Clinical profile of patients with lupus psychosis in a Colombian cohort.

The objective of this study is to describe the frequency and the clinical, paraclinical, and treatment profile of patients with lupus psychosis in a Colombian cohort of patients with systemic lupus erythematosus (SLE). This retrospective cohort study evaluated epidemiological and clinical characteristics, results of neuroimaging, analysis of the cerebrospinal fluid, treatment, and disease evolution in patients with lupus psychosis. Among 2,479 patients with SLE, six female patients aged between 20 and 50 years with a diagnosis of lupus psychosis were identified. In two patients, psychosis was present at disease onset and in the other four, SLE was already present, although the majority of them were diagnosed less than two years prior to the onset of psychosis. The entire cohort had high disease activity as measured by SLEDAI-2K. We found concomitant cutaneous, joint, and hematological alterations. Cerebrospinal fluid data were obtained in half of the patients and were normal. We performed brain tomography on most of our patients, which was almost always described as normal. In 5 out of 6 patients, the induction therapy to treat psychosis was based on steroids, and in the majority of them, a resolution of psychiatric symptoms was observed after initiating treatment. Lupus psychosis is a rare event that usually occurs early in the course of the disease and is associated with other manifestations of SLE. This investigation mainly found concomitant cutaneous, joint, and hematological manifestations, with a favorable outcome after treatment, as described in the literature.

Treatment with intravenous immunoglobulins in systemic lupus erythematosus: a single-center experience with 63 patients.

BACKGROUND: Intravenous immunoglobulin (IVIG) is prepared using purified human plasma. IVIG therapy has immunomodulatory effects on autoimmune diseases, including severe systemic lupus erythematosus (SLE). However, reports of its effects on large cohorts are scarce. METHODS: This single-center retrospective study included SLE patients treated with at least one IVIG cycle for SLE complications. Demographic data, indications, cycle numbers, and clinical improvement with IVIG were evaluated. SLE Disease Activity Index 2000 (SLEDAI-2K) scores were calculated at admission and after IVIG treatment in order to measure clinical improvement. RESULTS: Sixty-three SLE patients treated with IVIG (median age: 29 years; interquartile range 21-36 years; 84.13% female) were included, who received 2 g/kg IVIG for two to five days. Main indications were immune thrombocytopenia, hypogammaglobulinemia, infection during a SLE flare, bicytopenia, and immune hemolytic anemia. Seven patients received more than one IVIG cycle without severe adverse effects. Significant differences were found in SLEDAI-2K scores when the indications were immune thrombocytopenia and hypogammaglobulinemia, with a trend for hemolytic anemia. Patients with concomitant infection, myopathy, and gastrointestinal involvement showed a considerable reduction in their last SLEDAI-2K scores. Fourteen patients died during hospitalization, mainly due to septic shock and active SLE. CONCLUSIONS: IVIG showed adequate tolerance and effectiveness in selected severe SLE manifestations, mainly hematological involvement. It was useful for concomitant infection.

Identification of sperm morphometric subpopulations in cooled-stored canine sperm and its relation with sperm DNA integrity.

The aims of this study were to (i) identify different morphometric subpopulations in cooled-stored canine sperm and their patterns of distribution during cool-storage for up to 240 hr and (ii) determine whether or not morphometric sperm subpopulations (sP) are related to sperm DNA integrity. For that purpose, morphometric parameters were analysed by computer-assisted sperm analysis (CASA) and sperm DNA fragmentation (sDFi) using the sperm Halomax test. Four morphometric sperm heads subpopulations were identified: sP1 (large and rounded), sP2 (large and elongated), sP3 (small and rounded) and sP4 (small and elongated). sP1 was the most predominant subpopulation for up to 72 hr and thereafter sP3 increased progressively. sDFi increased after 48 hr of cool-storage. Although sP3 showed a positive correlation with sDFi, and both increased over time, it could not be ensured that only the sperm with fragmented DNA are accumulated in sP3. In conclusion, sP3 and DNA fragmentation increased progressively during cool-storage, becoming possible indicators of sperm damage. However, it cannot be concluded that sP3 only contains sperm with fragmented DNA.

