Biomarkers and Echocardiographic Predictors of Cardiovascular Outcome in Patients With Chronic Chagas Disease.

Background Chagas disease (CD) presents an ominous prognosis. The predictive value of biomarkers and new echocardiogram parameters in adjusted models have not been well studied. Methods and Results There were 361 patients with chronic CD (57.6% men, 61±11 years of age, clinical forms: indeterminate 27.1%, cardiac 56.6%, digestive 3.6%, cardiodigestive 12.7%) included in this single-center, observational, prospective longitudinal study. Echocardiographic evaluation included strain analyses of left atrial, left ventricular (LV), and right ventricular and 3-dimensional analyses of left atrial and LV volumes. Biomarkers included cardiac troponin I, brain natriuretic peptide, transforming growth factor ß1, tumor necrosis factor, matrix metalloproteinases, and Trypanosoma cruzi polymerase chain reaction. The studied end point was a composite of CD-related mortality, heart transplant, hospital admission due to worsening heart failure, or new cardiac device insertion. Event-free survival was analyzed by multivariable regression analyses adjusted for competing risks. P values <0.05 were considered significant. The composite event occurred in 79 patients after 4.9±2.0 years follow-up. LV end-diastolic volume (hazard ratio [HR], 1.01 [95% CI, 1.00-1.02]; P=0.02), peak negative global atrial strain (HR, 1.08 [95% CI, 1.00-1.17]; P=0.04), LV global circumferential strain (HR, 1.12 [95% CI, 1.04-1.21]; P=0.003), LV torsion (HR, 0.55 [95% CI, 0.35-0.81]; P=0.003), brain natriuretic peptide (HR, 2.03 [95% CI, 1.23-3.34]; P=0.005), and positive T cruzi polymerase chain reaction (HR, 1.80 [95% CI, 1.12-2.91]; P=0.01) were end point predictors independent from age, sex, 2-dimensional echocardiographic indexes, hypertension, previous cardiac device, and CD cardiac form. Conclusions Two-dimensional strain- and 3-dimensional-derived parameters, brain natriuretic peptide, and positive T cruzi polymerase chain reaction can be useful for prediction of CD cardiovascular events.

Dengue, chikungunya, and Zika virus infections in Latin America and the Caribbean: a systematic review / Infecciones por dengue, chikungunya y el virus de Zika en América Latina y el Caribe: revisión sistemática / Dengue, zika e chikungunya na América Latina e no Caribe: revisão sistemática

ABSTRACT Objectives. To characterize the distribution profile of dengue, chikungunya, and Zika virus infections in Latin America and the Caribbean and to identify possible factors associated with the risk of dissemination and severity of these arboviruses. Methods. The protocol of this review was registered on the PROSPERO platform. Searches were carried out in the following databases: Virtual Health Library, MEDLINE/PubMed, and Embase. The search terms were: Zika virus, Zika virus infection, dengue, dengue virus, chikungunya virus, chikungunya fever, epidemiology, observational study, Latin America, and Caribbean region. Studies that addressed the distribution of these arboviruses and the risk factors associated with dengue, Zika virus disease, and chikungunya, published between January 2000 and August 2020 in English, Portuguese, and Spanish, were included. Results. Of 95 studies included, 70 identified risk factors, clinical manifestations, and outcomes for arbovirus infections and 25 described complications and/or deaths. The highest frequency of confirmed cases was for dengue. Brazil reported most cases of the three arboviruses in the period analyzed. Environmental and socioeconomic factors facilitated the proliferation and adaptation of vectors, and host-related factors were reported to aggravate dengue. Most deaths were due to chikungunya, Zika virus disease caused most neurological alterations, and dengue resulted in greater morbidity leading to more frequent hospitalization. Conclusions. The review provides a broad view of the three arboviruses and the intrinsic aspects of infections, and highlights the factors that influence the spread of these viruses in the populations studied.

