Ridge regression and its applications in genetic studies

With the advancement of technology, analysis of large-scale data of gene expression is feasible and has become very popular in the era of machine learning. This paper develops an improved ridge approach for the genome regression modeling. When multicollinearity exists in the data set with outliers, we consider a robust ridge estimator, namely the rank ridge regression estimator, for parameter estimation and prediction. On the other hand, the efficiency of the rank ridge regression estimator is highly dependent on the ridge parameter. In general, it is difficult to provide a satisfactory answer about the selection for the ridge parameter. Because of the good properties of generalized cross validation (GCV) and its simplicity, we use it to choose the optimum value of the ridge parameter. The GCV function creates a balance between the precision of the estimators and the bias caused by the ridge estimation. It behaves like an improved estimator of risk and can be used when the number of explanatory variables is larger than the sample size in high-dimensional problems. Finally, some numerical illustrations are given to support our findings.

Renal impairment and its impact on clinical outcomes in patients who are critically ill with COVID-19: a multicentre observational study

Renal impairment is common in patients who are critically ill with coronavirus disease-19 (COVID-19). We examined the association between acute and chronic kidney disease with clinical outcomes in 372 patients with coronavirus disease-19 admitted to four regional intensive care units between 10 March 2020 and 31 July 2020. A total of 216 (58%) patients presented with COVID-19 and renal impairment. Acute kidney injury and/or chronic kidney disease was associated with greater in-hospital mortality compared with patients with preserved renal function (107/216 patients (50%) (95%CI 44-57) vs. 32/156 (21%) (95%CI 15-28), respectively; p < 0.001, relative risk 2.4 (95%CI 1.7-3.4)). Mortality was greatest in patients with renal transplants (6/7 patients (86%) (95%CI 47-100)). Mortality rates increased in patients with worsening renal injury according to the Kidney Disease: Improving Global Outcomes classification: stage 0 mortality 33/157 patients (21%) (95%CI 15-28) vs. stages 1-3 mortality 91/186 patients (49%) (95%CI 42-56); p < 0.001, relative risk 2.3 (95%CI 1.7-3.3). Survivors were less likely to require renal replacement therapy compared with non-survivors (57/233 patients (24%) vs. 64/139 patients (46%), respectively; p < 0.001, relative risk 1.9 (95%CI 1.4-2.5)). One-fifth of survivors who required renal replacement therapy acutely in intensive care continued to require renal support following discharge. Our data demonstrate that renal impairment in patients admitted to intensive care with COVID-19 is common and is associated with a high mortality and requirement for on-going renal support after discharge from critical care. Our findings have important implications for future pandemic planning in this patient cohort.

305Pacemaker therapy after cardiac valve replacement surgery: impact on heart failure hospitalizations

Background

Left ventricular (LV) function is a major determinant of long-term outcomes after valve replacement surgery. Although conventional (right ventricular) pacemaker therapy is life-saving, it may cause heart failure (HF).

Aims

To determine whether permanent pacemaker implantation (PPI) confers a risk of HF in surgical valve recipients.

Methods

The primary endpoint of HF hospitalization and the secondary endpoints of total mortality and total mortality / HF hospitalizations were compared in valve recipients with and without PPI. Traditional as well as multi-state, multivariable modelling was used to assess the influence of PPI on clinical outcomes.

Results

Amongst patients (n = 135,242) undergoing a first aortic (AVR; n = 111,674), mitral (MVR; n = 18,402) valve replacement, or AVR + MVR (n = 5,166) over 14 years in 176 centre, 12,952 (10.6%) had a PPI at any time during follow-up and 5,805 (4.3%) underwent PPI postoperatively. After 3.9 yrs (median, interquartile range: 6.1), heart failure (HF) hospitalizations (HR: 1.47, 95% C.I. 1.36-1.59), total mortality (HR: 1.10, 95% C.I. 1.05-1.16) and total mortality or HF hospitalizations (HR: 1.17, 95% C.I. 1.12-1.22; see figure) were higher in patients with post-operative PPI than in patients without. Multi-state modelling revealed that the transition hazard from PPI at any time to HF hospitalizations was markedly higher (transition hazard rate: 0.29, 95% C.I. 0.24-0.36) than from valve replacement surgery to HF hospitalization.

