Functional capacity and assistance from the caregiver during daily activities in Brazilian children with cerebral palsy

Abstract Background Cerebral Palsy (CP) presents changes in posture and movement as a core characteristic, which requires multiprofessional clinical treatments during children’s habilitation or rehabilitation. Besides clinical treatment, it is fundamental that professionals use evaluation systems to quantify the difficulties presented to the individual and their families in their daily lives. We aimed to investigate the functional capacity of individuals with CP and the amount of assistance required by the caregiver in day-to-day activities. Methods Twenty patients with CP, six-year-old on average, were evaluated. The Pediatric Evaluation Inventory of Incapacities was used (PEDI - Pediatric Evaluation Disability Inventory), a system adapted for Brazil that evaluates child's dysfunction in three 3 dimensions: self-care, mobility and social function. To compare the three areas, repeated measures analysis of variance (ANOVA) were used. Results We found the following results regarding the functional capacity of children: self-care, 27.4%, ±17.5; mobility, 25.8%, ±33.3 and social function, 36.3%, ±27.7. The results of the demand of aid from the caregiver according to each dimension were: self-care, 9.7%, ±19.9; mobility, 14.1%, ± 20.9 and social function, 19.8%, ±26.1. Conclusion We indicated that there was no difference between the performance of the subjects in areas of self-care, mobility and social function considering the functional skills and assistance required by the caregiver.

Sistematização de curativos para o tratamento clínico das feridas

O tratamento das feridas cutâneas inclui métodos clínicos e cirúrgicos, sendo o curativo um dos tratamentos clínicos mais frequentemente utilizados. Um vasto arsenal terapêutico composto por curativos passivos ou com princípios ativos é capaz de auxiliar na reparação do tegumento em diversas situações. Curativos visam a melhorar as condições do leito da ferida, podendo ser, em algumas ocasiões, o próprio tratamento definitivo, mas em muitas situações constituem apenas uma etapa intermediária para o tratamento cirúrgico. Curativos inteligentes e biológicos são hoje mais bem classificados como substitutos cutâneos e não serão considerados neste artigo. A escolha do curativo a ser utilizado deve ser baseada no conhecimento das bases fisiopatológicas da cicatrização e da reparação tecidual, sem nunca esquecer o quadro sistêmico do paciente.

Impatto di rifaximina sul microbiota intestinale: selezione di bifidobatteri antibiotico resistenti

