Preclinical development of cancer vaccines

Triplex cell vaccine is a cancer immunopreventive cell vaccine that can prevent almost completely mammary tumor onset in HER-2/neu transgenic mice. A future translation of cancer immunoprevention from preclinical to clinical studies should take into account several aspects. The work reported in this thesis deals with the study of three of these aspects: vaccine schedule, activity in a therapeutic set-up and second-generation DNA vaccines. An important element in determining human acceptance and compliance of a treatment protocol is the number of vaccinations. In order to improve the vaccination schedule a minimal protocol was searched, i.e. a schedule consisting of a lower number of administrations than standard protocol but with a similar efficacy. A candidate optimal protocol was identified by the use of an in silico model, SimTriplex simulator. The in vivo test of this schedule in HER-2/neu transgenic mice only partially confirmed in silico predictions. This result shows that in silico models have the potential ability to aid in searching of optimal treatment protocols, provided that they will be further tuned on experimental data. As a further result this preclinical study highlighted that kinetic of antibody response plays a major role in determining cancer prevention, leading to the hypothesis of a threshold that must be reached rapidly and maintained lifetime. Early clinical trials would be performed in a therapeutic, rather than preventive, setting. Thus, the activity of Triplex vaccine was investigated against experimental lung metastases in HER-2/neu transgenic mice in order to evaluate if the immunopreventive Triplex vaccine could be effective also against a pre-existing tumor mass. This preclinical model of aggressive metastatic development showed that the vaccine was an efficient treatment also 4 for the cure of micrometastases. However the immune mechanisms activated against tumor mass were not antibody dependent, i.e. different from those preventing the onset of primary mammary carcinoma. DNA vaccines could be more easily used than cellular ones. A second generation of Triplex vaccine based on DNA plasmids was evaluated in an aggressive preclinical model (BALBp53neu female mice) and compared with the preventive ability of cellular Triplex vaccine. It was observed that Triplex DNA vaccine was as effective as Triplex cell vaccine, exploiting a more restricted immune stimulation.