Conclusions

After valve replacement surgery, PPI is associated with increased HF hospitalization and total mortality, particularly after dual valve replacements.

Abstract Figure.

P3746Temporal patterns of premature atrial contractions predict atrial fibrillation occurrence in bradycardia patients continuously monitored through pacemaker diagnostics

Background

The frequency of premature atrial complexes (PACs) has been indirectly related with atrial fibrillation (AF) occurrence and adverse outcomes.

Objective

To evaluate whether temporal patterns of PACs are directly associated with AF onset in pacemaker patients with continuous monitoring of the atrial rhythm.

Methods

Overall, 193 pacemaker patients (49% female, 72±9 years old), enrolled in a national registry, were analyzed. Frequency of daily PACs was measured in a 14-day initial observation period, during which patients were in sinus rhythm. In the following period, temporal occurrence and frequency of daily PACs and eventual onset of AF were derived by pacemaker diagnostics.

Results

In the run-in period, median PACs frequency was 614 PACs/day (interquartile range=70–3056). Subsequently, in a median follow-up of 6 months, AF occurred in 109 patients, in particular in 37/96 (38.5%) patients with a PAC rate<614 PACs/day and in 72/97 (74.2%) patients with PAC rate≥614 PACs/day (p<0.001). In patients with AF occurrence, the number of daily PACs, normalized by dividing for the average of PACs in 10 preceding days, progressively increased in the 5–6 days preceding AF (Figure). Cox Model predictive analysis showed that the risk of AF was significantly higher in patients with a relative increase of the daily PACs higher than 30% compared with PACs average number in 10 preceding days (hazard ratio (95% confidence interval) = 3.67 (2.40–5.59), p<0.001).

PACs changes daily trend before AF

Conclusion

PACs frequency increases in the 5–6 days preceding AF onset. A relative increase of the daily PACs is significantly associated with the risk of AF occurrence.

Loss functions in restricted parameter spaces and their Bayesian applications

Squared error loss remains the most commonly used loss function for constructing a Bayes estimator of the parameter of interest. However, it can lead to suboptimal solutions when a parameter is defined on a restricted space. It can also be an inappropriate choice in the context when an extreme overestimation and/or underestimation results in severe consequences and a more conservative estimator is preferred. We advocate a class of loss functions for parameters defined on restricted spaces which infinitely penalize boundary decisions like the squared error loss does on the real line. We also recall several properties of loss functions such as symmetry, convexity and invariance. We propose generalizations of the squared error loss function for parameters defined on the positive real line and on an interval. We provide explicit solutions for corresponding Bayes estimators and discuss multivariate extensions. Four well-known Bayesian estimation problems are used to demonstrate inferential benefits the novel Bayes estimators can provide in the context of restricted estimation.

A proposal for a new PhD level curriculum on quantitative methods for drug development

This paper provides an overview of "Improving Design, Evaluation and Analysis of early drug development Studies" (IDEAS), a European Commission-funded network bringing together leading academic institutions and small- to large-sized pharmaceutical companies to train a cohort of graduate-level medical statisticians. The network is composed of a diverse mix of public and private sector partners spread across Europe, which will host 14 early-stage researchers for 36 months. IDEAS training activities are composed of a well-rounded mixture of specialist methodological components and generic transferable skills. Particular attention is paid to fostering collaborations between researchers and supervisors, which span academia and the private sector. Within this paper, we review existing medical statistics programmes (MSc and PhD) and highlight the training they provide on skills relevant to drug development. Motivated by this review and our experiences with the IDEAS project, we propose a concept for a joint, harmonised European PhD programme to train statisticians in quantitative methods for drug development.

Restatement of Lymphography in Childhood: Experience with 413 Consecutive Patients in Ten Years

From January 1969 to June 1978, 413 children under 15 years of age underwent lymphography at the Istituto Nazionale Tumori of Milan. Successful lymphatic cannulation was accomplished in 97.7% (769/787) of the sites where it was attempted. No major or permanent complications were encountered. In those children undergoing biopsy of opacified lymph nodes, the lymphographic-histologic correlation was 94.5% (104/110). This study has shown that lymphography in childhood can be as readily performed as in the adult and that its diagnostic accuracy is acceptable. As in adults, it is useful in treatment planning, evaluating results of therapy, and detecting a recurrent tumor.