The ideal approach for the long term treatment of intestinal disorders, such as inflammatory bowel disease (IBD), is represented by a safe and well tolerated therapy able to reduce mucosal inflammation and maintain homeostasis of the intestinal microbiota. A combined therapy with antimicrobial agents, to reduce antigenic load, and immunomodulators, to ameliorate the dysregulated responses, followed by probiotic supplementation has been proposed. Because of the complementary mechanisms of action of antibiotics and probiotics, a combined therapeutic approach would give advantages in terms of enlargement of the antimicrobial spectrum, due to the barrier effect of probiotic bacteria, and limitation of some side effects of traditional chemiotherapy (i.e. indiscriminate decrease of aggressive and protective intestinal bacteria, altered absorption of nutrient elements, allergic and inflammatory reactions). Rifaximin (4-deoxy-4’-methylpyrido[1’,2’-1,2]imidazo[5,4-c]rifamycin SV) is a product of synthesis experiments designed to modify the parent compound, rifamycin, in order to achieve low gastrointestinal absorption while retaining good antibacterial activity. Both experimental and clinical pharmacology clearly show that this compound is a non systemic antibiotic with a broad spectrum of antibacterial action, covering Gram-positive and Gram-negative organisms, both aerobes and anaerobes. Being virtually non absorbed, its bioavailability within the gastrointestinal tract is rather high with intraluminal and faecal drug concentrations that largely exceed the MIC values observed in vitro against a wide range of pathogenic microorganisms. The gastrointestinal tract represents therefore the primary therapeutic target and gastrointestinal infections the main indication. The little value of rifaximin outside the enteric area minimizes both antimicrobial resistance and systemic adverse events. Fermented dairy products enriched with probiotic bacteria have developed into one of the most successful categories of functional foods. Probiotics are defined as “live microorganisms which, when administered in adequate amounts, confer a health benefit on the host” (FAO/WHO, 2002), and mainly include Lactobacillus and Bifidobacterium species. Probiotic bacteria exert a direct effect on the intestinal microbiota of the host and contribute to organoleptic, rheological and nutritional properties of food. Administration of pharmaceutical probiotic formula has been associated with therapeutic effects in treatment of diarrhoea, constipation, flatulence, enteropathogens colonization, gastroenteritis, hypercholesterolemia, IBD, such as ulcerative colitis (UC), Crohn’s disease, pouchitis and irritable bowel syndrome. Prerequisites for probiotics are to be effective and safe. The characteristics of an effective probiotic for gastrointestinal tract disorders are tolerance to upper gastrointestinal environment (resistance to digestion by enteric or pancreatic enzymes, gastric acid and bile), adhesion on intestinal surface to lengthen the retention time, ability to prevent the adherence, establishment and/or replication of pathogens, production of antimicrobial substances, degradation of toxic catabolites by bacterial detoxifying enzymatic activities, and modulation of the host immune responses. This study was carried out using a validated three-stage fermentative continuous system and it is aimed to investigate the effect of rifaximin on the colonic microbial flora of a healthy individual, in terms of bacterial composition and production of fermentative metabolic end products. Moreover, this is the first study that investigates in vitro the impact of the simultaneous administration of the antibiotic rifaximin and the probiotic B. lactis BI07 on the intestinal microbiota. Bacterial groups of interest were evaluated using culture-based methods and molecular culture-independent techniques (FISH, PCR-DGGE). Metabolic outputs in terms of SCFA profiles were determined by HPLC analysis. Collected data demonstrated that rifaximin as well as antibiotic and probiotic treatment did not change drastically the intestinal microflora, whereas bacteria belonging to Bifidobacterium and Lactobacillus significantly increase over the course of the treatment, suggesting a spontaneous upsurge of rifaximin resistance. These results are in agreement with a previous study, in which it has been demonstrated that rifaximin administration in patients with UC, affects the host with minor variations of the intestinal microflora, and that the microbiota is restored over a wash-out period. In particular, several Bifidobacterium rifaximin resistant mutants could be isolated during the antibiotic treatment, but they disappeared after the antibiotic suspension. Furthermore, bacteria belonging to Atopobium spp. and E. rectale/Clostridium cluster XIVa increased significantly after rifaximin and probiotic treatment. Atopobium genus and E. rectale/Clostridium cluster XIVa are saccharolytic, butyrate-producing bacteria, and for these characteristics they are widely considered health-promoting microorganisms. The absence of major variations in the intestinal microflora of a healthy individual and the significant increase in probiotic and health-promoting bacteria concentrations support the rationale of the administration of rifaximin as efficacious and non-dysbiosis promoting therapy and suggest the efficacy of an antibiotic/probiotic combined treatment in several gut pathologies, such as IBD. To assess the use of an antibiotic/probiotic combination for clinical management of intestinal disorders, genetic, proteomic and physiologic approaches were employed to elucidate molecular mechanisms determining rifaximin resistance in Bifidobacterium, and the expected interactions occurring in the gut between these bacteria and the drug. The ability of an antimicrobial agent to select resistance is a relevant factor that affects its usefulness and may diminish its useful life. Rifaximin resistance phenotype was easily acquired by all bifidobacteria analyzed [type strains of the most representative intestinal bifidobacterial species (B. infantis, B. breve, B. longum, B. adolescentis and B. bifidum) and three bifidobacteria included in a pharmaceutical probiotic preparation (B. lactis BI07, B. breve BBSF and B. longum BL04)] and persisted for more than 400 bacterial generations in the absence of selective pressure. Exclusion of any reversion phenomenon suggested two hypotheses: (i) stable and immobile genetic elements encode resistance; (ii) the drug moiety does not act as an inducer of the resistance phenotype, but enables selection of resistant mutants. Since point mutations in rpoB have been indicated as representing the principal factor determining rifampicin resistance in E. coli and M. tuberculosis, whether a similar mechanism also occurs in Bifidobacterium was verified. The analysis of a 129 bp rpoB core region of several wild-type and resistant bifidobacteria revealed five different types of miss-sense mutations in codons 513, 516, 522 and 529. Position 529 was a novel mutation site, not previously described, and