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Sarcopenia, the progressive and generalised loss of muscle mass and strength/function, is a major health issue in older adults given its high prevalence and burdensome clinical implications. Over the years, this condition has been endorsed as a marker for discriminating biological from chronological age. However, the absence of a unified operational definition has hampered its full appreciation by healthcare providers, researchers and policy-makers. In addition to this unsolved debate, the complexity of musculoskeletal ageing represents a major challenge to the identification of clinically meaningful biomarkers. Here, we illustrate the advantages of biomarker discovery procedures in muscle ageing based on multivariate methodologies as an alternative approach to traditional single-marker strategies. The rationale, design and methods of the "BIOmarkers associated with Sarcopenia and PHysical frailty in EldeRly pErsons" (BIOSPHERE) study are described as an application of a multi-marker strategy for the development of biomarkers for the newly operationalised Physical Frailty & Sarcopenia condition., (Copyright © 2018 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

A significant percentage of patients on chronic hemodialysis have an interdialytic weight gain (IDWG) above the recommended values. High IDWG has detrimental effects on survival, cardiovascular outcomes, and quality of life. High IDWG is secondary to poor adherence to fluid restriction and to excessive intake of fluids, due to thirst and xerostomia. Various strategies have been proposed to limit IDWG such as the reduction of dietary salt intake, behavioral interventions aimed at improving the adherence to fluid restriction, the improvement of xerostomia, and the use of lower dialysate sodium concentration. The present narrative review aims to evaluate the efficacy of each of such strategies., (Copyright © 2018 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Mitochondrial structural and functional integrity is maintained through the coordination of several processes (e.g., biogenesis, dynamics, mitophagy), collectively referred to as mitochondrial quality control (MQC). Dysfunctional MQC and inflammation are hallmarks of aging and are involved in the pathogenesis of muscle wasting disorders, including sarcopenia and cachexia. One of the consequences of failing MQC is the release of mitochondria-derived damage-associated molecular patterns (DAMPs). By virtue of their bacterial ancestry, these molecules can trigger an inflammatory response by interacting with receptors similar to those involved in pathogen-associated responses. Mitochondria-derived DAMPs, especially cell-free mitochondrial DNA, have recently been associated with conditions characterized by chronic inflammation, such as aging and degenerative diseases. Yet, their actual implication in the aging process and muscle wasting disorders is at an early stage of investigation. Here, we review the contribution of mitochondria-derived DAMPs to age-related systemic inflammation. We also provide arguments in support of the exploitation of such signaling pathways for the management of muscle wasting conditions.

Background: Functional impairment is associated with adverse outcomes in older people, as well as in patients on chronic hemodialysis. The aim of this study was to evaluate if functional impairment represents a risk factor for reduced survival in patients on chronic hemodialysis., Methods: All incident chronic hemodialysis patients of Lazio, a large region of central Italy, registered in the Dialysis and Transplant Lazio Region Registry (DTLRR) in the period 2008-2013 were considered eligible. Inclusion criteria were: age > 18 years, resident in Lazio, still doing dialysis after 90 days from incidence date, doing hemodialysis or hemodiafiltration treatment for > 9 h/week. Patients were stratified into three classes of functional activity: total autonomy, autonomy in some activities, and not self-sufficient. Functional activity was assessed for each patient by the referring physician for the DTLRR from the ~ 90 hemodialysis units of the Lazio region. Each patient was followed from date of first dialysis treatment to the end of the study (31/12/2015) or death or renal transplant, whichever occurred first. Cox proportional hazard models were performed to obtain mortality hazard ratios (HR), 95% confidence intervals (CI), for each class of functional activity adjusting for sex, age, country of birth, city of residence, body mass index (BMI), type of nephropathy, vascular access, previous nephrology counselling, weekly hours of hemodialysis, serum albumin, hemoglobin, and presence of comorbidities (e.g. vascular diseases, coronary disease, and diabetes)., Results: A total of 3356 patients were studied. In the whole follow-up period, 1622 deaths occurred (48%). Functional impairment was associated with the risk of mortality: compared to 'total autonomy', the HR for 'autonomy in some activities' was 1.30 [95% CI: 1.14-1.49] and for 'not self-sufficient' 1.71 [1.47-1.99] (p for trend < 0.05). The number of evitable deaths attributable to reduced functional activity was 237., Conclusion: Functional impairment represents a risk factor for reduced survival in chronic hemodialysis patients. There is a need for early identification of patients who might benefit from interventions aimed at preventing, reversing or delaying the functional impairment.

Purpose: The symptom burden of fatigued hemodialysis patients is poorly known. We aimed to investigate possible differences in the prevalence and severity of symptoms between fatigued and not fatigued patients on chronic hemodialysis., Methods: All prevalent patients on chronic hemodialysis referring to the Hemodialysis Service between January 2016 and June 2017 were considered eligible. The Dialysis Symptom Index (DSI) questionnaire was performed during the dialysis treatment. Patients underwent assessment of fatigue using the Italian version of the vitality scale of the SF-36 (SF-36VS)., Results: We studied 137 patients: 107 (78.1%) were fatigued and 30 (31.9%) were non-fatigued. The median [95% CI] number of symptoms was 15 [14-16] for patients who reported fatigue and 9 [8-19] for the non-fatigued (P < 0.0001). In fatigued patients, with respect to non-fatigued ones, the prevalence of dry skin, itching, muscle soreness, bone or joint pain, restless legs, shortness of breath, feeling sad, feeling anxious, difficulty concentrating, and difficulty becoming sex aroused was significantly higher. Restless legs, feeling sad, difficulty concentrating, and difficulty becoming sex aroused were symptoms independently associated with fatigue. The severity of dry skin, trouble staying asleep, and bone/joint pain was higher in fatigued patients., Conclusion: Fatigued hemodialysis patients report suffering from physical and emotional symptoms more frequently than non-fatigued patients. This finding suggests the need to accurately and routinely define the symptom burden of chronic hemodialysis patients and may help to investigate eventually common underlying pathogenic mechanisms of symptoms in these patients.

Aim: The study aims to determine prevalence and severity of PDF and to define its associated variables., Methods: In five haemodialysis units of northern-centre Italy, patients were regarded to suffer from PDF if they spontaneously offered this complaint when asked the open-ended question: Do you feel better or worse after dialysis? If worse, please specify in which way. A complaint of fatigue would be probed further with questions directed at its duration, frequency and intensity, allowing creation of a fatigue index of severity (one third of the sum of these three parameters, each rated from 1 to 5). Patients were stratified into three groups according the severity of PDF: 1) score = 0; 2) score = 1-3; 3) score > 3., Results: We studied 271 patients: 164 had PDF and 107 did not. PDF patients had significantly longer time of recovery after dialysis (TIRD). TIRD was significantly associated with PDF duration, intensity, and frequency. Patients with PDF were older and had a lower ADL score. At multivariate analysis, PDF was significantly associated with TIRD. In a multivariate model that did not include TIRD, PDF was independently associated with age and ADL. Sixty patients had moderate PDF and 104 had severe PDF. In patients with severe PDF, age and dialytic age were higher, ADL and IADL scores were lower, TIRD was longer and the ultrafiltration rate was lower. At multivariate analysis, PDF severity was independently associated with TIRD. In the model without TIRD, PDF severity was associated with ADL only., Conclusion: Post-dialysis fatigue is frequent and associated with age and ADL. Dialytic variables seem unrelated to PDF., (© 2017 Asian Pacific Society of Nephrology.)