Antineuronal Antibodies in Patients with Neuroblastoma: Relationships with Clinical Features

We evaluated the frequency of serum antineuronal antibodies in a cohort of 39 neuroblastoma patients and related their presence to clinical features. Twelve patients displayed antineuronal antibodies at immunocytochemistry. Only one of these 12 patients suffered from a clinically overt paraneoplastic syndrome. No significant differences emerged between autoantibody-positive and autoantibody-negative patients in terms of progression-free and overall survival, although when only patients evolving to disease progression were considered, the time interval between diagnosis and progression was slightly longer in autoantibody-positive patients.

Clinical Utility of Radioimmunoscintigraphy of Non-Hodgkin's Lymphoma with Radiolabelled LL2 Monoclonal Antibody., Lymphoscan™: Preliminary Results

Aims and Background

Adequate clinical staging of non-Hodgkin's lymphoma patients is essential because only localized disease can be treated satisfactorily. Many imaging procedures are necessary to stage the disease accurately. The objective of this study was to evaluate the efficacy of an anti-lymphoma antibody in the Fab’ fragment form, labelled with 99mTc, to detect malignant lesions.

Methods

Radioimmunodetection (RAID) with 99mTc-labelled B-cell lymphoma monoclonal antibody IMMU-LL2-Fab’ (LymphoSCAN™; Immunomedics, Morris Plain, NJ, USA) was investigated in 10 patients (5 females and 5 males; age range, 20-72 years) with histologically proved non-Hodgkin's lymphoma. Of the 10 lymphomas, 7 were intermediate grade and 3 were low grade. Whole body images with multiple planar views were obtained at 30 min, 4-6 and 24 h after i.v. injection of 1 mg LL2-Fab’ labelled with 740-925 MBq of 99mTc. SPET of the chest or abdomen was performed in all patients 5-8 h after the immunoreagent injection.

Results

No adverse reactions were observed in any patient after Mab infusion, and no appreciable changes were seen in the blood counts, renal or liver function tests. A total of 18 of 21 (85.7%) lymphoma lesions were detected by RAID. All the tumor localizations were confirmed by clinical examination and with other imaging techniques, such as CT scan, MRI or gallium scan. In this series of patients no false-positive results were noted. As regards the biodistribution of the immunoreagent, no appreciable bone marrow activity was seen; splenic targeting was demonstrated in all patients; the tumor-to-non-tumor ratios ranged from 1.2 to 2.8 ad measured by the ROI technique; no difference in uptake was noted for different tumor grades. The images obtained 24 h after injection did not reveal new lesions, but areas of doubtful uptake were seen as positive focal areas in the delayed scan.

Conclusions

LymphoSCAN™ seems to be useful for detection, staging and follow-up of non-Hodgkin's lymphoma patients.

