Real-world use of oral versus subcutaneous semaglutide in a cohort of type 2 diabetic patients: which option to which patient?

PURPOSE: To evaluate the variables influencing the therapeutic choice toward oral versus subcutaneous semaglutide in a cohort of diabetic subjects. METHODS: We retrospectively collected data of 292 patients followed at the Diabetes Unit of the University Hospital of Siena and the Hospital of Grosseto, who were prescribed oral (n = 115) or subcutaneous (n = 177) semaglutide between October 2021 and October 2022. RESULTS: Oral semaglutide was preferentially prescribed in older subjects with longer disease duration in replacement of other antidiabetic drugs, while subcutaneous semaglutide was preferentially prescribed in add-on to metformin in subjects with higher body weight and BMI. After 6 months, both formulations significantly improved glycemic control and body weight, however injectable semaglutide showed a greater efficacy on A1c levels, weight loss, BMI and waist circumference reduction. No differences were found in terms of adverse events. CONCLUSION: In our experience, injectable semaglutide is preferred in patients with excess weight and shorter disease duration, while the oral formulation was used later and especially after therapeutic failure of previous therapies. Follow-up data indicate similar tolerability and efficacy of both formulations, despite subcutaneous semaglutide demonstrated greater efficacy.

Humanisation and health needs in children: present or future?

AIM: For a few years, teledentistry has been an emerging innovative strategy with potential in the field of paediatric dentistry. There are still few studies in this regard, so further research is needed to verify and ensure that teledentistry is not only an accessible mode of communication, but above all effective and evidence-based. This study aimed to use a preliminary telematic approach to promote the compliance of patients in the developmental age during the first dental visit. MATERIALS: Two hundred patients were selected according to the eligibility criteria, and distributed in two groups: a study group with the preliminary telematic approach (ATP) before the first visit and a control group with traditional first visit without ATP. Through an ordinal semi-proportional regression model, the degrees of collaboration between the study and control groups were compared, correcting the estimate for age groups, the presence of systemic pathologies, disorders of cognition, attention and learning, degree of anxiety and previous medical-dental experiences. CONCLUSION: The preliminary telematic approach could be useful as a support to the traditional paediatric dental visit, to promote better management and fidelity of the patient, reducing anxiety and increasing collaboration during the first visit.

Field and Temperature Shaping for Microwave Hyperthermia: Recent Treatment Planning Tools to Enhance SAR-Based Procedures.

The aim of the article is to provide a summary of the work carried out in the framework of a research project funded by the Italian Ministry of Research. The main goal of the activity was to introduce multiple tools for reliable, affordable, and high-performance microwave hyperthermia for cancer therapy. The proposed methodologies and approaches target microwave diagnostics, accurate in vivo electromagnetic parameters estimation, and improvement in treatment planning using a single device. This article provides an overview of the proposed and tested techniques and shows their complementarity and interconnection. To highlight the approach, we also present a novel combination of specific absorption rate optimization via convex programming with a temperature-based refinement method implemented to mitigate the effect of thermal boundary conditions on the final temperature map. To this purpose, numerical tests were carried out for both simple and anatomically detailed 3D scenarios for the head and neck region. These preliminary results show the potential of the combined technique and improvements in the temperature coverage of the tumor target with respect to the case wherein no refinement is adopted.

Galaxy clusters enveloped by vast volumes of relativistic electrons.

The central regions of galaxy clusters are permeated by magnetic fields and filled with relativistic electrons1. When clusters merge, the magnetic fields are amplified and relativistic electrons are re-accelerated by turbulence in the intracluster medium2,3. These electrons reach energies of 1-10 GeV and, in the presence of magnetic fields, produce diffuse radio halos4 that typically cover an area of around 1 Mpc2. Here we report observations of four clusters whose radio halos are embedded in much more extended, diffuse radio emission, filling a volume 30 times larger than that of radio halos. The emissivity in these larger features is about 20 times lower than the emissivity in radio halos. We conclude that relativistic electrons and magnetic fields extend far beyond radio halos, and that the physical conditions in the outer regions of the clusters are quite different from those in the radio halos.

Lacosamide in monotherapy in BTRE (brain tumor-related epilepsy): results from an Italian multicenter retrospective study.

