Tesi sul tema "Neck"

The Head and Neck Patients Concerns Inventory (HN-PCI) is a self-completed holistic tool that helps patients to disclose items of concern they wish to discuss. The MD study was designed to evaluate the roll-out of HN-PCI in subjects who were unfamiliar with it. The primary aim of the study was to evaluate HN-PCI can help patients self-disclose concerns. The secondary aims were to: (1) categorise HN-PCI items into domains; (2) develop a thematic content analysis; (5) examine associations between concerns and distress; (4) examine associations between clinicopathological factors with HN-PCI consultations; (5) determine if HN-PCI intervention changes consultations and the outcomes of consultations. Method: The MD work was divided into 3 sections and undertaken in the following order: (1) Pilot study; (2) Domain generation; and (3) Main study. Sections (1) and (2) were undertaken designed to support the Main study. In the Main study, patients were recruited prospectively to a non-randomised study design composed of 3 blocks. Block 1 constituted normal practice i.e. control group, Block 2 constituted patients exposed to HN-PCI but doctors were not i.e. control in attention, and Block 3 was the HN-PCI intervention group. The primary outcome measures were the number of concern and selected and/or discussed. The secondary outcome measures were patient satisfaction with consultation, consultation length, distress level and clinical outputs. i.e. clinical decision or action taken related to the consultation. Result: In the Pilot study, a content thematic framework was developed. Five domains were generated: (A) Physical and functional; (B) Psychological/emotional and spiritual well-being; (C) Social care/Social well-being; (D) Treatment-related; and (E) Other. In the Main study, 365 patients were recruited, producing a matching number of audiorecorded consultation i.e. Block 1: 136 patients; Block 2: 78 patients; and Block 3: 111 patients. Introduction of HN-PCI generated a trend towards an increased number of concerns discussed when compared with control consultations. A broader range of expressed concerns was addressed in HN-PCI intervention group. More items within the Psychological/emotional and Spiritual well-being Domain were discussed in HN-PCI intervention groups. In the HN-PCI intervention groups, doctors were fair to moderately more likely to take on the patient’s agenda for discussion by addressing the items selected. These were achieved with a trend towards longer consultations. Consultations with HN-PCI were significantly associated with certain clinicopathological factors. The HN-PCI intervention group showed higher number of medical outputs when compared with control group, suggesting that HN-PCI may facilitate collaborative decision-making. Patients with HN-PCI intervention showed a trend towards lower levels of distress post-consultation and reported significantly higher scores of satisfaction. This study also demonstrated that the HN-PCI was able to indirectly predict patients who experienced significant distress based on the number of items selected. Conclusions HN-PCI was able to help patients disclose a wider range of concerns in cohorts unfamiliar with the tool. Its use is associated with changes in the content of consultations, suggesting a more patient-concern focused consultation. This is possible to create a personalised, patient-centred HNV visit using the HN-PCI. However, there remain service-based barriers to fully realizing the HN-PCI tool in personalising HNC patient’s survivorship trajectory.

Chronic neck pain is a widespread problem that causes individual suffering as well as large costs for the society. The knowledge about the pathophysiology is poor and therefore specific diagnosis and causal treatment are rare. Important knowledge for characterization of the disorders has been gained from research on sensorimotor functions in people with neck pain. Moreover, rehabilitation regimes including sensorimotor exercises indicate promising results. The main objectives of this thesis were to extend the knowledge on sensorimotor dysfunctions in chronic neck pain, and to develop a new exercise method for improving sensorimotor functions of the neck. The studies focused on aspects of postural control and movements of the arm and neck. These are vital functions for many activities of daily living. People with chronic (>3 months) neck pain were compared to healthy controls (CON). Neck pain related to trauma was referred to as whiplash associated disorders (WAD), while neck pain without association to trauma was referred to as non-specific (NS). Arm-functioning was assessed in a pointing task. WAD and NS had reduced pointing precision compared to CON. The reduced precision was associated with self-rated difficulties performing neck movements, physical functioning, and in WAD, also pain and balance disturbances. Postural control was assessed in quiet standing on a force platform without vision. The center of pressure signal was decomposed into it’s slow and fast components. WAD and NS were compared to CON. The results revealed an effect of age on the magnitude of the fast sway component, but no effect of group. The magnitude of the slow component was elevated in both WAD and NS. This increase was associated with self-rated balance disturbance, arm-functioning, difficulties to run and sensory alterations in WAD, while in NS, the increase in the slow sway component was associated with concurrent low back pain. Neck movements were assessed in a cervical axial rotation test with maximal speed. In total 8 variables representing basic kinematics, including variables reflecting movement smoothness and conjunct motions were calculated. NS were compared to CON. Linear discriminant modelling indicated Peak Speed and conjunct motions as significant classification variables that together had a sensitivity of 76.3% and specificity of 77.6%. Retest reliability was good for Peak Speed but poor for the measure of conjunct motions. Peak Speed was slower in NS compared to CON, and even slower in a sub-group of NS with concurrent low back pain. Reduced Peak Speed was associated with self-rated difficulties performing neck movements, car driving, running, sleeping disturbances and pain. The clinical applicability of a novel method for neck coordination exercise was assessed in a pilot study on persons with NS. The results supported the applicability and indicated positive effects of the exercise: reduced postural sway in quiet standing and increased smoothness in cervical rotations. Indications on improvement in self-rated disability and fear of movement were seen at six months follow up. In conclusion, sensorimotor functions can be altered in chronic neck pain, particularly in neck disorders with concurrent low back pain and WAD. The discriminative ability and clinical validity displayed in pointing precision, postural sway and cervical axial rotation speed imply that such tests can be valuable tools in the assessment of chronic neck pain patients, and for selecting and evaluating treatment interventions. Indications of improvements seen in the pilot-study support a future RCT.

Background South Africa has a high rate of injuries related to violence which includes penetrating neck injuries (PNI’s). Of the 163 patients that are annually referred for contrast swallow studies to exclude associated pharyngo-oesophageal injuries (PPOI’s), only 0-14% contrast studies confirm injury. The contrast swallow is still viewed as the ‘gold standard’ for oesophageal pathology even in the modern era of digital general radiography and Multidetector Computerized Tomographic Angiogram (MDCTA). This procedure is however time consuming and requires good cooperation, sometimes from acutely ill patients which is not always possible. This contributes to delay in final management of the patient which is the most significant contributor to associated complications. The study reviewed whether the less time-consuming MDCTA’s and lateral soft tissue radiographs usually performed before the contrast swallow studies can also be used to diagnose POI’s. This will reduce dependence and possibly exclude the contrast swallow study, thus reducing the time delay in POI pre-operative investigations. Methods A retrospective review was undertaken of the radiological findings of all patients who presented at Groote Schuur Hospital over a 28-month period with suspected penetrating neck injuries and were investigated with a contrast swallow, MDCTA and lateral soft tissue radiograph. The time interval between request of the contrast swallow study and the final report was calculated as the difference in the time indicated on the Groote Schuur Hospital Philips Extended Internet Radiology Information System (XIRIS) by the requesting clinician and the time indicated on the radiology report after completion of the study on the Philips Picture Archiving and Communicating System (PACS). Results Of the 389 patients referred, 153 patients met the study criteria. Fourteen patients (9%) had PPOI’s on contrast swallow. The majority of the patients with PPOI’s had prevertebral air (12; sensitivity of 85.7%), however a majority of patients with prevertebral air had no POI’s (90; specificity of 35.3%). In 28 MDCTA’s where there was suspicion of PPOI’s, six contrast swallows confirmed oesophageal leaks (42.9% sensitivity). Although there was no suspicion of PPOI’S in 125 patients undergoing MDCTA’s, eight were found to be positive for leaks on contrast swallow (84.2% specificity). The mean time interval between request of the contrast swallow study and final report was 586 minutes. Conclusion Contrast swallow remains the gold ‘standard’ for diagnosing PPOI’s in patients with PNI’s. The lateral soft tissue radiograph was unreliable in predicting POI’s with a low specificity of 35%. MDCTA’s was also not contributory in assisting diagnoses of PPOI’s with a low sensitivity of 43%. The two modalities can thus not be considered as augmentation or alternative diagnostic modalities. The time delay between the request and reporting of the contrast swallow is longer than that in literature and needs improvement.

Background: Neck pain and injury is a common occurrence in high performance combat pilots (HPCP) around the world. The cause of this has been attributed to exposure to the unavoidable high mechanical loading related to the neck being positioned in non-neutral head postures whilst being exposed to moderate to high +Gz levels. Specific neck conditioning exercises have been proposed as being a possible method to decrease the incidence of neck pain and injury in this population. However, there has been sparsely published research examining the suitability of selected exercises for HPCP who participate in regular aerial combat manoeuvres (ACM).