RESUMEN Objetivos. Caracterizar el perfil de distribución de infecciones por dengue, chikungunya y el virus de Zika en América Latina y el Caribe, y determinar posibles factores relacionados con el riesgo de propagación y gravedad de estas arbovirosis. Métodos. Se registró el protocolo de esta revisión en la plataforma PROSPERO. Se realizaron búsquedas en las siguientes bases de datos: Virtual Health Library, MEDLINE/PubMed y Embase. Los términos de búsqueda fueron: "zika virus" [virus del Zika], "zika virus infection" [infección por el virus del Zika], "dengue", "dengue virus" [virus del dengue], "chikungunya virus" [virus del chikunguña], "chikungunya fever" [fiebre de chikunguña], "epidemiology" [epidemiología], "observational study" [estudio observacional], "Latin America" [América Latina] y "Caribbean región" [Caribe]. Se incluyeron estudios que abordaban la distribución de estas arbovirosis y los factores de riesgo asociados con el dengue, la enfermedad por el virus del Zika y el chikunguña, publicados entre enero del 2000 y agosto del 2020 en español, inglés y portugués. Resultados. De los 95 estudios incluidos, 70 establecieron factores de riesgo, manifestaciones clínicas y resultados de las infecciones por arbovirus y 25 describieron complicaciones o muertes. La mayor frecuencia de casos confirmados fue del dengue. Brasil notificó la mayoría de los casos de infección por los tres arbovirus en el período analizado. Los factores ambientales y socioeconómicos facilitaron la proliferación y adaptación de los vectores, y se notificó que los factores relacionados con el huésped agravaban el dengue. El chikunguña causó la mayor parte de las muertes, la enfermedad por el virus del Zika causó la mayor parte de las alteraciones neurológicas y el dengue fue responsable de una mayor morbilidad, lo que llevó a una hospitalización más frecuente. Conclusiones. Esta revisión ofrece un panorama de las tres arbovirosis y de los aspectos intrínsecos de las infecciones, y pone de relieve los factores que influyen en la propagación de estos virus en las poblaciones estudiadas.

RESUMO Objetivos. Descrever a distribuição das arboviroses causadas pelo vírus da dengue, zika e chikungunya na América Latina e no Caribe e identificar possíveis fatores associados ao potencial de disseminação e à gravidade dessas infecções. Métodos. O protocolo desta revisão sistemática foi registado na plataforma PROSPERO. Foram realizadas buscas nas bases de dados Biblioteca Virtual em Saúde, MEDLINE/PubMed e Embase. Os termos de busca foram: vírus zika, infecção pelo vírus zika, dengue, vírus da dengue, vírus chikungunya, febre chikungunya, epidemiologia, estudo observacional, América Latina e região do Caribe. Foram selecionados estudos publicados em inglês, português e espanhol, entre janeiro de 2000 e agosto de 2020, que tratavam da distribuição desses arbovírus e de fatores de risco associados à dengue, à infecção pelo vírus zika e à febre chikungunya. Resultados. Dos 95 estudos selecionados, 70 descreveram fatores de risco, manifestações clínicas e desfechos das arboviroses e 25 destacaram as complicações e/ou mortes. Houve uma maior taxa de casos confirmados de dengue. O Brasil foi o país onde se registrou a maioria dos casos dessas três arboviroses no período analisado. Fatores ambientais e socioeconômicos facilitaram a proliferação e a adaptação dos vetores dos arbovírus e fatores próprios do hospedeiro são determinantes na gravidade da dengue. As mortes ocorreram principalmente nos casos de febre chikungunya, as manifestações neurológicas foram mais comuns na infecção pelo vírus zika e a dengue resultou em maior morbidade e internação hospitalar. Conclusões. Esta revisão sistemática oferece um panorama destas três arboviroses e de suas peculiaridades destacando os fatores que influenciam a disseminação destes arbovírus nas populações estudadas.

