therapy, failure of ketamine was less frequent (7% vs. 36%; p < 0.02), with fewer adverse effects (33% vs. 68%; p < 0.01).

CONCLUSIONS

Pain was reduced or abolished in two-thirds of patients under ketamine therapy; ketamine was effective for patients taking opioids and resulted in few adverse effects.

Human sperm sex chromosome disomy and sperm DNA damage assessed by the neutral comet assay

STUDY QUESTION

Is there an association between human sperm sex chromosome disomy and sperm DNA damage?

SUMMARY ANSWER

An increase in human sperm XY disomy was associated with higher comet extent; however, there was no other consistent association of sex chromosome disomies with DNA damage.

WHAT IS KNOWN ALREADY

There is limited published research on the association between sex chromosome disomy and sperm DNA damage and the findings are not consistent across studies.

STUDY DESIGN, SIZE, AND DURATION

We conducted a cross-sectional study of 190 men (25% ever smoker, 75% never smoker) from subfertile couples presenting at the Massachusetts General Hospital Fertility Clinic from January 2000 to May 2003.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Multiprobe fluorescence in situ hybridization for chromosomes X, Y and 18 was used to determine XX, YY, XY and total sex chromosome disomy in sperm nuclei using an automated scoring method. The neutral comet assay was used to measure sperm DNA damage, as reflected by comet extent, percentage DNA in the comet tail, and tail distributed moment. Univariate and multiple linear regression models were constructed with sex chromosome disomy (separate models for each of the four disomic conditions) as the independent variable, and DNA damage parameters (separate models for each measure of DNA damage) as the dependent variable.

MAIN RESULTS AND THE ROLE OF CHANCE

Men with current or past smoking history had significantly greater comet extent (µm: regression coefficients with 95% CI) [XX18: 15.17 (1.98, 28.36); YY18: 14.68 (1.50, 27.86); XY18: 15.41 (2.37, 28.45); Total Sex Chromosome Disomy: 15.23 (2.09, 28.38)], and tail distributed moment [XX18: 3.01 (0.30, 5.72); YY18: 2.95 (0.24, 5.67); XY18: 3.04 (0.36, 5.72); Total Sex Chromosome Disomy: 3.10 (0.31, 5.71)] than men who had never smoked. In regression models adjusted for age and smoking, there was a positive association between XY disomy and comet extent. For an increase in XY disomy from 0.56 to 1.47% (representing the 25th to 75th percentile), there was a mean increase of 5.08 µm in comet extent. No other statistically significant findings were observed.

LIMITATIONS, REASONS FOR CAUTION

A potential limitation of this study is that it is cross-sectional. Cross-sectional analyses by nature do not lend themselves to inference about directionality for any observed associations; therefore we cannot determine which variable is the cause and which one is the effect. A small sample size may be a further limitation. Comparison of these findings to other studies is limited due to methodological differences.

WIDER IMPLICATIONS OF THE FINDINGS

Although consistent associations across sex chromosome disomies or DNA damage measures were not observed, this study highlights the need to explore etiologies of sperm DNA damage and sex chromosome disomy to better understand the potential mechanistic overlaps between the two.

STUDY FUNDING/COMPETING INTERESTS

This work was supported by NIOSH Grant T42 OH008416, and NIH/NIEHS Grants ES 009718, ES 000002, and R01 ES017457. During the study M.E.M. was affiliated with the Department of Environmental Health at the Harvard School of Public Health.

TRIAL REGISTRATION NUMBER

N/A.

Increasing Resistance According to Patient's Age and Sex inEscherichia coliIsolated from Urine in Italy

The prevalence of Escherichia coli among the uropathogens routinely isolated in non-hospital laboratories (Labs) and its susceptibility profiles were investigated. Thirty-three Labs were selected throughout Italy. In vitro assays were performed by means of disk diffusion according to the CLSI. Females were prevalent (79.9%) and the mean patient age was 58.6 (sd 20.4) years. Overall, the prevalence of E. coli was 55.3% (1375 strains), with Enterococcus spp 10.2 %, Proteus mirabilis 4.8%, coagulase-negative staphylococci 4.3% and Klebsiella 3.8% being the next most frequently encountered species. High compliance with quality control program was observed. Susceptibility figures in E. coli were consistently low for many antimicrobial agents such as ampicillin (51.3%) and co-trimoxazole (74.6%) and higher for others such as gentamicin (87.9%) and ceftazidime (95.1%). Resistance rates were higher among male patients and increased according to the patient's age.

Continuous circular cycling in bipolar disorder as a predictor of poor outcome

OBJECTIVE

This prospective study aims to determine if patients with bipolar disorder with a continuous circular course (CCC) are significantly different on clinical characteristics and response to long-term treatment from those with a non-continuous circular course (N-CCC). CCC was defined as the alternation of depression and (hypo)mania without a completely free interval, and N-CCC as the presence of free intervals after the sequence mania-depression or depression-mania.