PURPOSE: Lacosamide (LCM) is a third-generation anti-seizure medication (ASM) approved for focal onset epilepsy in patients aged ≥ 4.378 Previous studies have reported an efficacy of LCM as add-on treatment in brain tumor-related epilepsy (BTRE). To date, there are no studies in the literature focusing on lacosamide used in monotherapy to treat BTRE. In our retrospective study we investigated efficacy and tolerability of LCM in monotherapy in a multicenter national cohort of primary brain tumor patients. METHODS: We collected from 12 Italian Centers 132 patients with primary brain tumors who were treated with LCM in monotherapy. For each patient we evaluated seizure freedom at 3 and 6 months (primary endpoints), side effects and drop-out rate (secondary endpoints). RESULTS: Overall, LCM led to seizure freedom in 64.4% of patients at 3 months and 55% at 6 months. Patients who used two or more ASMs before LCM had a worse seizure control than patients in monotherapy with LCM as first choice. In 14 patients, we observed seizure control despite tumor progression on magnetic resonance (MRI). Multivariate analysis showed that gross-total resection at diagnosis was significantly associated with higher seizure freedom rate at 6 months. Side effects were mainly mild (grade 1-2 according to CTCAE classification) and drop-out rate was low (1.5%). Main side effects were dizziness and somnolence. CONCLUSIONS: This is the first study showing a good efficacy and tolerability of LCM when used in monotherapy in BTRE. Further prospective studies are needed to confirm these preliminary data, investigating also quality of life and neurocognitive functions.

Experimental Validation of the MRcollar: An MR Compatible Applicator for Deep Heating in the Head and Neck Region.

Clinical effectiveness of hyperthermia treatments, in which tumor tissue is artificially heated to 40-44 °C for 60-90 min, can be hampered by a lack of accurate temperature monitoring. The need for noninvasive temperature monitoring in the head and neck region (H&N) and the potential of MR thermometry prompt us to design an MR compatible hyperthermia applicator: the MRcollar. In this work, we validate the design, numerical model, and MR performance of the MRcollar. The MRcollar antennas have low reflection coefficients (<-15 dB) and the intended low interaction between the individual antenna modules (<-32 dB). A 10 °C increase in 3 min was reached in a muscle-equivalent phantom, such that the specifications from the European Society for Hyperthermic Oncology were easily reached. The MRcollar had a minimal effect on MR image quality and a five-fold improvement in SNR was achieved using the integrated coils of the MRcollar, compared to the body coil. The feasibility of using the MRcollar in an MR environment was shown by a synchronous heating experiment. The match between the predicted SAR and measured SAR using MR thermometry satisfied the gamma criteria [distance-to-agreement = 5 mm, dose-difference = 7%]. All experiments combined show that the MRcollar delivers on the needs for MR-hyperthermia in the H&N and is ready for in vivo investigation.

ESHO benchmarks for computational modeling and optimization in hyperthermia therapy.

BACKGROUND: The success of cancer hyperthermia (HT) treatments is strongly dependent on the temperatures achieved in the tumor and healthy tissues as it correlates with treatment efficacy and safety, respectively. Hyperthermia treatment planning (HTP) simulations have become pivotal for treatment optimization due to the possibility for pretreatment planning, optimization and decision making, as well as real-time treatment guidance. MATERIALS AND METHODS: The same computational methods deployed in HTP are also used for in silico studies. These are of great relevance for the development of new HT devices and treatment approaches. To aid this work, 3 D patient models have been recently developed and made available for the HT community. Unfortunately, there is no consensus regarding tissue properties, simulation settings, and benchmark applicators, which significantly influence the clinical relevance of computational outcomes. RESULTS AND DISCUSSION: Herein, we propose a comprehensive set of applicator benchmarks, efficacy and safety optimization algorithms, simulation settings and clinical parameters, to establish benchmarks for method comparison and code verification, to provide guidance, and in view of the 2021 ESHO Grand Challenge (Details on the ESHO grand challenge on HTP will be provided at https://www.esho.info/). CONCLUSION: We aim to establish guidelines to promote standardization within the hyperthermia community such that novel approaches can quickly prove their benefit as quickly as possible in clinically relevant simulation scenarios. This paper is primarily focused on radiofrequency and microwave hyperthermia but, since 3 D simulation studies on heating with ultrasound are now a reality, guidance as well as a benchmark for ultrasound-based hyperthermia are also included.

Simulation guided design of the MRcollar: a MR compatible applicator for deep heating in the head and neck region.