Echtzeitsuche nach Neutrinoausbrüchen von Supernovae mit dem AMANDA-II-Detektor

Der AMANDA-II Detektor ist primär für den richtungsaufgelösten Nachweis hochenergetischer Neutrinos konzipiert. Trotzdem können auch niederenergetische Neutrinoausbrüche, wie sie von Supernovae erwartet werden, mit hoher Signifikanz nachgewiesen werden, sofern sie innerhalb der Milchstraße stattfinden. Die experimentelle Signatur im Detektor ist ein kollektiver Anstieg der Rauschraten aller optischen Module. Zur Abschätzung der Stärke des erwarteten Signals wurden theoretische Modelle und Simulationen zu Supernovae und experimentelle Daten der Supernova SN1987A studiert. Außerdem wurden die Sensitivitäten der optischen Module neu bestimmt. Dazu mussten für den Fall des südpolaren Eises die Energieverluste geladener Teilchen untersucht und eine Simulation der Propagation von Photonen entwickelt werden. Schließlich konnte das im Kamiokande-II Detektor gemessene Signal auf die Verhältnisse des AMANDA-II Detektors skaliert werden. Im Rahmen dieser Arbeit wurde ein Algorithmus zur Echtzeit-Suche nach Signalen von Supernovae als Teilmodul der Datennahme implementiert. Dieser beinhaltet diverse Verbesserungen gegenüber der zuvor von der AMANDA-Kollaboration verwendeten Version. Aufgrund einer Optimierung auf Rechengeschwindigkeit können nun mehrere Echtzeit-Suchen mit verschiedenen Analyse-Zeitbasen im Rahmen der Datennahme simultan laufen. Die Disqualifikation optischer Module mit ungeeignetem Verhalten geschieht in Echtzeit. Allerdings muss das Verhalten der Module zu diesem Zweck anhand von gepufferten Daten beurteilt werden. Dadurch kann die Analyse der Daten der qualifizierten Module nicht ohne eine Verzögerung von etwa 5 Minuten geschehen. Im Falle einer erkannten Supernova werden die Daten für die Zeitdauer mehrerer Minuten zur späteren Auswertung in 10 Millisekunden-Intervallen archiviert. Da die Daten des Rauschverhaltens der optischen Module ansonsten in Intervallen von 500 ms zur Verfgung stehen, ist die Zeitbasis der Analyse in Einheiten von 500 ms frei wählbar. Im Rahmen dieser Arbeit wurden drei Analysen dieser Art am Südpol aktiviert: Eine mit der Zeitbasis der Datennahme von 500 ms, eine mit der Zeitbasis 4 s und eine mit der Zeitbasis 10 s. Dadurch wird die Sensitivität für Signale maximiert, die eine charakteristische exponentielle Zerfallszeit von 3 s aufweisen und gleichzeitig eine gute Sensitivität über einen weiten Bereich exponentieller Zerfallszeiten gewahrt. Anhand von Daten der Jahre 2000 bis 2003 wurden diese Analysen ausführlich untersucht. Während die Ergebnisse der Analyse mit t = 500 ms nicht vollständig nachvollziehbare Ergebnisse produzierte, konnten die Resultate der beiden Analysen mit den längeren Zeitbasen durch Simulationen reproduziert und entsprechend gut verstanden werden. Auf der Grundlage der gemessenen Daten wurden die erwarteten Signale von Supernovae simuliert. Aus einem Vergleich zwischen dieser Simulation den gemessenen Daten der Jahre 2000 bis 2003 und der Simulation des erwarteten statistischen Untergrunds kann mit einem Konfidenz-Niveau von mindestens 90 % gefolgert werden, dass in der Milchstraße nicht mehr als 3.2 Supernovae pro Jahr stattfinden. Zur Identifikation einer Supernova wird ein Ratenanstieg mit einer Signifikanz von mindestens 7.4 Standardabweichungen verlangt. Die Anzahl erwarteter Ereignisse aus dem statistischen Untergrund beträgt auf diesem Niveau weniger als ein Millionstel. Dennoch wurde ein solches Ereignis gemessen. Mit der gewählten Signifikanzschwelle werden 74 % aller möglichen Vorläufer-Sterne von Supernovae in der Galaxis überwacht. In Kombination mit dem letzten von der AMANDA-Kollaboration veröffentlicheten Ergebnis ergibt sich sogar eine obere Grenze von nur 2.6 Supernovae pro Jahr. Im Rahmen der Echtzeit-Analyse wird für die kollektive Ratenüberhöhung eine Signifikanz von mindestens 5.5 Standardabweichungen verlangt, bevor eine Meldung über die Detektion eines Supernova-Kandidaten verschickt wird. Damit liegt der überwachte Anteil Sterne der Galaxis bei 81 %, aber auch die Frequenz falscher Alarme steigt auf bei etwa 2 Ereignissen pro Woche. Die Alarm-Meldungen werden über ein Iridium-Modem in die nördliche Hemisphäre übertragen, und sollen schon bald zu SNEWS beitragen, dem weltweiten Netzwerk zur Früherkennung von Supernovae.

Molecular approach to Neurodegenerative Disorders: Role of Nociceptin/Orphanin FQ - NOP System in Parkinson and Epigenetic Mechanism in Alzheimer's Disease