Single Agent Sequential Chemotherapy in Non-Hodgkin's Lymphomas

A retrospective analysis of 118 patients with non-Hodgkin's lymphomas who received one or more drugs of single agent chemotherapy was conducted to determine the relationship between the histopathologic category of lymphoma, based on the classification proposed by Rappaport et al., and the results (type of regression and survival) of sequential chemotherapy. In 96/118 cases, slides were available for histopathologic reclassification. Patients were selected according to the following criteria: chemotherapy with single agents administered in sequence (e.g. alkylating agents, vincristine, adriamycin, bleomycin); change in drug administration only after an adequate course and either no response or clinical resistance after prior regression; measurable disease; performance status greater than 40. Prior to chemotherapy 66 patients had diffuse (extranodal) disease, 39 adenopathies above and below the diaphragm, and 13 adenopathies only above or below the diaphragm. 49/118 patients were pretreated with radiotherapy. The data were most complete for alkylating agents which were administered as a single agent in 93 patients. Complete remission (CR) plus partial remission (PR) greater than 50% occurred in 39% of patients with lymphocytic lymphoma, in 39% with histiocytic and in 50% with mixed type lymphoma (table 4). This type of response was observed with all drugs in 70% of nodular lymphomas and in 36% of diffuse lymphomas (table 7). The overall response rate to adriamycin was 75% in nodular lymphomas, and 55% in diffuse lymphomas. These data were 40% and respectively 14% after treatment with bleomycin. Median survival of all non-Hodgkin's lymphomas was 16.2 months (fig. 1); median survival was 23.4 months for nodular lymphomas and 17.4 months for diffuse lymphomas (fig. 2). Among nodular lymphomas, no significant differences were observed between nodular histiocytic and nodular lymphocytic well differentiated (fig. 3). Diffuse lymphocytic well differentiated lymphomas showed better survival in comparison to diffuse lymphocytic poorly differentiated, diffuse histiocytic and diffuse undifferentiated types (fig. 4). Patients responding to 2 drugs or more showed a better median survival (66 months) than those responding only to one drug (22.4 months) and unresponsive patients (10.2 months) (fig. 5). This study confirms most of the data reported by the Stanford group and emphasizes the need to employ a more deteailed histopathologic classification such as that proposed by Rappaport et al. Although this retrospective analysis has a number of drawbacks, it does provide, in terms of survival, a measurable indication that the responsiveness to at least two drugs is associated with better survival in non-Hodgkin's lymphomas than little or no responsiveness.

Ten Years Experience with Ewing's Sarcoma

The series comprises 57 consecutive patients with Ewing's sarcoma admitted to the National Cancer Institute of Milan from 1965 to 1976. In 75 % the disease was confined to one bone, while in 25 % multiple bone and/or visceral lesions were present. Patients with clinically localized tumor treated before 1971 with local therapy, showed a median disease-free survival of 5 months. After 1971, radiotherapy and/or surgery to local tumor was combined with multiple drug chemotherapy (ADM, VCR, CTX) and the projected median disease-free survival increased to 24+ months. In previously untreated patients with advanced tumor adriamycin, used as single drug, achieved an overall response rate of 73 %. This is comparable to that achieved by a new combination including ADM, VCR, CTX, CCNU (75%). This multiple drug regimen is, however, expected to prolong the duration of response.

Response and Survival in Hodgkin's Disease after Sequential Chemotheraphy Employing a Single Agent

The therapeutic results obtained in 59 patients with advanced Hodgkin's disease treated from 1964 to 1969 with sequential chemotherapy employing a single agent are reported. The main sequence was alkylating agent first, vinblastine second and procarbazine third. Complete plus partial remission (> 50 %) ranged from a minimum of 37 % for patients treated with procarbazine to a maximum of 42 % for those given vinblastine. The median duration of response ranged from 4 to 5 months. Overall median survival from institution of chemotherapy was 24 months. Patients (26 cases) responding to 2 or more drugs showed a median survival of 40 months, which was statistically greater than that observed in an equal number of cases responding only to one drug (13 months) and than that of 7 patients unresponsive to all drugs (9 months). It is concluded from this retrospective study that survival in advanced Hodgkin's disease is longer in patients responding to at least two drugs that in patients responding less or not at all.

Anti-Melanoma Monoclonal Antibody 225-28S: Evaluation of Toxicity in Man

To investigate possible undesirable effects due to the intravenous administration of a reagent of a xenogenic nature (monoclonal antibody 225-28S) in man, a toxicologic study was carried out on 85 patients with metastatic cutaneous melanoma. Two reagents were tested in this study: purified monoclonal antibody (MoAb) 225-28S and its F(ab')2 fragment. Purified MoAb was labelled with 131I and F(ab')2 fragment with 131I, or 123I, or 111In or 99Tc. The quantity of MoAb or F(ab')2 injected ranged from 14 to 750 μg, and the specific activity from 37.0 to 2116.4 MBq/mg. The total radioactivity injected varied from 25.9 to 891.7 MBq/mg. In addition to a careful clinical examination, the following tests were done to monitor possible adverse effects: blood glucose, azotemia, RBC, WBC, platelet count, serum creatinine, creatinine clearance, plasma electrolyte levels, serum proteins, albumin/globulin ratio, serum bilirubin, SGOT, SGPT, γGT, and CPK. These tests were done before the injection and on days 7 and 14. No patient experienced adverse general effects like fever, nausea, vomiting or allergic reactions. None of the aforementioned hematometric and biochemical tests showed significant variations compared with the initial values. It is concluded that a single injection of these reagents at the dosages tested is completely atoxic.