A phase II trial of induction chemotherapy and chemo-IMRT for head and neck squamous cell cancers at risk of bilateral nodal spread: the application of a bilateral superficial lobe parotid-sparing IMRT technique and treatment outcomes.

PURPOSE: To determine the feasibility of induction chemotherapy and chemo-IMRT in head and neck squamous cell cancers at risk of bilateral nodal spread (midline tumours) and to evaluate whether bilateral superficial lobe parotid-sparing IMRT can reduce the incidence of ⩾G2 subjective xerostomia. METHODS: Patients with midline tumours were enrolled to a phase II trial to receive induction platinum/5-fluorouracil and concomitant platinum with combined superficial lobe parotid-sparing IMRT. The primary site and involved nodal levels received 65 Gy in 30 fractions (f) and at risk nodal levels, 54 Gy/30f. Incidence of ⩾G2 subjective xerostomia was defined as the primary endpoint. Secondary endpoints included incidences of acute and late toxicities and survival outcomes dependent on human papilloma virus (HPV) status. RESULTS: One hundred and twenty patients with midline cancers completed treatment between December 2005 and May 2010 with median follow-up of 50 months. Incidences of ⩾G2 acute toxicities were: dysphagia 75%; xerostomia 65%; mucositis 86%; pain 83%; and fatigue 64%. At 12 months, ⩾G2 subjective xerostomia was observed in 21% (17% in HPV +ve). Two-year loco-regional progression-free survival (PFS) was 90.7% (95% CI: 85.2-96.2). According to HPV status, there was a significant difference for 2-year loco-regional PFS, 76.8% (HPV-negative) vs 98.6% (HPV-positive), P=0.001. 2-year overall survival was 93% for HPV-positive compared with 52% for HPV-negative cases, P<0.001. CONCLUSIONS: Sequential chemotherapy/chemo-IMRT for midline tumours is feasible, with excellent survival outcomes. At 1 year, 21% experience ⩾G2 subjective xerostomia. Two-year survival outcomes differ significantly between HPV-positive and HPV-negative disease, suggesting development of different treatment schedules for the different disease entities.

Colloid single-layer centrifugation improves post-thaw donkey (Equus asinus) sperm quality and is related to ejaculate freezability.

The aim of this study was to determine whether colloid single-layer centrifugation (SLC) improves post-thaw donkey sperm quality and if this potential enhancement is related to ejaculate freezability. Semen from Andalusian donkeys was frozen following a standard protocol. SLC was performed on frozen-thawed semen and post-thaw sperm parameters were compared with uncentrifuged samples. Sperm quality was estimated by integrating in a single value sperm motility (assessed by computer-assisted sperm analysis), morphology and viability (evaluated under brightfield or fluorescence microscopy). Sperm freezability was calculated as the relationship between sperm quality obtained before freezing and after thawing. Ejaculates were classified into low, medium and high freezability groups using the 25th and 75th percentiles as thresholds. All sperm parameters were significantly (P<0.01) higher in SLC-selected samples in comparison to uncentrifuged frozen-thawed semen and several kinematic parameters were even higher than those obtained in fresh semen. The increment of sperm parameters after SLC selection was correlated with ejaculate freezability, obtaining the highest values after SLC in semen samples with low freezability. We concluded that, based on the sperm-quality parameters evaluated, SLC can be a suitable procedure to improve post-thaw sperm quality of cryopreserved donkey semen, in particular for those ejaculates with low freezability.

Antral follicle populations and embryo production--in vitro and in vivo--of Bos indicus-taurus donors from weaning to yearling ages.

