Exploring Regorafenib Responsiveness and Uncovering Molecular Mechanisms in Recurrent Glioblastoma Tumors through Longitudinal In Vitro Sampling.

Glioblastoma, a deadly brain tumor, shows limited response to standard therapies like temozolomide (TMZ). Recent findings from the REGOMA trial underscore a significant survival improvement offered by Regorafenib (REGO) in recurrent glioblastoma. Our study aimed to propose a 3D ex vivo drug response precision medicine approach to investigate recurrent glioblastoma sensitivity to REGO and elucidate the underlying molecular mechanisms involved in tumor resistance or responsiveness to treatment. Three-dimensional glioblastoma organoids (GB-EXPs) obtained from 18 patients' resected recurrent glioblastoma tumors were treated with TMZ and REGO. Drug responses were evaluated using NAD(P)H FLIM, stratifying tumors as responders (Resp) or non-responders (NRs). Whole-exome sequencing was performed on 16 tissue samples, and whole-transcriptome analysis on 13 GB-EXPs treated and untreated. We found 35% (n = 9) and 77% (n = 20) of tumors responded to TMZ and REGO, respectively, with no instances of TMZ-Resp being REGO-NRs. Exome analysis revealed a unique mutational profile in REGO-Resp tumors compared to NR tumors. Transcriptome analysis identified distinct expression patterns in Resp and NR tumors, impacting Rho GTPase and NOTCH signaling, known to be involved in drug response. In conclusion, recurrent glioblastoma tumors were more responsive to REGO compared to TMZ treatment. Importantly, our approach enables a comprehensive longitudinal exploration of the molecular changes induced by treatment, unveiling promising biomarkers indicative of drug response.

The Role of Double Interatrial Septum in Cryptogenic Stroke.

In this work, the case of a 70-year-old Caucasian woman affected by cryptogenic stroke is reported. After discarding other sources of embolism, a transesophageal echocardiogram was performed, which revealed the presence of a double interatrial septum associated with a left-sided atrial pouch. The persistent interatrial space was identified as the most probable source of thrombus.

O-(2-18F-fluoroethyl)-L-tyrosine (18F-FET) PET as a potential selection tool for second surgery in glioblastoma patients.

BACKGROUND: Treatment-related changes still represent a diagnostic challenge in the management of patients with suspect of recurrent glioblastoma. The specificity of conventional MRI in detecting recurrence remains limited. Brain PET imaging provides information on tumor metabolism and can contribute to improving the diagnostic accuracy of cerebral neoplasms. We performed a retrospective analysis to evaluate the clinical value of O-(2-18F-fluoroethyl)-L-tyrosine (18F-FET) PET in the diagnosis of glioblastoma recurrence. METHODS: A retrospective analysis on patients considered suitable for salvage surgery for recurrence glioblastoma was performed. 18F-FET-PET was performed to investigate gadolinium enhancement suspected for recurrence. Static and kinetic 18F-FET parameters were analyzed and related to O-6-methylguanine-DNA methyltransferase (MGMT) status. RESULTS: Forty-two of the 51 patients who underwent 18F-FET-PET were re-operated. In each case, neuropathological diagnosis of tumor recurrence was confirmed. pMGMT hypermethylation was detected in 21 patients. Mean tumor-to-brain ratios (TBR) max was 3.87 (range 2.6-6.0). Static and kinetic 18F-FET parameters were similar according to MGMT status. CONCLUSIONS: 18FET-PET can be a reliable tool to improve the selection of patients suitable for salvage surgery for glioblastoma recurrence.

Innovative Approach to Isolate and Characterize Glioblastoma Circulating Tumor Cells and Correlation with Tumor Mutational Status.