position 522 appeared interesting for both the double point substitutions and the heterogeneous profile of nucleotide changes. The sequence heterogeneity of codon 522 in Bifidobacterium leads to hypothesize an indirect role of its encoded amino acid in the binding with the rifaximin moiety. These results demonstrated the chromosomal nature of rifaximin resistance in Bifidobacterium, minimizing risk factors for horizontal transmission of resistance elements between intestinal microbial species. Further proteomic and physiologic investigations were carried out using B. lactis BI07, component of a pharmaceutical probiotic preparation, as a model strain. The choice of this strain was determined based on the following elements: (i) B. lactis BI07 is able to survive and persist in the gut; (ii) a proteomic overview of this strain has been recently reported. The involvement of metabolic changes associated with rifaximin resistance was investigated by proteomic analysis performed with two-dimensional electrophoresis and mass spectrometry. Comparative proteomic mapping of BI07-wt and BI07-res revealed that most differences in protein expression patterns were genetically encoded rather than induced by antibiotic exposure. In particular, rifaximin resistance phenotype was characterized by increased expression levels of stress proteins. Overexpression of stress proteins was expected, as they represent a common non specific response by bacteria when stimulated by different shock conditions, including exposure to toxic agents like heavy metals, oxidants, acids, bile salts and antibiotics. Also, positive transcription regulators were found to be overexpressed in BI07-res, suggesting that bacteria could activate compensatory mechanisms to assist the transcription process in the presence of RNA polymerase inhibitors. Other differences in expression profiles were related to proteins involved in central metabolism; these modifications suggest metabolic disadvantages of resistant mutants in comparison with sensitive bifidobacteria in the gut environment, without selective pressure, explaining their disappearance from faeces of patients with UC after interruption of antibiotic treatment. The differences observed between BI07-wt e BI07-res proteomic patterns, as well as the high frequency of silent mutations reported for resistant mutants of Bifidobacterium could be the consequences of an increased mutation rate, mechanism which may lead to persistence of resistant bacteria in the population. However, the in vivo disappearance of resistant mutants in absence of selective pressure, allows excluding the upsurge of compensatory mutations without loss of resistance. Furthermore, the proteomic characterization of the resistant phenotype suggests that rifaximin resistance is associated with a reduced bacterial fitness in B. lactis BI07-res, supporting the hypothesis of a biological cost of antibiotic resistance in Bifidobacterium. The hypothesis of rifaximin inactivation by bacterial enzymatic activities was verified by using liquid chromatography coupled with tandem mass spectrometry. Neither chemical modifications nor degradation derivatives of the rifaximin moiety were detected. The exclusion of a biodegradation pattern for the drug was further supported by the quantitative recovery in BI07-res culture fractions of the total rifaximin amount (100 μg/ml) added to the culture medium. To confirm the main role of the mutation on the β chain of RNA polymerase in rifaximin resistance acquisition, transcription activity of crude enzymatic extracts of BI07-res cells was evaluated. Although the inhibition effects of rifaximin on in vitro transcription were definitely higher for BI07-wt than for BI07-res, a partial resistance of the mutated RNA polymerase at rifaximin concentrations > 10 μg/ml was supposed, on the basis of the calculated differences in inhibition percentages between BI07-wt and BI07-res. By considering the resistance of entire BI07-res cells to rifaximin concentrations > 100 μg/ml, supplementary resistance mechanisms may take place in vivo. A barrier for the rifaximin uptake in BI07-res cells was suggested in this study, on the basis of the major portion of the antibiotic found to be bound to the cellular pellet respect to the portion recovered in the cellular lysate. Related to this finding, a resistance mechanism involving changes of membrane permeability was supposed. A previous study supports this hypothesis, demonstrating the involvement of surface properties and permeability in natural resistance to rifampicin in mycobacteria, isolated from cases of human infection, which possessed a rifampicin-susceptible RNA polymerase. To understand the mechanism of membrane barrier, variations in percentage of saturated and unsaturated FAs and their methylation products in BI07-wt and BI07-res membranes were investigated. While saturated FAs confer rigidity to membrane and resistance to stress agents, such as antibiotics, a high level of lipid unsaturation is associated with high fluidity and susceptibility to stresses. Thus, the higher percentage of saturated FAs during the stationary phase of BI07-res could represent a defence mechanism of mutant cells to prevent the antibiotic uptake. Furthermore, the increase of CFAs such as dihydrosterculic acid during the stationary phase of BI07-res suggests that this CFA could be more suitable than its isomer lactobacillic acid to interact with and prevent the penetration of exogenous molecules including rifaximin. Finally, the impact of rifaximin on immune regulatory functions of the gut was evaluated. It has been suggested a potential anti-inflammatory effect of rifaximin, with reduced secretion of IFN-γ in a rodent model of colitis. Analogously, it has been reported a significant decrease in IL-8, MCP-1, MCP-3 e IL-10 levels in patients affected by pouchitis, treated with a combined therapy of rifaximin and ciprofloxacin. Since rifaximin enables in vivo and in vitro selection of Bifidobacterium resistant mutants with high frequency, the immunomodulation activities of rifaximin associated with a B. lactis resistant mutant were also taken into account. Data obtained from PBMC stimulation experiments suggest the following conclusions: (i) rifaximin does not exert any effect on production of IL-1β, IL-6 and IL-10, whereas it weakly stimulates production of TNF-α; (ii) B. lactis appears as a good inducer of IL-1β, IL-6 and TNF-α; (iii) combination of BI07-res and rifaximin exhibits a lower stimulation effect than BI07-res alone, especially for IL-6. These results confirm the potential anti-inflammatory effect of rifaximin, and are in agreement with several studies that report a transient pro-inflammatory response associated with probiotic administration. The understanding of the molecular factors determining rifaximin resistance in the genus Bifidobacterium assumes an applicative significance at pharmaceutical and medical level, as it represents the scientific basis to justify the simultaneous use of the antibiotic rifaximin and probiotic bifidobacteria in the clinical treatment of intestinal disorders.