Sarcopenia is a well-known geriatric syndrome that has been endorsed over the years as a biomarker allowing for the discrimination, at a clinical level, of biological from chronological age. Multiple candidate mechanisms have been linked to muscle degeneration during sarcopenia. Among them, there is wide consensus on the central role played by the loss of mitochondrial integrity in myocytes, secondary to dysfunctional quality control mechanisms. Indeed, mitochondria establish direct or indirect contacts with other cellular components (e.g. endoplasmic reticulum, peroxisomes, lysosomes/vacuoles) as well as the extracellular environment through the release of several biomolecules. The functional implications of these interactions in the context of muscle physiology and sarcopenia are not yet fully appreciated and represent a promising area of investigation. Here, we present an overview of recent findings concerning the interrelation between mitochondrial quality control processes, inflammation and the metabolic regulation of muscle mass in the pathogenesis of sarcopenia highlighting those pathways that may be exploited for developing preventive and therapeutic interventions against muscle aging.

The goal of the pharmacological therapy in secondary hyperparathyroidism (SHPT) is to reduce serum levels of parathyroid hormone and phosphorus, to correct those of calcium and vitamin D, to arrest or reverse the parathyroid hyperplasia. However, when nodular hyperplasia or an autonomous adenoma develops, surgery may be indicated. We reviewed the literature with the aim of defining if the echographic criteria predictive of unresponsiveness of SHPT to calcitriol therapy are valid also in the cinacalcet era and if drug therapy may reverse nodular hyperplasia of parathyroid gland (PTG). The responsiveness to therapy and regression of the nodular hyperplasia of PTG remains an open question in the calcimimetic era as well as the cutoff between medical and surgical therapy. Prospective studies are needed in order to clarify if an earlier use of cinacalcet in moderate SHPT might arrest the progression of parathyroid growth and stabilize SHPT., (© 2017 International Society for Apheresis, Japanese Society for Apheresis, and Japanese Society for Dialysis Therapy.)

Objectives: The clinical practice guidelines published by the Renal Physicians Association (USA) recommend instituting advance care planning (ACP) for patients with end-stage renal disease. Studies on this issue are lacking in Italy. Our aim was to determine the attitudes of patients on ACP in our dialysis centre., Methods: We performed a cross-sectional survey. We recruited patients on maintenance haemodialysis (HD) at Hemodialysis Center of Università Cattolica del Sacro Cuore, from 1 March 2014 to 31 March 2015. The only exclusion criterion was inability to give an informed consent. Patients completed a questionnaire concerning their treatment preferences in three hypothetical disease scenarios: persistent vegetative state, advanced dementia, severe terminal illness; for each patients, we also collected clinical, functional and socioeconomic data., Results: Thirty-four HD outpatients completed the study questionnaire. The majority of respondents (85%) considered information about prognosis, health conditions and treatment options, including withdrawing dialysis, as very important and 94% of respondents considered treatment of uraemic/dialytic symptoms the most important issue. In the health scenarios provided, dialysis was the treatment least withheld. Dependence on instrumental activities of daily living (0.048) and higher Charlson Comorbidity Index scores (p = 0.035) were associated with continuing dialysis in at least one scenario., Conclusions: ACP should be tailored to patients' value, culture and preferences. A significant proportion of patients, however, do not want to be involved in end of life decisions. Frail elderly patients, in particular, are not inclined to interrupt dialysis, despite poor quality of life or a poor prognosis., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Exposure to heavy metals has been associated with kidney disease. We investigated the spatial distribution of kidney disease in the industrially contaminated site of Taranto., Methods: Cases were subjects with a first hospital discharge diagnosis of kidney disease. Cases affected by specific comorbidities were excluded. Standardized Hospitalization Ratios (SHRs) were computed for low/high exposure area and for modeled spatial distribution of cadmium and fine particulate matter., Result: Using the high/low exposure approach, in subjects aged 20-59 years residing in the high exposure area a significant excess of hospitalization was observed in males and a non-significant excess in females. No excesses were observed in subjects aged 60 years and over. The analysis by the modeling approach did not show a significant association with the greatest pollution impact area., Conclusion: Due to the excesses of hospitalization observed in the high/low exposure approach, a continuing epidemiological surveillance of residents and occupational groups is warranted., (© 2017 Wiley Periodicals, Inc.)

Purpose: Fatigue is common in end-stage renal disease patients receiving hemodialysis, reduces significantly their quality of life and is associated with all-cause and cardiac-related mortality. Unfortunately, little is known about the course of fatigue in patients on chronic hemodialysis., Methods: The Vitality Subscale of the SF-36 (SF-36 VS), Short-Form Health Survey, was administered to 45 patients in January (T1), June (T2) and November (T3) 2015., Results: The score of the SF-36 VS did not differ significantly among T1, T2 and T3. Similarly, the 1-year course of the SF-36 Vitality Subscale score did not differ significantly among T1, T2 and T3 after stratification of patients for sex, age, BMI, IADL and Charlson. Between T1 and T2, 21 out of 45 patients (46.6%) changed their fatigue status: 8 fatigued patients became not-fatigued and 13 not-fatigued patients became fatigued. Between T2 and T3, 12 out of 45 (26.6%) patients changed their fatigue status: 5 fatigued patients became not-fatigued and 7 not-fatigued patients became fatigued. Between T1 and T3, 19 out of 45 patients (42.2%) changed their fatigue status: 6 fatigued patients became not-fatigued and 13 not-fatigued became fatigued., Conclusion: The present study is the first to identify variations in fatigue status among patients on chronic hemodialysis during 1-year course. These findings suggest to frequently assess the presence and severity of fatigue in patients on chronic hemodialysis.