METHOD

The study sample includes 140 consecutive patients with bipolar I or II disorder according to DSM-IV criteria, aged 18-65 years and receiving prophylactic treatment for. Treatment was based upon international guidelines and clinical experience at the time of patient's enrollment (from January 1998 to January 2006). Primary outcome was the absence of new episodes during the follow-up. Significance level was set at p<0.05.

RESULTS

Twenty-eight percent of the sample has CCC. Compared with N-CCC, CCC patients were older, had a later onset, a higher number of total, depressive and (hypo)manic episodes, and of switches, and spent a higher percentage of time ill in the year before entering the study. Polarity at onset and subsequent recurrences were more frequently mixed in N-CCC than in CCC patients. The proportion of patients in the CCC group who had no recurrences during the follow-up was significantly lower than in the N-CCC group.

CONCLUSION

The presence or absence of a free intervals over the course of illness identifies two subtypes of bipolar disorder that differ in clinical presentation, outcome, and response to long-term treatment.

A Pilot Study on Prevention of Catheter-Related Urinary Tract Infections with Fluoroquinolones

The objective of this multicenter, randomized, controlled, parallel group trial was to evaluate the efficacy of levofloxacin 250 mg oral, once daily (LVFX), placebo one tablet oral once daily (Placebo [P] group) and ciprofloxacin (CPFX) 500 mg oral, twice daily (single blind), prophylaxis in preventing bacteriuria (> or = 10(3) CFU/ml) in post-surgical catheterized patients. In the modified intention-to-treat (M-ITT) population of the 82 enrolled patients, negative bacteriuria was observed in 92% of LVFX group, in 80% of P group and in 100% of CPFX group while in the per-protocol (PP) population figures were: 100%, 86.4% and 100% respectively. Only one symptomatic urinary tract infection and one surgical wound infection were observed in the P group. Both drugs were well tolerated, showing a safety profile comparable to placebo. The high frequency of negative bacteriuria in the placebo group sounds encouraging as it underlines that the adoption of closed urinary drainage system catheters in hospital setting may reduce the frequency of hospital-acquired infections.

Prevalence and Clinical Management of Complicated Urinary Tract Infections in Italy: a Prospective Multicenter Epidemiological Study in Urological Outpatients

The objectives of the study were to evaluate the prevalence of complicated urinary tract infections among Italian patients attending the urologist's office, to describe the frequency of different complication factors, the encountered bacterial pathogens and the clinical attitude of urologists in management of complicated urinary tract infections (CUTIs). The study was a prospective, multicenter study which was undertaken by office urologists throughout Italy. During the May-June 2002 timeframe, the prevalence of each urologist's diagnosis of CUTIs was noted for a 4-week slot. The prevalence of CUTIs in over 13,000 patients observed was 10.8% (n = 1201), with a trend (not statistically significant) of higher figures in the South/Islands (12.2%) with respect to Center (11.4%) or North (8.7%) of Italy. We have confirmed the significant relevance of CUTI among the Italian patients attending the urologist office and the clinical data collected may contribute to improve the diagnosis and empiric therapy of complicated urinary tract infections.

Treating bipolar depression - antidepressants and alternatives: a critical review of the literature

OBJECTIVE

Although depressive symptoms are preponderant in the course of bipolar (BP) disorders, the treatment of BP depression remains a controversial issue with different clinical approaches available. This review addresses the issues of whether antidepressants (ADs) are effective in treating acute and long-term BP depression, risks linked to ADs and what alternatives to ADs are available.

METHODS

We searched the MEDLINE databases using the following syntax: [bipolar depression AND unipolar depression AND (antidepressants OR anticonvulsants OR lithium OR antipsychotics OR dopamine-agonists OR psychoeducation OR psychotherapy OR electroconvulsive therapy OR transcranial magnetic stimulation)]. The search included studies published up to 31 May 2009 and conducted on adults.

RESULTS

In the acute treatment of BP depression ADs are effective with no differences among drug classes. However, neither the switch into (hypo)mania induction rate nor the suicide risk linked to AD use are definitely established. The effectiveness of long-term AD use is limited to highly selected samples of patients with positive acute response. The risk of long-term ADs causing cycle acceleration and rapid cycling induction concerns a subpopulation of patients. Valid alternatives to ADs in treating acute BP depression are quetiapine, an olanzapine-fluoxetine combination, and electroconvulsive therapy for more severe patients. Lamotrigine is effective and safe in preventing depressive relapses. Psychotherapy and psychoeducation represent effective adjunctive treatments.

CONCLUSION

In the treatment of BP depression there is not a specific effective treatment for all the patients. Interventions should therefore be personalised and the scientific evidence should be adapted to each patient's clinical features.