PURPOSE: To develop a head and neck hyperthermia phased array system compatible with a 1.5 T magnetic resonance (MR) scanner for noninvasive thermometry. METHODS: We designed a dielectric-parabolic-reflector antenna (DiPRA) based on a printed reflector backed dipole antenna and studied its predicted and measured performance in a flat configuration (30 mm thick water bolus and muscle equivalent layer). Thereafter, we designed a phased array applicator model ('MRcollar') consisting of 12 DiPRA modules placed on a radius of 180 mm. Theoretical heating performance of the MRcollar model was benchmarked against the current clinical applicator (HYPERcollar3D) using specific (3D) head and neck models of 28 treated patients. Lastly, we assessed the influence of the DiPRA modules on MR scanning quality. RESULTS: The predicted and measured reflection coefficients (S11) of the DiPRA module are below -20 dB. The maximum specific absorption rate (SAR) in the area under the antenna was 47% higher than for the antenna without encasing. Compared to the HYPERcollar3D, the MRcollar design incorporates 31% less demineralized water (-2.5 L), improves the predicted TC25 (target volume enclosed by 25% iso-SAR contour) by 4.1% and TC50 by 8.5%, while the target-to-hotspot quotient (THQ) is minimally affected (-1.6%). MR experiments showed that the DiPRA modules do not affect MR transmit/receive performance. CONCLUSION: Our results suggest that head and neck hyperthermia delivery quality with the MRcollar can be maintained, while facilitating simultaneous noninvasive MR thermometry for treatment monitoring and control.

Impact of lockdown on children's lifestyle and their collaboration during dental sessions.

AIM: To analyse lifestyle of Italian families during lockdown, evaluating its possible impact on the collaboration of children with the paediatric dentist and associated predictive factors. MATERIALS AND METHODS: Only patients aged between 3 and 16 years, who had started treatment before the lockdown and had spent this periodwith both parents were included in the study. The interviews were carried out using an anonymous questionnaire that assessed school and play activities, the type of diet, the time dedicated to home oral hygiene and the activities carried out with parents. Parents' work situation during lockdown was included to correlate it with time spent at home. The Frankl Behavior Rating Scale was used to determine the degree of cooperation during dental sessions pre- and post-lockdown. Chi-square test and Fisher's Exact tests were used to identify statistical associations of improvement with each categorical variable. Student's t-test was used to highlight the differences in mean values of continuous variables between subjects considered more cooperative and unimproved subjects. Hosmer-Lemeshow test was used to assess the goodness-of-fit of the model. Assumption of linearity of independent variables and log-odds were assessed by Box-Tidwell transformation. Final selection was carried out using the Akaike criterion and all statistical analyses were carried out using the STATA statistical software package. RESULTS: The sample consisted of 212 patients (103F; 109M). The age ranged between 3 and 16 years with an average age of 9.03 years; 82.08% (95% CI 76.24-86.99) of the subjects showed an improvement in collaboration compared to pre-lockdown. Logistic analysis reveals a statistically significant increase of the odds of improvement in patients with a lower pre-lockdown collaboration (OR: 6.05, p = 0.001), in children with a parental presence at home (jobless, OR : 30.55, p <0.001; in "smart working", OR: 23.06, p <0.001) when compared to children whose parents work away from home. From a further exploratory analysis, time dedicated to home oral hygiene was increased if associated with an increased presence of the parents at home (p = 0.015). CONCLUSION: Changes in family routines and increased parental presence at home, during the COVID-19 pandemic lockdown, are associated with improved collaboration of children during dental sessions. A statistical association between the increase in time spent on oral hygiene and the increased presence of parents at home was found.

Dual-Function MR-Guided Hyperthermia: An Innovative Integrated Approach and Experimental Demonstration of Proof of Principle.

Temperature monitoring plays a central role in improving clinical effectiveness of adjuvant hyperthermia. The potential of magnetic resonance thermometry for treatment monitoring purposes led to several MR-guided hyperthermia approaches. However, the proposed solutions were sub-optimal due to technological and intrinsic limitations. These hamper achieving target conformal heating possibilities (applicator limitations) and accurate thermometry (inadequate signal-to-noise-ratio (SNR)). In this work, we studied proof of principle of a dual-function hyperthermia approach based on a coil array (64 MHz, 1.5 T) that is integrated in-between a phased array for heating (434 MHz) for maximum signal receive in order to improve thermometry accuracy. Hereto, we designed and fabricated a superficial hyperthermia mimicking planar array setup to study the most challenging interactions of generic phased-array setups in order to validate the integrated approach. Experiments demonstrated that the setup complies with the superficial hyperthermia guidelines for heating and is able to improve SNR at 2-4 cm depth by 17%, as compared to imaging using the body coil. Hence, the results showed the feasibility of our dual-function MR-guided hyperthermia approach as basis for the development of application specific setups.