Circulating tumor cells (CTCs) are one of the most important causes of tumor recurrence and distant metastases. Glioblastoma (GBM) has been considered restricted to the brain for many years. Nevertheless, in the past years, several pieces of evidence indicate that hematogenous dissemination is a reality, and this is also in the caseof GBM. Our aim was to optimize CTCs' detection in GBM and define the genetic background of single CTCs compared to the primary GBM tumor and its recurrence to demonstrate that CTCs are indeed derived from the parental tumor. We collected blood samples from a recurrent IDH wt GBM patient. We genotyped the parental recurrent tumor tissue and the respective primary GBM tissue. CTCs were analyzed using the DEPArray system. CTCs Copy Number Alterations (CNAs) and sequencing analyses were performed to compare CTCs' genetic background with the same patient's primary and recurrent GBM tissues. We identified 210 common mutations in the primary and recurrent tumors. Among these, three somatic high-frequency mutations (in PRKCB, TBX1, and COG5 genes) were selected to investigate their presence in CTCs. Almost all sorted CTCs (9/13) had at least one of the mutations tested. The presence of TERT promoter mutations was also investigated and C228T variation was found in parental tumors and CTCs (C228T heterozygous and homozygous, respectively). We were able to isolate and genotype CTCs from a patient with GBM. We found common mutations but also exclusive molecular characteristics.

Metabolic-imaging of human glioblastoma live tumors: A new precision-medicine approach to predict tumor treatment response early.

Background: Glioblastoma (GB) is the most severe form of brain cancer, with a 12-15 month median survival. Surgical resection, temozolomide (TMZ) treatment, and radiotherapy remain the primary therapeutic options for GB, and no new therapies have been introduced in recent years. This therapeutic standstill is primarily due to preclinical approaches that do not fully respect the complexity of GB cell biology and fail to test efficiently anti-cancer treatments. Therefore, better treatment screening approaches are needed. In this study, we have developed a novel functional precision medicine approach to test the response to anticancer treatments in organoids derived from the resected tumors of glioblastoma patients. Methods: GB organoids were grown for a short period of time to prevent any genetic and morphological evolution and divergence from the tumor of origin. We chose metabolic imaging by NAD(P)H fluorescence lifetime imaging microscopy (FLIM) to predict early and non-invasively ex-vivo anti-cancer treatment responses of GB organoids. TMZ was used as the benchmark drug to validate the approach. Whole-transcriptome and whole-exome analyses were performed to characterize tumor cases stratification. Results: Our functional precision medicine approach was completed within one week after surgery and two groups of TMZ Responder and Non-Responder tumors were identified. FLIM-based metabolic tumor stratification was well reflected at the molecular level, confirming the validity of our approach, highlighting also new target genes associated with TMZ treatment and identifying a new 17-gene molecular signature associated with survival. The number of MGMT gene promoter methylated tumors was higher in the responsive group, as expected, however, some non-methylated tumor cases turned out to be nevertheless responsive to TMZ, suggesting that our procedure could be synergistic with the classical MGMT methylation biomarker. Conclusions: For the first time, FLIM-based metabolic imaging was used on live glioblastoma organoids. Unlike other approaches, ex-vivo patient-tailored drug response is performed at an early stage of tumor culturing with no animal involvement and with minimal tampering with the original tumor cytoarchitecture. This functional precision medicine approach can be exploited in a range of clinical and laboratory settings to improve the clinical management of GB patients and implemented on other cancers as well.

Single-Cell Molecular Characterization to Partition the Human Glioblastoma Tumor Microenvironment Genetic Background.

BACKGROUND: Glioblastoma (GB) is a devastating primary brain malignancy. The recurrence of GB is inevitable despite the standard treatment of surgery, chemotherapy, and radiation, and the median survival is limited to around 15 months. The barriers to treatment include the complex interactions among the different cellular components inhabiting the tumor microenvironment. The complex heterogeneous nature of GB cells is helped by the local inflammatory tumor microenvironment, which mostly induces tumor aggressiveness and drug resistance. METHODS: By using fluorescent multiple labeling and a DEPArray cell separator, we recovered several single cells or groups of single cells from populations of different origins from IDH-WT GB samples. From each GB sample, we collected astrocytes-like (GFAP+), microglia-like (IBA1+), stem-like cells (CD133+), and endothelial-like cells (CD105+) and performed Copy Number Aberration (CNA) analysis with a low sequencing depth. The same tumors were subjected to a bulk CNA analysis. RESULTS: The tumor partition in its single components allowed single-cell molecular subtyping which revealed new aspects of the GB altered genetic background. CONCLUSIONS: Nowadays, single-cell approaches are leading to a new understanding of GB physiology and disease. Moreover, single-cell CNAs resource will permit new insights into genome heterogeneity, mutational processes, and clonal evolution in malignant tissues.