Deep brain stimulation of the pedunculopontine tegmentum and subthalamic nucleus: effects on gait in Parkinson's disease

OBJECTIVE

This study examines the effects of subthalamic nucleus (STN) deep brain stimulation (DBS) and pedunculopontine tegmentum (PPTg) DBS in advanced Parkinson's disease using gait analysis.

METHODS

Five people underwent bilateral DBS in both the STN and PPTg. Gait analysis was performed one year after neurosurgery using an optoelectronic system. The effects of DBS (STN, PPTg and STN+PPTg) were studied in two clinical conditions: without (Off) and during (On) antiparkinsonian therapy.

RESULTS

PPTg and STN DBS were associated with changes in spatio-temporal and kinematics variables.

CONCLUSIONS

Although experimental data cannot be generalized widely due to the small sample, PPTg DBS appears to affect the neuronal circuits subserving gait.

[Breast cancer metastasis in distal phalanx of the big toe. Case report]

Breast cancer represents the most prevalent malignancies in women and bone is the first site of metastasis in 26-50% of cases. Usually metastasis involve limbs in 16%. We present a rare case of 47-year-old woman, who underwent to monolateral mastectomy for lobular cancer. After 8 years from surgery, she presented pain, swelling and functional limitations, gradually increasing, to the left big toe. X-rays and MRI showed a lucent area of bone destruction on the shaft of the distal phalanx of the left big toe. Surgical biopsy on the excised bone assessed for breast cancer metastasis.

Does delay of adjuvant chemotherapy affect the clinical outcome in patients with colon cancer?

4046

Background: Adjuvant chemotherapy (AC) in patients with stage III colon adenocarcinoma prevents recurrences and improves survival. Although most trials mandate initiation of AC within 8 weeks of resection, the impact of timing of AC is still not clear with few studies reporting conflicting results. We hypothesized that AC commenced within 60 days of resection would increase survival in patients with stage II and III colon cancer. Methods: Patients with newly diagnosed stage II or III colon adenocarcinoma who received fluoropyrimidine based AC in two centers (a private cancer center and a large community hospital) between 2000 and 2007 were included into analysis. Time to adjuvant chemotherapy (TTC), overall survival (OS), and relapse-free survival (RFS) were calculated from the surgery date. Patients were dichotomized into early- (group 1) and late-treatment (group 2) groups using the TTC of 60 days. The demographic, clinical, and laboratory characteristics of patients in two groups were compared using chi-square and t-test. Kaplan-Meier survival curves were constructed employing univariate log-rank test to assess the effects of demographic and clinical characteristics on OS. Then the impact of TTC on OS and RFS was analyzed using a Cox proportional hazard model incorporating the significant factors found in the univariate analysis. Results: 190 patients were eligible for the study (median age: 57 yrs [range 14–84]). 116 patients (61%) were female and 35 patients (18%) had stage II disease. Median TTC was 49 days (range 24–196) and median follow-up was 143 weeks (range 9–451). 134 patients (70%) received AC within 60 days of surgery (group 1) and 56 (30%) received after (group 2). The only difference between the two groups was the higher N stage in group 1. The treating hospital and the N stage were found to be the factors affecting the OS in univariate analysis. Five-year OS for group I was 75.2% as compared to 61.3% for group II (HR 2.11, CI: 1.00–4.45, p=0.049). Five-year RFS for group I was 65.7% as compared to 59.0% for group II (HR: 1.19, CI: 0.65–2.20, p=0.570). Conclusions: Delay of AC more than 60 days after resection is associated with inferior survival in stage II/III colon cancer.

No significant financial relationships to disclose.

Burden of rotavirus disease and cost-effectiveness of universal vaccination in the Province of Genoa (Northern Italy)

Rotavirus is acknowledged to be a major cause of acute gastroenteritis in infants and young children. As gastroenteritis due to rotavirus is a public health problem and two new vaccines are currently available, we investigated the rotavirus burden and developed a cost-effectiveness analysis, using data collected in the Province of Genoa (Italy), to evaluate the benefits of new borns vaccination. The cost-effectiveness of a rotavirus vaccination programme in the Province of Genoa was performed, in comparison with no vaccination, for both the regional healthcare system (RHS) and society (S). In 2006, admissions to the paediatric emergency department for gastroenteritis numbered 2338 (about 11% of total admissions); of these 33% were hospitalised. In 28% of cases, the children tested positive for rotavirus. During epidemics, paediatricians receive from 3 to 5 calls per day for gastroenteritis, carry out 1 or 2 ambulatory examinations and for children with a severe case history, make house visits. A rotavirus immunisation programme would have a great impact on disease burden, in that 90% coverage would reduce the number of severe cases by more than 85%. From the perspective of both the RHS and S, vaccination proved to be highly cost-effective.