Stereotactic radiosurgery for intracranial metastases: linac-based and gamma-dedicated unit approach

Introduction: For intracranial metastases, the role of stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy is well recognized.

Areas covered: Historically, the first technology, for stereotactic device able to irradiate a brain tumor volume, was Gamma Knife® (GK). Due to the technological advancement of linear accelerator (Linac), there was a continuous increasing interest in SRS Linac-based applications. In those decades, it was assumed a superiority of GK compared to SRS Linac-based for brain tumor in terms of dose conformity and rapid fall-off dose close to the target.

Expert commentary: Recently, due to the Linac technologic advancement, the choice of SRS GK-based is not necessarily so exclusive. The current review discussed in details the technical and clinical aspects comparing the two approaches for brain metastases.     

Care available to severely disabled older persons living at home in Florence, Italy

AIMS: To characterize the epidemiology of disability in, and the level of care available to, older community-dwellers in an Italian urban sample. METHODS: In a 2-phase survey, persons aged 65+ years, randomly selected from the patients lists of 98 primary care physicians (PCP), were screened (phase I) by their PCP with a structured questionnaire to detect the presence of: 1) need of help in performing Basic and 2) Instrumental Activities of Daily Living (BADL, IADL); 3) poor vision or 4) hearing; 5) weight loss; 6) use of home care services; 7) self-perceived inadequacy of income. Subjects reporting 2+ problems were further evaluated in face-to-face structured interviews (phase II). RESULTS: Of 5,445 participants, 597 (11%) screened positive in phase I and 416 were interviewed in phase II. Of these, 4, 29, 19 and 49% were disabled in 1-2 IADL, 3+ IADL, 1-2 BADL, and 3+ BADL. The extent of the support network increased with disability severity (p<0.01). The 274 participants with BADL disability received most of their help from close relatives (58.3+/-2.5%), followed by salaried assistants (20.5+/-2.1%), other relatives (19.5+/-1.9%), and public healthcare services (0.6+/-0.36%). Of the 397 care-givers interviewed, one-third were willing to institutionalize the older participants in case of further functional deterioration. This propensity was predicted only by a self-reported poor attitude towards caring. CONCLUSION: Many severely disabled older Italians receive care in their home by highly supportive family members. The level of assistance provided to them by public healthcare services is minimal.     

Winners and losers at the rosiglitazone gamble A meta-analytical approach at the definition of the cardiovascular risk profile of rosiglitazone

The treatment with rosiglitazone could be associated with increased risk for myocardial infarction (MI). This meta-analysis is aimed at identifying moderators of the effect of rosiglitazone on the risk of MI and chronic heart failure (CHF) in type 2 diabetic patients. The risk ratio (RR) of MI and CHF was calculated for each trial as the ratio of incidence density in rosiglitazone and comparator groups. A total of 86 trials were included. After adjusting for trial duration, RR for MI showed a significant inverse correlation with mean baseline HbA1c, triglycerides, and LDL-cholesterol (r=-0.24, -0.45, and -0.33, respectively; all p<0.05). Conversely, rosiglitazone-associated risk of MI was increased in trials with higher mean BMI or greater proportion of insulin-treated patients (r=0.26 and 0.42, respectively; p<0.05). Lower triglyceride levels were also associated with a higher rosiglitazone-induced risk of CHF (r=-0.23, p<0.05). Treatment with rosiglitazone could have divergent effects on cardiovascular risk, depending on the characteristics of the patients. Benefits could outweigh harms in patients with poor glycemic control and worse lipid profile; conversely, the drug could increase the risk of MI in obese or insulin-treated patients.