A multicentric quality-control study of exercise Doppler echocardiography of the right heart and the pulmonary circulation. The RIGHT Heart International NETwork (RIGHT-NET).

PURPOSE: This study was a quality-control study of resting and exercise Doppler echocardiography (EDE) variables measured by 19 echocardiography laboratories with proven experience participating in the RIGHT Heart International NETwork. METHODS: All participating investigators reported the requested variables from ten randomly selected exercise stress tests. Intraclass correlation coefficients (ICC) were calculated to evaluate the inter-observer agreement with the core laboratory. Inter-observer variability of resting and peak exercise tricuspid regurgitation velocity (TRV), right ventricular outflow tract acceleration time (RVOT Act), tricuspid annular plane systolic excursion (TAPSE), tissue Doppler tricuspid lateral annular systolic velocity (S'), right ventricular fractional area change (RV FAC), left ventricular outflow tract velocity time integral (LVOT VTI), mitral inflow pulsed wave Doppler velocity (E), diastolic mitral annular velocity by TDI (e') and left ventricular ejection fraction (LVEF) were measured. RESULTS: The accuracy of 19 investigators for all variables ranged from 99.7 to 100%. ICC was > 0.90 for all observers. Inter-observer variability for resting and exercise variables was for TRV = 3.8 to 2.4%, E = 5.7 to 8.3%, e' = 6 to 6.5%, RVOT Act = 9.7 to 12, LVOT VTI = 7.4 to 9.6%, S' = 2.9 to 2.9% and TAPSE = 5.3 to 8%. Moderate inter-observer variability was found for resting and peak exercise RV FAC (15 to 16%). LVEF revealed lower resting and peak exercise variability of 7.6 and 9%. CONCLUSIONS: When performed in expert centers EDE is a reproducible tool for the assessment of the right heart and the pulmonary circulation.

Inkjet-printed graphene Hall mobility measurements and low-frequency noise characterization.

We report room temperature Hall mobility measurements, low temperature magnetoresistance analysis and low-frequency noise characterization of inkjet-printed graphene films on fused quartz and SiO2/Si substrates. We found that thermal annealing in vacuum at 450 °C is a necessary step in order to stabilize the Hall voltage across the devices, allowing their electrical characterization. The printed films present a minimum sheet resistance of 23.3 Ω sq-1 after annealing, and are n-type doped, with carrier concentrations in the low 1020 cm-3 range. The charge carrier mobility is found to increase with increasing film thickness, reaching a maximum value of 33 cm2 V-1 s-1 for a 480 nm-thick film printed on SiO2/Si. Low-frequency noise characterization shows a 1/f noise behavior and a Hooge parameter in the range of 0.1-1. These results represent the first in-depth electrical and noise characterization of transport in inkjet-printed graphene films, able to provide physical insights on the mechanisms at play.

Sex-related differences in exercise performance and outcome of patients with hypertrophic cardiomyopathy.