Previous studies in animals and humans show anatomic and physiological connections between the trigeminal and cervical regions. This investigation tested the hypothesis of a functional integration between the human jaw and neck motor systems in rhythmic jaw activities. By means of a wireless optoelectronic 3-D movement recording system, spatiotemporal characteristics of mandibular and head-neck movements were studied during rhythmic jaw opening-closing and chewing tasks, in healthy and in individuals with pain and dysfunction in the jaw and neck region following neck trauma, Whiplash-associated Disorders (WAD). As a basis, a methodological study evaluated the applicability of skin and teeth attached reflex markers fixed to the lower jaw and to the head in optoelectronic recording of chewing movements. The results showed concomitant and coordinated mandibular and head movements during rhythmic jaw tasks. The start of the head movement generally preceded the start of the mandibular movement. For chewing, larger size and harder texture of bolus were associated with larger head extension and larger amplitude of both mandibular and head movements. Immobilization of the head by mechanical fixation deranged jaw motor behaviour with regard to speed and amplitude of mandibular movements. Even with head fixation, muscle activity was present in neck muscles during activities. Compared to healthy subjects, WAD individuals showed smaller amplitudes and disturbed coordination of mandibular and head movements. Furthermore, a dynamic load test showed a reduced endurance during chewing in the WAD group. In conclusion, the results suggest that optimal jaw function requires free unrestricted head-neck movements and support the hypothesis of a close functional relationship between the jaw and the neck regions in rhythmic jaw activities. A new concept for human jaw function is proposed, in which "functional jaw movements" are the result of activation of jaw as well as neck muscles, leading to simultaneous movements in the temporomandibular, atlanto-occipital and cervical spine joints. The finding of an association between neck injury and disturbed jaw behaviour suggest that assessment and management of neck injured patients should include jaw function.

The epidemiology of head and neck squamous cell carcinomas (HNSCC), primarily those of the oropharynx, has changed dramatically over the last two decades. Specifically, HNSCC appears to be a distinct entity that is related to infection by human papilloma virus (HPV)(Vokes et al., 2015) (Fakhry et al., 2008). Moreover, the incidence of HPV-associated oropharyngeal (OP) cancers is rising, likely as a consequence of changing life styles and sexual behaviors. These tumors appear to be biologically and clinically distinct from other HNSCC tumors affecting predominantly middle-aged white men having no or only a brief history of tobacco consumption. The cell cycle regulatory protein, p16, is usually over expressed in HPV-OPSCC, and its detection using immunohistochemistry and in situ hybridization is a reliable surrogate marker for the disease (Ang et al., 2012). When compared to traditional head and neck cancer that is associated with the repeated insult of tobacco use, HPV-related OPSCC has a favorable natural history and is more responsive to treatment. As a result, patients with this cancer have improved long-term survival and consequently are more likely to experience chronic therapy-induced morbidity (Ang et al., 2012). The purpose of this thesis is to provide a comprehensive review of the molecular mechanisms that underlie HPV-mediated OPSCC, and the licensed prophylactic HPV vaccinations available, and to discuss the current thoughts on whether to deescalate potentially damaging treatments in these patients.

My thesis explores the act of violation in the context of trauma and healing through the use of personal narratives and experimental film. My research allows personal storytelling to transform into a larger and more universal theme of generational trauma and dysfunction. Through a feminist lens, I challenge social norms of body autonomy for the sick and abused, capitalism’s social effects on the poor, and passed down maternal lessons from the women who are doing the best that they can with the lives and opportunities that they have been given. This work is created in spite of the labels my mother, the women before her, and I may hold. It is an act of resistance to who and what is allowed to be seen or heard. It is my confession, but it is not my confession alone.

Background: Patients with chronic neck pain have a number of factors that could constitute a predisposition for respiratory dysfunction. However, the existing evidence is limited and not well established, and many questions such as the association of neck pain deficits with respiratory function remain unanswered. Thus, the aim of this study was to investigate whether patients with chronic neck have accompanying respiratory dysfunction and which are the neck pain deficits which principally predispose to these respiratory disturbances.Methods: In this case-control observational study, 45 patients with chronic idiopathic neck pain (>6 months, at least once per week) and 45 healthy age-, gender-, height- and weight-matched controls were voluntarily recruited. A third group of 10 patients with chronic non-spinal musculoskeletal pain was also used, but only for future reference. Participants' neck muscle strength and endurance were measured by an isometric neck dynamometer and craniocervical flexion test respectively. Range of movement was assessed by using an ultrasound-based motion analysis system. Forward head posture was assessed by obtaining lateral photographs and calculating the craniovertebral angle. Disability and neck pain intensity were assessed through the Neck Disability Index and Visual Analogue Scale. Psychological assessment was performed by using the Hospital Anxiety and Depression Scale, the Pain Catastrophizing Scale and the Tampa Scale for Kinesiophobia. Spirometry was used for assessing pulmonary volumes, flows and maximal voluntary ventilation. Respiratory muscle strength was assessed by using a mouth pressure meter. Finally, PaCO2 was assessed by using transcutaneous blood gas monitoring.Results: Patients with chronic neck pain were found to have weaker respiratory muscles than healthy controls (p<0.05). Their pulmonary volumes and maximal voluntary ventilation were also found to be reduced (p<0.05). Their mean respiratory flows were found to be unaffected (p>0.05), whereas their peak flows were reduced (p<0.05). Their partial pressure of carbon dioxide was also found to be affected (p<0.05), revealing existence of hypocapnia (PaCO2<35mmHg). The neck pain deficits that were found to be mostly correlated with these respiratory parameters were the neck muscle strength, neck muscle endurance, kinesiophobia, catastrophizing and pain intensity (r>0.3, p<0.05). Finally, the regression models revealed that neck pain deficits and especially neck muscle strength can provide a quite generalizable accurate estimation of this respiratory dysfunction (R2=0.28-0.52).Conclusions: Patients with chronic neck pain present dysfunction of their respiratory system which can be mainly manifested as respiratory weakness and/or hypocapnia. Pain intensity, neck muscle weakness, fatigue and kinesiophobia seem to be the most important deficits predisposing to this respiratory dysfunction. The understanding of this dysfunction could have a great impact on various clinical aspects notably patient assessment, rehabilitation and drug prescription. However, further research is suggested mainly directed towards optimizing treatment protocols and developing classification systems improving clinical reasoning.

Includes bibliographical references (leaves 33-34).
The objectives of the study were to determine the accuracy of Sentinel Lymph Node Biopsy (SLNB) in head and neck squamous cell carcinoma (SCC); to determine its role in the approach to the clinically N+ neck in a Developing World setting; and its accuracy as an indicator of regional lymph node status in the clinically N neck.

Background: Head and neck cancer (HNSCC) affects 650,000 people annually. Laryngeal cancer (LSCC) and oropharyngeal cancer (OPSCC) are amongst the commonest sub-types. For other cancers e.g. breast cancer, personalised treatments based on tumour markers have improved patient survival. With the exception of human papilloma virus (HPV); there are no clinically utilised biomarkers in HNSCC. Insulin growth factor receptor 1 (IGF-1R) and HPV are promising molecular markers in LSCC and OPSCC respectively. This thesis investigates the use of IGF-1R as a marker of radiotherapy resistance in LSCC and evaluates HPV detection in patients with OPSCC. Aims: • To assess IGF-1R as a marker of radiotherapy resistance in LSCC. • To determine the diagnostic accuracy of salivary PCR to detect HPV in patients with OPSCC. Methods: Immunohistochemistry (IHC) was used to compare IGF-1R levels between patients with LSCC achieving long-term remission and experiencing recurrence after radiotherapy. LSCC cells were used to create and interrogate an in vitro model of radiation resistance. Following the completion of a systematic review on HPV testing in OPSCC, a diagnostic accuracy study was performed to determine the sensitivity and specificity of saliva testing for HPV in OPSCC. Results: IGF-1R levels are higher in radioresistant LSCC and increase following radiotherapy. IGF-1R inhibition appears to be more effective at limiting cell survival in cells with IGF-1R overexpression. The sensitivity and specificity of saliva testing when compared to p16 IHC and HPV DNA in situ hybridisation is 72.2% and 90%. Conclusions: Elevated IGF-1R appears to associate with previous radiotherapy and radiotherapy resistance in LSCC. Treatments accounting for IGF-1R status, or molecular therapies targeting this receptor, may have merit in patients whose tumours overexpress IGF-1R. Saliva testing for HPV is a promising alternative to p16 IHC performed on tumour tissue. In selected patients, this might avoid the need for surgical biopsies and expedite treatment.