Rehabilitación cardiorrespiratoria en hipertensión pulmonar: experiencia en un centro de referencia / Cardiorespiratory rehabilitation in pulmonary hypertension: experience in a reference center

RESUMEN Introducción: La hipertensión pulmonar (HP) abarca un grupo heterogéneo de enfermedades que genera discapacidad y aumento de la morbimortalidad. La rehabilitación cardiorrespiratoria (RC) es un recurso terapéutico subutilizado en esta condición. Objetivo: Estimar los efectos de un programa de RC en una prueba de caminata de campo y en la calidad de vida de pacientes con diagnóstico de HP de los grupos I y IV. Materiales y Métodos: Los pacientes fueron evaluados antes y después de la intervención mediante la prueba de caminata de 6 minutos (PC6M) y el Saint George's Respiratory Questionnaire (SGRQ). El programa de RC consistió en 8 semanas de ejercicios supervisados con modalidad institucional. Resultados: Se incluyeron 19 pacientes con diagnóstico de HP precapilar por cateterismo cardíaco derecho, 18 mujeres (94,7%) con una media de edad de 45,5 ± 14,3 años. Trece (68,4%) presentaron HP del grupo I, y 6 (31,6%) HP del grupo IV. Se observaron cambios estadísticamente significativos en la PC6M (diferencia de medias -DM- 31 ± 27,3 metros; p <0,001), y en el SGRQ (DM 8,2 ± 10,2; p<0,01). No se reportaron eventos adversos graves durante el programa. Conclusiones: Nuestro estudio sugiere que un programa de RC supervisado en pacientes con HP podría mejorar la distancia caminada y la calidad de vida.

ABSTRACT Background: Pulmonary hypertension (PH) comprises a heterogeneous group of diseases resulting in disability and increased morbidity and mortality. Cardiopulmonary rehabilitation (CR) is a therapeutic resource not widely used in this condition. Objective: The aim of this study was to evaluate the effects of a CR program on a walking test and on the quality of life in patients with group 1 and group 4 PH Methods: Patients were evaluated before and after the intervention with the six-minute walk test (6MWT) and Saint George's Respiratory Questionnaire (SGRQ). The program consisted of 8 weeks of supervised exercises within the institution. Results: Nineteen patients with precapillary PH diagnosed by right heart catheterization were included; 18 were women (94.7%) with a mean age of 45.5±14.3 years. Thirteen (68.4%) patients had group 1 PH and 6 (31.6%) had group 4 PH. There were statistically significant changes in the 6MWT [mean difference (MD) 31±27.3 m; p<0.001], and in the SGRQ (MD 8.2±10.2; p<0.01). No adverse events were reported during the program. Conclusions: Our study suggests that a supervised CR program in patients with PH could improve the distance walked and the quality of life.

Discovery of a new class of triazole based inhibitors of acetyl transferase KAT2A.

We have recently developed a new synthetic methodology that provided both N-aryl-5-hydroxytriazoles and N-pyridine-4-alkyl triazoles. A selection of these products was carried through virtual screening towards targets that are contemporary and validated for drug discovery and development. This study determined a number of potential structure target dyads of which N-pyridinium-4-carboxylic-5-alkyl triazole displayed the highest score specificity towards KAT2A. Binding affinity tests of abovementioned triazole and related analogs towards KAT2A confirmed the predictions of the in-silico assay. Finally, we have run in vitro inhibition assays of selected triazoles towards KAT2A; the ensemble of binding and inhibition assays delivered pyridyl-triazoles carboxylates as the prototype of a new class of inhibitors of KAT2A.

On the clinical acceptance of black-box systems for EEG seizure prediction.

Seizure prediction may be the solution for epileptic patients whose drugs and surgery do not control seizures. Despite 46 years of research, few devices/systems underwent clinical trials and/or are commercialized, where the most recent state-of-the-art approaches, as neural networks models, are not used to their full potential. The latter demonstrates the existence of social barriers to new methodologies due to data bias, patient safety, and legislation compliance. In the form of literature review, we performed a qualitative study to analyze the seizure prediction ecosystem to find these social barriers. With the Grounded Theory, we draw hypotheses from data, while with the Actor-Network Theory we considered that technology shapes social configurations and interests, being fundamental in healthcare. We obtained a social network that describes the ecosystem and propose research guidelines aiming at clinical acceptance. Our most relevant conclusion is the need for model explainability, but not necessarily intrinsically interpretable models, for the case of seizure prediction. Accordingly, we argue that it is possible to develop robust prediction models, including black-box systems to some extent, while avoiding data bias, ensuring patient safety, and still complying with legislation, if they can deliver human- comprehensible explanations. Due to skepticism and patient safety reasons, many authors advocate the use of transparent models which may limit their performance and potential. Our study highlights a possible path, by using model explainability, on how to overcome these barriers while allowing the use of more computationally robust models.