RNA Interference and cyclooxygenase-2 (COX-2) regulation in colon cancer cells

Despite new methods and combined strategies, conventional cancer chemotherapy still lacks specificity and induces drug resistance. Gene therapy can offer the potential to obtain the success in the clinical treatment of cancer and this can be achieved by replacing mutated tumour suppressor genes, inhibiting gene transcription, introducing new genes encoding for therapeutic products, or specifically silencing any given target gene. Concerning gene silencing, attention has recently shifted onto the RNA interference (RNAi) phenomenon. Gene silencing mediated by RNAi machinery is based on short RNA molecules, small interfering RNAs (siRNAs) and microRNAs (miRNAs), that are fully o partially homologous to the mRNA of the genes being silenced, respectively. On one hand, synthetic siRNAs appear as an important research tool to understand the function of a gene and the prospect of using siRNAs as potent and specific inhibitors of any target gene provides a new therapeutical approach for many untreatable diseases, particularly cancer. On the other hand, the discovery of the gene regulatory pathways mediated by miRNAs, offered to the research community new important perspectives for the comprehension of the physiological and, above all, the pathological mechanisms underlying the gene regulation. Indeed, changes in miRNAs expression have been identified in several types of neoplasia and it has also been proposed that the overexpression of genes in cancer cells may be due to the disruption of a control network in which relevant miRNA are implicated. For these reasons, I focused my research on a possible link between RNAi and the enzyme cyclooxygenase-2 (COX-2) in the field of colorectal cancer (CRC), since it has been established that the transition adenoma-adenocarcinoma and the progression of CRC depend on aberrant constitutive expression of COX-2 gene. In fact, overexpressed COX-2 is involved in the block of apoptosis, the stimulation of tumor-angiogenesis and promotes cell invasion, tumour growth and metastatization. On the basis of data reported in the literature, the first aim of my research was to develop an innovative and effective tool, based on the RNAi mechanism, able to silence strongly and specifically COX-2 expression in human colorectal cancer cell lines. In this study, I firstly show that an siRNA sequence directed against COX-2 mRNA (siCOX-2), potently downregulated COX-2 gene expression in human umbilical vein endothelial cells (HUVEC) and inhibited PMA-induced angiogenesis in vitro in a specific, non-toxic manner. Moreover, I found that the insertion of a specific cassette carrying anti-COX-2 shRNA sequence (shCOX-2, the precursor of siCOX-2 previously tested) into a viral vector (pSUPER.retro) greatly increased silencing potency in a colon cancer cell line (HT-29) without activating any interferon response. Phenotypically, COX-2 deficient HT-29 cells showed a significant impairment of their in vitro malignant behaviour. Thus, results reported here indicate an easy-to-use, powerful and high selective virus-based method to knockdown COX-2 gene in a stable and long-lasting manner, in colon cancer cells. Furthermore, they open up the possibility of an in vivo application of this anti-COX-2 retroviral vector, as therapeutic agent for human cancers overexpressing COX-2. In order to improve the tumour selectivity, pSUPER.retro vector was modified for the shCOX-2 expression cassette. The aim was to obtain a strong, specific transcription of shCOX-2 followed by COX-2 silencing mediated by siCOX-2 only in cancer cells. For this reason, H1 promoter in basic pSUPER.retro vector [pS(H1)] was substituted with the human Cox-2 promoter [pS(COX2)] and with a promoter containing repeated copies of the TCF binding element (TBE) [pS(TBE)]. These promoters were choosen because they are partculary activated in colon cancer cells. COX-2 was effectively silenced in HT-29 and HCA-7 colon cancer cells by using enhanced pS(COX2) and pS(TBE) vectors. In particular, an higher siCOX-2 production followed by a stronger inhibition of Cox-2 gene were achieved by using pS(TBE) vector, that represents not only the most effective, but also the most specific system to downregulate COX-2 in colon cancer cells. Because of the many limits that a retroviral therapy could have in a possible in vivo treatment of CRC, the next goal was to render the enhanced RNAi-mediate COX-2 silencing more suitable for this kind of application. Xiang and et al. (2006) demonstrated that it is possible to induce RNAi in mammalian cells after infection with engineered E. Coli strains expressing Inv and HlyA genes, which encode for two bacterial factors needed for successful transfer of shRNA in mammalian cells. This system, called “trans-kingdom” RNAi (tkRNAi) could represent an optimal approach for the treatment of colorectal cancer, since E. Coli in normally resident in human intestinal flora and could easily vehicled to the tumor tissue. For this reason, I tested the improved COX-2 silencing mediated by pS(COX2) and pS(TBE) vectors by using tkRNAi system. Results obtained in HT-29 and HCA-7 cell lines were in high agreement with data previously collected after the transfection of pS(COX2) and pS(TBE) vectors in the same cell lines. These findings suggest that tkRNAi system for COX-2 silencing, in particular mediated by pS(TBE) vector, could represent a promising tool for the treatment of colorectal cancer. Flanking the studies addressed to the setting-up of a RNAi-mediated therapeutical strategy, I proposed to get ahead with the comprehension of new molecular basis of human colorectal cancer. In particular, it is known that components of the miRNA/RNAi pathway may be altered during the progressive development of colorectal cancer (CRC), and it has been already demonstrated that some miRNAs work as tumor suppressors or oncomiRs in colon cancer. Thus, my hypothesis was that overexpressed COX-2 protein in colon cancer could be the result of decreased levels of one or more tumor suppressor miRNAs. In this thesis, I clearly show an inverse correlation between COX-2 expression and the human miR- 101(1) levels in colon cancer cell lines, tissues and metastases. I also demonstrate that the in vitro modulating of miR-101(1) expression in colon cancer cell lines leads to significant variations in COX-2 expression, and this phenomenon is based on a direct interaction between miR-101(1) and COX-2 mRNA. Moreover, I started to investigate miR-101(1) regulation in the hypoxic environment since adaptation to hypoxia is critical for tumor cell growth and survival and it is known that COX-2 can be induced directly by hypoxia-inducible factor 1 (HIF-1). Surprisingly, I observed that COX-2 overexpression induced by hypoxia is always coupled to a significant decrease of miR-101(1) levels in colon cancer cell lines, suggesting that miR-101(1) regulation could be involved in the adaption of cancer cells to the hypoxic environment that strongly characterize CRC tissues.