AIMS: Exercise performance is known to predict outcome in hypertrophic cardiomyopathy (HCM), but whether sex-related differences exist is unresolved. We explored whether functional impairment, assessed by exercise echocardiography, has comparable predictive accuracy in females and males with HCM. METHODS: We retrospectively evaluated 292 HCM patients (46 ± 16 years, 72% males), consecutively referred for exercise echocardiography; 242 were followed for 5.9 ± 4.2 years. RESULTS: Peak exercise capacity was 6.5 ± 1.6 metabolic equivalents (METs). Sixty patients (21%) showed impaired exercise capacity (≤5 METs). Exercise performance was reduced in females, compared with males (5.6 ± 1.6 vs 6.9 ± 1.5 METs, p < 0.001; peak METs ≤ 5 in 40% vs 13%, p < 0.001), largely driven by a worse performance in women >50 years of age. At multivariable analysis, female sex was independently associated with impaired exercise capacity (odds ratio: 4.67; 95% confidence interval (CI): 1.83-11.90; p = 0.001). During follow-up, 24 patients (10%) met the primary endpoint (a combination of cardiac death, heart failure requiring hospitalization, sustained ventricular tachycardia, appropriate implantable cardioverter defibrillator discharge, resuscitated sudden cardiac death and cardioembolic stroke). Event-free survival was reduced in females (p = 0.035 vs males). Peak METs were inversely related to outcome in males (hazard ratio (HR) per unit increase: 0.57; 95% CI: 0.39-0.84; p = 0.004) but not in females (HR: 1.22; 95% CI: 0.66-2.24; p = 0.53). CONCLUSIONS: Female patients with HCM showed significant age-related impairment in functional capacity compared with males, particularly evident in post-menopausal age groups. While women were at greater risk of HCM-related complications and death, impaired exercise capacity predicted adverse outcome only in men. These findings suggest the need for sex-specific management strategies in HCM.

Acute Symptomatic Sinus Bradycardia in High-Dose Methylprednisolone Therapy in a Woman With Inflammatory Myelitis: A Case Report and Review of the Literature.

High dose corticosteroid therapy is widely used as attack therapy of inflammatory central nervous system disorders and can induce several adverse reactions. Bradycardia is an infrequent event after corticosteroids administration and is often asymptomatic. We report a case of a woman admitted to the neurological department of our hospital for paraesthesias of the lower limbs. She received adiagnosis of inflammatory myelitis and high dose corticosteroid therapy was prescribed. During the therapy she complained of chest tightness, dyspnoea, weakness and malaise. An electrocardiogram revealed sinus bradycardia. A significant increase in body weight, probably due to plasma volume expansion, was detected. Bradycardia and high blood pressure spontaneously resolved in few days. We provide a collection and a statistical analysis of literature data about steroid induced bradycardia. We found that higher total doses are associated with lower pulse rate and symptomatic bradycardia. Bradycardia is more frequent in older patients and those with underlying cardiac disease or with autonomic disturbance. However clinicians must be aware about the occurrence of symptomatic bradycardia in all patients who undergo high dose corticosteroid therapy, not only in those at risk, to early detect and treat this potentially dangerous condition.

Pulmonary Circulation on the Crossroads Between the Left and Right Heart in Systemic Sclerosis: A Clinical Challenge for Cardiologists and Rheumatologists.

Involvement of the right heart-pulmonary circulation system in systemic sclerosis is a typical feature, with critical prognostic implications. Pulmonary hypertension may occur in association with interstitial lung disease or as a result of an isolated pulmonary vascular disease that may affect both the precapillary arterioles and the postcapillary venules, as well as a consequence of left heart involvement. These apparently different phenotypes often underlie a significant pathophysiologic overlap, which makes the diagnosis and management of these patients highly complex and uncertain.

The Right Heart International Network (RIGHT-NET): Rationale, Objectives, Methodology, and Clinical Implications.

The Right Heart International Network is a multicenter international study aiming to prospectively collect exercise Doppler echocardiography tests of the right heart pulmonary circulation unit (RHPCU) in large cohorts of healthy subjects, elite athletes, and individuals at risk of or with overt pulmonary hypertension. It is going to provide standardization of exercise stress echocardiography of RHPCU and explore the full physiopathologic response.

Temperature Compensation of Silicon Lamé Resonators Using Etch Holes: Theory and Design Methodology.