Natural and Synthetic Halogenated Amino Acids-Structural and Bioactive Features in Antimicrobial Peptides and Peptidomimetics.

The 3D structure and surface characteristics of proteins and peptides are crucial for interactions with receptors or ligands and can be modified to some extent to modulate their biological roles and pharmacological activities. The introduction of halogen atoms on the side-chains of amino acids is a powerful tool for effecting this type of tuning, influencing both the physico-chemical and structural properties of the modified polypeptides, helping to first dissect and then rationally modify features that affect their mode of action. This review provides examples of the influence of different types of halogenation in amino acids that replace native residues in proteins and peptides. Examples of synthetic strategies for obtaining halogenated amino acids are also provided, focusing on some representative compounds and their biological effects. The role of halogenation in native and designed antimicrobial peptides (AMPs) and their mimetics is then discussed. These are in the spotlight for the development of new antimicrobial drugs to counter the rise of antibiotic-resistant pathogens. AMPs represent an interesting model to study the role that natural halogenation has on their mode of action and also to understand how artificially halogenated residues can be used to rationally modify and optimize AMPs for pharmaceutical purposes.

Overexpression of Plasmodium falciparum M1 Aminopeptidase Promotes an Increase in Intracellular Proteolysis and Modifies the Asexual Erythrocytic Cycle Development.

Plasmodium falciparum, the most virulent of the human malaria parasite, is responsible for high mortality rates worldwide. We studied the M1 alanyl-aminopeptidase of this protozoan (PfA-M1), which is involved in the final stages of hemoglobin cleavage, an essential process for parasite survival. Aiming to help in the rational development of drugs against this target, we developed a new strain of P. falciparum overexpressing PfA-M1 without the signal peptide (overPfA-M1). The overPfA-M1 parasites showed a 2.5-fold increase in proteolytic activity toward the fluorogenic substrate alanyl-7-amido-4-methylcoumarin, in relation to the wild-type group. Inhibition studies showed that overPfA-M1 presented a lower sensitivity against the metalloaminopeptidase inhibitor bestatin and to other recombinant PfA-M1 inhibitors, in comparison with the wild-type strain, indicating that PfA-M1 is a target for the in vitro antimalarial activity of these compounds. Moreover, overPfA-M1 parasites present a decreased in vitro growth, showing a reduced number of merozoites per schizont, and also a decrease in the iRBC area occupied by the parasite in trophozoite and schizont forms when compared to the controls. Interestingly, the transgenic parasite displays an increase in the aminopeptidase activity toward Met-, Ala-, Leu- and Arg-7-amido-4-methylcoumarin. We also investigated the potential role of calmodulin and cysteine proteases in PfA-M1 activity. Taken together, our data show that the overexpression of PfA-M1 in the parasite cytosol can be a suitable tool for the screening of antimalarials in specific high-throughput assays and may be used for the identification of intracellular molecular partners that modulate their activity in P. falciparum.

Microplastics in the Center of Mediterranean: Comparison of the Two Calabrian Coasts and Distribution from Coastal Areas to the Open Sea.

Plastic is everywhere-increasing evidence suggests that plastic pollution is ubiquitous and persistent in ecosystems worldwide. Microplastic pollution in marine environments is particularly insidious, as small fragmentation can increase interaction with biota and food chain access. Of particular concern is the Mediterranean Sea, which has become a large area of accumulation of plastic debris, including microplastics, whose polymeric composition is still largely unknown. In this study, we analyzed the polymeric composition, particle size distribution, shape, and color of small plastic particles (ranging from 50 to 5000 µm) collected from the sea surface in six stations at the center of the Mediterranean Sea. We also described, for the first time, the different distribution of microplastics from coastal areas up to 12 nautical miles offshore. The microplastic density was 0.13 ± 0.19 particles/m2, with a marked prevalence of smaller particles (73% < 3 mm) and a peak between 1 and 2 mm (34.74%). Microplastics composition analysis showed that the most abundant material was polyethylene (69%), followed by polypropylene (24%). Moreover, we reported a comparison of the two Calabrian coasts providing the first characterization of a great difference in microplastic concentration between the Tyrrhenian and Ionian sides (87% vs. 13%, respectively), probably due to the complex marine and atmospheric circulation, which make the Tyrrhenian side an area of accumulation of materials originating even from faraway places. We demonstrate, for the first time, a great difference in microplastic concentration between Tyrrhenian and Ionian Calabrian coasts, providing a full characterization and highlighting that microplastic pollution is affected by both local release and hydrography of the areas.