Riabilitazione e valutazione di pazienti con deficit neurologici mediante l'utilizzo di realtà virtuale, feedback aumentati, sensori inerziali e tecnologie video a basso costo.

La neuroriabilitazione è un processo attraverso cui individui affetti da patologie neurologiche mirano al conseguimento di un recupero completo o alla realizzazione del loro potenziale ottimale benessere fisico, mentale e sociale. Elementi essenziali per una riabilitazione efficace sono: una valutazione clinica da parte di un team multidisciplinare, un programma riabilitativo mirato e la valutazione dei risultati conseguiti mediante misure scientifiche e clinicamente appropriate. Obiettivo principale di questa tesi è stato sviluppare metodi e strumenti quantitativi per il trattamento e la valutazione motoria di pazienti neurologici. I trattamenti riabilitativi convenzionali richiedono a pazienti neurologici l’esecuzione di esercizi ripetitivi, diminuendo la loro motivazione. La realtà virtuale e i feedback sono in grado di coinvolgerli nel trattamento, permettendo ripetibilità e standardizzazione dei protocolli. È stato sviluppato e valutato uno strumento basato su feedback aumentati per il controllo del tronco. Inoltre, la realtà virtuale permette l’individualizzare il trattamento in base alle esigenze del paziente. Un’applicazione virtuale per la riabilitazione del cammino è stata sviluppata e testata durante un training su pazienti di sclerosi multipla, valutandone fattibilità e accettazione e dimostrando l'efficacia del trattamento. La valutazione quantitativa delle capacità motorie dei pazienti viene effettuata utilizzando sistemi di motion capture. Essendo il loro uso nella pratica clinica limitato, una metodologia per valutare l’oscillazione delle braccia in soggetti parkinsoniani basata su sensori inerziali è stata proposta. Questi sono piccoli, accurati e flessibili ma accumulano errori durante lunghe misurazioni. È stato affrontato questo problema e i risultati suggeriscono che, se il sensore è sul piede e le accelerazioni sono integrate iniziando dalla fase di mid stance, l’errore e le sue conseguenze nella determinazione dei parametri spaziali sono contenuti. Infine, è stata presentata una validazione del Kinect per il tracking del cammino in ambiente virtuale. Risultati preliminari consentono di definire il campo di utilizzo del sensore in riabilitazione.

Observable stages and scheduling for alveolar remodeling following antemortem tooth loss

Zahnverlust zu Lebzeiten („antemortem tooth loss“, AMTL) kann als Folge von Zahnerkrankungen, Traumata, Zahnextraktionen oder extremer kontinuierlicher Eruption sowie als Begleiterscheinung fortgeschrittener Stadien von Skorbut oder Lepra auftreten. Nach dem Zahnverlust setzt die Wundheilung als Sekundärheilung ein, während der sich die Alveole mit Blut füllt und sich ein Koagulum bildet. Anschließend erfolgt dessen Umwandlung in Knochengewebe und schließlich verstreicht die Alveole derart, dass sie makroskopisch nicht mehr erkannt werden kann. Der Zeitrahmen der knöchernen Konsolidierung des Kieferkammes ist im Detail wenig erforscht. Aufgrund des gehäuften Auftretens von AMTL in menschlichen Populationen, ist die Erarbeitung eines Zeitfensters, mit dessen Hilfe durch makroskopische Beobachtung des Knochens die Zeitspanne seit dem Zahnverlust („time since tooth loss“, TSL) ermittelt werden kann, insbesondere im archäologischen Kontext äußerst wertvoll. Solch ein Zeitschema mit Angaben über die Variabilität der zeitlichen Abläufe bei den Heilungsvorgängen kann nicht nur in der Osteologie, sondern auch in der Forensik, der allgemeinen Zahnheilkunde und der Implantologie nutzbringend angewandt werden. rnrnNach dem Verlust eines Zahnes wird das Zahnfach in der Regel durch ein Koagulum aufgefüllt. Das sich bildende Gewebe wird rasch in noch unreifen Knochen umgewandelt, welcher den Kieferknochen und auch die angrenzenden Zähne stabilisiert. Nach seiner Ausreifung passt sich das Gewebe schließlich dem umgebenden Knochen an. Das Erscheinungsbild des Zahnfaches während dieses Vorgangs durchläuft verschiedene Stadien, welche in der vorliegenden Studie anhand von klinischen Röntgenaufnahmen rezenter Patienten sowie durch Untersuchungen an archäologischen Skelettserien identifiziert wurden. Die Heilungsvorgänge im Zahnfach können in eine prä-ossale Phase (innerhalb einer Woche nach Zahnverlust), eine Verknöcherungsphase (etwa 14 Wochen nach Zahnverlust) und eine ossifizierte bzw. komplett verheilte Phase (mindestens 29 Wochen nach Zahnverlust) eingeteilt werden. Etliche Faktoren – wie etwa die Resorption des Interdentalseptums, der Zustand des Alveolarknochens oder das Individualgeschlecht – können den normalen Heilungsprozess signifikant beschleunigen oder hemmen und so Unterschiede von bis zu 19 Wochen verursachen. Weitere Variablen wirkten sich nicht signifikant auf den zeitlichen Rahmen des Heilungsprozesse aus. Relevante Abhängigkeiten zwischen verschiedenen Variabeln wurden ungeachtet der Alveolenauffüllung ebenfalls getestet. Gruppen von unabhängigen Variabeln wurden im Hinblick auf Auffüllungsgrad und TSL in multivariablen Modellen untersucht. Mit Hilfe dieser Ergebnisse ist eine grobe Einschätzung der Zeitspanne nach einem Zahnverlust in Wochen möglich, wobei die Einbeziehung weiterer Parameter eine höhere Präzision ermöglicht. rnrnObwohl verschiedene dentale Pathologien in dieser Studie berücksichtigt wurden, sollten zukünftige Untersuchungen genauer auf deren potenzielle Einflussnahme auf den alveolaren Heilungsprozess eingehen. Der kausale Zusammenhang einiger Variablen (wie z. B. Anwesenheit von Nachbarzähnen oder zahnmedizinische Behandlungen), welche die Geschwindigkeit der Heilungsrate beeinflussen, wäre von Bedeutung für zukünftige Untersuchungen des oralen Knochengewebes. Klinische Vergleichsstudien an forensischen Serien mit bekannter TSL oder an einer sich am Anfang des Heilungsprozesses befindlichen klinischen Serie könnten eine Bekräftigung dieser Ergebnisse liefern.