Mitochondrial dysfunction is involved in the loss of muscle featuring both aging and cancer cachexia (CC). Whether mitochondrial quality control (MQC) is altered in skeletal myocytes of old patients with CC is unclear. The present investigation therefore sought to preliminarily characterize MQC pathways in muscle of old gastric cancer patients with cachexia. The study followed a case-control cross-sectional design. Intraoperative biopsies of the rectus abdominis muscle were obtained from 18 patients with gastric adenocarcinoma (nine with CC and nine non-cachectic) and nine controls, and assayed for the expression of a set of MQC mediators. The mitofusin 2 expression was reduced in cancer patients compared with controls, independent of CC. Fission protein 1 was instead up-regulated in CC patients relative to the other groups. The mitophagy regulators PTEN-induced putative kinase 1 and Parkin were both down-regulated in cancer patients compared with controls. The ratio between the protein content of the lipidated and non-lipidated forms of microtubule-associated protein 1 light chain 3B was lower in CC patients relative to controls and non-cachectic cancer patients. Finally, the expression of autophagy-associated protein 7, lysosome-associated membrane protein 2, peroxisome proliferator-activated receptor-γ coactivator-1α, and mitochondrial transcription factor A was unvarying among groups. Collectively, our findings indicate that, in old patients with gastric cancer, cachexia is associated with derangements of the muscular MQC axis at several checkpoints: mitochondrial dynamics, mitochondrial tagging for disposal, and mitophagy signaling. Further investigations are needed to corroborate these preliminary findings and determine whether MQC pathways may become target for future interventions., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Fatigue is still present in approximately 40%-50% of kidney transplant recipients (KTR), rates comparable to that of the hemodialysis population. Correlates of fatigue include inflammation, symptoms of depression, sleep disorders, and obesity. Fatigue in KTR determines a significant severe functional impairment, either when globally considered or when analyzed at the level of the single domains such as sleep and rest, homemaking, mobility, social interaction, ambulation, leisure activities, alertness behavior, and work limitations. In addition, fatigue in KTR is significantly associated with a severe deterioration of quality of life. Fatigue is very common among KTR poorly adherent to immunosuppressive therapy. Unfortunately, there is no evidence of studies about the treatments of this symptom in KTR. Efforts to detect and treat fatigue should be a priority in order to improve quality of life of KTR., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Restorative proctocolectomy with ileal pouch-anal anastomosis (RP-IPAA) is the gold standard surgical treatment for ulcerative colitis. However, despite the widespread use of RP-IPAA, many aspects of this treatment still remain controversial, such as the approach (open or laparoscopic), number of stages in the surgery, type of pouch, and construction type (hand-sewn or stapled ileal pouch-anal anastomosis). The present narrative review aims to discuss current evidence on the short-, mid-, and long-term results of each of these technical alternatives as well as their benefits and disadvantages. A review of the MEDLINE, EMBASE, and Ovid databases was performed to identify studies published through March 2016. Few large, randomized, controlled studies have been conducted, which limits the conclusions that can be drawn regarding controversial issues. The available data from retrospective studies suggest that laparoscopic surgery has no clear advantages compared with open surgery and that one-stage RP-IPAA may be indicated in selected cases. Regarding 2- and 3-stage RP-IPAA, patients who underwent these surgeries differed significantly with respect to clinical and laboratory variables, making any comparisons extremely difficult. The long-term results regarding the pouch type show that the W- and J-reservoirs do not differ significantly, although the J pouch is generally preferred by surgeons. Hand-sewn and stapled ileal pouch-anal anastomoses have their own advantages, and there is no clear benefit of one technique over the other.

Background: Functional impairment is associated with adverse outcomes in older people, as well as in patients on chronic hemodialysis. The aim of the present study was to determine the characteristics associated with functional impairment in chronic hemodialysis, and to evaluate if functional impairment represents a risk factor for reduced survival in chronic hemodialysis., Methods: All 132 chronic hemodialysis referring to the Hemodialysis Service of the Catholic University, Rome, Italy between November 2007 and May 2015 were included. All patients underwent comprehensive geriatric assessment; functional ability was estimated using two questionnaires exploring independency in bathing, dressing, toileting, transferring, continence, feeding (ADLs), and independency in using the telephone, shopping, food preparation, housekeeping, laundering, traveling, taking medications, and handling finances (IADLs). Functional impairment was diagnosed in presence of dependence in one or more ADLs/IADLs. Mood was assessed using the 30-item Geriatric Depression Scale. Logistic regression was used to evaluate factors associated with functional impairment. The association between functional impairment and survival was assessed by Cox regression., Results: ADLs impairment was present in 34 (26 %) participants, while IADLs impairment was detected in 64 (48 %) subjects. After a follow up of 90 months, 55 (42 %) patients died. In logistic regression, depressive symptoms were associated with ADLs and IADLs impairment (OR 1.12; 95 % CI = 1.02-1.23; OR 1.16; 95 % CI = 1.02-1.33; respectively). In Cox regression, ADLs impairment was associated with mortality (HR 2.47; 95 % CI-1.07-5.67) while IADLs impairment was not associated with reduced survival (HR .80; 95 % CI-.36-1.76)., Conclusions: Functional impairment is associated with depressive symptoms; also, impairment in the ADLs represents a risk factor of reduced survival in chronic hemodialysis. These associations and their potential implication should be assessed in dedicated studies.

Background: Sarcopenia has been proposed as a potentially amenable factor impacting the clinical outcomes of hip-fractured elderly. The identification of specific biological targets is therefore crucial to developing pharmacological interventions against age-related muscle wasting. The present work reports promising preliminary data on the association between alterations of myocyte quality control (MQC) signaling and sarcopenia in old patients with hip fracture., Methods: Twenty-five elderly hip-fractured patients (20 women and 5 men; mean age 84.9±1.65years) were enrolled as part of the Sarcopenia in HIp FracTure (SHIFT) study. Intraoperative biopsies of the vastus lateralis muscle were obtained and assayed for the expression of a set of MQC signaling proteins. The presence of sarcopenia was established according to the European Working Group on Sarcopenia in Older People (EWGSOP) criteria, with bioelectrical impedance analysis used for fat-free mass estimation., Results: Sarcopenia was identified in 10 patients (40%). Protein expression of the mitochondrial fusion factor mitofusin (Mfn) 2 and the autophagy mediator microtubule-associated protein 1 light chain 3B (LC3B) was significantly lower in patients with sarcopenia compared with non-sarcopenic controls. No differences between groups were observed for Mfn1, optic atrophy protein 1 (OPA1), fission protein 1 (Fis1), and the master regulator of mitochondrial biogenesis peroxisome proliferator-activated receptor-γ coactivator-1α (PGC-1α)., Conclusion: Data from this exploratory study show that a reduced expression of the mitochondrial fusion factor Mfn2 and the autophagy mediator LC3B is associated with sarcopenia in old hip-fractured patients. Future larger-scale studies are needed to corroborate these preliminary findings and determine whether MQC pathways may be targeted to improve muscle health and promote functional recovery in old patients with hip fracture., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Muscle wasting is the most important phenotypic and clinical feature of cancer cachexia, and the principal cause of impaired physical function, fatigue, and respiratory complications. Muscle loss has been attributed to a variable combination of reduced nutritional intake and an imbalance between anabolic and catabolic processes. It has been suggested that defective skeletal muscle regeneration may also contribute to muscle wasting in cancer patients. However, there is little in vitro or in vivo data available, in either animals or in humans, regarding skeletal muscle regeneration in cancer wasting. The aim of the present review is to define the role of skeletal muscle regeneration in the muscle wasting of cancer patients and to determine possible therapeutic implications., (© 2016 John Wiley & Sons Australia, Ltd.)