With life expectancies increasing around the world, populations are getting age and neurodegenerative diseases have become a global issue. For this reason we have focused our attention on the two most important neurodegenerative diseases: Parkinson’s and Alzheimer’s. Parkinson’s disease is a chronic progressive neurodegenerative movement disorder of multi-factorial origin. Environmental toxins as well as agricultural chemicals have been associated with PD. Has been observed that N/OFQ contributes to both neurotoxicity and symptoms associated with PD and that pronociceptin gene expression is up-regulated in rat SN of 6-OHDA and MPP induced experimental parkinsonism. First, we investigated the role of N/OFQ-NOP system in the pathogenesis of PD in an animal model developed using PQ and/or MB. Then we studied Alzheimer's disease. This disorder is defined as a progressive neurologic disease of the brain leading to the irreversible loss of neurons and the loss of intellectual abilities, including memory and reasoning, which become severe enough to impede social or occupational functioning. Effective biomarker tests could prevent such devastating damage occurring. We utilized the peripheral blood cells of AD discordant monozygotic twin in the search of peripheral markers which could reflect the pathology within the brain, and also support the hypothesis that PBMC might be a useful model of epigenetic gene regulation in the brain. We investigated the mRNA levels in several genes involve in AD pathogenesis, as well DNA methylation by MSP Real-Time PCR. Finally by Western Blotting we assess the immunoreactivity levels for histone modifications. Our results support the idea that epigenetic changes assessed in PBMCs can also be useful in neurodegenerative disorders, like AD and PD, enabling identification of new biomarkers in order to develop early diagnostic programs.

Statistical Physics and Modeling of Human Mobility

In this thesis, we extend some ideas of statistical physics to describe the properties of human mobility. By using a database containing GPS measures of individual paths (position, velocity and covered space at a spatial scale of 2 Km or a time scale of 30 sec), which includes the 2% of the private vehicles in Italy, we succeed in determining some statistical empirical laws pointing out "universal" characteristics of human mobility. Developing simple stochastic models suggesting possible explanations of the empirical observations, we are able to indicate what are the key quantities and cognitive features that are ruling individuals' mobility. To understand the features of individual dynamics, we have studied different aspects of urban mobility from a physical point of view. We discuss the implications of the Benford's law emerging from the distribution of times elapsed between successive trips. We observe how the daily travel-time budget is related with many aspects of the urban environment, and describe how the daily mobility budget is then spent. We link the scaling properties of individual mobility networks to the inhomogeneous average durations of the activities that are performed, and those of the networks describing people's common use of space with the fractional dimension of the urban territory. We study entropy measures of individual mobility patterns, showing that they carry almost the same information of the related mobility networks, but are also influenced by a hierarchy among the activities performed. We discover that Wardrop's principles are violated as drivers have only incomplete information on traffic state and therefore rely on knowledge on the average travel-times. We propose an assimilation model to solve the intrinsic scattering of GPS data on the street network, permitting the real-time reconstruction of traffic state at a urban scale.

De Novo Design of Foldamers for Preparation of Nanostructured Materials

This thesis deals with the synthesis and the conformation analysis of hybrid foldamers containing the 4-carboxyoxazolidin-2-one unit or related molecules, in which an imido-type function is obtained by coupling the nitrogen of the heterocycle with the carboxylic acid moiety of the next unit. The imide group is characterized by a nitrogen atom connected to an endocyclic and an exocyclic carbonyl, which tend always to adopt the trans conformation. As a consequence of this locally constrained disposition effect, these imide-type oligomers are forced to fold in ordered conformations. The synthetic approach is highly tuneable with endless variations, so, simply by changing the design and the synthesis, a wide variety of foldamers with the required properties may be prepared “on demand”. Thus a wide variety of unusual secondary structures and interesting supramolecular materials may be obtained with hybrid foldamers. The behaviour in the solid state of some of these compounds has been analyzed in detail, thus showing the formation of different kinds of supramolecular materials that may be used for several applications. A winning example is the production of a bolaamphiphilic gelators that may also be doped with small amounts of dansyl containing compounds, needed to show the cellular uptake into IGROV-1 cells, by confocal laser scanning microscopy. These gels are readily internalized by cells and are biologically inactive, making them very good candidates in the promising field of drug delivery. In the last part of the thesis, a particular attention was directed to the search of new scaffolds that behave as constrained amino acid mimetics, showing that tetramic acids derivatives could be good candidates for the synthesis and applications of molecules having an ordered secondary structure.