Modelli e strumenti di supporto alla scelta informata del paziente: un argine alla medicina difensiva

L’aumento esponenziale del contenzioso medico-legale – originatosi negli USA negli anni Sessanta in proporzioni tali da far parlare di medical liability crisis, e sviluppatosi in Italia a partire dalla metà degli anni Ottanta – ha comportato e continua a comportare, unitamente ad altre conseguenze negative, il ricorso sempre più frequente dei sanitari alle pratiche di medicina difensiva, con elevatissimi costi a carico del Servizio Sanitario Nazionale dovuti alla sovrabbondanza di trattamenti e ricoveri inutili e di procedure diagnostiche invasive non necessarie, peraltro produttive di stress emotivo nei pazienti. La causa dell’aumento della litigiosità deve essere ricercata in buona parte nella relazione medico-paziente, in particolar modo con riferimento al momento informativo che precede l’acquisizione del consenso informato al trattamento clinico. In Italia, i limiti che per lo più caratterizzano gli studi riguardanti il consenso informato derivano principalmente dal fatto che essi tendono a focalizzarsi unicamente sulla componente scritta del medesimo. Il fulcro del consenso informato, invece, deve ritenersi rappresentato da una comunicazione tra sanitario e paziente relativa ad un trattamento proposto ed alle possibili alternative, alla non sottoposizione ad alcun trattamento e ai rischi e benefici di ciascuna di queste opzioni. In un tale contesto il tema della comunicazione tra il professionista e la persona assistita sta suscitando interesse poiché ci si aspetta che esso conduca a miglioramenti degli outcome dei pazienti e alla diminuzione delle denunce da parte di questi ultimi per casi di responsabilità sanitaria. La maggiore attenzione al rapporto medico - paziente ha fatto emergere il bisogno di migliorare e potenziare le abilità comunicative dei medici, in un’ottica in cui il momento comunicativo possa essere percepito dal professionista come fulcro del rapporto medico-paziente, nella prospettiva di una elaborazione di strategie di prevenzione e contrasto ai fenomeni di medicina difensiva.

Chirurgische und interventionelle Behandlung der chronisch-kritischen Beinischämie

Die chronisch-kritische Beinischämie (CLI) ist die schwerste Form der peripher-arteriellen Verschlusskrankheit und geht mit einem erhöhten Risiko für letale kardiovaskuläre Ereignisse einher. Die meisten Patienten überleben aber die ersten Jahre nach Diagnosestellung und sind für den Erhalt ihrer Selbständigkeit auf eine nachhaltige Verbesserung der Beindurchblutung angewiesen. Dieser CME-Artikel fasst die chirurgischen und endovaskulären Optionen zur Revaskularisierung zusammen und geht auf deren Nachhaltigkeit bei CLI ein. Grenzen der verfügbaren Evidenz werden aufgezeigt. Sie beruhen vor allem auf dem Fehlen einer einheitlichen Definition des Behandlungserfolges. Ein klinisch orientierter Lösungsvorschlag wird diskutiert, der helfen könnte, die verschiedenen Behandlungsindikationen zu schärfen. Da sich aber nur die wenigsten Patienten gleich gut für verschiedene Verfahren eignen, werden CLI-Patienten auch in Zukunft am besten in einem interdisziplinär arbeitenden Team betreut sein.