Peptide receptor radionuclide therapy in patients with metastatic progressive pheochromocytoma and paraganglioma: long-term toxicity, efficacy and prognostic biomarker data of phase II clinical trials.

BACKGROUND: Pheochromocytoma and paraganglioma (PPGL) have currently only limited treatment options available for patients in the metastatic phase (mPPGL) in either post-surgery or inoperable settings. However, these rare tumors overexpress somatostatin receptors and can thus be treated with peptide receptor radionuclide therapy (PRRT). We present data about our 10-year experience treating 46 consecutive mPPGL patients with 90Y-DOTATOC or 177Lu-DOTATATE. PATIENTS AND METHODS: All patients (20 men and 26 women, median age 52 years) showed positive scintigraphic imaging at 111In-octreotide or 68Ga-DOTATOC positron emission tomography/computed tomography (PET/CT). 90Y-DOTATOC was administered in 12 patients, with cumulative dosages ranging from 7.4 to 11 GBq, while 34 patients received 18.5 or 27.5GBq of 177Lu-DOTATATE. We used Southwest Oncology Group Response Evaluation Criteria in Solid Tumors criteria to evaluate treatment efficacy and Common Terminology Criteria for Adverse Events criteria to assess toxicity. The prognostic role of primary tumor site, hormone secretion, succinate dehydrogenase (SDHx) mutation, and metastatic involvement was also evaluated. RESULTS: Both 90Y-DOTATOC and 177Lu-DOTATATE PRRT were well tolerated by patients without significant renal or bone marrow toxicity. The median follow-up was 73 months (range 5-146 months). The overall disease control rate (DCR) was 80% [95% confidence interval (CI) 68.9% to 91.9%] with a mean five cycles of therapy. However, 177Lu-DOTATATE patients showed a longer median overall survival (mOS) than those receiving 90Y-Dotatoc and a better DCR when higher dosages were administered, even if a direct comparison was not carried out. Syndromic patients had a poorer mOS. SDHx mutations did not interfere with treatment efficacy. CONCLUSIONS: PRRT is safe and effective for the treatment of patients with progressive mPPGL, especially at higher dosages. The longer mOS of 177Lu-DOTATATE-treated patients in our protocols indicates the former radiopharmaceutical as the better candidate for further clinical application.

Inflammation Precedes Fat Deposition in an Experimental Model of Lymphedema.

Background: Chronic lymphedema is a common complication of lymphatic obstruction, particularly after cancer treatment, characterized by an increased volume of the affected extremity, partly caused by the accumulation of excessive adipose tissue. The relationship between lymph vessels' obstruction and fat deposit is, however, poorly understood. Objective: Our central hypothesis was that the inflammatory process caused by lymph stasis precedes the adipocyte differentiation and fat deposition. Methods and Results: We used a modified mouse tail model to produce secondary lymphedema. Animals were treated with dexamethasone, or the procedure was performed in nitric oxide synthase 2 (NOS2)-deficient mice to evaluate the role of inflammation in lymphedema formation. Adipose tissue (Lipin) and inflammatory markers (IL-6, MCP-1, and F4-80) were analyzed in histological samples and by quantitative polymerase chain reaction. We observed an increased deposition of fat into the affected area that starts 3 weeks after lymph vessel ligation; it further increased after 6 weeks. Genes involved in the inflammatory process were upregulated before adipocyte maturation. Treatment with dexamethasone or the use of inducible nitric oxide synthase knockout mice blocked the inflammatory reaction and inhibited the accumulation of fat distal to the lymphatic obstruction. Conclusion: In the modified mouse tail lymphedema, inflammation precedes adipogenesis. Our data suggest that MCP-1 and nitric oxide may be potential targets for lymphedema management.