Postpartum screening for type 2 diabetes mellitus in women with gestational diabetes: Is it really performed?

AIMS: This study evaluates the adherence to postpartum type 2 diabetes mellitus (T2DM) screening in women with previous gestational diabetes (GDM) and identifies elements associated with poor attendance. METHODS: We retrospectively collected data from 650 consecutive women with GDM between 2016 and 2018, who should had 75 g-OGTT, 4-12 weeks after delivery. Impaired glucose regulation (IGR) was defined according with ADA criteria. RESULTS: Only 41% of women had postpartum OGTT. Of these, 1.9% received T2DM diagnosis, with IGR prevalence of 18%. After introducing a recommendation letter, adherence to screening increased (47% in 2017 and 43% in 2018 vs. 32% in 2016). Screening procedure was less common in women with: no-family history of T2DM (38% vs. 46%; p < 0.05), age <35 (33% vs. 47%; p < 0.01), lower level of education (32% no-high-school-diploma vs. 35% high-school-diploma vs. 49% university-degree; p < 0.01) and unstable employment (35% vs. 44%; p < 0.05). At multivariate logistic regression analysis, age <35 years (OR 1.61; 95%CI: 1.14-2.28) and lowest educational level (OR 1.64; 95% CI: 1.13-2.37, compared to University degree) were independently associated with non-adherence. CONCLUSION: Only 41% of women had postpartum T2DM screening. Women with lower attendance are those with age <35 years or low educational level. Further strategies are needed to implement postpartum test.

Standardization of patient modeling in hyperthermia simulation studies: introducing the Erasmus Virtual Patient Repository.

Purpose: Thermal dose-effect relations have demonstrated that clinical effectiveness of hyperthermia would benefit from more controlled heating of the tumor. Hyperthermia treatment planning (HTP) is a potent tool to study strategies enabling target conformal heating, but its accuracy is affected by patient modeling approximations. Homogeneous phantoms models are being used that do not match the body shape of patients in treatment position and often have unrealistic target volumes. As a consequence, simulation accuracy is affected, and performance comparisons are difficult. The aim of this study is to provide the first step toward standardization of HTP simulation studies in terms of patient modeling by introducing the Erasmus Virtual Patient Repository (EVPR): a virtual patient model database.Methods: Four patients with a tumor in the head and neck or the pelvis region were selected, and corresponding models were created using a clinical segmentation procedure. Using the Erasmus University Medical Center standard procedure, HTP was applied to these models and compared to HTP for commonly used surrogate models.Results: Although this study was aimed at presenting the EVPR database, our study illustrates that there is a non-negligible difference in the predicted SAR patterns between patient models and homogeneous phantom-based surrogate models. We further demonstrate the difference between actual and simplified target volumes being used today.Conclusion: Our study describes the EVPR for the research community as a first step toward standardization of hyperthermia simulation studies.

The Potential of Adjusting Water Bolus Liquid Properties for Economic and Precise MR Thermometry Guided Radiofrequency Hyperthermia.

The potential of MR thermometry (MRT) fostered the development of MRI compatible radiofrequency (RF) hyperthermia devices. Such device integration creates major technological challenges and a crucial point for image quality is the water bolus (WB). The WB is located between the patient body and external sources to both couple electromagnetic energy and to cool the patient skin. However, the WB causes MRT errors and unnecessarily large field of view. In this work, we studied making the WB MRI transparent by an optimal concentration of compounds capable of modifying T 2 * relaxation without an impact on the efficiency of RF heating. Three different T 2 * reducing compounds were investigated, namely CuSO 4 , MnCl 2 , and Fe 3 O 4 . First, electromagnetic properties and T 2 * relaxation rates at 1.5 T were measured. Next, through multi-physics simulations, the predicted effect on the RF-power deposition pattern was evaluated and MRT precision was experimentally assessed. Our results identified 5 mM Fe 3 O 4 solution as optimal since it does not alter the RF-power level needed and improved MRT precision from 0.39 ∘ C to 0.09 ∘ C. MnCl 2 showed a similar MRT improvement, but caused unacceptable RF-power losses. We conclude that adding Fe 3 O 4 has significant potential to improve RF hyperthermia treatment monitoring under MR guidance.

Quantitative, Multi-institutional Evaluation of MR Thermometry Accuracy for Deep-Pelvic MR-Hyperthermia Systems Operating in Multi-vendor MR-systems Using a New Anthropomorphic Phantom.