Objective: The usefulness, the methods and the criteria of intra-operative monitoring of the parathyroid hormone (ioPTH) during parathyroidectomy (PTX) for renal secondary hyperparathyroidism (rSHPT) in patients on chronic hemodialysis remain still matter of debate. The present study aimed to evaluate the ability of a low cost central-laboratory second generation PTH assay to predict an incomplete resection of parathyroid glands (PTG)., Methods: The ioPTH decay was determined In 42 consecutive patients undergoing PTX (15 subtotal and 27 total without auto-transplant of PTG) for rSHPT. The ioPTH monitoring included five samples: pre-intubation, post-manipulation of PTG and at 10, 20 and 30min post-PTG excision. The patients with PTH exceeding the normal value (65pg/ml) at the first postoperative week, 6 and 12months were classified as persistent rSHPT., Results: The concentrations of ioPTH declined significantly over time in patients who received total or subtotal PTX; however, no difference was found between the two types of PTX. Irrespective of the type of PTX and the number of PTG removed, combining the absolute and percentage of ioPTH decay at 30min after PTG excision, we found high sensitivity (100%), specificity (92%), negative predictive value (100%) and accuracy (93%) in predicting the persistence of rSHPT., Conclusions: The monitoring of the ioPTH decline by a low cost central-laboratory second generation assay is extremely accurate in predicting the persistence of disease in patients on maintenance hemodialysis undergoing surgery for rSHPT., (Copyright © 2016 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.)

Postdialysis fatigue (PDF) is a frequent and debilitating symptom of patients on chronic hemodialysis that affects their daily living and quality of life. Little is known about the mechanisms underlying this symptom and its severity. Only a few studies have investigated therapeutic interventions and with conflicting results. Given the major impact of PDF on the quality of life of hemodialysis patients, a larger effort is warranted to better understand, prevent, and treat PDF., (© 2016 Wiley Periodicals, Inc.)

Background: This study aims to evaluate, in patients on chronic hemodialysis (PHD), the levels of endotoxin through a chemiluminescent bioassay based on the oxidative burst reaction of activated neutrophils to complement coated LPS-IgM immune complexes and define the variables possibly correlated., Methods: In 61 PHD, we measured serum endotoxin activity (EA) with the Endotoxin Activity Assay (EAA™) and we defined the possible association with demographic, clinical and laboratory variables., Results: Mean serum EA was 0.43 ± 0.26 UI. EA was low (<0.40) in 29 patients (47.5%), intermediate (0.40-0.60) in 14 (23%) and high (>0.60) in 18 (29.5%). A significant exponential relationship was detected between EA and serum interleukin-6 (IL-6) levels (r = 0.871). At the multiple regression analysis, intermediate-high EA was directly associated only with serum IL-6 levels. In a second model of multiple regression analysis without the variable serum IL-6 levels, intermediate-high EA was directly associated with constipation and serum troponin levels and inversely associated with serum albumin and the monthly number of sevelamer tablets., Conclusions: A high percentage of PHD has intermediate or high EA. Intermediate-high EA is significantly associated with serum IL-6 levels., (© 2016 S. Karger AG, Basel.)

Aim: Data on the outcome of chronic kidney disease (CKD) patients who are hospitalized and start unplanned urgent haemodialysis (HD) are lacking. This prospective, longitudinal, observational study aimed to define the hospital mortality rate and associated factors in CKD patients who start unplanned urgent HD., Methods: Between January 2003 and December 2009, all patients with CKD who were hospitalized, diagnosed with ESRD and started unplanned urgent haemodialysis at Haemodialysis Service of the Catholic University of Rome, Italy were recruited. Exclusion criteria were: acute renal failure, prior history of dialysis, multiple organ failure, coma, and dementia. Hospital mortality rate was the primary outcome., Results: Three and hundred sixteen patients were studied: 99 died after 19.5 ± 27.3 days and 217 survived until discharge. Of these, 154 were prescribed chronic HD and 63 restored renal function. Patients who died were significantly older and had a higher Charlson Comorbidity Index score. The mortality rates were 51.1% in patients with 81-90 years, 37.8% with 71-80 years, 34.1% with 61-70 years and 13.9% with age ≤60 years. Logistic regression analysis showed that age only was an independent risk factor for all-cause mortality., Conclusions: In CKD patients who need hospitalization and start unplanned urgent haemodialysis the mortality is very high and significantly related to age., (© 2015 Asian Pacific Society of Nephrology.)

Context: Little is known about activated immune-inflammatory pathways and interleukin-6 (IL-6) in the development of fatigue and/or depression in patients with end-stage renal disease on chronic hemodialysis (HD)., Objectives: To evaluate the possible correlation between fatigue and serum levels of IL-6 in patients on chronic HD., Methods: One hundred HD patients were assessed for the presence of fatigue using the SF-36 Vitality subscale and were administered the Beck Depression Inventory (BDI), the Hamilton Anxiety Rating Scale (HARS), the Mini-Mental State Examination (MMSE), the activities of daily living (ADL), and the instrumental activities of daily living (IADL). We also calculated the time of recovery after hemodialysis (TIRD) and the number/severity of comorbidities using the Charlson Comorbidity Index (CCI). Laboratory parameters were measured as well as serum IL-6., Results: Forty-three patients constituted the fatigued group and 57 the nonfatigued group. Age, CCI, BDI, HARS, and TIRD were significantly higher in fatigued patients than in the nonfatigued patients. Conversely, the scores of ADL, IADL, and MMSE were significantly lower in fatigued than in nonfatigued patients. Serum IL-6 levels (pg/mL) were higher in the fatigued group (5.1 ± 3.4) than in the nonfatigued group (1.6 ± 1.5; P < 0.001); serum albumin and creatinine levels were significantly lower. Twenty-six patients (26%) had no symptoms of depression (BDI score <10), and 74 patients (74%) had symptoms of depression (BDI score >9). Patients with a BDI score >9 were older; had a higher CCI; a lower MMSE; a higher TIRD; lower serum albumin, creatinine, and urea levels; and higher serum IL-6 levels. The correlation analyses showed that the score of the SF-36 Vitality subscale was associated with age, dialytic age, TIRD, ADL, IADL, CCI, BDI, HARS, MMSE, serum urea, creatinine, albumin, and IL-6 levels. On multivariate general linear model analyses, with fatigue as the dependent variable and gender as a second factor, BDI and serum IL-6 levels were independently associated with the score of the SF-36 Vitality subscale. A canonical correlation analysis was performed including in the model fatigue, BDI, and biomarkers; the correlation was 0.679 (R(2) = 0.462). Fatigue, BDI, and IL-6 among biomarkers showed the strongest association with the underlying construct (standardized canonical coefficients = -0.989, 0.015, and 0.852, respectively), thus explaining a correlation of IL-6 with both depression and fatigue., Conclusion: Fatigue was significantly associated with symptoms of depression and serum IL-6 levels in patients receiving chronic HD., (Copyright © 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

The present review aimed to define the role of nutritional interventions in the prevention and treatment of malnutrition in HNC patients undergoing CRT as well as their impact on CRT-related toxicity and survival. Head and neck cancer patients are frequently malnourished at the time of diagnosis and prior to the beginning of treatment. In addition, chemo-radiotherapy (CRT) causes or exacerbates symptoms, such as alteration or loss of taste, mucositis, xerostomia, fatigue, nausea and vomiting, with consequent worsening of malnutrition. Nutritional counseling (NC) and oral nutritional supplements (ONS) should be used to increase dietary intake and to prevent therapy-associated weight loss and interruption of radiation therapy. If obstructing cancer and/or mucositis interfere with swallowing, enteral nutrition should be delivered by tube. However, it seems that there is not sufficient evidence to determine the optimal method of enteral feeding. Prophylactic feeding through nasogastric tube or percutaneous gastrostomy to prevent weight loss, reduce dehydration and hospitalizations, and avoid treatment breaks has become relatively common. Compared to reactive feeding (patients are supported with oral nutritional supplements and when it is impossible to maintain nutritional requirements enteral feeding via a NGT or PEG is started), prophylactic feeding does not offer advantages in terms of nutritional outcomes, interruptions of radiotherapy and survival. Overall, it seems that further adequate prospective, randomized studies are needed to define the better nutritional intervention in head and neck cancer patients undergoing chemoradiotherapy.