Purpose: The management of head and neck squamous cell carcinoma (HNSCC) is complex and often involves multimodality treatment. Currently, most management decisions are based on clinical parameters with little appreciation of patient differences in underlying tumour biology. The identification of biomarkers that predict response to radiotherapy would be clinically useful in determining optimal management. The purpose of the thesis was to investigate potential biomarkers that might predict radiotherapy outcome in patients with HNSCC. Aims: 1) To investigate the hypoxia-associated biomarkers carbonic anhydrase 9 (CA9) and hypoxia-inducible factor -1α (HIF-1α) in patients with early glottis cancer who underwent radiotherapy as their primary mode of treatment, furthermore to investigate the role of accelerated hypofractionated radiotherapy in the management of T2 glottic cancer. 2) To investigate markers of hypoxia (CA9 and HIF-1α) and viral infection in oropharyngeal cancer, and in particular to test for an association between hypoxia markers and viral infection. 3) To investigate HIF-1 and CA9 in a series of patients undergoing surgery as their primary mode of treatment to explore whether they are associated specifically with radioresponsiveness or a general poor prognosis. Results: 1) Adverse prognostic factors for locoregional control were low pre-treatment haemoglobin (Hb; p = 0.010), advancing T stage (p = 0.001) and high CA9 expression (p = 0.032). Low Hb and high CA9 expression were independent factors on multivariate analysis; and combined predicted locoregional recurrence with an odds ratio of 8.0 (95% CI: 2.7-23.9), or either/or with an odds ratio of 3.3 (95% CI 1.5-7.1). In the subset of T2 patients, five-year locoregional control following radiotherapy was 82% and cancer specific survival was 90%. Serious morbidity occurred in 1.8% of patients. T stage subdivided by vocal cord movement was significant for local control. 2) Features associated with a poor locoregional control were older age (p=0.002), tongue base subsite (p=0.002), heavy alcohol use (p=0.004), heavy smoker (p=0.0002), low Hb level (p=0.001), advancing T (p=<0.0001), N (p=0.001) and AJC (p=0.001) stage, high CA9 expression (p=0.020) and high HIF-1α expression (p<0.0001). In multivariate analysis T stage (p=0.003) and high HIF-1α expression (p=0.001) remained significant. 3) Extracapsular spread was significantly associated with poor cancer specific survival (p=0.022). No other patient variables were associated with outcome. HIF-1α expression was significantly associated with poorly differentiated tumour (p=0.019) and the tumour having a cohesive front (p=0.026). Conclusion: 1) Hb and CA9 have potential to be used together as a biomarker to identify glottis cancer patients with a high probability of a poor outcome following radiotherapy, furthermore, vocal cord movement should be taken into consideration when managing glottis cancer. 2) As it does not appear to be influenced by HPV status, HIF-1α warrants further investigation as a biomarker in oropharyngeal patients treated with primary radiotherapy. 3) As HIF-1α and CA9 had no prognostic significance in patients undergoing surgery, they should be explored further as markers to help guide management decisions in patients with HNSCC.

Extracellular DNA (eDNA) is a ubiquitous component of the extracellular matrix of microbial biofilms. It has a number of functions that include a role as an adhesin during biofilm attachment, and facilitating matrix stability in mature biofilms. Increasingly, deoxyribonuclease (DNase) enzymes have been shown to reduce the colonisation of many microbial biofilms, both bacterial and fungal. Biofilms are estimated to be responsible for around 60% of bacterial infections, including many chronic diseases. The aim of this work was to determine the role of eDNA in chronic mixed-species biofilm infections, and to explore the potential of DNase enzymes for biofilm control. This included three major areas of research, focusing on chronic rhinosinusitis, tracheoesophageal speech valves (TESVs), and dental plaque. An important aspect was to test the efficacy of a novel bacterial nuclease, NucB, isolated from a seaweed-associated strain of Bacillus licheniformis, against microbial biofilms. The colonisation of speech valves by micro-organisms was studied using scanning electron microscopy (SEM). In keeping with previous observations, these biofilms were co-aggregations of fungal and bacterial species. Using confocal laser scanning microscopy, eDNA was observed in the biofilm matrix. Extracellular DNA was extracted and quantified from TESV biofilms. All six biofilms studied had detectable nucleic acids, as measured by NanoDrop spectrophotometry. The eDNA was apparently heavily degraded, and produced smears by agarose gel electrophoresis. Nevertheless, eDNA appeared to be providing biofilm stability since micro-organisms were liberated from the surface of the valves following treatment with NucB in over 60% of the TESVs tested. To assess the role of eDNA in biofilms associated with chronic rhinosinusitis, ‘obstructive mucin’ and sinus mucosa biopsy samples collected during functional endoscopic sinus surgery at the Freeman Hospital, Newcastle, were analysed for the presence of biofilms and biofilm-forming micro-organisms. An average of 3.75 bacterial species per patient were cultured from obstructive mucin. The most commonly isolated micro-organisms were Staphylococcus aureus, coagulase-negative staphylococci and α-haemolytic streptococci. Micro-organisms were not detected by transmission electron microscopy of the obstructive mucin and this material appeared to originate through a host inflammatory response. However, bacteria were visualised on the surface of sinus mucosa using a peptide nucleic acid fluorescence in situ hybridization (PNA-FISH) universal bacteria probe. Twenty-four bacterial isolates were iv assessed for their ability to form biofilms in a microtitre plate model. All micro-organisms tested formed biofilms, and 14 of 22 were susceptible to NucB. In total, 15 of 24 microbial species produced eDNA that was detectable by agarose gel electrophoresis. By SEM, cellular colonisation was lower in treated samples and, in the case of Streptococcus constellatus FH20 stringy, matrix-like material was not present after DNase treatment. The role of eDNA in matrix stability and initial biofilm attachment was also studied in oral bacteria. Streptococcus gordonii DL1, Streptococcus mutans GS-5, Fusobacterium nucleatum 25586 and Actinomyces oris MG1 were examined using DNase treatment, CLSM, and eDNA extraction. Of these species, all except S. gordonii appeared to rely on high molecular weight (HMW) eDNA for biofilm attachment and biofilm stability. Although S. gordonii did not produce detectable HMW eDNA, nucleic acids were detectable by NanoDrop spectrophotometry. Furthermore, this species produces an extracellular nuclease which may degrade the HMW eDNA in the conditions used to culture biofilms. Interestingly, four S. mutans strains differed in their sensitivity to DNase treatment. Oral biofilms were also modelled in a BioFlux microfluidics device using flowing human saliva. Mixed-species biofilms and single species biofilms of S. mutans UA159 and S. gordonii DL1 were cultured using this technique, to determine whether this model would allow more realistic experiments for DNase testing. Finally, the extracellular nuclease, SsnA, of S. gordonii DL1 was characterised. A nuclease-deficient mutant did not produce extracellular nuclease activity on DNase Test agar or during a Forster Resonance Energy Transfer (FRET) assay. Nuclease activity was cell-wall-associated as predicted from the predicted amino acid sequence of SsnA. Allelic exchange mutagenesis determined that ssnA expression was regulated by CcpA in response to repressing sugars. However, in planktonic culture non-repressing carbon sources also inhibited enzyme activity during a FRET assay. Further experiments using acidic buffers replicated the inhibition of SsnA without the presence of sugars. SsnA was purified as a GST-tagged fusion protein in an Escherichia coli protein expression system, and had anti-biofilm activity against S. mutans GS-5. However, this species is strongly acidogenic and therefore it is hypothesised that although SsnA may be a competition biofilm factor, acid production by S. mutans may reduce its efficacy in vivo. In conclusion, this thesis has provided strong evidence for the role of eDNA in facilitating biofilm formation and mature biofilm stability of clinically relevant v biofilms. Nucleic acids were present in biofilms associated with a chronic infection, medical implant biofouling and dental plaque. A variety of DNase enzymes (NucB, DNase I, and SsnA) were capable of reducing biofilm colonisation. Given the adhesive function of eDNA in biofilm matrices it is proposed that DNase enzymes may be beneficial for controlling healthcare-related biofilms.

Photodynamic therapy, PDT, is a method to diagnose and treat cancer. In PDT a sensitizer is administered to the patient and this sensitizer is accumulated in tumors. If the sensitizer-containing tumor is subjected to a laser of a specific wavelength the tumor is fluorescing allowing diagnostics. If other wavelengths are used a process involving reactive oxygen species and singlet oxygen is started and the tumor cells are killed. This process thus requires oxygen as well. This thesis investigates how UV-induced damage of the skin and different physiological factors of the skin influences the uptake of 5- aminolevulinic acid, ALA, and its conversion to the active sensitizer protoporphyrin IX, PpIX. It shows that UV-induced damage affects both the uptake and production of PpIX. UV-induced damage lowers the PpIX produced after ALA application both if the damage is acute and in chronically UV-affected skin. The PpIX production differs inter and intra individually. When looking how different physiological factors affect the PpIX production after topically applied ALA the thesis shows that an increase of temperature increases the production. No correlation between the formation of PpIX and the density of hair follicles was found and a weak correlation was seen comparing the epidermal and total dermal thickness and PpIX production The thesis also shows how PDT is used in treating laryngeal malignancies. It shows that it is possible to cure laryngeal tumors (both squamous cell carcinomas and sarcomas) using PDT primarily, and that the cure rate as well as outcome of voice and patient safety is comparable to the conventional treatment modalities. PDT can also be used as a function and organ sparing treatment for recurring laryngeal cancers, both squamous cell carcinomas and sarcomas.