Analysis and modelling of the performance of technologies for flue gas treatment in Waste-to-Energy processes

Waste management represents an important issue in our society and Waste-to-Energy incineration plants have been playing a significant role in the last decades, showing an increased importance in Europe. One of the main issues posed by waste combustion is the generation of air contaminants. Particular concern is present about acid gases, mainly hydrogen chloride and sulfur oxides, due to their potential impact on the environment and on human health. Therefore, in the present study the main available technological options for flue gas treatment were analyzed, focusing on dry treatment systems, which are increasingly applied in Municipal Solid Wastes (MSW) incinerators. An operational model was proposed to describe and optimize acid gas removal process. It was applied to an existing MSW incineration plant, where acid gases are neutralized in a two-stage dry treatment system. This process is based on the injection of powdered calcium hydroxide and sodium bicarbonate in reactors followed by fabric filters. HCl and SO2 conversions were expressed as a function of reactants flow rates, calculating model parameters from literature and plant data. The implementation in a software for process simulation allowed the identification of optimal operating conditions, taking into account the reactant feed rates, the amount of solid products and the recycle of the sorbent. Alternative configurations of the reference plant were also assessed. The applicability of the operational model was extended developing also a fundamental approach to the issue. A predictive model was developed, describing mass transfer and kinetic phenomena governing the acid gas neutralization with solid sorbents. The rate controlling steps were identified through the reproduction of literature data, allowing the description of acid gas removal in the case study analyzed. A laboratory device was also designed and started up to assess the required model parameters.

Context sensitive design of provincial road Galliera SP4.

In the past centuries and before the invention of automobile, roads consisted mainly of unpaved paths connecting only few cities. Later, in the beginning of the twentieth century, the automobile was introduced and a new type of the transportation system was born. Therefore, it was necessary to change the condition of roads to fit with the automobiles. With the spread and the development of the automobiles, roads also have developed and increased all over the world. That caused negative effects on the environment and humans’ life quality. Thus, highways associations and communities had to take some steps to reduce these effects and care about environmental and cultural issues with the traditional commitment to safety and mobility, and that is known as context sensitive design. The aim of this thesis is to use the concepts of context sensitive design to reduce the negative environmental impacts of provincial road Galliera, which connects via Colombo in city of Bologna to provincial road 3 in Argelato city. Some solutions were proposed in this thesis to reduce traffic noise, fragmentation, fauna mortality and to improve the aesthetics of the road.

An interferon regulatory factor element controls the major immune modulator of murine cytomegalovirus

Immune modulation by herpesviruses, such as cytomegalovirus, is critical for the establishment of acute and persistent infection confronting a vigorous antiviral immune response of the host. Therefore, the action of immune-modulatory proteins has long been the subject of research, with the final goal to identify new strategies for antiviral therapy.rnIn the case of murine cytomegalovirus (mCMV), the viral m152 protein has been identified to play a major role in targeting components of both the innate and the adaptive immune system in terms of infected host-cell recognition in the effector phase of the antiviral immune response. On the one hand, it inhibits cell surface expression of RAE-1 and thereby prevents ligation of the activating natural killer (NK)-cell receptor NKG2D. On the other hand, it decreases cell surface expression of peptide-loaded MHC class I molecules thereby preventing antigen presentation to CD8 T cells. Ultimately, the outcome of CMV infection is determined by the interplay between viral and cellular factors.rnIn this context, the work presented here has revealed a novel and intriguing connection between viral m152 and cellular interferon (IFN), a key cytokine of the immune system: rnthe m152 promoter region contains an interferon regulatory factor element (IRFE) perfectly matching the consensus sequence of cellular IRFEs.rnThe biological relevance of this regulatory element was first suggested by sequence comparisons revealing its evolutionary conservation among various established laboratory strains of mCMV and more recent low-passage wild-derived virus isolates. Moreover, search of the mCMV genome revealed only three IRFE sites in the complete sequence. Importantly, the functionality of the IRFE in the m152 promoter was confirmed with the use of a mutant virus, representing a functional deletion of the IRFE, and its corresponding revertant virus. In particular, m152 gene expression was found to be inhibited in an IRFE-dependent manner in infected cells. Essentially, this inhibition proved to have a severe impact on the immune-modulatory function of m152, first demonstrated by a restored direct antigen presentation on infected cells for CD8 T-cell activation. Even more importantly, this effect of IRFE-mediated IFN signaling was validated in vivo by showing that the protective antiviral capacity of adoptively-transferred, antigen-specific CD8 T cells is also significantly restored by the IRFE-dependent inhibition of m152. Somewhat curious and surprising, the decrease in m152 protein simultaneously prevented an enhanced activation of NK cells in acute-infected mice, apparently independent of the RAE-1/NKG2D ligand/receptor interaction but rather due to reduced ‘missing-self’ recognition.rnTaken together, this work presents a so far unknown mechanism of IFN signaling to control mCMV immune modulation in acute infection.rnrn