Background: Little is known about the correlation between fatigue and survival in patients on chronic hemodialysis and whether fatigue is an independent predictor of outcome above and beyond the effects of depression. The aim of the present study was to determine if fatigue is a predictor of mortality in patients on chronic hemodialysis (CHP) and if this occurs independently of the symptoms of depression., Methods: CHP referring to the Hemodialysis Service of the Università Cattolica of Rome, Italy between November 2007 and January 2015 were studied. Demographic, clinical, and laboratory data were recorded for each patient at the moment of the inclusion in the study. Fatigue levels were assessed in patients using the Vitality Scale of SF-36 (SF-36 VS), functional ability by the activities of daily living (ADL) and instrumental activities of daily living (IADL), depressive symptoms through the Geriatric Depression Scale (GDS), cognitive function using the Mini Mental State Examination (MMSE), and comorbidity through the Charlson Comorbidity Index (CCI). Patients were grouped into four groups (quartiles): Quartile 1 (Q1), >65; Q2, ≥50 to <65; Q3, ≥35 to <50; Q4, <35., Results: We studied 126 patients: 11 were transplanted and 53 died. Patients who later died were older and had a worse cognitive performance, higher CCI and GDS scores, lower ADL, IADL and SF-36 VS scores, lower serum creatinine and albumin levels. Kaplan-Meier survival was significantly lower in Q4 than in Q1 (p = 0.0001). According to Cox regression analysis, higher fatigue (Q4) was associated with a higher risk of mortality (HR, 95% CI: 5.29, 2.2-12.73)., Conclusion: Fatigue is associated with an increased risk of mortality in CHP, with the relationship independent of symptoms of depression. Fatigue should be assessed routinely and may be a potential target of interventions that aim to reduce mortality in CHP., (© 2015 S. Karger AG, Basel.)

Background: Cognitive impairment is a common finding in end-stage renal disease patients on chronic hemodialysis, but data on the associated factors are still scanty., Aims: The present study evaluated the association between cognitive function and left ventricular systolic function in hemodialysis patients., Methods: We enrolled 72 patients admitted to the Hemodialysis Unit of the Catholic University, Rome. Cognitive performance was evaluated using the Mini Mental State Examination (MMSE); a cutoff of 24 was used to diagnose cognitive impairment. Left ventricular ejection fraction (LVEF) was assessed by echocardiography. Multivariable linear and logistic regressions were adopted to assess the adjusted association between cognitive performance and LVEF. Also, linear discriminant analysis was performed to ascertain the cutoff level of LVEF which best predicted cognitive impairment., Results: Cognitive impairment was found in 37 (51 %) patients. According to linear regression, MMSE was independently associated with LVEF (B = 0.06; 95 % CI = 0.01-0.12; P = 0.040). Logistic regression confirmed the inverse association between LVEF and cognitive impairment (OR = 0.87; 95 % CI = 0.78-0.98; P = 0.022). In linear discriminant analysis, the LVEF cutoff level that best predicted cognitive impairment was ≤51 %., Conclusion: Cognitive impairment is a common finding in hemodialysis patients. Even mildly depressed LVEF is independently associated with cognitive impairment. This association and its potential therapeutic implications should be assessed in dedicated studies.

Purpose: We aimed to estimate dietary intakes of trace elements, minerals, and vitamins in hemodialysis patients (HDP) of three centers in one metropolitan and two urban areas of Italy., Methods: Daily dietary intake was assessed using a 3-day diet diary in 128 HDP., Results: Mean daily intakes of trace elements were as follows: zinc, 7.6 ± 5.4 mg; copper, 14.3 ± 11.8 mg; selenium, 28.3 ± 18.1 μg; and iron, 7.2 ± 4.1 mg (7.8 ± 2.6 mg in women, 6.9 ± 2.4 mg in men). The distribution of patients by daily intakes of trace elements showed most were under the recommended values, with the exception of copper intake, which was much higher. Mean daily intakes of minerals were as follows: magnesium, 174.4 ± 94.3 mg; phosphorus, 842.6 ± 576.8 mg; calcium, 371.8 ± 363.7 mg; potassium, 1,616.2 ± 897.3 mg; and sodium, 1,350 ± 1,281 mg. Mean daily intakes of vitamins were as follows: vitamin A, 486.1 ± 544.6 μg; vitamin B1, 0.86 ± 0.7 mg; vitamin B2, 1.1 ± 0.7 mg; vitamin B3, 13.3 ± 8.1 mg; vitamin C, 47.8 ± 50.3 mg; and vitamin E, 9.5 ± 3.6 mg. The distribution of patients by daily intakes of vitamins showed most were under the recommended values. Daily intakes of trace elements and vitamins were similar among the three centers and did not differ between dialysis and non-dialysis days., Conclusions: Many HDP have daily dietary intakes of trace elements and vitamins below the recommended values, whereas the intake of copper is much higher.

Introduction: We evaluated the gene expression levels of atrogin-1, MuRF1, myostatin, follistatin, activin A, and inhibin alpha in skeletal muscle samples of patients with gastric cancer and controls., Methods: We studied 38 cancer patients and 12 controls who underwent surgery for gastric adenocarcinoma and benign abdominal diseases, respectively. A biopsy specimen was obtained from the rectus abdominis muscle from all participants. The relative gene expression of atrogin-1, MuRF1, myostatin, follistatin, activin A, and inhibin alpha was determined by quantitative real-time polymerase chain reaction analysis., Results: Atrogin-1 and MuRF1 mRNA expression was similar between cancer patients and controls and was unaffected by the disease stage or the severity of body weight loss. Transcript levels of myostatin and follistatin did not differ between cases and controls and were similar across disease stages and categories of weight loss. Finally, no differences were detected in activin A and inhibin alpha gene expression between cancer patients and controls., Conclusions: In skeletal muscle, the gene expression of atrogin-1, MuRF1, myostatin, follistatin, activin A, and inhibin alpha is not affected by the presence of cancer. The expression of atrophy-related genes is unaffected by the disease stage and the degree of weight loss., (Copyright © 2013 Wiley Periodicals, Inc.)