Head and neck cancer is a heterogeneous group of tumours, of which certain subgroups such as cancer of the mobile tongue frequently are associated with a relatively poor prognosis due to the high risk of regional failure and mortality rates that haven’t improved in a significant way over the last 3 decades, despite advancements in both diagnostics and treatment. Today we lack means to assess the biological aggressiveness of each individual tumour, which varies largely. Treatment comprises of surgery with additional radiotherapy and medical therapies in more advanced tumours. The focus in this thesis is on molecular biomarker expression in head and neck cancer and especially in association with radiotherapy. Increased knowledge paves the way to a more individualized cancer treatment aiming for better outcome and less overtreatment and sequelae. The aims of this thesis was: To map the effects of radiotherapy in both tumour and adjacent tissue for the possible markers hyaluronan, EGFR and mast cells. To investigate whether the expression of hyaluronan in the epithelium and connective tissue stroma and EGFR in the tumour correlates with the risk for developing cervical metastasis in N0 patients, and to find out whether the 3-year tumour-specific survival rates correlates with the expression of HA in the epithelium and EGFR in the tumour. To establish an animal model for radiation-induced mucositis and to use that model to examine the pattern of invading inflammatory cells. To investigate whether the expression of podoplanin in tongue cancer correlates with the risk for cervical metastasis and to determine whether the total amount of lymph vessels in the diagnostic biopsy has any impact on the clinical outcome. To investigate the differences in the metabolome of tongue cancer cell lines with different radiosensitivity. The most important findings of this thesis were: The expression of EGFR and hyaluronan hade the same pattern of expression in both tumour and adjacent tissues before radiotherapy. The expression of EGFR was increased in the epithelium of the adjacent tissue close to the tumour after radiotherapy. The intensity of the staining of hyaluronan was correlated to the 3-year survival rates in patients with tongue cancer. An experimental model for radiation-induced oral mucositis in rat was established and in this model a temporal pattern of macrophage invasion with two different subtypes of macrophages was found. There were no correlation between the expression of podoplanin in the tumour tissue and the cervical metastasis rate in patients with tongue cancer, but the younger patients were more likely to have a higher expression of podoplanin in their tumour than elder patients. Tongue cancer cell lines with different radiosensitivity respond to irradiation with different patterns of metabolic expressions.

The neural connections between the vestibular, visual, proprioceptive and voluntary inputs are essential for the control of neck posture and movements. One mechanism how this is achieved is by vestibulo-spinal reflexes, such as vestibulo-collic reflex (VCR), and cervico-collic reflexes (CCR). The main role of these reflexes is to stabilize the head either in space or relative to the trunk, respectively. The VCR stabilises the head in space while the CCR tends to re-align the head on the trunk. These two reflexes can work synergistically or an-tagonistically according to context and movement goals. The aim of this thesis is to investigate the sensory-motor control of the sternocleidomastoid muscle and the nature of the functional interactions between the vestibular system and neck muscles in healthy participants and in patients with bilateral vestibular loss. Specifically, the experiments performed were designed to a) investigate how head control is organised in healthy subjects and b) to examine how this functional interaction is modulated in patients with vestibular dysfunction. Firstly, a novel head-restraint paradigm is used in order to attempt to isolate a neck stretch reflex in the SCM muscle. Using this paradigm, the activation of the vestibular system is minimised. This permits differentiation between vestibular and neck muscles reflexes. Forehead skull taps and tendon taps were used to differentiate between vestibular-mediated response and stretch responses and vestibularless patients were also included to aid with assessing the contribution of stretch reflexes to head control. Secondly, the sensory-motor organization of the induced responses by tendon tap was investigated following vestibular caloric stimulation to see if it was modulated by vestibular input. Finally, in order to assess cortical aspects of neck control the cortico-spinal excitability of the sternomastoid muscle have been assessed, with non-invasive brain stimulation (transcranial magnetic stimulation), and visual stimulation (rotating disc) in healthy participants. To be able to better understand visual processing of the latter (motion visual stimuli).In the final part of the thesis the effects of visual motion stimulation on the excitability of the visual cortex, both in areas V1 and V5 were investigated. Applying tendon taps of the left sterno-mastoid (SM) relatively long latencies (32msec) EMG responses have been recorded from the ipsilateral and contralateral SCM muscles in con-tracted and relaxed conditions in both healthy and bilateral vestibular failure subjects (BVF). These latencies (32ms) indicating a long loop, possibly via the cortex or subcortical struc-tures would suggest a long loop reflex. These long loop responses are not modulated applying caloric vestibular stimulation and suggest that although the vestibular system is activated, the neural pathway between the vestibular system and the motor cortex is not activated by the tap since this is purely a spinal reflex. In addition the physiological mechanisms of head neck control are significantly influenced by the visual cues. Visual-vestibular and proprioceptive loops are probably involved in head-neck sensory motor control.