Interest in indicus-taurus cattle has been increasing, as these animals are likely to present the best characteristics of Zebu and European bovine breeds. The aim of this study was to compare the embryo production of indicus-taurus donors with high vs low antral follicle counts obtained by ovum pickup/in vitro production (OPU/IVP) and superovulation (SOV)/embryo collection. Braford females at weaning age (3/8 Nelore × 5/8 Hereford, n = 137, 9 ± 1 month old) were subjected to six serial ovarian ultrasonographs and were assigned to two groups according to the number of antral follicles ≥ 3 mm as follows: G-High antral follicular count (AFC, n = 20, mean ≥ 40 follicles) and G-Low AFC (n = 20, mean ≤ 10 follicles). When the females (n = 40) reached 24 months of age, they were subjected to both OPU/IVP and SOV/embryo collection. The average number of follicles remained highly stable throughout all of the ultrasound evaluations (range 0.90-0.92). The mean number of COCs recovered (36.90 ± 13.68 vs 5.80 ± 3.40) was higher (p < 0.05) for females with high AFC, resulting in higher (p < 0.05) numbers of total embryos among females with high vs low AFC (6.10 ± 4.51 vs 0.55 ± 0.83). The mean number of embryos per collection was also higher (p < 0.05) for G-High vs G-Low (6.95 ± 5.34 vs 1.9 ± 2.13). We conclude that a single ultrasound performed at pre-pubertal ages to count antral follicles can be used as a predictor of embryo production following IVP and SOV/embryo collection in indicus-taurus females.

Management of chronic constipation in general practice.

BACKGROUND: Chronic constipation is often diagnosed and treated by general practitioners (GPs). The aim of the study was to evaluate the management of constipation by a cohort of Italian GPs. METHODS: Over the course of 1 month, 41 GPs recorded tests and therapies suggested to patients complaining of chronic constipation. They were classified according to the Rome III criteria as constipated irritable bowel syndrome (C-IBS), functional constipation (FC), or "self-perceived constipation" (SPC) (not consistent with the Rome criteria). RESULTS: The most frequently prescribed tests for the 229 patients (147 FC, 50 C-IBS, 32 SPC) were routine blood tests (59.3 %), abdominal ultrasounds (37.2 %), thyroid function (36.7 %), fecal occult blood tests (36.7 %), and tumor markers (35 %). Patient sex and age, GP age, and whether the diagnosis was new influenced the GP's request, but FC, C-IBS, or SPC status did not. Dietary suggestions (81.9 %), fiber supplements (59.7 %), reassurance (50.9 %), and laxatives (30.5 %) were the most frequently prescribed treatments. Antispasmodics were more frequently suggested for C-IBS patients; dietary suggestions, fiber, and enemas were more frequently prescribed in SPC patients. Patient and GP age and whether the diagnosis was new influenced the GP's choice of treatment. CONCLUSIONS: The Rome III criteria do not influence diagnostic strategies and only slightly influence therapeutic strategies of GPs. Other factors (age, gender, new or old diagnosis) have more influence on GPs choice of investigations and treatment.

Relationship between changes in plasma leptin concentrations and plasminogen activator inhibitor-1 in obese prepubertal children after nine months of treatment.

BACKGROUND/AIMS: The metabolic syndrome (MS) is associated with insulin resistance (IR), inappropriate fibrinolysis and high plasma leptin concentrations. The aim of this study was to quantify fibrinolysis and MS-related variables in obese prepubertal children and to evaluate changes in these variables as a result of improved body mass index (BMI), IR and leptin levels following 9 months of treatment. METHODS: The homeostasis model assessment for insulin resistance (HOMA-IR), leptin, plasminogen activator inhibitor-1 (PAI-1) and lipid profile were studied at baseline in obese (n = 50) and nonobese children (n = 50), and after 9 months of treatment in obese children. RESULTS: In the cross-sectional study the mean values for insulin, HOMA-IR, triglycerides, leptin and PAI-1 were significantly higher in obese children than in controls. High-density lipoprotein cholesterol (HDLc) and apolipoprotein A-1 were significantly lower. In the longitudinal study, after 9 months, children with lowered BMI standard deviation score displayed a significant decrease in insulin, HOMA-IR, PAI-1, leptin and triglyceride levels, and an increase in HDLc. Only leptin proved to be an independent predictive factor for changes in PAI-1 (p = 0.010). CONCLUSION: Obesity-linked disorders appear in obese children prior to puberty; these disorders can be improved by decreasing BMI. Changes in leptin levels were found to independently predict changes in PAI-1 in obese children and can help to diagnose complications associated with the obesity.