Background and Aims: The knowledge of the barriers that are associated with decreased physical activity (PA) in patients on chronic hemodialysis (PCH) may be of primary importance for the nephrologists. Thus, we aimed to assess the barriers associated with the absent or reduced PA in PCH of a Mediterranean country., Methods: Patients were invited to answer the question 'How often do you exercise during your leisure time?'. Also, patients included in the study were asked to answer questions regarding barriers to physical activity lower than desired., Results: We studied 105 patients. Forty (38.1%) patients reported to never exercise, 6 (5.7%) reported to exercise less than once/week, 4 (3.8%) once/week, 23 (21.9%) two to three times/week, 12 (11.4%) four to five times/week and 20 (19%) daily. Overall, 46 (43.8%) patients never exercised or exercised less than once/week ('inactive') and 59 (56.2%) did exercise more often ('active'). At the multivariate analysis, reduced walking ability, fatigue on the non-dialysis days, and shortness of breath were independently and negatively associated with PA. The same results were found when the reduced model of the multivariate logistic backward regression was built introducing in the model also clinical and laboratory variables., Conclusion: In PCH, fatigue on the non-dialysis days, reduced walking ability, and shortness of breath are barriers independently associated to decreased PA. Knowledge about the causes and mechanisms that generate these barriers has to be acquired., (© 2014 S. Karger AG, Basel.)

Objective: The objective of this study was to assess variables associated with xerostomia in patients on chronic hemodialysis (HD)., Design and Methods: This was a cross-sectional study of 75 HD patients at an outpatient HD service. Demographic, clinical (renal disease, HD regimen/duration, Charlson comorbidity index, activities of daily living, instrumental activities of daily living [IADL], body mass index), and laboratory (hemoglobin, albumin, interleukin-6 [IL-6], and parathyroid hormone) parameters were recorded. We assessed the appetite through the Hemodialysis Study Appetite questionnaire and xerostomia through the Xerostomia Inventory (XI). A single question ("How often does your mouth feel dry?"; never = Class 1, almost never = Class 2, occasionally = Class 3, often = Class 4, very often = Class 5) was also included in the study questionnaire., Main Outcome Measure: The main outcome measure was factors correlated with XI., Results: The median XI score was 18 (min-max = 11-33). Forty patients had an XI score of 18 or less (Group 1) and between 18 and 35 (Group 2). In Group 2, age, Charlson comorbidity index score, and number of patients with poor/very poor appetite were significantly higher. At the univariate analysis, the score of the XI was significantly associated with age, appetite, IADL, Charlson comorbidity index, and serum IL-6 levels. Multiple linear regression analysis showed that the XI was independently associated with age and appetite. Thirty-one patients were in Class 1 to 2, 23 were in Class 3, and 21 were in Class 4 to 5. In Classes 4 to 5, age and the number of patients with poor/very poor appetite were higher (P = .012 and .09, respectively)., Conclusion: Xerostomia is associated with old age and poor appetite in patients on chronic HD., (Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: Intradialytic hypotension (IDH) is common in patients on chronic hemodialysis, but knowledge on determinants is still unclear. The present study aims at evaluating the association between IDH and dialytic age (DA) in patients on chronic hemodialysis., Methods: Between January 2012 and January 2013, 82 patients on chronic hemodialysis for at least 1 year were screened for inclusion in the present study. Of these, 14 were excluded because of advanced heart failure (n.9), history of alcohol/substance abuse (n.1), diagnosis of dementia (n.2), actual instability of clinical conditions requiring hospitalization (n.2). IDH was defined as a decrease in systolic blood pressure ≥20 mmHg or a decrease in mean arterial pressure (MAP) by 10 mmHg associated with clinical events and need for nursing interventions. The number of IDH episodes in 10 consecutive hemodialysis sessions was recorded for each patient. Linear and logistic regressions were adopted to assess the adjusted association between IDH and DA., Results: The mean DA was 92 ± 81. Eleven patients (16%) experienced IDH. DA was associated with IDH (OR = 1.01; 95% CI = 1.01-1.02; p = 0.048), after adjusting for potential confounders. DA was associated with the numbers of IDH events in the unadjusted model (B = 0.02; 95% CI = 0.01-0.03; p = 0.042), after adjusting for age and sex (B = 0.01; 95% CI = 0.01-0.03; p = 0.042) as well as in the multivariable model (B = 0.02; 95% CI = 0.01-0.05; p = 0.045)., Conclusion: DA is associated with an increased probability of IDH and with increased number of IHD events. Studies are needed to understand the underlying factors of such an association.

Background: We aimed to measure the dietary intake of calories, proteins, carbohydrates, lipids and fiber in patients on chronic hemodialysis (HD) at 3 centers in 1 metropolitan and 2 urban areas of Italy, and to evaluate whether it met the dietary guidelines for cardiovascular risk reduction., Methods: Daily dietary intake was assessed through a 3-day diet diary in 128 HD patients at the hemodialysis units of the Catholic University of Rome, Hospital A. Murri of Jesi and Hospital Principe di Piemonte of Senigallia, Italy., Results: Mean dietary calorie and protein intakes were 22.9 ± 9.1 kcal/kg per day and 0.95 ± 0.76 g protein/kg per day, respectively. Daily carbohydrate and lipid intakes as a percentage of total calorie intake were 51.8% ± 8.9% and 32.1% ± 7.1%. Mean daily dietary cholesterol intake was 206.6 ± 173.6 mg. Mean daily dietary intakes of omega-3 and omega-6 fatty acids were 0.49 ± 0.28 g and 5.1 ± 2.5 g, respectively, while the mean ratio of omega-6 to omega-3 intake was 11.5 ± 4.8. Forty-eighty percent of patients had an omega-6 to omega-3 ratio =10. Mean daily dietary intakes of saturated fatty acids (SFAs), monounsaturated fatty acids and polyunsaturated fatty acids were 5.5 ± 3.3 g, 28.9 ± 9.1 g and 3.1 ± 1.7 g, respectively. Ninety-six percent of HD patients had an SFA intake <10% of total calories. Most unsaturated fatty acids intakes were under the value of =30%. Mean daily dietary fiber intake was 11.8 ± 6.1 g., Conclusion: In HD patients from a Mediterranean country (Italy), daily intakes of calories, proteins and fiber were lower than the recommended values, whereas the intake of lipids was closer to being adequate.