INTRODUCTION Urinary incontinence and bladder voiding symptoms are extremely frequent in the general population, in both sexes, independently from race and age. The onset of voiding disorders is slow in time; therefore, subjects develop adaptation mechanisms. Patients may lose their reference to normality, considering as physiological what in reality is a pathological condition [Abrams, 2013]. For reasons deeply investigated in this doctoral thesis, it is difficult to collect definitive and reliable epidemiological data on lower urinary tract symptoms and on urinary incontinence in the general population [Burkhard FE, 2016], principally in males. Urinary continence and micturition strongly depend on the integration of two different functional units of the lower urinary tract: the bladder and the urethral sphincter complex (bladder neck and rabdosphincter). Coordination within the system is guaranteed by neural control at three different levels: peripheral ganglia, spinal cord and brain [Morrison JF, 2005]. This normal physiology of the system is extensively reviewed in the thesis. A crucial step in micturition is represented by the relaxation of the urethral sphincters, which depends both on the disappearance of adrenergic and somatic excitatory inputs and on the activation of a parasympathetic reflex. This neuromuscular integrated system involves not only bladder neck and the urethral sphincters, but also the pelvic diaphragm, which is composed by a complex set of structures: the levator ani muscle, the coccygeal muscle and the surrounding connective tissue and fascias [Ayoub SF, 1979; Wallner C, 2009]. The present doctoral thesis is focused on primary bladder neck obstruction (PBNO), which is an under-investigated niche of pathology characterized by an incomplete relaxation or by an over-activity of the urethral sphincters [Nitti VW, 2005]. This urological disease is quite frequent in the young male, being identified in up to 47-54% of male patients aged 18-45 years with chronic voiding dysfunction symptoms [Kaplan SA, 1996; Nitti VW, 2002]. Unfortunately, symptoms at first presentation are vague ant too often patients are thought to be affected by chronic abacterial prostatitis, chronic pelvic pain syndrome or psychogenic voiding dysfunction. Moreover, PBNO patients in fact may be extremely disturbed by symptoms, and to date and to the best of our knowledge there are still no recognized effective treatments. In our opinion, this reflects the lack in knowledge of etiopathogenetic mechanisms. AIMS OF THE RESEARCH In the present research we intended to qualitatively and quantitatively analyse multiple variables in patients diagnosed with PBNO. The first aim of the research was to define whether a correlation between voiding dysfunction and postural or musculoskeletal aspects existed. If so, we were willing to understand if this association was only statistical/epidemiological or if a cause/effect relationship was present. The third aim was to define, if possible, the underlying etiopathogenic mechanism, in order to identify an effective treatment strategy. Finally, aim of this doctoral research was also to analyse the extent to which urological patients needed for rehabilitative medicine and dedicated rehabilitations in the field of Urology. In fact, this topic represents an innovative and challenging subject for the modern medicine, which is increasingly devoted to the patient’s needs. More efforts are needed in this field and, more in general, in functional urology, in order to provide better quality of life to our patients. MATERIALS AND METHODS From November 2013 to October 2017 all the patients presented for outpatient urological consultation to the same urologist (Tommaso Ciro Camerota) were prospectively evaluated. Among more than 6.000 outpatient evaluations and diagnostic procedures individually performed, 71 male subjects reporting chronic voiding dysfunction were diagnosed with PBNO. Patients with neurological disorders, diabetes mellitus, previous major injuries, lower limbs or back surgery were excluded from the study. All the subjects enrolled in the present research were diagnosed and personally evaluated by the researcher Tommaso Ciro Camerota. All the urologic diagnostic procedures were carried out by the same physician, and all the imaging and neurological evaluations were reviewed by the researcher. Urologic assessment was carried out according to the latest available recommendations and Guidelines on non-neurogenic LUTS. Few additional imaging and procedures were carried out. Patients were comprehensively evaluated with deep investigation of general and medical history, careful characterization of the reported symptoms, accurate physical examination, urinalysis, administration of validated questionnaires (patient reported outcome measures), collection of voiding and bowel diaries (frequency-volume charts), uroflowmetry with post-void residual urine, abdominal ultrasound, outpatient flexible urethrocystoscopy, second level imaging (full spine X-ray or pelvic-perineal MRI), neurophysiological testing, pain and postural assessment, gait analysis. Not all the subjects reporting voiding dysfunction suggestive for PBNO underwent all of these diagnostic procedures. RESULTS In our study population, median age at diagnosis was 41 years (interquartile range: 33.25 - 47.75), while median symptoms duration until diagnosis was 12 months (interquartile range: 6.5 - 25.5). Almost all the subjects (97%; n.69/71) reported the presence of a physiological urinary stimulus, with no differences in perception (increased or decreased). Seventy percent of the patients (n.51/71) were afflicted by both irritative and obstructive voiding symptoms; 13% of the subjects (n.9/71) exclusively reported obstructive urinary symptoms, while 3 patients (4%) had only irritative symptoms. Voiding symptoms were not isolated in our study population; the concomitant presence of other pelvic o perineal disorders was relevant. Among all the subjects enrolled, 34% reported defecation disorders, 25% reported a variable degree of impairment in erectile function, 35% reported ejaculation disorders, while pain was present in 76% of the subjects. 62% of the entire study population correctly filled and delivered bladder diaries, which showed an increased voiding frequency per 24 hours (mostly during daytime hours), a preserved total voided volume per 24 hours, and a significant reduction of the volume emptied per single void (median 172.5, interquartile range 141.3 – 287.8). Uroflowmetry showed reduced mean peak flow rate (12.89 ± 4.58 mL/s), reduced mean average flow rate (6.22 ± 2.98 mL/s), and pathological mean post-void residual urine (72.72 ± 53.32 mL); mean voided volume was 304.2 mL. Twenty-eight percent (n. 20/71) patients presented intermittent (complete or incomplete) stream 69% (n. 49/71) subjects had plateau flow, while 82% (n. 58/71) of the study population had urinary straining. The great majority of patients presented a combination of more than one of these flow characteristics. At urethrocystoscopy, all the 71 PBNO patients presented small non-obstructive prostate, tight external urethral sphincter, and contracted bladder neck; none had cicatricial urethral strictures, benign prostatic obstruction, transitional cell carcinoma of the bladder or vesical stones. Forty-nine percent (n. 35/71) of the study population underwent full spine X-ray on a single image. None of the patients showed a physiologic appearance. When compared to normalcy, the major pathological findings were lumbar hyperlordosis, horizontalization of the sacrum and increase of the sacral slope, hooked coccyx, anterior tilt of the pelvis, lower limb length discrepancy, variable degrees of scoliosis, obturator foramina asymmetry, partial or complete congenital sacralization of L5 vertebrae, mild anterolisthesis of L5 on S1, radiographic L5-S1 disk height reduction; cervical spine rectification. MRI of the pelvis and of the perineum (axial, coronal, and sagittal 1.5T or 3T, depending on the scanner) was obtained in 31% (n. 22/71) of the patients enrolled in this research. Hypertonicity or hypertrophy of pelvic floor muscles were identified in all the 22 subjects. Moreover, various and heterogeneous anomalies (skeletal or muscular) were identified, as for example: external urethral muscle thickening, hooked coccyx or its anterior angulation, sacroiliac joint sclerosis or sacroiliitis, posterior disc protrusion al L3-L4-L5-S1, sacrotuberous ligament thickening, piriformis muscle contraction or hypertrophy, pelvic upslip or rotation, femoroacetabolar impingement, levator ani muscle thickening, sacralization or hemisacralization of L5, sclerosis or erosion at the pubic symphysis, etc. Neurophysiological testing was carried out in 23 subjects. Among these, 87% presented a variable degree (from mild to moderate) of sacral and/or pudendal neuropathy, which could be either unilateral or bilateral. Pain was found to be present in a relevant percentage of subjects enrolled in this research (76%). A deep clinical evaluation was carried out by dedicated physicians. Characteristics, entity and time of onset of pain were extremely variable among our study population (12.64±10.87 months, mean±SD). Pain was reported to be distributed in different areas: lumbar muscles and vertebrae, sacroiliac joint, hip, coccyx, pubic bones, pelvic muscles, iliohypogastric, ilioinguinal, genitofemoral and pudendal nerves. A significant amount of patients presented a myofascial pain syndrome or articular pain, while neuropathic pain was found in only 5% of the studied patients. Gait analysis was carried out on 7 patients diagnosed with PBNO. A different degree of discordancy from normal controls was found to be present in 6/7 subjects enrolled. This non-invasive procedure allowed to identify the pelvis level as the variable more different from controls, followed by variables at the ankle level. Post-treatment clinical outcome was collected in 25% of the study population (n. 18/71). No traditional urological treatments (e.g. alpha-lytic drugs, bladder neck incision, etc) were proposed to any of the enrolled patients. Interestingly, when PBNO subjects were comprehensively treated (rehabilitation, myorelaxants, pain therapy, plantar in case of lower limbs dysmetria, etc.) an immediate and significant improvement was noticed in post-treatment bladder diaries and uroflowmetries collected. DISCUSSION According to the available literature [Kaplan, 1994; Nitti, 2002; Camerota, 2016], the results provided in this doctoral research confirm that PBNO is characterized by a significant clinical heterogeneity. Voiding symptoms (e.g.: hesitancy, decreased force of stream, intermittent stream, incomplete emptying), storage symptoms (e.g.: frequency, urgency), or a combination of the both may be reported by patients at first presentation. Frequency was the most common symptom in our study population (69%), coherently with previously published papers which showed a variable incidence from 74% to 79% [Yang SS, 2002; Grafstein NH, 2005; Glassberg KI, 2010]. Other common complaints were straining (65%), urgency (54%), feeling of incomplete voiding (58%) and intermittent stream (41%); nycturia and urinary incontinence were occasionally present. The collected bladder diaries showed multiple low-volume voids during daytime, few to none voids during night-time, and normal voided volumes at first micturition after awakening. As previously shown in females [Weiss JM, 2001; Peters KM, 2006, Butrick CW, 2009c], hypertonicity of pelvic floor muscles may be confused and interpreted as a normal stimulus to void. In this scenario, when subjects lie down – fact that usually occurs at night – intrapelvic pressure reduces, pelvic floor relaxes, and the false urinary stimulus disappears. Consequently, the bladder has the time and the physical space to fill up, and patients urinate when a proper voiding stimulus is generated at an adequate bladder volume. In our study population, pain represented a relevant component of the initial clinical presentation in our cohort of patients (76%); more than one pain trigger was present in the same PBNO patient. Therefore, an accurate pain assessment is suggested in a second-level specialist pain centre. In fact, similarly to traumas, muscular hypertonicity represents an inflammatory trigger which induces local release of prostaglandins, histamine, serotonin and bradykinins [Butrick CW, 2009b]. This mediators act as sensitizers on muscle nociceptors; the result is the development of mechanical allodynia and hyperalgesia, also known as peripheral sensitization. It is also known that, in the presence of a prolonged noxious stimulus, neuroplastic changes occur in the central nervous system. These are characterized by the amplification of entity and/or area of the initial pain impulse, or by the generation of independent (spontaneous) pain impulses. This phenomenon is also known as central sensitization. Moreover, pelvic hypertonicity may result in myofascial pain syndrome [Butrick CW, 2009b]. In patients reporting LUTS, a deep investigation of general and urological history is mandatory as it should support the proper identification of the possible causes of reported disorder [Novara G, 2006; Irani J, 2003; McVary KT, 2011; Bosch J, 2013]. Moreover, a careful characterization of the reported symptoms is strongly suggested. In fact, patients tend to focus only on a predominant symptom and have no complete perception of the complexity of the micturition discomfort or of other associated disorders (bowel or penile sensitivity alteration, pelvic or perineal pain or dysesthesia). Frequently patients realize their whole symptomatology during the urological evaluation; in this occasion, they also may discover correlations with daily activity or other dysfunction. Moreover, an accurate physical examination was performed on all patients by the same urologist (Tommaso Ciro Camerota). The examination focused on abdominal, flank, pelvic and suprapubic evidences, in order to rule out conditions which may interfere with normal bladder voiding (e.g.: bladder overdistension/urinary retention, urethral meatal stenosis, urethral discharge, phimosis, etc.). Digital rectal examination was performed only in case of long-term presence of symptoms (more than two years), reported fever (to exclude prostatitis), age over 40 years-old, or in case benign prostatic enlargement were suspected. A deep neurological evaluation was performed by a pain management specialist, in order to rule out neurological diseases. Frequency-volume charts were pathologic in all the patients, with a substantial increased voiding frequency per 24 hours with low-volume voided per individual void. Uroflowmetric measurements were performed accordingly with 2016 International Continence Society Good Urodynamic Practices and Terms [Rosier PFWM, 2017]. PVR measurement was always obtained by transabdominal ultrasound; we preferred this method to bladder scan or catheterization respectively because of its reliability/reproducibility and because of its non-invasiveness. In the present research, frequently observed pathological patterns at pre-treatment uroflowmetry were reduced voided volume and morphology of the curve characterized by the presence of a plateau flow and/or stream intermittency. Due to the increased urinary frequency and/or to the increased perception of bladder fullness, these patients usually present a reduction of voided volume per each bladder emptying. But when considering the sum of voided volume and post-void residual urine, the full bladder filling volume before uroflowmetry usually appears to be more than adequate (being quite always more than 150 mL). Therefore, the collected uroflowmetries are considered reliable. Invasive procedures are justified if uroflowmetry shows pathological results in patients with bothersome symptomatology [Nitti VW, 2002]. In PBNO patients urethrocystoscopy allows to exclude cicatricial urethral strictures, benign prostatic obstruction, transitional cell carcinoma of the bladder or vesical stones. In all the patients enrolled in this doctoral research, not only the internal urinary sphincter (bladder neck) but also the external urethral sphincter (rabdosphincter) was found to be contracted endoscopically. Neurophysiological testing showed the presence of a variable degree (from mild to moderate) of sacral and/or pudendal neuropathy, which could be either unilateral or bilateral. None of the 23 patients studied had a clear nerve injury, but only a malfunctioning along pelvic nerves path. These evidences are consistent with previously published observations in women with pelvic floor disorders [Walters MD, 2014]. Three subjects showed normal results. Motor unit potential of irregular and polyphasic shape were observed, in the absence of signs of neuropathy. This is an indirect sign of rearrangements of motor unit fibres, which is typical of slowly progressing processes [Zalewska E, 1998]. Full spine X-ray provided interesting data in our study population. All the PBNO patients studied (n. 35/71, 49%) with this imaging showed discordance from normalcy. Obturator foramina asymmetry reflects pelvic torsion, which was subsequently confirmed at gait analysis. Cervical spine rectification, increased sacral slope, reduction of thoracic kyphosis and other changes in spino-pelvic parameters are known compensatory mechanisms to lumbar lordosis modifications [During J, 1985; Jackson RP, 2000; Roussouly P, 2005; Vaz G, 2002]. In few patients we also found a partial or complete congenital sacralization/hemisacralization of L5. A significant variability was observed in our study population. All the subjects studied with MRI presented various degree of discordances from normalcy. Some of these pathological aspects were recurrent, but unfortunately a unique common pattern was not identified. Nevertheless, we were able to categorize abnormalities into four groups: 1. hypertrophy or hypertonicity of pelvic floor muscles, which were present – with different degrees – in all the 22 subjects; 2. tendon inflammation; 3. joints (e.g. sacroiliac or pubic symphysis) inflammation or sclerosis; 4. skeletal abnormalities as for example anterolisthesis, hooked coccyx, posterolateral disc protrusion at lumbar spine or femoroacetabolar impingement. Recurvatum coccyx was found to be present in 15 of the 22 subjects who underwent MRI (68%), consistently with the results we obtained from full spine X-ray performed in another group of 35 patients with PBNO. This morphologic modification suggests the presence of a chronic condition, which had time to shape the coccyx. Another frequent observation was the evidence of an anococcygeal raphe thickening. This condition was usually associated with a reduction in the rectal angle due to anococcygeus muscles hypertonicity. When looking at the results of the performed evaluations, one of the main findings of this doctoral research is that patients with voiding dysfunction may present a variable degree of abnormal kinematic gait patterns. In particular, we recorded gait cycles of seven self-selected subjects already diagnosed with PBNO, and we were able to quantitatively detect deviations at the ankle and pelvis level with respect to normal subjects. Four patients differed from controls in more than a third of the variables, two patients presented a mild discordance, while only one patient (P3) was almost comparable to normal subjects. Postural defects were not subjectively perceived by any of the seven participants in the gait study. In fact, all patients were completely asymptomatic from a musculoskeletal point of view. A comprehensive approach was used to treat PBNO patients enrolled in this doctoral research. These treatments provided good results. When analysing PBNO patients before and after treatment, our outcome measures were: improvement in uroflowmetric parameters (peak flow rate, average flow rate, PVR, and morphology of the curve), reduction or disappearance of pain (if present at first consultation), improvement in bladder diaries or in patient’s perceived discomfort. An increase in voided volume and a normalization of the curve shape was observed in all the uroflowmetries collected after rehabilitative treatments (25%, n. 18/71). Urethrocystoscopy was not repeated due to its invasiveness; moreover, we believe that it would not have added any further useful information. The relationship between urinary continence and posture was previously proposed and evaluated in a female population [Sahinkanat T, 2011]. In addition, affections in the musculoskeletal system were previously proposed as influencing elements in other pelvic dysfunctions such as chronic pelvic pain in male patients [Segura JW, 1979; Salvati EP, 1987; Hetrick DC, 2003] or anal incontinence in both male and female patients [Altomare DF, 2001]. In females, variations in the contractility of pelvic floor muscles and in the generation of intra-pelvic pressure may occur in case of maladjustment of the lumbo-pelvic area [O’Sullivan PB, 2002; Hungerford B, 2004; Bø K, 2005]. To the best of our knowledge, no previous scientific study proved a correlation between postural defects/modifications and bladder voiding disorders in the male population (e.g.: urgency, frequency, intermittency, etc.). We previously hypothesised the existence of a possible correlation between altered biomechanics of the pelvis and urethral sphincters activity in male patients reporting voiding dysfunction in the absence of neurological or orthopaedic signs [Camerota TC, 2016]. The results of this doctoral research show that gait variables at ankle and pelvis level were vastly discordant from normalcy, while gait variables at knee and trunk level were little-to-no interested. In our hypothesis, a modification in the normal static posture of the pelvis (for example, in the case of anteversion, retroversion or torsion) invariably determines a variation in the contractile state of the pelvic floor muscles. This support system behaves like a hammock between two trees: a movement in the structural part induces an adjustment on the elastic side. In the case of PBNO, we propose that the urethral sphincters hypertonicity might depend from a hypercontraction of the entire pelvic floor, due to an adaptation sustained by a modified static of the pelvis. Moreover, when magnetic resonance imaging was performed in a group of consecutive subjects enrolled in this doctoral research, it was frequently observed a hypertonicity of muscular structures of the perineal plane and/or a variation in the angle of inclination of the coccyx. An increased activity of the pelvic floor muscles may determine a modification of the coccygeal curvature; in our patients, this modification was evident both at MRI and at traditional X-ray imaging. Moreover, when we evaluated the full spine X-ray in two projections of the seven participants to gait analysis, we observed various discordant aspects from normality (e.g.: slight pelvic upslip, moderate sacral horizontalization, or scoliosis). These characteristics are coherent with previously published evidences. In fact, it is known that poor posture contributes to pelvic floor muscle shortening or tensing. Based on the evidences produced with the present doctoral research, we propose the following pathogenic mechanisms as underlying causes for PBNO: - at a static evaluation, a horizontalization of the sacrum linked to an anteversion of the pelvis causes a flexion of the coccyx; - when a dynamic approach is applied, postural imbalances identified at gait analysis determine an anomalous activation of the pelvic floor muscles, with consequent perineal plane hypertonicity; - from a morphological and functional point of view, this is accompanied by a shortening of pelvic floor muscles length. All these mechanisms may lead to urinary sphincters hypercontraction and to the development of urinary voiding symptoms in male patients with no significant morphological alterations. Moreover, a diffuse hypertonia of the pelvic floor may lead to a further modification of the coccygeal curvature, which consequently appears dysmorphic at X-ray and at magnetic resonance imaging. In this setting, PBNO may be a possible presentation of the so called “overactive pelvic floor muscles” condition. CONCLUSIONS The relationship between musculoskeletal affections and pelvic dysfunctions (such as chronic pelvic pain, or anal incontinence) have been previously described [Hetrick DC, 2003; Salvati EP, 1987; Segura JW, 1979; Altomare DF, 2001], mainly in the female population. The most innovative aspect of our research is the application of this hypothesis to a new study population. To the best of our knowledge, in the male population, the association between postural impairments and voiding symptoms has never been investigated with the approach we are proposing in this doctoral thesis. In our research we proved that – when examining male patients with chronic voiding symptoms (with or without associated pelvic pain) suspected for PBNO – comprehensive urologic, neurologic and pain assessment evaluations with deep pelvic floor muscle examination are required. This is crucial for the clear comprehension of patients’ discomfort (for example, to rule out other possible interference factors), for the definition of the optimal diagnostic workflow, and for the identification of the best therapeutic approach. The observations provided in this doctoral thesis are coherent with our initial hypothesis [Camerota TC, 2016] and preliminary data [Zago M, 2017], and may be summarized as follows: - a variable combination of irritative and obstructive voiding symptoms are reported at the first clinical evaluation; - pathologic flow characteristics were always present at uroflowmetry, with recurrent patterns (e.g.: plateau and stream intermittency); - internal and external urethral sphincters hypercontraction (urethral functional stricture) was always found at a flexible outpatient urethrocystoscopy; - myofascial pain syndrome was frequently diagnosed at pelvic pain assessment; - hooked coccyx, lumbar hyperlordosis, short leg syndrome, and different degrees of modifications in spino-pelvic parameters (e.g.: pelvic tilt) were identified at full spine X-ray; - external urethral sphincter thickening, pelvic floor muscles hypertonicity, hooked coccyx, sacroiliac joint sclerosis, and different degrees of modifications in spino-pelvic parameters (e.g.: pelvic tilt) were shown at MRI; - different degrees of pudendal or sacral neuropathy were found at neurophysiological testing, while sustained contractions and/or poor post-contraction relaxations were found at EMG; - non-subjectively perceived postural defects were identified in all the subjects who underwent gait analysis. In a general framework, our data confirm that static and dynamic pelvic balances are associated with pelvic floor muscles hypertonicity which is in the end responsible for voiding symptoms. In our cohort of patients, voiding dysfunction and pain appear to derive from a common pathogenetic mechanism: muscular hypertonicity is both a trigger for pain and an obstacle to normal urine flow. Moreover, the evidence of both sacroiliac joint suffering and modifications in coccygeal appearance at imaging confirm the presence of an important hypertonic contraction of the pelvic floor muscles in patients diagnosed with PBNO. This hypertonicity is strictly associated with postural imbalances, as shown by kinematics. Gait analysis is a useful tool to quantitatively measure kinematic variables of human movement. In our research, this methodology showed a significant deviation from normalcy in PBNO patients, with alterations mainly at the pelvis and ankle levels. Unfortunately, it was not possible to identify a clear correlation between the severity of urological reported symptomatology and the altered gait pattern per each patient (as quantified by the gait score), maybe due to the reduced sample size. In addition, it was not possible to find a unique morphologic pattern at imaging. Gait analysis is a reliable and reproducible functional test, it is both non-invasive and inexpensive. Unfortunately, gait evaluations are time-consuming and cannot be used on a routine basis due to equipment availability. Moreover, data analysis requires highly-specialized competences (e.g.: biomedical engineering). Furthermore, gait analysis is not currently recognized as a diagnostic procedure in Urology, and there is no reimbursement from the National Health System. Considering its positive characteristics, we propose gait analysis as a potential innovative tool for longitudinal study and for monitoring clinical response to treatment in PBNO. To the best of our knowledge, this research is the first to investigate and to prove a correlation among voiding dysfunction and postural/kinematic patterns in males. Pelvic floor hypertonicity is easy to be diagnosed and treated. In our opinion, the actual major limitation in the everyday clinical practice is represented by the fact that this condition is not looked for in males, and thus remains misunderstood. With our research we provide evidences proving that PBNO and pelvic floor muscles hypertonicity are strictly linked. Performing unconventional imaging in patients with dysfunctional voiding may be crucial to get an accurate diagnosis, thus leading to optimal clinical and therapeutic management. Therefore, multimodal comprehensive therapeutic plans are essential to properly treat patients diagnosed with PBNO. Pelvic floor rehabilitation is a crucial component of this approach. Patients should first of all understand the normal function of their pelvic floor; relaxation exercises and physical manipulations represent a second step. We strongly believe that this doctoral research may open up new possible horizons in the field of Urology. In fact, voiding symptoms and urological diseases were traditionally considered to be mostly surgical. Our recent innovative experience sustains the hypothesis that – if properly identified and diagnosed – there is a group of urological patients who may benefit from alternative treatments. Moreover, it is still well known that comprehensive treatments are more effective when the underlying mechanisms of a disease are properly understood. Therefore, results provided with our research appear to be relevant as they reveal an important need for rehabilitative medicine. Unfortunately, to date there is still insufficient knowledge of the real need for rehabilitation in Urology. In our opinion, the proper identification and characterization of these new needs represents the most ambitious challenge for innovative urologic services. Future researches are needed to verify after treatment results in the entire study population. Long-term follow-up (maintenance of clinical benefits over time) is also required. Cost/effect ratio needs to be thoroughly investigated. Moreover, additional research in the field of gait analysis applied to functional urological patients should be done. Further researches are also needed to better assess the cause/effect sequence between pelvic floor muscles hypertonicity and skeletal disorders (e.g.: hooked coccyx, sacroiliac joint dysfunction). Finally, the following limitations can be identified in this doctoral research: 1. PBNO is a heterogeneous disease, therefore it’s possible that – due to the selection criteria adopted – we are comparing subjects belonging to different clinical groups; 2. our follow-up (maximum four years) is not sufficient to affirm that PBNO does not represent the first clinical manifestation of an evolutive major neurological disorder; 3. the absence of a clear direct correlation between the severity of urological reported symptomatology and the altered gait pattern per each patient may be strongly influenced by the sample size of our study population; 4. some important morphometric characteristics may be missed while interpreting results, due to the lack of body mass index; 5. post-treatment urological and clinical improvements were proved in the group of PBNO patients whose data were available (25% of the entire study population); therefore, statistical results may change as we receive the missing data. REFERENCES Abrams P et al. 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This study aimed at identifying the factors contributing towards work related neck pain amongst university administrative staff, its impact on everyday life activities and in turn its prevalence. A quantitative descriptive cross sectional study design was used amongst the administrative staff at the University of The Western Cape, South Africa. Data collection was carried out with the help of a questionnaire which was administered by the researcher in person. Data was analysed with both descriptive and inferential statistics using SPSS and SAS for windows. Chi-square test and logistic regression analysis was done. The results of this study revealed a very high prevalence of work related neck pain amongst university administrative staff.