Cognitive Assessment and Rehabilitation of subjects with Traumatic Brain Injury

This thesis regards the study and the development of new cognitive assessment and rehabilitation techniques of subjects with traumatic brain injury (TBI). In particular, this thesis i) provides an overview about the state of art of this new assessment and rehabilitation technologies, ii) suggests new methods for the assessment and rehabilitation and iii) contributes to the explanation of the neurophysiological mechanism that is involved in a rehabilitation treatment. Some chapters provide useful information to contextualize TBI and its outcome; they describe the methods used for its assessment/rehabilitation. The other chapters illustrate a series of experimental studies conducted in healthy subjects and TBI patients that suggest new approaches to assessment and rehabilitation. The new proposed approaches have in common the use of electroencefalografy (EEG). EEG was used in all the experimental studies with a different purpose, such as diagnostic tool, signal to command a BCI-system, outcome measure to evaluate the effects of a treatment, etc. The main achieved results are about: i) the study and the development of a system for the communication with patients with disorders of consciousness. It was possible to identify a paradigm of reliable activation during two imagery task using EEG signal or EEG and NIRS signal; ii) the study of the effects of a neuromodulation technique (tDCS) on EEG pattern. This topic is of great importance and interest. The emerged founding showed that the tDCS can manipulate the cortical network activity and through the research of optimal stimulation parameters, it is possible move the working point of a neural network and bring it in a condition of maximum learning. In this way could be possible improved the performance of a BCI system or to improve the efficacy of a rehabilitation treatment, like neurofeedback.

90 Nb: potential radionuclide for application in immuno-PET : development of appropriate production strategy and first in vivo evaluation of 90 Nb-labeled monoclonal antibody