We present a new approach to the temperature compensation of MEMS Lamé resonators, based on the combined effect of the doping concentration and of the geometry of etch holes on the equivalent temperature coefficients of silicon. To this purpose, we develop and validate an analytical model which describes the effect of etch holes on the temperature stability of Lamé resonators through comparison with experiments available in the literature and finite-element method (FEM) simulations. We show that two interesting regions of the design space for Lamé resonators exist, where a cancellation of the first-order temperature coefficient of the resonance frequency is possible: [100]-oriented silicon with n-doping of 2.5 ·1019 cm -3 , and [110]-oriented silicon with p-doping higher than 1.4 ·1020 cm -3 .

A Fast Multiobjective Optimization Strategy for Single-Axis Electromagnetic MOEMS Micromirrors.

Micro-opto-electro-mechanical (MOEMS) micromirrors are an enabling technology for mobile image projectors (pico-projectors). Low size and low power are the crucial pico-projector constraints. In this work, we present a fast method for the optimization of a silicon single-axis electromagnetic torsional micromirror. In this device, external permanent magnets provide the required magnetic field, and the actuation torque is generated on a rectangular multi-loop coil microfabricated on the mirror plate. Multiple constraints link the required current through the coil, its area occupancy, the operating frequency, mirror suspension length, and magnets size. With only rather general assumptions about the magnetic field distribution and mechanical behavior, we show that a fully analytical description of the mirror electromagnetic and mechanical behavior is possible, so that the optimization targets (the assembly size, comprising the mirror and magnets, and the actuation current) can be expressed as closed functions of the design parameters. Standard multiobjective optimization algorithms can then be used for extremely fast evaluation of the trade-offs among the various optimization targets and exploration of the Pareto frontier. The error caused by model assumptions are estimated by Finite Element Method (FEM) simulations to be below a few percent points from the exact solution.

Narrow- (3.0 mm) Versus Standard-Diameter (4.0 and 4.5 mm) Implants for Splinted Partial Fixed Restoration of Posterior Mandibular and Maxillary Jaws: A 5-Year Retrospective Cohort Study.

BACKGROUND: Evidence concerning predictability of narrow-diameter implants (NDIs) (<3.3 mm) to restore partially edentulous posterior maxillary and mandibular areas is limited. The aim of this study is to compare the 5-year outcomes of NDIs (3.0 mm) and standard-diameter implants (SDIs) (4.0 to 4.5 mm) supporting fixed partial dentures (FPDs) in posterior mandibular and maxillary jaws. METHODS: All patients treated with at least two adjacent NDIs or SDIs according to available bone thickness and with a minimum follow-up of 5 years after placement were invited to undergo a clinical and radiologic examination. Outcome measures were implant and FPD failures, biologic and prosthetic complications, and marginal bone loss. RESULTS: A total of 107 out of 127 patients attended the examination: 49 (113 implants) of the NDI group, and 58 (126 implants) of the SDI group. Two NDIs failed in one patient versus four SDIs in four patients (P = 0.37). One FPD failed in the NDI group versus two FPDs in the SDI group (P >0.99). Nine biologic complications occurred in the NDI group and twelve in the SDI group (P = 0.81). Twelve prosthetic complications occurred in the NDI group and only two in the SDI group (P = 0.001). Peri-implant marginal bone loss at 5 years was 0.95 ± 0.84 mm for the NDI group and 1.2 ± 0.86 mm for the SDI group (P = 0.06). CONCLUSION: Five-year data indicate that FPD treatment in posterior mandibular and maxillary jaws with NDIs was as reliable as with SDIs, although NDIs showed a higher risk of prosthetic complications.

Rehabilitation of the Atrophic Posterior Maxilla Using Splinted Short Implants or Sinus Augmentation with Standard-Length Implants: A Retrospective Cohort Study.