Abstract The etiology of musculoskeletal disorders remains largely unclear, pain being the predominant complaint. The prevalence of neck pain (NP), shoulder pain (SP), and low back pain (LBP) increases drastically during adolescence. Potentially modifiable risk factors of NP, SP, and LBP should be identified at that age. First, this study evaluated the prevalence of NP, SP, LBP and peripheral pains (upper or lower extremities) and the prevalence of multiple pains. Second, the study determined the role of a set of potentially modifiable risk factors for adolescents’ NP, SP, and LBP (physical activity, inactivity, sedentary activities in cross-sectional study design and quantity and quality of sleep in follow-up study design). The study population belongs to the 1986 Northern Finland Birth Cohort (NFBC 1986), consisting of 9,479 children with an expected date of birth between July 1, 1985 and June 30, 1986 in the two northernmost provinces of Finland, Oulu and Lapland. NP, SP, and LBP were common at the ages 16 and 18, while medical consultations for these pains were less frequent. The prevalence of pain increased with age. Peripheral pains were rare. Surprisingly many adolescents reported multiple musculoskeletal pains. Girls were more likely to report pain than boys. Both low and high level of physical activity, some risk sport activities, high amount of sedentary activities, and insufficient quantity and quality of sleep increased the risk of NP, SP, and LBP in adolescence. It may be possible to reduce the occurrence of musculoskeletal pain by having a positive impact on potentially modifiable risk factors, such as physical activity, sedentary activities and sleep hygiene. Therefore, intervention studies focusing on these factors are needed in the future
Tiivistelmä Useimmiten tuki- ja liikuntaelinsairauksien tarkka syy jää epäselväksi ja kipu on niiden pääasiallinen ilmentymä. Niska-, hartia- ja alaselkäkipujen esiintyvyys väestössä nousee merkittävästi teini-iässä. Tämän vuoksi niska-, hartia- ja alaselkäkivun riskitekijöitä tulisikin tutkia nuoruudessa, jotta niihin päästäisiin vaikuttamaan ajoissa. Tässä väitöskirjassa selvitettiin niska-, hartia-, alaselkä- ja laaja-alaisten tuki- ja liikuntaelinkipujen esiintyvyyttä nuorilla. Päätavoite oli kuitenkin tutkia liikunnan, eri urheilulajien, liikkumattomuuden, istumisen ja unen laadun ja määrän yhteyttä niska-, hartia- ja alaselkäkipujen esiintyvyyteen. Tutkimusaineisto muodostui Pohjois-Suomen syntymäkohortin 1986 nuorista, joiden laskettu syntymäaika oli 1.7.1985–30.6.1986. Nuorille lähetettiin 16-vuotiaana postikysely, joka sisälsi tuki- ja liikuntaelinoirekyselyn, kysymyksiä liikunnan, istumisen ja unen määrästä ja laadusta, sekä muista elämäntavoista. Kahden vuoden kuluttua, 18-vuotiaana lähetettiin toinen kysely joka sisälsi mm. tuki- ja liikuntaelinoirekyselyn. Tulokset osoittavat että niska-, hartia- ja alaselkäkivut olivat yleisiä nuoruudessa, joskin hoitoa vaativat kivut ja raajojen kipuoireilu olivat harvinaisia. Laaja-alaiset tuki- ja liikuntaelinkivut olivat odotettua yleisempiä. Tytöt oireilivat enemmän kuin pojat ja oireilu lisääntyi iän myötä. Hyvin aktiivinen liikunnan harrastaminen (6h/vko tai enemmän ripeää liikuntaa) ja erityisesti tietyt riskilajit olivat yhteydessä suurempaan niska-, hartia- ja alaselkäkipujen esiintyvyyteen. Samoin suuri istumisen määrä, riittämätön uni ja huono unen laatu lisäsivät kipujen todennäköisyyttä. Nuorten tuki- ja liikuntaelinkipuja voitaisiin mahdollisesti vähentää vaikuttamalla muunneltavissa oleviin riskitekijöihin, kuten vähentämällä istumista, lisäämällä terveysliikuntaa, sekä parantamalla unitottumuksia. Tämän takia jatkossa tarvitaan näihin riskitekijöihin kohdistuvia interventiotutkimuksia