Candida parapsilosis endocarditis: a comparative review of the literature

Fungal endocarditis (FE) is an uncommon disease, and while accounting for only 1.3-6% of all cases of infectious endocarditis, it carries a high mortality risk. Although Candida albicans represents the main etiology of FE, C. parapsilosis is the most common non-albicans species. We report the case of a 32-year-old man with a history of prior intravenous drug (IVD) use hospitalized with endocarditis due to C. parapsilosis and review all 71 additional cases documented in the literature. A retrospective analysis of the 72 C. parapsilosis cases compared to 52 recently reviewed cases of C. albicans endocarditis was conducted to identify organism-specific clinical peculiarities. The most common predisposing factor for C. parapsilosis endocarditis (41/72; 57.4%) involved prosthetic valves followed by IVD use (12/72; 20%). Peripheral embolic and/or hemorrhagic events occurred in 28/64 (43.8%) patients, mostly in cerebral and lower limb territories. Overall mortality was 41.7%. Combined surgical and clinical treatment was associated with a lower mortality. Few patients received the newer antifungal agents, and it would appear that more experience is required for their use in the treatment of C. parapsilosis endocarditis.

Return to Work after Traumatic Hand Injuries: Medical, Personal and Work-related Factors

PURPOSE This study aimed to examine the work-related impact of open hand injuries, specifically, the amount of lost work days subsequent to the injury and factors associated with work-related rehabilitation. PATIENTS AND METHODS We retrospectivley included consecutive patients with acute hand injuries who were operated between 2008 and 2009 in the Division of Hand Surgery (n=435) at the Department of Orthopaedic, Plastic and Hand Surgery. Information was obtained from the medical records and via a self-reported questionnaire sent out in 2011. Patients younger than 18 or older than 65 years, as well as the unemployed were excluded from the study. Descriptive group analysis was used to establish statistical relationships between time off work (TOW) and possible influencing variables. Multiple linear regression was applied to analyse the impact of injury, personal and/or work-related factors on TOW. RESULTS The sample included 290 patients with a mean age of 38.9 (SD 13.2) years of whom 98.6% returned to work after a median absence of 45.5 days. Univariate analysis demonstrated an association of length of absence from work with socio-demographic, clinical and work-related factors. Multiple regression analysis indicated that the location of injury, the number of injured regions, the need for secondary surgery, age, and the type of occupation were independently associated with TOW. CONCLUSION Most factors associated with TOW after traumatic hand injuries could not be influenced. Possible interventions should probably target improved injury prevention, optimal clinical treatment and rehabilitation starting early after injury. Whether improvements in communication and enhancement of cooperation between the treatment teams, the workplace and the insurance carrier may support a staged and earlier return to work remains to be investigated.

The effect of pain on involuntary and voluntary capture of attention

BACKGROUND: There is converging evidence for the notion that pain affects a broad range of attentional domains. This study investigated the influence of pain on the involuntary capture of attention as indexed by the P3a component in the event-related potential derived from the electroencephalogram. METHODS: Participants performed in an auditory oddball task in a pain-free and a pain condition during which they submerged a hand in cold water. Novel, infrequent and unexpected auditory stimuli were presented randomly in a series of frequent standard and infrequent target tones. P3a and P3b amplitudes were observed to novel, unexpected and target-related stimuli, respectively. RESULTS: Both electrophysiological components were characterized by reduced amplitudes in the pain compared with the pain-free condition. Hit rate and reaction time to target stimuli did not differ between the two conditions presumably because the experimental task was not difficult enough to exceed attentional capacities under pain conditions. CONCLUSIONS: These results indicate that voluntary attention serving the maintenance and control of ongoing information processing (reflected by the P3b amplitude) is impaired by pain. In addition, the involuntary capture of attention and orientation to novel, unexpected information (measured by the P3a) is also impaired by pain. Thus, neurophysiological measures examined in this study support the theoretical positions proposing that pain can reduce attentional processing capacity. These findings have potentially important implications at the theoretical level for our understanding of the interplay of pain and cognition, and at the therapeutic level for the clinical treatment of individuals experiencing ongoing pain.

ICAM1 depletion reduces spinal metastasis formation in vivo and improves neurological outcome