Structural Insights on Tiny Peptide Nucleic Acid (PNA) Analogues of miRNA-34a: An in silico and Experimental Integrated Approach.

In the present work, structural features of the interaction between peptide nucleic acid (PNA)-based analogs of the tumor-suppressor microRNA-34a with both its binding sites on MYCN mRNA were investigated. In particular, the region from base 1 to 8 ("seed" region) of miR-34a was reproduced in the form of an 8-mer PNA fragment (tiny PNA), and binding to target 3'UTR MYCN mRNA, was studied by a seldom reported and detailed NMR characterization, providing evidence for the formation of anti-parallel duplexes with a well-organized structural core. The formation of PNA-3'UTR duplexes was also confirmed by Circular Dichroism, and their melting curves were measured by UV spectroscopy. Nevertheless, this study offered a valuable comparison between molecular dynamics predictions and experimental evidence, which showed great correlation. Preliminary uptake assays were carried out in Neuroblastoma Kelly cells, using short peptide conjugates as carriers and FITC fluorescent tag for subcellular localization. Moderate internalization was observed without the use of transfecting agents. The reported results corroborate the interest toward the design and development of chimeric PNA/RNA sequences as effective RNA-targeting agents.

Sensitivity of CE-MRI in detecting local recurrence after radical prostatectomy.

AIM: The aim of our study was to evaluate the sensitivity of contrast-enhanced magnetic resonance (CE-MR) with phased array coil in the diagnosis of local recurrence in patients with prostate cancer after radical prostatectomy and referred for salvage radiotherapy (SRT). MATERIALS AND METHODS: This retrospective study included 73 patients treated with SRT after radical prostatectomy in the period between September 2006 and November 2017. All patients performed a CE-MRI with phased array coil before the start of SRT. A total of 213 patients treated at the ASST Grande Ospedale Metropolitano Niguarda in the period between September 2006 and November 2017 with SRT after radical prostatectomy were reviewed. Seventy-three patients with a CE-MRI with phased array coil of the pelvis before the start of SRT were included in the present study. RESULTS: At imaging review, recurrence local recurrent disease was diagnosed in 48 of 73 patients. By considering as reference standard the decrease in prostate-specific antigen (PSA) value after radiotherapy, we defined: 41 true positive (patients with MRI evidence of local recurrence and PSA value decreasing after SRT), 7 false positive (patients with MRI evidence of local recurrence without biochemical response after SRT), 3 true negative (patients without MRI evidence of local recurrence and stable or increased PSA value after SRT) and 22 false negative (patients without MRI evidence of local recurrence and PSA value decreasing after SRT) cases. The sensitivity values were calculated in relation to the PSA value before the start of treatment, obtaining a value of 74% for PSA above 0.2 ng/mL. CONCLUSION: The sensitivity of CE-MRI in local recurrence detection after radical prostatectomy increases with increasing PSA values. CE-MRI with phased array coil can detect local recurrences after radical prostatectomy with a good sensitivity in patients with pre-RT PSA value above 0.2 ng/mL.

A combined experimental and computational study on peptide nucleic acid (PNA) analogues of tumor suppressive miRNA-34a.

MicroRNAs are a ubiquitous class of non-coding RNAs able to regulate gene expression in diverse biological processes. Widespread miRNAs deregulation was reported in numerous diseases including cancer, with several miRNAs playing oncogenic and/or tumor suppressive role by targeting multiple mRNAs simultaneously. Based on these findings, miRNAs have emerged as promising therapeutic tools for cancer treatment. Herein, for the first time, peptide nucleic acids (PNAs) were studied to develop a new class of molecules able to target 3'UTR on MYCN mRNA without a fully complementary base pairing sequence (as miRNAs). For our proof of concept study we have selected as a model the miRNA-34a, which acts as a tumor suppressor in a number of cancers including neuroblastoma. In particular, miRNA-34a is a direct regulator of MYCN oncogene, whose overexpression is a prominent biomarker for the highly aggressive neuroblastoma phenotype. The design and synthesis of three PNA-based oligomers of different length was described, and their interaction with two binding sites on the target MYCN mRNA was investigated by molecular dynamics simulation, and spectroscopic techniques (CD, UV). Intake assay and confocal microscopy of PNA sequences were also carried out in vitro on neuroblastoma Kelly cells. Despite the presence of multiple mismatches, the PNA/RNA hetero duplexes retain very interesting features in terms of stability, affinity as well as of cellular uptake.