Urgent surgery in patients with a recently implanted coronary drug-eluting stent: a phase II study of 'bridging' antiplatelet therapy with tirofiban during temporary withdrawal of clopidogrel.

BACKGROUND: Patients with a recently implanted coronary drug-eluting stent (DES) who need urgent surgery are at increased risk of surgical bleeding unless clopidogrel is discontinued beforehand, but clopidogrel discontinuation has been associated with a high rate of adverse events due to stent thrombosis. This pilot study tested the hypothesis that the i.v. perioperative administration of the short-acting antiplatelet agent tirofiban allows the safe withdrawal of clopidogrel without increasing the rate of surgical bleeding. METHODS: Phase II study with a Simon two-stage design. RESULTS: Thirty patients with a recently implanted DES [median (range) 4 (1-12) months] and high-risk characteristics for stent thrombosis underwent urgent major surgery or eye surgery. Clopidogrel was to be withdrawn 5 days before surgery, and tirofiban started 24 h later, continued until 4 h before surgery, and resumed 2 h after surgery until oral clopidogrel was resumed. The use of aspirin was decided by the surgeon. There were no cases of death, myocardial infarction, stent thrombosis, or surgical re-exploration due to bleeding during the index admission, with a risk estimate of 0-11.6% (one-tail 97.5% CI). There was one case of thrombolysis in myocardial infarction (TIMI) major and one of TIMI minor bleeding in the postoperative phase; another four patients were transfused without meeting the TIMI criteria for major or minor bleeding. CONCLUSIONS: In patients with a recently implanted DES and high-risk characteristics for stent thrombosis needing urgent surgery, a 'bridging strategy' using i.v. tirofiban may allow temporary withdrawal of oral clopidogrel without increasing the risk of bleeding.

Exploring the radiosensitizing potential of magnetotherapy: a pilot study in breast cancer cells.

Aim: To explore the influence of electromagnetic fields (EMFs) on the cell cycle progression of MDA-MB-231 and MCF-7 breast cancer cell lines and to evaluate the radiosensitizing effect of magnetotherapy during therapeutic co-exposure to EMFs and radiotherapy. Material and methods: Cells were exposed to EMFs (25, 50 and 100 Hz; 8 and 10 mT). In the co-treatment, cells were first exposed to EMFs (50 Hz/10 mT) for 30 min and then to ionizing radiation (IR) (2 Gy) 4 h later. Cell cycle progression and free radical production were evaluated by flow cytometry, while radiosensitivity was explored by colony formation assay. Results: Generalized G1-phase arrest was found in both cell lines several hours after EMF exposure. Interestingly, a marked G1-phase delay was observed at 4 h after exposure to 50 Hz/10 mT EMFs. No cell cycle perturbation was observed after repeated exposure to EMFs. IR-derived ROS production was enhanced in EMF-exposed MCF-7 cells at 24 h post-exposure. EMF-exposed cells were more radiosensitive in comparison to sham-exposed cells. Conclusions: These results highlight the potential benefits of concomitant treatment with magnetotherapy before radiotherapy sessions to enhance the effectiveness of breast cancer therapy. Further studies are warranted to identify the subset(s) of patients who would benefit from this multimodal treatment.

Team approach to ERCP-directed single-brush cytology for the diagnosis of malignancy.