Die Nuklearmedizin ist ein modernes und effektives Werkzeug zur Erkennung und Behandlung von onkologischen Erkrankungen. Molekulare Bildgebung, die auf dem Einsatz von Radiopharmaka basiert, beinhaltet die Einzel-Photonen-Emissions-Tomographie (SPECT) und Positronenemissions¬tomographie (PET) und ermöglicht die nicht-invasive Visualisierung von Tumoren auf nano-und picomolarer Ebene.rnDerzeit werden viele neue Tracer für die genauere Lokalisierung von kleinen Tumoren und Metastasen eingeführt und hinsichtlich ihrer Eignung untersucht. Die meisten von ihnen sind Protein-basierte Biomoleküle, die die Natur selbst als Antigene für die Tumorzellen produziert. Dabei spielen Antikörper und Antikörper-Fragmente eine wichtige Rolle in der Tumor-Diagnostik und Behandlung. Die PET-Bildgebung mit Antikörpern und Antikörperfragmenten bezeichnet man als immuno-PET. Ein wichtiger Aspekt hierbei ist, dass entsprechende Radiopharmaka benötigt werden, deren Halbwertszeit mit der Halbwertszeit der Biomoleküle korreliert ist.rnIn neueren Arbeiten wird 90Nb als potenzieller Kandidat für die Anwendung in der immuno-PET vorgeschlagen. Seine Halbwertszeit von 14,6 Stunden ist geeignet für die Anwendung mit Antikörperfragmenten und einige intakten Antikörpern. 90Nb hat eine relativ hohen Anteil an Positronenemission von 53% und eine optimale Energie für die β+-Emission von 0,35 MeV, die sowohl eine hohe Qualität der Bildgebung als auch eine niedrige Aktivitätsmenge des Radionuklids ermöglicht.rnErsten grundlegende Untersuchungen zeigten: i) dass 90Nb in ausreichender Menge und Reinheit durch Protonen-Bombardierung des natürlichen Zirkonium Targets produziert, ii) aus dem Targetmaterial in entsprechender radiochemischer Reinheit isoliert und iii) zur Markierung des monoklonalen Antikörpers (Rituximab) verwendet werden kann und iv) dieser 90Nb-markierte mAb eine hohe in vitro Stabilität besitzt. Desweiteren wurde eine alternative und schnelle Abtrennungsmethode entwickelt, die es erlaubt 90Nb, mit einer geeigneten radiochemischen und radionuklidischen Reinheit für eine anschließende Markierung von Biomolekülen in einer Stunde zu aufzureinigen. Schließlich wurden erstmals 90Nb-markierte Biomolekülen in vivo untersucht. Desweiteren wurden auch Experimente durchgeführt, um den optimalen bifunktionellen Chelatbildner (BFC) für 90Niob zu finden. Mehrere BFC wurden hinsichtlich Komplexbildung mit NbV untersucht. Desferrioxamin (Df) erwies sich als geeignetster Chelator für 90Nb. Der monoklonale Antikörper Bevacizumab (Avastin®) wurde mit 90Nb markiert und eine Biodistributionsstudie und eine PET-Untersuchung durchgeführt. Alle diese Ergebnisse zeigten, dass 90Nb ein vielversprechendes Radionuklid für die Immuno-PET ist, welches sogar für weitere kommerzielle Anwendungen in der klinischen Routine geeignet zu sein scheint.rn

Efficacy of experimental treatments compared with standard treatments in non-inferiority trials: a meta-analysis of randomized controlled trials

Background There is concern that non-inferiority trials might be deliberately designed to conceal that a new treatment is less effective than a standard treatment. In order to test this hypothesis we performed a meta-analysis of non-inferiority trials to assess the average effect of experimental treatments compared with standard treatments. Methods One hundred and seventy non-inferiority treatment trials published in 121 core clinical journals were included. The trials were identified through a search of PubMed (1991 to 20 February 2009). Combined relative risk (RR) from meta-analysis comparing experimental with standard treatments was the main outcome measure. Results The 170 trials contributed a total of 175 independent comparisons of experimental with standard treatments. The combined RR for all 175 comparisons was 0.994 [95% confidence interval (CI) 0.978–1.010] using a random-effects model and 1.002 (95% CI 0.996–1.008) using a fixed-effects model. Of the 175 comparisons, experimental treatment was considered to be non-inferior in 130 (74%). The combined RR for these 130 comparisons was 0.995 (95% CI 0.983–1.006) and the point estimate favoured the experimental treatment in 58% (n = 76) and standard treatment in 42% (n = 54). The median non-inferiority margin (RR) pre-specified by trialists was 1.31 [inter-quartile range (IQR) 1.18–1.59]. Conclusion In this meta-analysis of non-inferiority trials the average RR comparing experimental with standard treatments was close to 1. The experimental treatments that gain a verdict of non-inferiority in published trials do not appear to be systematically less effective than the standard treatments. Importantly, publication bias and bias in the design and reporting of the studies cannot be ruled out and may have skewed the study results in favour of the experimental treatments. Further studies are required to examine the importance of such bias.