Discovering biomarkers and molecular drivers of head and neck endocrine tumors was the inspiration for this thesis. Here, I describe the molecular evaluation of tumors of the thyroid and parathyroid endocrine glands for the purpose of identifying somatic driver alterations in these cancers. While molecular interplay of the germline genomic background of an individual and the somatic genome that emerges throughout the lifetime plays significant roles in increasing the susceptibility to cancer and in driving the malignant phenotype, the major known contributors to cancer remain the acquired somatic mutations. Analysis of a sporadic and recurring parathyroid carcinoma, with incidence of 1 per million population, revealed mutations in mTOR, MLL2, CDKN2C and PIK3CA and comparison of patient-matched primary and recurrent malignant tumors uncovered loss of PIK3CA activating mutation during the evolution of the tumor. Loss of the short arm of chromosome 1 along with somatic missense and truncating mutations in CDKN2C and THRAP3 provided new evidence for the potential role of these as tumor suppressors. Hürthle cell thyroid carcinoma accounts for a small proportion of all thyroid cancers; however, this malignancy often presents at an advanced stage and poses unique challenges. Genomic analysis revealed large regions of copy number variation encompassing nearly the entire genomes accompanied also by near haploidization. Moreover, I identified loss-of-function mutations of the tumor suppressor gene MEN1 in 4% of patients. Repeated alterations of the epigenetic machinery in anaplastic thyroid carcinoma, one of the most fatal of all adult solid malignancies, and novel gene fusions including MKRN1-BRAF, FGFR2-OGDH and SS18-SLC5A11 are reported here. The transcriptomic analysis suggested known drug targets such as FGFRs, VEGFRs, KIT and RET to have low expressions in this cancer; however, through integrative data analysis, I identified the mTOR signaling pathway as a potential therapeutic target for anaplastic thyroid cancer. Molecular analysis of papillary thyroid carcinoma and benign thyroid nodules revealed very low mutation rates in these tumors with CYP1B1, PTPRE, CTSH and RUNX1 emerging as promising diagnostic markers. The key somatic mutations identified in these studies can serve as novel diagnostic markers as well as therapeutic targets.
Science, Faculty of
Graduate