OBJECTIVE: To evaluate the clinical usefulness of single-brush cytology performed at ERCP as initial method for detecting pancreatobiliary malignancy, ensuring a very close relationship between endoscopists, cytotechnicians, and cytopathologists. STUDY DESIGN: All 125 cytodiagnoses considered in this study correspond to the first brushing for each patient, collected by one of the three members of a fixed team of endoscopists in the presence of the same cytotechnician. Smears were fixed immediately with Merckofix spray, stained with Papanicolau, and analyzed by the same cytopathologist in a laboratory exclusively devoted to gastrointestinal cytopathology located at the endoscopy unit. RESULTS: Of 125 cytological diagnoses 94 were considered benign, 4 suspicious, and 27 malignant. These findings were compared to the final diagnosis of 45 malignant and 80 benign lesions obtained either by surgical pathology or after at least one year of clinical follow-up. The comparison yielded 30 true positives, 78 true negatives, 1 false positive and 16 false negative results, which corresponds to a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 65.2, 98.7, 96.8, 83, and 86.4%, respectively. CONCLUSION: Results seem to confirm the usefulness of an effective team approach to ERCP-directed brush cytology for the diagnosis of pancreatobiliary malignancy. However, sensitivity continues to be rather low.

[Sleep disorders in cement workers]. / I disturbi del sonno nei lavoratori dell'industria del cemento.

Obstructive Sleep Apnea Syndrome (OSAS) and Excessive Daytime Sleepiness (EDS) are sleep disorders which can increase cardiovascular risk. An health survey was performed on the cement workers to estimate the prevalence of sleep disorders and to investigate occupational, personal and health risk factors that could influence it. A total of 761 male workers, employed at 10 different cement plants of South Italy and Sicily, were examined. All subjects gave informed consent to take part in the survey. The following questionnaires were administered: Berlin Questionnaire to estimate the high risk of OSAS, Epworth Sleepiness Scale for EDS, a questionnaire posing questions about working conditions, personal characteristic, lifestyle, past history of disease and present illness. Statistical analysis was performed with the statistical package SPSS. The prevalence of high risk of OSAS and of EDS resulted respectively in 24.2% and 3.4% of workers. Sleep disorders detected with the two questionnaires were significantly associated. A positive and significant association between OSAS and respectively age, time of employment, BMI, ex-smoker status, neck, waist or hip circumferences, chronic fatigue and arterial hypertension was observed. Subjective variables regarding working conditions (job interest, evaluation oforganization of work and job satisfaction) and alcohol consumption were not associated with the high risk of OSAS. Shift work (2 and 3 shifts) was not associated with the high risk of OSAS. An healthy worker effect was observed for workers who changed from shift work (2 or 3 shifts) to fixed daytime work. For them, this change to fixed daytime work was conditioned by chronic disease like hypertension and obesity. EDS was not dependent, associated or correlated with any of the occupational, personal or pathologic variables investigated in the study. In conclusion the research showed no relationship between working conditions, particularly shift work, and the high risk of OSAS, and the influence of obesity in determining the high risk of OSAS, itself a potential cardiovascular risk factor. The interest of occupational physician has been focused on introducing in health surveillance also measures of health promotion regarding sleep disorders with the aim of preserving health condition in workers.

Intensity modulated radiotherapy in locally advanced thyroid cancer: Outcomes of a sequential phase I dose-escalation study.