A review of the cost effectiveness of bisphosphonates in the treatment of post-menopausal osteoporosis in Switzerland

The economic burden associated with osteoporosis is considerable. As such, cost-effectiveness analyses are important contributors to the diagnostic and therapeutic decision-making process. The aim of this study was to review the cost effectiveness of treating post-menopausal osteoporosis with bisphosphonates and identify the key factors that influence the cost effectiveness of such treatment in the Swiss setting. A systematic search of databases (MEDLINE, EMBASE and the Cochrane Library) was conducted to identify published literature on the cost effectiveness of bisphosphonates in post-menopausal osteoporosis in the Swiss setting. Outcomes were compared with similar studies in Western European countries. Three cost-effectiveness studies of bisphosphonates in this patient population were identified; all were from a healthcare payer perspective. Outcomes showed that, relative to no treatment, treatment with oral bisphosphonates was predicted to be cost saving for most women aged ≥70 years with osteoporosis or at least one risk factor for fracture, and cost effective for women aged ≥75 years without prior fracture when used as a component of a population-based screen-and-treat programme. Results were most sensitive to changes in fracture risk, cost of fractures, cost of treatment, nursing home admissions and adherence with treatment. Swiss results were generally comparable to those in other European settings. Assuming similar clinical efficacy, lowering treatment cost (through the use of price-reduced brand-name or generic drugs) and/or improving adherence should both contribute to further improving the cost effectiveness of bisphosphonates in women with post-menopausal osteoporosis. Published evidence indicates that bisphosphonates are estimated to be similarly cost effective or cost saving in most treatment scenarios of post-menopausal osteoporosis in Switzerland and in neighbouring European countries.

Efficacy of communication skills training courses in oncology: a systematic review and meta-analysis

Objective: Group training in communication skills [communication skills training (CST)] has become partly mandatory for oncology staff. However, so far, a comprehensive meta-analysis on the efficacy is lacking. Design: Included studies either compare the efficacy of a specific training with a control group or look at the additional effect of booster sessions on communication behaviour, attitudes or patient outcomes. Methods: Four electronic databases were searched up to July 2008 without language restriction, and reference lists of earlier reviews were screened. Effect sizes (ESs) were extracted and pooled in random effects meta-analyses. Results: We included 13 trials (three non-randomised), 10 with no specific intervention in the control group. Meta-analysis showed a moderate effect of CST on communication behaviour ES = 0.54. Three trials compared basic training courses with more extensive training courses and showed a small additional effect on communication skills ES = 0.37. Trials investigating participants' attitudes ES = 0.35 and patient outcomes ES = 0.13 (trend) confirmed this effect. Conclusions: Training health professionals by CST is a promising approach to change communication behaviour and attitudes. Patients might also benefit from specifically trained health professionals but strong studies are lacking. However, feasibility and economic aspects have to be kept in mind when considering providing a training of optimal length.

Thrombophilia and outcomes of assisted reproduction technologies: a systematic review and meta-analysis

Thrombophilia has been associated with pregnancy complications and recurrent miscarriage. The aim of this systematic review was to evaluate the controversial association between thrombophilia and failures of assisted reproduction technology (ART). A systematic search of the literature for studies reporting on thrombophilia in women undergoing ART up to April 2011 yielded 33 studies (23 evaluating anti-phospholipid antibodies, 5 inherited thrombophilia, and 5 both) involving 6092 patients. Overall, methodologic quality of the studies was poor. Combined results from case-control studies showed that factor V Leiden was significantly more prevalent among women with ART failure compared with fertile parous women or those achieving pregnancy after ART (odds ratio = 3.08; 95% confidence interval, 1.77-5.36). The prothrombin mutation, methylenetetrahydrofolate reductase mutation, deficiency of protein S, protein C, or anti-thrombin were all not associated with ART failure. Women with ART failure tested more frequently positive for anti-phospholipids antibodies (odds ratio = 3.33; 95% confidence interval, 1.77-6.26) with evidence of high degree of between-study heterogeneity (I(2) = 75%; P < .00001). Prospective cohort studies did not show significant associations between thrombophilia and ART outcomes. Although case-control studies suggest that women experiencing ART failures are more frequently positive for factor V Leiden and anti-phospholipid antibodies, the evidence is inconclusive and not supported by cohort studies.