Purpose: Appetite in patients on chronic hemodialysis (HD) may be constantly very good/good or fair/poor or may fluctuate up and down over time. When constantly fair/poor, appetite has been shown to be associated with older age, more comorbidities, and more hospitalizations; however, it is unknown if it predicts survival. The aim of the present study was to assess appetite monthly for 6 months in patients on chronic HD and to determine if the course of appetite over time predicts mortality., Methods: Ninety-two HD patients were evaluated at baseline for appetite, nutritional and inflammatory markers, comorbid conditions, and Charlson's comorbidity index. Appetite assessment was repeated monthly for 6 consecutive months. Survival in relation with the course of appetite over time was determined., Results: Appetite was constantly very good/good in 45 patients (Group 1), fair/poor/very poor in 30 (Group 2), and fluctuated in 17 (Group 3). Twenty-seven (29.3 %) patients died after a mean period of 28 ± 13 months. Overall, the mean survival time was 42.1 ± 1.2 months. For Groups 1, 2, and 3, the mean survival time was 46.1 ± 0.92, 37.9 ± 2.5, and 39.1 ± 3.7 months, respectively (p < 0.0001). After multivariate logistic regression analysis, the course of appetite over time was not found to be an independent risk factor for mortality., Conclusions: The course of appetite over time does not seem to predict mortality in patients on chronic hemodialysis. Considering that the study included a relatively small number of patients, larger similar studies are desirable.

Background: The aim of this study was to evaluate the relationship among time of recovery after hemodialysis (TIRD) and the demographic, social, clinical and laboratory characteristics of hemodialysis patients of a Mediterranean country., Methods: One hundred hemodialysis patients were invited to answer the following question: "How long does it take you to recover from a dialysis session?" Demographic, clinical (Charlson Comorbidity Index [CCI], Mini-Mental State Examination [MMSE] and Geriatric Depression Scale [GDS]) and laboratory variables were recorded, and fatigue qualities (FQs) were assessed through 5 questions: Do you feel tired much of the time? (general); Do you feel that life is empty? (emotional); Do you have trouble concentrating? (cognitive); Do you have difficulty sleeping? (sleepiness); Do you have muscle weakness? (weakness); and Do you feel full of energy? (lack of energy)., Results: The means ± SD of TIRD was 205.5 ± 198.6 minutes: 79 patients reported a TIRD

Background: Cinacalcet is a new effective treatment of secondary hyperparathyroidism (SHPT) in hemodialysis patients (HP), but the alterations of parathyroid gland (PTG) hyperplasia determined by cinacalcet and vitamin D have not been extensively investigated in humans., Methods: We performed histological analyses of 94 PTGs removed from 25 HP who underwent parathyroidectomy (PTx) because of SHPT refractory to therapy with vitamin D alone (group A=13 HP and 46 PTGs) or associated with cinacalcet (group B=12 HP and 48 PTGs). The number, weight, the macroscopic cystic/hemorrhagic changes, and type of hyperplasia of PTG (nodular=NH, diffuse=DH) were assessed. In randomly selected HP of group A (4 HP and 14 PTGs) and group B (4 HP and 15 PTGs), the labeling index of cells positive to Ki-67 and TUNEL and the semiquantitative score of immunohistochemistry staining of vitamin D receptor, calcium-sensing receptor, and vascular endothelial growth factor-α (VEGF-α) were measured in the entire PTGs and in the areas with DH or NH., Results: The number and weight of single and total PTG of each HP were similar in the two groups as well as the number of PTG with macroscopic cystic/hemorrhagic areas. TUNEL, Ki-67, and VEGF-α scores were higher in NH than in DH areas., Conclusion: This observational study of a highly selected population of HP, submitted to PTx because SHPT refractory to therapy, shows that the macroscopic, microscopic, and immunochemistry characteristics of PTG in HP who received or did not receive cinacalcet before PTx did not differ significantly.

Muscle loss during aging and disuse is a highly prevalent and disabling condition, but knowledge about cellular pathways mediating muscle atrophy is still limited. Given the postmitotic nature of skeletal myocytes, the maintenance of cellular homeostasis relies on the efficiency of cellular quality control mechanisms. In this scenario, alterations in mitochondrial function are considered a major factor underlying sarcopenia and muscle atrophy. Damaged mitochondria are not only less bioenergetically efficient, but also generate increased amounts of reactive oxygen species, interfere with cellular quality control mechanisms, and display a greater propensity to trigger apoptosis. Thus, mitochondria stand at the crossroad of signaling pathways that regulate skeletal myocyte function and viability. Studies on these pathways have sometimes provided unexpected and counterintuitive results, which suggests that they are organized into a complex, heterarchical network that is currently insufficiently understood. Untangling the complexity of such a network will likely provide clinicians with novel and highly effective therapeutics to counter the muscle loss associated with aging and disuse. In this review, we summarize the current knowledge on the mechanisms whereby mitochondrial dysfunction intervenes in the pathogenesis of sarcopenia and disuse atrophy, and highlight the prospect of targeting specific processes to treat these conditions.

Neoadjuvant chemoradiation (CRT), tailored mesorectal excision, and intraoperative radiotherapy (IORT) have become the leading measures for rectal cancer treatment. The objective of this study was to evaluate early and long-term results of a multimodal treatment model for rectal cancer followed by curative surgery. Prospectively collected hospital records of 338 patients surgically treated for rectal cancer between January 1998 and December 2008 were retrospectively reviewed. Patients with high rectum level cancers and those with middle and low rectum cancers with clinical stage T1 to T2 underwent surgery, whereas those with T3 to T4 and N+ disease at the middle and low rectum received neoadjuvant CRT in 96.2 per cent of cases. Short-course neoadjuvant radiotherapy was not considered for neoadjuvant treatment. Postoperative major complications and mortality rates were 12.7 and 2.3 per cent, respectively. Overall 5-year disease-specific and disease-free survival were 80 and 73.1 per cent, respectively, whereas local recurrence rate was 6.1 per cent. At multivariate analysis, nodal status and circumferential margin status were independently associated with poor survival; local recurrence rates were independently affected by nodal and marginal status and tumor stage. The extent of mesorectal excision should be tailored depending on tumor location and the use of neoadjuvant chemotherapy, combined with IORT in advanced middle and low rectal cancer, leading to remarkable tumor downstaging with excellent prognosis in responding patients.

Aim: The aim of this cross-sectional study was to assess the correlation between self-reported appetite and the time of recovery after the hemodialysis session (TIRD)., Methods: All patients on chronic hemodialysis at the Hemodialysis Service of the Catholic University of Rome underwent assessment of appetite through the first three questions of the Hemodialysis Study Appetite questionnaire, TIRD (through the question 'How long does it take you to recover from a dialysis session?'), number and severity of comorbidities according to the Charlson Comorbidity Index (CCI), and daily activities through the ADL (activities of daily living) and the IADL (instrumental activities of daily living)., Results: We studied 106 patients. According to the appetite questionnaire, in 45 patients appetite was very good or good (group 1), in 33 fair (group 2) and in 28 poor or very poor (group 3). Age, CCI, TIRD and serum parathyroid hormone levels were significantly higher in group 3 than in groups 1 and 2, while the IADL was significantly lower. Age, CCI, TIRD, IADL and serum parathyroid hormone were significantly correlated with appetite. At multiple regression analysis, TIRD and CCI only were independently correlated with appetite., Conclusion: Poor appetite is independently associated with the time of recovery after the hemodialysis session., (Copyright © 2013 S. Karger AG, Basel.)