Clinical outcome of hyperthermia depends on the achieved target temperature, therefore target conformal heating is essential. Currently, invasive temperature probe measurements are the gold standard for temperature monitoring, however, they only provide limited sparse data. In contrast, magnetic resonance thermometry (MRT) provides unique capabilities to non-invasively measure the 3D-temperature. This study investigates MRT accuracy for MR-hyperthermia hybrid systems located at five European institutions while heating a centric or eccentric target in anthropomorphic phantoms with pelvic and spine structures. Scatter plots, root mean square error (RMSE) and Bland-Altman analysis were used to quantify accuracy of MRT compared to high resistance thermistor probe measurements. For all institutions, a linear relation between MRT and thermistor probes measurements was found with R2 (mean ± standard deviation) of 0.97 ± 0.03 and 0.97 ± 0.02, respectively for centric and eccentric heating targets. The RMSE was found to be 0.52 ± 0.31 °C and 0.30 ± 0.20 °C, respectively. The Bland-Altman evaluation showed a mean difference of 0.46 ± 0.20 °C and 0.13 ± 0.08 °C, respectively. This first multi-institutional evaluation of MR-hyperthermia hybrid systems indicates comparable device performance and good agreement between MRT and thermistor probes measurements. This forms the basis to standardize treatments in multi-institution studies of MR-guided hyperthermia and to elucidate thermal dose-effect relations.

Early vs. standard screening and treatment of gestational diabetes in high-risk women - An attempt to determine relative advantages and disadvantages.

BACKGROUND AND AIMS: Screening for Gestational Diabetes (GDM) is usually recommended between 24 and 28 weeks of pregnancy; however available evidence suggests that GDM may be already present before recommended time for screening, in particular among high-risk women as those with prior GDM or obesity. The purpose of this retrospective study was to evaluate whether early screening (16-18 weeks) and treatment of GDM may improve maternal and fetal outcomes. METHODS AND RESULTS: In 290 women at high-risk for GDM, we analyzed maternal and fetal outcomes, according to early or standard screening and GDM diagnosis time. Early screening was performed by 50% of high-risk women. The prevalence of GDM was 62%. Among those who underwent early screened, GDM was diagnosed at the first evaluation in 42.7%. Women with early diagnosis were more frequently treated with insulin and had a slightly lower HbA1c than women with who were diagnosed late. No differences were observed in the prevalence of Cesarean section, operative delivery, gestational age at the delivery, macrosomia, neonatal weight, Ponderal Index and Large-for-Gestational-Age among women with early or late GDM diagnosis or NGT. However, compared to NGT women, GDM women, irrespective of the time of diagnosis, had a lower gestational weight gain, lower prevalence of macrosomia (3.9% vs. 11.4%), small (1.7% vs. 8.3%) as well as large for gestational age (3.3% vs. 16.7%), but higher prevalence of pre-term delivery (8.9% vs. 2.7%). CONCLUSION: Early vs. standard screening and treatment of GDM in high-risk women is associated with similar short-term maternal-fetal outcomes, although women with an early diagnosis were treated to a greater extent with insulin therapy.

Predictive value of SAR based quality indicators for head and neck hyperthermia treatment quality.

PURPOSE: Hyperthermia treatment quality determines treatment effectiveness as shown by the clinically derived thermal-dose effect relations. SAR based optimization factors are used as possible surrogate for temperature, since they are not affected by thermal tissue properties uncertainty and variations. Previously, target coverage (TC) at the 25% and 50% iso-SAR level was shown predictive for treatment outcome in superficial hyperthermia and the target-to-hot-spot-quotient (THQ) was shown to highly correlate with predictive temperature in deep pelvic hyperthermia. Here, we investigate the correlation with temperature for THQ and TC using an 'intermediate' scenario: semi-deep hyperthermia in the head & neck region using the HYPERcollar3D. METHODS: Fifteen patient-specific models and two different planning approaches were used, including random perturbations to circumvent optimization bias. The predicted SAR indicators were compared to predicted target temperature distribution indicators T50 and T90, i.e., the median and 90th percentile temperature respectively. RESULTS: The intra-patient analysis identified THQ, TC25 and TC50 as good temperature surrogates: with a mean correlation coefficient R2T50 = 0.72 and R2T90=0.66. The inter-patient analysis identified the highest correlation with TC25 (R2T50 = 0.76, R2T90=0.54) and TC50 (R2T50 = 0.74, R2T90 = 0.56). CONCLUSION: Our investigation confirmed the validity of our current strategy for deep hyperthermia in the head & neck based on a combination of THQ and TC25. TC50 was identified as the best surrogate since it enables optimization and patient inclusion decision making using one single parameter.