Adriamycin as a Single Agent in Various Forms of Advanced Neoplasia of Adults and Children

This paper reviews the effects of adriamycin (ADM) observed in a series of 485 patients (419 adults and 66 children) treated at the Istituto Nazionale Tumori, Milan, from September 1968 to December 1973. Nine two patients were insufficiently treated to provide meaningful information on drug effects. The drug was administered by rapid intravenous injection through 6 dose schedules. In the last two schedules ADM was administered every 3 weeks at the dose of 20–25 mg/m2 for 3 consecutive days (schedule E) or of 60–75 mg/m2 in a single injection (schedule F). With schedules E and F there was an appreciable decrease in the incidence of stomatitis and of severe myelosuppression. Thrombocytopenia occurred in about 10 % of patients. The overall incidence of cardiomyopathy was 1.9 %. As observed by American investigators, cardiomyopathy occurred especially after a total dose exceeding 600 mg/m2 (17 %) and 4/9 patients died of irreversible heart failure. Congestive failure occurred in 7/9. In 6/9 patients showing cardiomyopathy ADM was administered through schedules E or F. One patient was a child 3 years old and 8 were adults with a mean age of 39 years. Non specific electrocardiographic abnormalities were present in about 10 % of patients during treatment with ADM but only exceptionally were they able to predict subsequent cardiomyopathy. The therapeutic results were promising in several types of previously treated and untreated neoplastic disease. The best responses (complete plus partial remission greater than 50 %) were observed in the group of malignant lymphomas (44%) especially in histiocytic lymphoma (67 %), in Ewing's sarcoma (41 %), Wilms's tumor (55 %), carcinoma of thyroid (45 %), testicular tumors (39 %), neuroblastoma (38 %), naso-pharyngeal carcinoma (29 %), breast cancer (26 %), as well as in the small series of acute and chronic myeloproliferative disorders. Significant regressions were also obtained in transitional carcinoma of urinary bladder (2/6) ovarian carcinomas (29 %), in soft tissue sarcomas (22 %) and in mesothelioma (25 %). A lower rate of substantial tumor response was seen in bronchogenic (15 %) and gastrointestinal carcinomas (22 %) as well as in epidermoid carcinomas of head and neck (10 %). No significant regression was noted in osteogenic sarcomas, chondrosarcoma, renal carcinoma and malignant melanoma. In responsive patients the mean duration of response was usually short. This could be in part explained by the fact that (41 %) of patients had previously been treated with conventional drugs. Our experience shows that ADM is useful in a number of neoplastic diseases, where it produces a prompt tumor regression in responsive patients. The successful results achieved with ADM as a single agent indicate that the drug should be incorporated in several protocols of combination chemotherapy and of combined treatment modalities provided the total dose does not exceed 550 mg/m2.

Enhancement of in vivo Monoclonal Antibody Targeting with Recombinant Interferon and Cytokines

Up to now a number of studies have been performed to determine whether the combined use of cytokines and monoclonal antibodies (MAbs) directed against tumor-associated antigens (TAA) can increase the sensitivity of radioimmunoscintigraphy (RIS).

It well known that human natural and recombinant interferons can enhance the cell surface expression of HLA Class I and II antigens as well as some specific tumor antigens, but there is scanty and conflicting information about the expression and shedding of TAA.

Some authors reported that alpha-IFN enhances the expression of a melanoma-associated antigen (MAA), recognized by conventional antiserum. Other authors have found no changes in the expression of MAA identified by MAbs (17, 18).

In a pilot study on patients with malignant melanoma Rosenblum demonstrated an increase in tumor uptake of the anti-melanoma MAb 96.5 after IFN administration.

In our study we performed immunoscintigraphy with the anti-melanoma MAb 225.28S in the same patient before and after IFN administration in different doses. We point out the difference in biodistribution in different organs and in blood clearance and discuss the possibility to improve the sensitivity of RIS.