We aimed to assess the relationship among fatigue qualities (FQ) and the association of FQ with various characteristics of chronic hemodialysis (HD) patients. In 68 HD patients, we assessed the Charlson Comorbidity Index (CCI), the Geriatric Depression Scale score (GDS), the Mini Mental Status Examination (MMSE), and measured the laboratory parameters. In addition, patients answered to six questions about FQ (Tiredness: Do you feel tired much of the time? Emotional: Do you feel that life is empty? Cognitive: Do you have trouble concentrating? Sleepiness: Have you had difficulty sleeping in the past month? Weakness: Have you had muscle weakness in the past month? Lack of energy: Do you feel full of energy?). At least one FQ was reported by 62 patients. Muscle weakness (61.7%) was the most frequent and cognitive fatigue (22%) the least. Physical FQ were all more common than the mental ones. Correlation between the two mental FQ (emotional and cognitive) was 0.381 (p = 0.002). Six patients reported none of the FQ, 20 one FQ, 13 two FQ, and 29 three or more FQ. CCI and GDS were associated with all FQ and MMSE with all FQ but sleepiness. Patients reporting ≥3 FQ were older, had more comorbidities, more symptoms of depression, and a lower MMSE score. At multivariate linear regression analysis, the GDS was the only significant predictor of the number of FQ. HD patients report a variety of qualities of fatigue and the number of FQ is independently associated with symptoms of depression., (© 2012 The Authors. Hemodialysis International © 2012 International Society for Hemodialysis.)

Background: Little is known about the course of the symptoms of depression/anxiety and the factors predictive of such courses in hemodialysis (HD) patients. This study aimed at evaluating the possible changes of Beck Depression Inventory (BDI) and Hamilton Anxiety Rating Scale (HARS) over time, and factors associated with such changes in HD patients., Methods: We screened 110 patients for study participation. Of these, 30 were excluded because of dialytic vintage <6 months, alcohol/substance abuse, inability to answer to the questionnaires, diagnosis of psychotic or neurological disorders or recent stressful life events. Eighty patients were included in the study and BDI, HARS, Charlson Comorbidity Index, SF-36 Vitality Subscale, Mini-Mental State Examination (MMSE), routine laboratory parameters, C-reactive protein (CRP) and interleukin-6 were measured at baseline. The 18-month course of BDI and HARS was measured in patients with baseline BDI ≤14., Results: At baseline, 42 patients had BDI >14 and 38 patients ≤14. In patients with BDI ≤14, the BDI decreased/remained stable in 19 and increased in 19. Patients with increased BDI had lower baseline MMSE (22.6 ± 2.6 vs. 25.9 ± 2.7, p=0.004) and higher baseline serum CRP (6.07 ± 4.2 vs. 1.64 ± 1.59, p=0.003). At multivariate analysis the relationship between BDI changes and MMSE and serum CRP was statistically significant. In 25 patients, the HARS decreased/remained stable, while in 13 it increased. Characteristics of the 2 groups of patients did not differ significantly., Conclusions: In a meaningful proportion of HD patients, symptoms of depression worsen over time, and CRP and MMSE are independent predictors of such change.

Background: For more than a century the extent of surgical treatment of gastric cancer is a matter of debate. Through experience, evaluation and research, the outcome of gastric cancer has improved. Many aspects are of influence of outcome, but only a radical resection can offer long-term outcomes. In this review, we will discuss the history and current status of the extent of lymph node dissection., Materials and Methods: Some issues about the extent of gastric resection seem to have been settled. For survival it is not necessary to perform a total gastrectomy if free resection margins can be obtained with a subtotal gastrectomy. In the context of postoperative morbidity and mortality a subtotal gastrectomy is to be preferred. Microscopic resection line involvement has shown to be of great influence on prognosis., Discussion: At this moment the main discussion centres around the extent of lymph node dissection, locoregional recurrence and to the influence of additional treatment. For many years it has been debated whether an extended lymph node dissection for gastric cancer is beneficial. Theoretically, removal of a wider range of lymph nodes by extended lymph node dissection increases the chances for cure. Such resection, however, may be irrelevant if there are no lymph nodes affected or if the cancer has developed into a systemic disease, or if it increases morbidity and mortality substantially., Conclusion: Relapse after curative surgery because of local recurrence or regional lymph node metastasis have been shown in up to 87.5% of patients. The extent of surgery, however, may be of influence on the locoregional recurrence rate.

Background: The aim of our study was to measure reactive oxygen metabolites (ROMs) in chronic hemodialysis (HD) patients and evaluate the possible association with cardiovascular disease (CVD) and mortality., Methods: We measured ROMs in 76 HD patients and correlated with CVD, cardiovascular (CV) events in the follow-up and all-cause and CVD-related mortality., Results: The levels of ROMs presented a median value of 270 (238.2-303.2) CARR U (interquartile range). We created a ROC curve (ROMs levels vs. CVD) and we identified a cut-off point of 273 CARR U. Patients with ROMs levels ≥273 CARR U were significantly older, had higher C-reactive protein levels and lower creatinine concentrations. The prevalence of CVD was higher in patients with ROMs levels ≥273 (87.1%) than in those with ROMs levels <273 CARR U (17.7%; p<0.0001). ROMs levels were significantly higher in patients with CVD (317±63.8) than in those without (242.7±49.1; p<0.0001). At multiple regression analysis, age, creatinine and C-reactive protein were independent factors associated with ROMs. At multiple logistic regression analysis the association between ROMs and CVD was independent (OR: 1.02, 95% CI: 1.00-1.05; p=0.03). Twenty six patients developed cardiovascular (CV) events during the follow-up. Of these, seven were in the group with ROMs levels <273 CARR U and 19 in the group with ROMs levels ≥273 CARR U. The logistic regression analysis showed that both age (OR: 1.06, 95% CI: 1.01-1.12; p=0.013) and ROMs levels (OR: 1.10, 95% CI: 1.00-1.02; p=0.045) were independently associated with CV events in the follow-up., Conclusions: ROMs are independently associated with CVD and predict CV events in chronic HD patients.

Xerostomia is the subjective feeling of a dry mouth, which is relatively common in patients on chronic hemodialysis. Xerostomia can be caused by reduced salivary flow secondary to atrophy and fibrosis of the salivary glands, use of certain medications, restriction of fluid intake and old age. In patients undergoing hemodialysis, xerostomia is associated with the following problems: difficulties in chewing, swallowing, tasting and speaking; increased risk of oral disease, including lesions of the mucosa, gingiva and tongue; bacterial and fungal infections, such as candidiasis, dental caries and periodontal disease; interdialytic weight gain resulting from increased fluid intake; and a reduction in quality of life. Unfortunately, no effective treatment exists for xerostomia in patients on chronic hemodialysis. The stimulation of salivary glands by mechanical means (such as chewing gum) or pharmacological agents (such as pilocarpine and angiotensin-converting-enzyme inhibitors, the latter alone or in combination with angiotensin-receptor blockers), as well as saliva substitutes, are all ineffective, or effective only in the short term. Xerostomia remains a frustrating symptom for patients on hemodialysis, and further efforts should be made to find an effective treatment for it in the near future., (© 2012 Macmillan Publishers Limited. All rights reserved)