BACKGROUND AND PURPOSE: To determine the safety and tolerability of dose-escalation using modestly accelerated IMRT in high-risk locally advanced thyroid cancer requiring post-operative radiotherapy, and to report preliminary data on efficacy. MATERIALS AND METHODS: A sequential Phase I dose-escalation design was used. Dose level one (DL1) received 58.8 Gy/28F to the post-operative bed and 50 Gy/28F to elective nodes. DL2 received 66.6 Gy/30F to the thyroid bed, 60 Gy/30F to post-operative nodal levels and 54 Gy/30F to elective nodal levels. Acute (NCICTCv.2.0) and late toxicities (RTOG and modified LENTSOM) were recorded. The primary endpoint was the number of patients with ≥Grade 3 (G3) toxicity at 12 months post-treatment. RESULTS: Fifteen patients were recruited to DL1 and twenty-nine to DL2. At 12 months ≥G3 toxicities were 8.3% in both DL1 and DL2. At 60 months, ≥G3 toxicity was reported in 3 (33%) patients in DL1 and 1 (7%) in DL2. One patient in DL2 died at 24 months from radiation-induced toxicity. Time to relapse and overall survival rates were higher in DL2, but this was not statistically significant. Dose-escalation using this accelerated regimen can be safely performed with a toxicity profile similar to reported series using conventional doses.

Target volume definition for head and neck intensity modulated radiotherapy: pre-clinical evaluation of PARSPORT trial guidelines.

AIMS: There is considerable controversy surrounding target volume definition for parotid-sparing intensity modulated radiotherapy (IMRT) for head and neck cancer. The aim of this study was to evaluate the dosimetric and radiobiological predictors of outcome anticipated by application of the detailed target volume definition guidelines agreed for the UK multicentre randomised controlled trial of parotid-sparing IMRT (PARSPORT). MATERIALS AND METHODS: Five patients eligible for the study were delineated using the trial guidelines. Following the protocol, plans were produced to treat these volumes with three-dimensional radiotherapy (control arm) and IMRT aimed to spare dose to the contralateral parotid gland (experimental arm). Dosimetric comparisons were made between plans, and normal tissue complication probability (NTCP) modelling for salivary glands was carried out. RESULTS: Doses delivered to the planning target volumes (PTV) were similar with each technique, although IMRT produced more homogeneous irradiation of the PTV. Mean doses to the contralateral parotid gland were 22.4+/-1.7 Gy with the IMRT plans vs 60.0+/-7.2 Gy with three-dimensional radiotherapy, P=0.0003. Calculated contralateral parotid gland NTCP values for grade 2 xerostomia were 20-22% for IMRT and 98-100% for three-dimensional radiotherapy (P<0.0001). CONCLUSION: Pre-clinical evaluation of the PARSPORT trial target volume definition guidelines provides theoretical support for a significant reduction in xerostomia rates. These data await confirmation from the clinical trial results.

Workers safety in public psychiatric services: problems, laws and protections.

The dramatic case of murder of a psychiatrist during her service in her public office (Centro di Salute Mentale of Bari-Libertà) has led the authors to reflect on the safety of workplaces, in detail of public psychiatric services. It is in the light of current legislation, represented by the Legislative Decree of April 9th, 2008 no. 81, which states the implementing rules of Law 123/2007. In particular, the Authors analyzed the criticalities of the application of this Law, with the aim of safeguarding the health and safety of the workers in all psychiatric services (nursing departments, outpatient clinics, community centers, day care centers, etc.). The Authors suggest the need to set up an articulated specific organizational system of risk assessment of psychiatric services, that can prevent and protect the workers from identified risks, and finally to ensure their active participation in prevention and protection activities, in absence of which specific profiles of responsibility would be opened up to the employers.

Comparison of DNA fragmentation of frozen-thawed epididymal sperm of dogs using Sperm Chromatin Structure Analysis and Sperm Chromatin Dispersion test.