Gallium-67 as a Tumor-seeking Agent in Lymphomas - a Review

Background

At present 67Ga can be considered one of the most widely used viability radiotracers. There is general consensus in the literature that 67Ga has the highest clinical value in the management of lymphoma patients.

Methods

We critically discuss the role of gallium scintigraphy in lymphoma patients on the basis of the experience of the Nuclear Medicine Division at the National Cancer Institute of Milan.

Results and Conclusions

The sensitivity of gallium scan is very high (80-90%) in the staging and follow-up of Hodgkin's disease, and the method is also of great importance in the follow-up of lymphoma patients. We recommend scintigraphy to study the residual mediastinal mass after treatment. Our experiences during the follow-up of 189 lymphoma patients clearly showed the superior performance of gallium scan compared to MRI in the study of the mediastinal region after treatment. Sensitivity and specificity were both very high (90% and 96.9% vs 88.7% and 89.2%, respectively). Gallium scintigraphy can also be used to study the disease-free interval, posttreatment survival, early signs of recurrence and treatment response times. Comparison of the survival curves of 33 patients with diffuse large cell Non-Hodgkin's lymphoma examined at the National Cancer Institute showed a statistically significant difference (logrank test, P=0.0125) between patients with positive and those with negative gallium scan after 4-6 cycles of chemotherapy.

Lung Resection as Salvage Treatment for Metastatic Osteosarcoma

Resection of pulmonary metastases has achieved a central role in the overall management of osteosarcoma, since a number of studies have demonstrated that salvage surgery is able to cure 20 to 40% of all relapsing patients. This paper presents the results of surgical management of 27 consecutive cases of pulmonary metastases from osteosarcoma, who underwent complete resection at the Istituto Nazionale Tumori of Milan between 1975 and 1986. In the present series, overall actuarial survival at 3 years from the first thoracotomy was 47%, with a median survival of 28 months and no operative mortality. Better results were observed in patients with single lesions (68% survival) or when the interval to lung metastases exceeded 12 months (60% survival). These data support the concept of pulmonary metastasectomy as effective salvage therapy for metastatic osteosarcomas whose distant spread is confined in the lungs.

Radioimmunodetection of Melanoma: Preliminary Results of a Prospective Study

A prospective study to evaluate the clinical usefulness of radioimmunodetection of melanoma in clinical practice is ongoing at the National Cancer Institute of Milan, Italy. Technical conditions for the application of the method were previously reported. In this trial, 99mTc-labelled F(ab’) 2 fragments of the 225.28S monoclonal antibody were used against a high molecular weight melanoma associated antigen (HMW-MAA).

Retrospective studies on radioimmunodetection of melanoma have already been made by our group and by other Centers in about 300 patients.

This study concerns the evaluation of the regional extension of primary melanoma. 23 patients with 32 suspected lymphatic involvements of melanoma on the trunk and arms underwent immunoscintigraphy. No false positive results were observed; 3 false negatives, one corresponding to a micrometastasis, were noticed. Specificity corresponds to 100% and sensitivity to 78.6%.

Monoclonal anti-CEA Antibody: Factors Affecting Localization in a Preclinical Study

131I-labelled anti-CEA monoclonal antibody was tested in an animal model to evaluate: influence of antibody type (whole versus F(ab’)2 fragments), administration route (i.v. versus i.p.), dose of tracer (100 μCi versus 1000 μCi), growth site (s.c. versus i.p.) and size of tumor. Athymic mice bearing CEA-producing human colon carcinoma (HT-29) or human melanoma as an irrelevant tumor (MeWo) received tracer and immunoscintigraphy and the localization ratios (LR) were compared. In HT-29 bearing animals F(ab’)2 fragments localized better than the whole antibody. The LR were higher after i.p. administration of the tracer, independently of the tumor characteristics or the injected dose. The highest values were achieved when the radioactivity remaining in the whole body was below 2% of the injected dose. The images were negative when the i.p. injected dose was low or tumor growth was i.p. but positive in the other conditions (i.v. administration, high tracer dose, s.c. tumor growth).

In the animals bearing melanoma, images scored positive or negative when the tumor weight was respectively above or below 400 mg, but the LR were always low.