Promoter haplotypes of the corticotropin-releasing hormone encoding gene modulate the physiological stress response in vitro and in vivo.

The corticotropin-releasing hormone (CRH) is a neuropeptide mediating stress responses. CRH exerts effects via the hypothalamus pituitary adrenal axis as well as immediate effects on the sympathetic-adrenal-medullary system. Genetic variants of the CRH promoter were previously found to be associated with altered CRH promoter activity and physiological reactions. Functional characterization of three CRH promoter haplotypes have been performed in vitro using a reporter gene assay under different stimulation conditions. Furthermore, 232 healthy subjects were genotyped and the influence of CRH haplotypes on basal parameters such as post-awakening cortisol and blood pressure as well as on stress reactivity measured after socially evaluated cold pressor test (SeCPT) was investigated. In vitro, CRH haplotype 2 showed the highest promoter activity under baseline conditions and after forskolin stimulation compared with other haplotypes. Forskolin treatment resulted in a two fold increase of haplotype 2 promoter activity compared with the baseline condition. Cell line-dependent promoter activation was found after hydrocortisone treatment. In vivo, CRH haplotype 2 carriers showed significant higher baseline blood pressure (p = .002) and blood pressure after SeCPT (p < .001), but did not differ in cortisol levels. This study provides converging evidence for the importance of CRH promoter variants on physiological stress response parameters.

Quality of life and associated factors in patients with chronic Chagas disease.

OBJECTIVES: To evaluate the quality of life (QoL) of patients with Chagas disease (CD) and the association between QoL domains and several clinical, socioeconomic and lifestyle characteristics of this population. METHODS: Cross-sectional observational study conducted from March 2014 to March 2017 including a total of 361 outpatients followed at Evandro Chagas National Institute of Infectious Disease, Brazil. QoL was assessed using the Portuguese shorter version of the original WHO Quality of Life questionnaire (WHOQOL-BREF). Information about clinical CD presentation, presence of comorbidities, functional class, previous benznidazole treatment, socioeconomic profile and lifestyle was also obtained. RESULTS: Environment and physical domains presented the worst QoL scores, while the social relationship domain presented the highest score. Multivariate regression analysis demonstrated that variables independently associated with QoL were functional class, sex, clinical presentation of CD, sleep duration, schooling, physical activity level, smoking, income per capita and residents by domicile. CONCLUSIONS: The low socioeconomic status and the physical limitations imposed by the disease presented an important impact on the QoL reduction among CD patients, especially on environment and physical domains. Strategies to improve QoL among CD patients should be tailored and consider many different variables to maximise improvements not only of patients' physical but also of their mental health.

Equipment, staffing, and provision of radiotherapy in Lombardy, Italy: Results of three surveys performed between 2012 and 2016.

INTRODUCTION:: Several efforts are being implemented at the European level to measure provision of up-to-date radiation treatments across the continent. METHODS:: A snapshot survey involving all radiation oncology centers within Lombardy, Italy, was performed in 2012 and repeated in 2014 and 2016, in cooperation with regional governmental officers. Centers were asked to provide detailed information concerning all individual patients being treated on the index day, and to report data on available local resources. RESULTS:: We observed an increase in the number of centers and of megavoltage units (MVU) (from 76 to 87, i.e., 8.7 MVU per million inhabitants in 2016). Mean number of MVU per center was 2.5. Average age of MVU increased from 5.3 to 7.5 years and patients on the waiting list also increased. Conformal 3D radiotherapy (RT) treatments decreased from 56% to 42% and were progressively replaced by intensity-modulated RT treatments (from 39% to 49%). Waiting times were overall satisfactory. Radiation oncologists treated on average 152 and radiation therapists 100 RT courses per year. Average reimbursement per course was €4,879 (range €2,476-€8,014). CONCLUSIONS:: The methodology of snapshot survey proved feasible and provided valuable information about radiation oncology provision and accessibility in Lombardy.