The aim of this study was to compare sperm DNA fragmentation of frozen-thawed epididymal sperm of dogs using the SCSA (Sperm Chromatin Structure Assay) and SCDt (Sperm Chromatin Dispersion test). For this purpose, epididymis from neutered dogs were minced and incubated in a Tris-based extender. The recovered sperm were frozen in a two-step cooling protocol with Tris-based, egg yolk extender and increasing glycerol concentrations, and stored in liquid nitrogen. After thawing, each replica was incubated at 38°C for 24h. Sperm DNA fragmentation index (sDFi) was assessed by SCSA and SCDt at 0, 3, 6 and 24h of incubation and compared within treatments. The relationship and agreement between techniques were evaluated by Pearson's coefficient and Intraclass Correlation Coefficient (ICC). The results were expressed as mean±standard error of the mean (SEM). Both techniques indicated there was a significant increase of DNA fragmentation after 24h of incubation. Moderate correlation (r=0.65; P<0.01) but lack of agreement (ICC=0.451; P>0.05) was found between SCSA and SCDt. The lack of agreement indicates that SCSA and SCDt measure different aspects of DNA fragmentation. Four halo morphologies were detected after 24h of incubation using the SCDt: un-fragmented DNA with a small halo, fragmented DNA with large halo and two new halo presentations never described before for dog sperm: receding sperm with a disappearing halo and "bald" sperm without chromatin dispersion halo around the core. Sperm without a halo of chromatin dispersion are not described by the manufacturer and are similar to un-fragmented sperm, which could lead to erroneous results when using the SCDt. Further studies with different incubation periods and including the new morphologies described in this study should be performed. In conclusion, although SCSA and SCDt can evaluate the changes in the sperm DNA fragmentation dynamics of frozen-thawed epididymal dog sperm, these provided different findings on sperm DNA fragmentation.

Role of Anti-Inflammatory Cytokines on Muscle Mass and Performance Changes in Elderly Men and Women.

OBJECTIVES: Investigate the presence of a correlation between systemic inflammatory profile of community-dwelling individuals and the loss of muscular mass and performance in old age over a 4.5y follow-up, focusing on the role of anti-inflammatory cytokines in muscular changes in elderly. DESIGN: Longitudinal clinical study. SETTING: Subjects were randomly selected from lists of 11 general practitioners in the city of Verona, Italy. PARTICIPANTS: The study included 120 subjects, 92 women and 28 men aged 72.27±2.06 years and with BMI of 26.52±4.07 kg/m2 at baseline. MEASUREMENTS: Six minutes walking test (6MWT), appendicular and leg fat free mass (FFM) as measured with Dual Energy X-ray absorptiometry, were obtained at baseline and after 4.5 years (4.5y) of mean follow-up. Height, weight, body mass index (BMI), and circulating levels of TNFα, IL-4, IL-10, and IL-13 were evaluated at baseline. RESULTS: A significant reduction of appendicular FFM, leg FFM and 6MWT performance (all p<0.001) was observed after 4.5 y follow-up. In a stepwise regression model, considering appendicular FFM decline as dependent variable, lnIL-4, BMI, baseline appendicular FFM, lnTNFα and lnIL-13 were significant predictors of appendicular FFM decline explaining 30.8% of the variance. While building a stepwise multiple regression considering leg FFM as a dependent variable, lnIL-4, BMI and leg FFM were significant predictors of leg FFM decline and explained 27.4% of variance. When considering 6MWT decline as a dependent variable, baseline 6MWT, lnIL-13 and lnTNFα were significant predictors of 6MWT decline to explain 22.9% of variance. CONCLUSIONS: Our study suggest that higher serum levels of anti-inflammatory markers, and in particular IL-4 and IL-13, may play a protective role on FFM and performance maintenance in elderly subjects.

Intensity-modulated radiotherapy in patients with locally advanced rectal cancer reduces volume of bowel treated to high dose levels.