PURPOSE: To retrospectively compare short implants (6 to 8 mm) (short group) to standard-length implants (≥ 11 mm) inserted in combination with a lateral sinus elevation procedure (sinus group), supporting partial fixed prostheses in the atrophic posterior maxilla. MATERIALS AND METHODS: Records of 118 patients treated with fluoride-modified implants in the atrophic posterior maxilla between January 2009 and December 2011 were screened in two private practices. Two to four implants were placed in each patient and loaded after 5 to 6 months with partial fixed prostheses. Patients were followed for at least 3 years after implant placement. Patients were contacted and invited for clinical and radiologic follow-up examinations. Outcome measures were implant failures, complications, soft tissue parameters, and marginal bone levels. Fisher exact and unpaired t tests were used to compare proportions and means at the .05 level of significance. RESULTS: A total of 101 patients attended the examination: 53 (112 implants) in the sinus group and 48 (109 implants) in the short group. The mean observation period was 47.03 ± 7.46 months for the sinus group and 44.18 ± 6.42 months for the short group. Ten surgical complications occurred in nine patients of the sinus group versus only one complication in the short group; the difference was statistically significant (P = .01). Six implants failed in five patients of the sinus group versus two implants in two patients of the short group. At follow-up, mean marginal bone loss was 0.64 ± 0.58 mm in the sinus group vs 0.48 ± 0.5 mm in the short group. No significant difference was observed in terms of implant failures, prosthetic complications, soft tissue parameters, or marginal bone loss between the two groups. CONCLUSION: Within the limitations of this study, both techniques showed similar medium-term outcomes, but short implants provided advantages in terms of a reduced number of surgical complications.

Clinical, esthetic, and radiographic evaluation of small-diameter (3.0-mm) implants supporting single crowns in the anterior region: a 3-year prospective study.

Fifty patients underwent single-tooth replacement in the maxillary and mandibular incisor area using two-piece 3.0-mm-diameter implants. Clinical and radiographic measurements of soft and hard tissue levels and esthetic parameters (pink esthetic score/white esthetic score [PES/WES]) were assessed at 3 years. No implant failed (success rate: 100%), and facial soft tissues and marginal bone levels remained stable throughout the study period. The mean total PES/WES was high (14.1 ± 1.75), and only one implant demonstrated an unfavorable esthetic outcome (PES/WES = 10). The use of 3.0-mm-diameter implants appears to be a viable treatment procedure in the medium term for single-tooth anterior restorations with limited dimensions.

Esthetic outcome and tissue stability of maxillary anterior single-tooth implants following reconstruction with mandibular block grafts: a 5-year prospective study.

PURPOSE: The aim of this prospective study was to evaluate the hard and soft tissue stability and esthetic outcomes of single-tooth implants placed in the anterior atrophic maxilla, following augmentation with mandibular block grafts covered with bovine hydroxyapatite and a resorbable collagen membrane, over a 5-year period. MATERIALS AND METHODS: Patients with a bony deficiency of ≥ 3 mm horizontally and ≤ 3 mm vertically were treated consecutively with reconstructive procedures and implant placement 6 months afterward. Alveolar ridge dimensions were measured before and after augmentation using computed tomography. Clinical and radiographic measurements of soft and hard tissue levels and esthetic parameters (pink esthetic score [PES]) were performed annually to assess treatment outcomes. RESULTS: Twenty-nine patients were treated. One patient had partial graft exposure after 1 month that required regrafting at the time of implant placement. Mean bone gain was 4.23 ± 0.69 mm horizontally and 1.71 ± 0.75 mm vertically. The implant cumulative success rate was 100%, according to the criteria of Albrektsson et al. Mean crestal bone resorption after 5 years was low (0.61 ± 0.33 mm). Moderate recession of the facial mucosa (-1.12 ± 0.4 mm) was observed during the study period, while mesial and distal papilla heights increased slightly (0.13 ± 0.17 and 0.19 ± 0.37 mm, respectively). Mean PES ratings remained stable, varying from 9.07 ± 1.49 at the moment of definitive crown delivery to 8.61 ± 1.55 at 5 years. Only two cases (7%) were considered slightly below the defined threshold (PES = 8) of marginal esthetic acceptability. CONCLUSIONS: This study demonstrated that implants placed in anterior atrophic maxillae augmented with mandibular block grafts showed stable hard and soft tissue levels and reasonable esthetic outcomes over the medium term, although ongoing recession of the facial mucosa was observed.