Combined BRAFV600E analysis and 99mTc-MIBI scintigraphy can be a useful diagnostic tool in differentiated thyroid cancer patients with incomplete bio-chemical response to first radioiodine therapy (RAIT): a pilot investigation.

PURPOSE: The aim of the present study was to evaluate the possible diagnostic role of the combined performance of BRAF mutation analysis and MIBI scintigraphy in papillary thyroid cancer (PTC) patients with incomplete bio-chemical response to first radioiodine therapy (RAIT) performed for thyroid remnant ablation. METHODS: The records of 15 PTC patients with bio-chemical incomplete response to first RAIT were retrospectively analyzed. BRAFV600E analysis on primary tumor samples was obtained in all cases along with neck ultrasonography and 99mTc-MIBI scintigraphy of the neck-thorax regions at first follow-up. All patients then underwent RAIT with high radioiodine activities. A post-therapy whole-body scan (pT-WBS) was acquired 5-7 days after RAIT. RESULTS: Abnormal radioiodine uptake was found in 10 out of the 15 patients (67%, 131I+ve), while in the remaining 33%, no abnormal radioiodine uptake was detected (5/15, 131I-ve). Abnormal tracer uptake was found in 6 out of 10 131I+ve patients at 99mTc-MIBI scintigraphy (MIBI+ve). BRAFV600E mutation was not found in the majority of 131I+ve patients (9 out of 10 BRAFV600E-ve). On the contrary, in the 5 131I-ve patients, 99mTc-MIBI scintigraphy did not show any abnormal tracer uptake (MIBI-ve), while BRAFV600E mutation was present (BRAFV600E+ve). Thus, in our series, the association between MIBI-ve scintigraphy and BRAF+ve mutation was a useful diagnostic tool in predicting negative pT-WBS outcome. CONCLUSION: Albeit obtained in a small retrospective series, our results suggest that the combination of BRAFV600E+ve mutation and MIBI-ve scintigraphy may be considered a negative prognostic clue, which predicts the absence of radioiodine uptake at pT-WBS in DTC patients with incomplete bio-chemical response to first RAIT.

Genetic landscape of ultra-stable chronic lymphocytic leukemia patients.

Background: Chronic lymphocytic leukemia (CLL) has a heterogeneous clinical course. Beside patients requiring immediate treatment, others show an initial indolent phase followed by progression and others do not progress for decades. The latter two subgroups usually display mutated IGHV genes and a favorable FISH profile. Patients and methods: Patients with absence of disease progression for over 10 years (10-34) from diagnosis were defined as ultra-stable CLL (US-CLL). Forty US-CLL underwent extensive characterization including whole exome sequencing (WES), ultra-deep sequencing and copy number aberration (CNA) analysis to define their unexplored genetic landscape. Microarray analysis, comparing US-CLL with non-US-CLL with similar immunogenetic features (mutated IGHV/favorable FISH), was also carried out to recognize US-CLL at diagnosis. Results: WES was carried out in 20 US-CLL and 84 non-silent somatic mutations in 78 genes were found. When re-tested in a validation cohort of 20 further US-CLL, no recurrent lesion was identified. No clonal mutations of NOTCH1, BIRC3, SF3B1 and TP53 were found, including ATM and other potential progression driving mutations. CNA analysis identified 31 lesions, none with known poor prognostic impact. No novel recurrent lesion was identified: most cases showed no lesions (38%) or an isolated del(13q) (31%). The expression of 6 genes, selected from a gene expression profile analysis by microarray and quantified by droplet digital PCR on a cohort of 79 CLL (58 US-CLL and 21 non-US-CLL), allowed to build a decision-tree capable of recognizing at diagnosis US-CLL patients. Conclusions: The genetic landscape of US-CLL is characterized by the absence of known unfavorable driver mutations/CNA and of novel recurrent genetic lesions. Among CLL patients with favorable immunogenetics, a decision-tree based on the expression of 6 genes may identify at diagnosis patients who are likely to maintain an indolent disease for decades.