PURPOSE: To investigate the potential for intensity-modulated radiotherapy (IMRT) to spare the bowel in rectal tumors. METHODS AND MATERIALS: The targets (pelvic nodal and rectal volumes), bowel, and bladder were outlined in 5 patients. All had conventional, three-dimensional conformal RT and forward-planned multisegment three-field IMRT plans compared with inverse-planned simultaneous integrated boost nine-field equally spaced IMRT plans. Equally spaced seven-field and five-field and five-field, customized, segmented IMRT plans were also evaluated. RESULTS: Ninety-five percent of the prescribed dose covered at least 95% of both planning target volumes using all but the conventional plan (mean primary and pelvic planning target volume receiving 95% of the prescribed dose was 32.8 +/- 13.7 Gy and 23.7 +/- 4.87 Gy, respectively), reflecting a significant lack of coverage. The three-field forward planned IMRT plans reduced the volume of bowel irradiated to 45 Gy and 50 Gy by 26% +/- 16% and 42% +/- 27% compared with three-dimensional conformal RT. Additional reductions to 69 +/- 51 cm(3) to 45 Gy and 20 +/- 21 cm(3) to 50 Gy were obtained with the nine-field equally spaced IMRT plans-64% +/- 11% and 64% +/- 20% reductions compared with three-dimensional conformal RT. Reducing the number of beams and customizing the angles for the five-field equally spaced IMRT plan did not significantly reduce bowel sparing. CONCLUSION: The bowel volume irradiated to 45 Gy and 50 Gy was significantly reduced with IMRT, which could potentially lead to less bowel toxicity. Reducing the number of beams did not reduce bowel sparing and the five-field customized segmented IMRT plan is a reasonable technique to be tested in clinical trials.

The impact of introducing intensity modulated radiotherapy into routine clinical practice.

BACKGROUND AND PURPOSE: Intensity modulated radiotherapy (IMRT) at the Royal Marsden Hospital London was introduced in July 2001. Treatment delivery was dynamic using a single-phase technique. Concerns were raised regarding increased clinical workload due to introduction of new technology. The potential increased use of resources was assessed. PATIENTS AND METHODS: IMRT patient selection was within guidelines of clinical trials and included patients undergoing prostate plus pelvic lymph node (PPN) irradiation and head and neck cancer (HNC) treatment. Patient planning, quality assurance and treatment times were collected for an initial IMRT patient group. A comparative group of patients with advanced HNC undergoing two- or three-phase conventional radiotherapy, requiring matched photon and electron fields, were also timed. RESULTS: The median overall total planning time for IMRT was greater for HNC patients compared to the PPN cohort. For HNC the overall IMRT planning time was significantly longer than for conventional. The median treatment time for conventional two- or three-phase HNC treatments, encompassing similar volumes to those treated with IMRT, was greater than that for the IMRT HNC patient cohort. A reduction in radiographer man hours per patient of 4.8h was recorded whereas physics time was increased by 4.9h per patient. CONCLUSIONS: IMRT currently increases overall planning time. Additional clinician input is required for target volume localisation. Physics time is increased, a significant component of this being patient specific QA. Radiographer time is decreased. For HNC a single phase IMRT treatment has proven to be more efficient than a multiple phase conventional treatment. IMRT has been integrated smoothly and efficiently into the existing treatment working day. This preliminary study suggests that IMRT could be a routine treatment with efficient use of current radiotherapy resources.

Assessment of a customised immobilisation system for head and neck IMRT using electronic portal imaging.

PURPOSE: To evaluate set-up reproducibility of a cabulite shell and determine CTV-PTV margins for head and neck intensity-modulated-radiotherapy. MATERIALS AND METHODS: Twenty patients were entered into the study. A total of 354 anterior and lateral isocentric electronic portal images (EPIs) were compared to simulator reference images. RESULTS: About 94% of all translational displacements were < or =3 mm, and 99% < or =5 mm. The overall systematic error was 0.9 mm (+/-1.0SD) in the Right-Left, 0.7 mm (+/-0.9SD) in the Superior-Inferior and -0.02 mm (+/-1.1SD) in the Anterior-Posterior directions. The corresponding SDs of the random errors were +/-0.4, +/-0.6 and +/-0.7 mm. The estimated margins required from CTV-PTV were calculated according to the Van Herk formula was 2.9, 2.6 and 3.3 mm, respectively. CONCLUSIONS: This head and neck immobilisation system is of sufficient accuracy for its use with IMRT treatments and a 3 mm CTV-PTV margin has been adopted.