Malignant Ovarian Neoplasms in Childhood

From 1962 to 1976, 15 children up to the age of 15 years with malignant neoplasms of the ovary were observed at the Istituto Nazionale Tumori of Milan. 13 patients had a germ cell tumor and 2 a stromal tumor. Natural history and treatment results are reported. Out of 7 patients with dysgerminoma, 3 at stage IA, 2 at stage III retroperitoneal and 1 with recurrent disease are alive and disease free 38+, 20+, 36+, 16+, 23+, 156+ months after the histologic diagnosis; the last case with stage III peritoneal disease died 2 months after the diagnosis. Four children had immature malignant teratoma: 2 patients are alive and disease free 19+ and 51+ months, 1 is alive with disease 20+ months and 1 died 16 months after histologic diagnosis. Two patients with extra-embryonal teratoma died 7 and 12 months after diagnosis. One patient, treated by surgery plus chemotherapy for granulosa cell tumor at stage III, is alive 43+ months later. The child with arrhenoblastoma at stage III treated by surgery plus radiochemotherapy died 6 months after diagnosis. Through a close scrutiny of the literature and by drawing on experience gained in the treatment of the same tumors in adults, a rational approach to the diagnosis and treatment of each childhood ovarian tumor histotype is worked out.

Clinical findings and prognosis of interference injuries to the palmar aspect of the forelimbs in Standardbred racehorses: A study on 74 cases

BACKGROUND

Information on interference injuries in racehorses is lacking.

OBJECTIVE

To describe clinical findings and prognosis of palmar forelimb interference injuries in Standardbreds.

STUDY DESIGN

Retrospective cohort study.

METHODS

Records of 74 racehorses sustaining palmar forelimb interference injuries were studied; 7 occurred during training and 67 during racing. The number of starts before injury, hind shoeing status, gait penalties and racing speeds in cases occurring during racing were compared with negative controls (67 age, sex and speed category matched horses) from the same races. The number of starts and racing speed in 30 racing days preceding recruitment were compared with those following recruitment (negative controls) or return to racing (cases). Clinical aspects and outcome in interference-induced superficial digital flexor (SDF) tendonitis were compared with 77 horses with overstrain-induced SDF tendonitis.

RESULTS

In 89% of cases, there was SDF tendonitis and this was associated with a longer time to return to racing (6 months vs. 1 months; P<0.001). The presence of gait penalties (odds ratio (OR) 11.13; 95% CI 3.74, 41.64; P<0.001) and unshod hind feet (OR = 6.26, 95% CI 2.26, 19.62; P<0.001) increased risk of interference injuries. After recruitment/return to racing, horses with interference injuries participated in a lower number of races (24 starts per racing day, interquartile range [IQR] 20-32) compared with controls (49, IQR 43-55, P<0.0001). Interference-induced tendonitis cases (n = 58) had a shorter time to return to racing (245 ± 137 days) than overstrain-induced tendonitis cases (331 ± 118 days, P<0.001).

MAIN LIMITATIONS

Data were collected retrospectively; time of ultrasonographic assessment varied and health status of the racing controls is unknown.

CONCLUSIONS

SDF tendonitis is common with palmar forelimb interference injuries in Standardbreds and increases time to return to racing. Interference-induced SDF tendonitis has a better prognosis than overstrain-induced tendonitis.

Pilot, Multicenter and Prospective Trials with an Anti-CEA Antibody

In this paper we summarize the investigations performed by our group utilizing an anti-CEA monoclonal antibody (F023C5) labelled with different radionuclides in humans. Since 1983 radioimmunoscintigraphy (RIS) was performed on 51 patients with 64 localizations of colorectal carcinoma (pilot study). A multicenter clinical trial in a large number of patients (509 pts of which 284 with gastrointestinal cancer) was subsequently carried out in collaboration with ten nuclear medicine centres. High sensitivity and specificity values were obtained by these studies and many unsuspected lesions were recorded. In order to better define the clinical role of RIS, a prospective study was performed on 59 patients with suspected local relapses of colorectal cancer. A comparative evaluation of RIS, CT scan, US and MRI was done. RIS and MRI had the highest accuracy (86%) followed by CT scan (68%) and US (54%).