INTRODUCTION Clinical treatment of spinal metastasis is gaining in complexity while the underlying biology remains unknown. Insufficient biological understanding is due to a lack of suitable experimental animal models. Intercellular adhesion molecule-1 (ICAM1) has been implicated in metastasis formation. Its role in spinal metastasis remains unclear. It was the aim to generate a reliable spinal metastasis model in mice and to investigate metastasis formation under ICAM1 depletion. MATERIAL AND METHODS B16 melanoma cells were infected with a lentivirus containing firefly luciferase (B16-luc). Stable cell clones (B16-luc) were injected retrogradely into the distal aortic arch. Spinal metastasis formation was monitored using in vivo bioluminescence imaging/MRI. Neurological deficits were monitored daily. In vivo selected, metastasized tumor cells were isolated (mB16-luc) and reinjected intraarterially. mB16-luc cells were injected intraarterially in ICAM1 KO mice. Metastasis distribution was analyzed using organ-specific fluorescence analysis. RESULTS Intraarterial injection of B16-luc and metastatic mB16-luc reliably induced spinal metastasis formation with neurological deficits (B16-luc:26.5, mB16-luc:21 days, p<0.05). In vivo selection increased the metastatic aggressiveness and led to a bone specific homing phenotype. Thus, mB16-luc cells demonstrated higher number (B16-luc: 1.2±0.447, mB16-luc:3.2±1.643) and increased total metastasis volume (B16-luc:2.87±2.453 mm3, mB16-luc:11.19±3.898 mm3, p<0.05) in the spine. ICAM1 depletion leads to a significantly reduced number of spinal metastasis (mB16-luc:1.2±0.84) with improved neurological outcome (29 days). General metastatic burden was significantly reduced under ICAM1 depletion (control: 3.47×10(7)±1.66×10(7); ICAM-1-/-: 5.20×10(4)±4.44×10(4), p<0.05 vs. control) CONCLUSION Applying a reliable animal model for spinal metastasis, ICAM1 depletion reduces spinal metastasis formation due to an organ-unspecific reduction of metastasis development.

Cellular and molecular effects of the mTOR inhibitor everolimus.

mTOR (mechanistic target of rapamycin) functions as the central regulator for cell proliferation, growth and survival. Up-regulation of proteins regulating mTOR, as well as its downstream targets, has been reported in various cancers. This has promoted the development of anti-cancer therapies targeting mTOR, namely fungal macrolide rapamycin, a naturally occurring mTOR inhibitor, and its analogues (rapalogues). One such rapalogue, everolimus, has been approved in the clinical treatment of renal and breast cancers. Although results have demonstrated that these mTOR inhibitors are effective in attenuating cell growth of cancer cells under in vitro and in vivo conditions, subsequent sporadic response to rapalogues therapy in clinical trials has promoted researchers to look further into the complex understanding of the dynamics of mTOR regulation in the tumour environment. Limitations of these rapalogues include the sensitivity of tumour subsets to mTOR inhibition. Additionally, it is well known that rapamycin and its rapalogues mediate their effects by inhibiting mTORC (mTOR complex) 1, with limited or no effect on mTORC2 activity. The present review summarizes the pre-clinical, clinical and recent discoveries, with emphasis on the cellular and molecular effects of everolimus in cancer therapy.

Molecular alterations in nucleotide excision repair genes in malignant glioma and their relevance to malignant progression and drug resistance

Recently, it has become apparent that DNA repair mechanisms are involved in the malignant progression and resistance to therapy of gliomas. Many investigators have shown that increased levels of O6-methyl guanine DNA alkyltransferase, a DNA monoalkyl adduct repair enzyme, are correlated with resistance of malignant glioma cell lines to nitrosourea-based chemotherapy. Three important DNA excision repair genes ERCC1 (excision repair cross complementation group 1), ERCC2 (excision repair cross complementation group 2), and ERCC6 (excision repair cross complementation group 6) have been studied in human tumors. Gene copy number variation of ERCC1 and ERCC2 has been observed in primary glioma tissues. A number of reports describing a relationship between ERCC1 gene alterations and resistance to anti-cancer drugs have been also described. The levels of ERCC1 gene expression, however, have not been correlated with drug resistance in gliomas. The expression of ERCC6 gene transcribes has been shown to vary with tissue types and to be highest in the brain. There have been no comprehensive studies so far, however, of ERCC6 gene expression and molecular alterations in malignant glioma. This project examined the ERCC1 expression levels and correlated them with cisplatin resistance in malignant glioma cell lines. We also examined the molecular alterations of ERCC6 gene in primary glioma tissues and cells and analyzed whether these alterations are related to tumor progression and chemotherapy resistance. Our results indicate the presence of mutations and/or deletions in exons II and V of the ERCC6 gene, and these alterations are more frequent in exon II. Furthermore, the mutations and/or deletions in exon II were shown to be associated with increased malignant grade of gliomas. The results on the Levels of ERCC1 gene transcripts showed that expression levels correlate with cisplatin resistance. The increase in ERCC1 mRNA induced by cisplatin could be down-regulated by cyclosporin A and herbimycin A. The results of this study are likely to provide useful information for clinical treatment of human gliomas. ^

Texas dental hygiene/dietitian occupational health study

Occupational asthma is the most common form of reported occupational respiratory disease in many industrialized countries. Recent studies show that environmental exposures account for up to 40% of the cases of asthma and that 2% to 15% of all cases of asthma are attributable to occupational exposures. In the dental workplace, dental hygienists are exposed to hazardous substances. Among these hazards are respiratory sensitizers, irritants and infectious agents. A cross-sectional study of Texas dental hygienists was conducted to assess the prevalence of occupational asthma. Registered dietitians were surveyed as a comparison group, because this group is similar in demographic makeup to dental hygienists, but conducts no clinical treatment with associated hazardous exposures. Neither the questionnaire survey nor the cover letter revealed the focus of this investigation. Three hundred and thirty five dental hygienists licensed to practice in the state of Texas as of January 1, 1999, and 320 dietitians that are also licensed by the state of Texas were randomly selected. (Abstract shortened by UMI.)^