Neuropsychological predictors of rapidly progressive Alzheimer's disease

OBJECTIVE

Alzheimer's disease (AD), the most common cause of dementia, typically shows a slow clinical progression over time. 'Rapidly progressive' AD, a variant of the disease characterized by an aggressive course, exhibits distinct clinical, biological, and neuropathological features. Here, we investigate neuropsychological predictors of rapid decline in a group of mild patients with AD.

METHODS

One hundred fifty-three mild patients with AD admitted to a memory disorder clinic and followed for up to 3 years were included in this study. A comprehensive neuropsychological (NP) battery was performed at the time of enrollment. Patients were defined as 'rapidly progressive' if they exhibited a drop of 6 or more points on the Mini Mental State Examination (MMSE) between two consecutive annual visits. This event defined the main outcome in multiple analyses of variance and Cox proportional hazards models that investigated the impact of NP predictors. Categorical principal component analysis (CATPCA) was also employed in order to delineate clusters of NP tests and to test their effect on the outcome.

RESULTS

Of 153 subjects, thirty-seven (24%) were classified as 'rapidly progressive'; those subjects showed younger age of symptoms onset compared to slow decliners (68 vs 71.5 years old). Baseline lower performance on a neuropsychological test of naming predicted a rapid decline over the follow-up (P = 0.001). Three clusters of NP were defined by CATPCA: (i) executive/language, (ii) visuospatial memory, and (iii) verbal memory. The executive/language component predicted a rapid decline over the follow-up (P = 0.016).

CONCLUSION

Early executive/language impairment is highly predictive of a rapid progression of AD.

(18)F-FDG PET/CT versus bone scintigraphy in the follow-up of gastric cancer

A 53-year-old patient underwent a positron emission tomography/computed tomography with 2-fluoro-2-deoxy-d-glucose ((18)F-FDG PET/CT) in the suspicious of gastric tumor recurrence (mediastinal and abdominal lymph nodes). PET/CT identified only an area of (18)F-FDGuptake in the twelfth thoracic vertebrae. Unexpectedly, a bone scintigraphy revealed many "hot" spots changing the diagnosis (single metastasis versus plurimetastatic disease) and impacting on patient's management.

Binge eating and fast cognitive worsening in an early-onset bvFTD patient carrying C9ORF72 expansion

An expanded hexanucleotide (GGGGCC) repeat in a non-coding promoter region of open reading frame 72 of chromosome 9 (C9ORF72) has been recently identified as a major cause of familial and sporadic frontotemporal lobar degeneration. We describe the clinical picture of a 64-year-old woman carrying the hexanucleotide repeat expansion, who developed a sporadic early-onset form of behavioral variant frontotemporal dementia characterized by the occurrence of uncommon behavioral manifestations such as binge eating disturbance and by a rapid worsening of cognitive abilities. Our report confirms previous studies asserting that C9ORF72 repeats may sustain heterogeneous clinical syndromes.

Restless legs syndrome in a group of patients with Alzheimer's disease

BACKGROUND

Restless legs syndrome (RLS) is a neurological disorder characterized by the urge to move the legs associated with peculiar unpleasant sensations during periods of rest and inactivity that are relieved by movement. A few studies analyzed RLS in neurodegenerative diseases such as Alzheimer's Disease (AD). The aim of our study was to assess the prevalence and the clinical characteristics of RLS in a cohort of AD patients.

METHODS

Three hundred and thirty-nine subjects with a diagnosis of AD were recruited. Cognitive, functional, and neuropsychiatric measures were collected at baseline and six-monthly for a 2-years follow-up

RESULTS

Fourteen subjects met the RLS criteria. RLS subjects were more frequently male (p:0,006) and younger than AD subject without RLS (p:0,029). MMSE, ADL and IADL were not significantly different. NPI total scores did not differ significantly, however, AD patients with RLS were found to be more apathetic (p:0,001) than AD subjects without RLS.

CONCLUSION

RLS prevalence in our AD cohort was estimated to be about 4%. RLS appeared to be associated with neuropsychiatric symptoms such as apathy. RLS and apathy might share a common pathophysiological basis represented by a dysfunction of the central dopaminergic system.