The role of the anterior neck muscles in cervical dysfunction has become an area of interest in the physiotherapy literature, resulting in the development of new methods for assessing and treating dysfunction of these muscles. However, these methods are based primarily on electromyographic (EMG) and various imaging studies, and lack a detailed anatomical or biomechanical foundation. The purpose of this work was to examine the morphology and basic biomechanics of the sternocleidomastoid (SCM); scalenus anterior, medius, and posterior; longus capitis and colli; rectus capitis anterior and lateralis muscles with a view to better understanding the capabilities of these muscles. This will contribute to our understanding of the mechanisms of cervical disorders and inform more evidence based approaches to treatment. This research was completed in three stages: dissection of the fascicular anatomy of the anterior neck muscles in embalmed cadavers; magnetic resonance imaging (MRI) of these muscles in young volunteers; and biomechanical modelling. Descriptive and morphological data from both the dissection and MRI studies were recorded, and cross-referenced for input into the biomechanical model. The biomechanical study involved calculating the peak force capabilities of each fascicle, and deriving the orientation and distribution of these forces across the cervical motion segments using CT scans. The result was a detailed breakdown of the peak torque, compression and shear forces generated by the anterior neck muscles at a fascicular level, calculated with reference to each cervical motion segment. The dissection study revealed several interesting findings regarding the structure of these muscles, adding considerable detail to anatomical textbook descriptions. Findings are described for each individual muscle. The MRI study found substantially larger muscle volumes than found in the dissection study, due to changes both with age and embalming. Biomechanical modelling demonstrated that in the neutral position the anterior neck muscles are not capable of exerting large forces, and do not act equally on all the cervical motion segments. Moment generating capacity into flexion was dominated by the SCM, and increased at lower levels in the cervical spine. All muscles were capable of producing compression, and total compression capacity remained relatively even at different cervical levels. Shear capacity was minimal, and was only potentially produced by the SCM in the lower cervical spine. The anterior neck muscles are complex and interesting muscles for which textbook descriptions tend to be simplified. These muscles act closely on the cervical motion segments, producing largely compressive forces. The more deeply placed longus and scalene muscles demonstrated a limited capacity for producing flexion moments, especially compared to the SCM. At C2-3 the SCM produced a net extension moment, suggesting that at this level (and above) the longus capitis and colli may proportionally play a greater role in cervical flexion. However, the force capabilities of these muscles remain very small and may be insufficient to produce actions attributed to these muscles in the clinical literature. This research presents data fundamental to understanding the function of these muscles, and which has the potential to contribute towards many different biomechanical applications in future research.

The purpose of this study was to classify oral squamous cell carcinomas (OSCCs) based on their gene expression profiles, to identify differentially expressed genes in these cancers, and to correlate genetic deregulation with clinical-histopathological data and patient outcome. After conducting proof of principle experiments utilizing six head and neck squamous cell carcinomas (HNSCCs) cell lines, the gene expression profiles of 20 OSCCs and subsequently an additional 8 OSCCs were determined using cDNA microarrays containing 19,200 sequences and the Binary Tree-Structured Vector Quantization (BTSVQ) method of data analysis. Two sample clusters were identified in the group of 20 tumors that correlated with T3-T4 category of disease (P=0.035) and nodal metastasis( p=0.035). Samplec lustering of 28 OSCCsa nd the 6 cell lines revealed a correlation with disease free survival. BTSVQ analysis identified a subset of 23 differentially expressed genes with the lowest quantization error scores in the cluster containing more advanceds taget umors from the 20 OSCC dataset.T he expressiono f six of these differentially expressedg enesw as validated by quantitative real-time RT-PCR. Statistical analysis of quantitative real-time RT-PCR data was performed and, after Bonferroni correction, CLDNI (p = 0.007) over-expressionw as significantly correlated with the cluster containing more advanced stage tumors. Despite the clinical heterogeneity of OSCC, molecular subtyping by cDNA microarray analysis was able to identify distinct patternso f genee xpressiona ssociatedw ith relevant clinical parameters. The application of this methodology represents an advance in the classification of oral cavity tumors, and may ultimately aid in the development of more tailored therapies for oral carcinoma.

Head and neck cancer is the 6th most common cancer and is generally treated with surgery and post surgical radiotherapy (RT) alone or in combination with chemotherapy (CT). Over 50% of the patients fail to respond to such treatment while suffering the undesirable side effects of radio-chemotherapy. This highlights the need for new strategies to be able to select patients who could benefit from a specific treatment type to spare cost and suffering to the patients. Furthermore, there is need for targeted and effective therapeutics for this disease. TRAIL and Smac mimetics are novel promising anticancer agents. However, their effect on head and neck cancers so far has not been tested. The main objective of this research was to investigate biomarkers which could predict response of head and neck squamous cell carcinoma (HNSCC) to novel and conventional therapies. This has been conducted using two different approaches: The first was to test the sensitivity of HNSCC cell lines to two novel anticancer therapeutic agents, TRAIL and Smac mimetics, and further to identify the biomarkers which could predict response of HNSCC cell lines to these drugs. Furthermore, the underlying mechanisms by which these two agents induce apoptosis in HNSCC cell lines were examined. Nine HNSCC cell lines were tested for their sensitivity to either recombinant TRAIL (h-IZTRAIL) and/or Smac mimetic (Smac59). The pathways involved in their apoptotic response were studied using western blotting, enzyme linked immunosorbent assays and FACS analysis. Overexpression and knockdown experiments were used to examine the importance of certain apoptotic regulators in response to TRAIL and Smac59 treatment. All 9 HNSCC cell lines were found to be successfully killed with either TRAIL or Smac59. TNF-a, caspaseS, bc!2 and EGFR expression levels correlated with TRAIL/Smac59 sensitivity. There was no correlation between the expression of inhibito. The second part of the study was a retrospective study to assess response of HNSCC to treatment (surgery and/or radiotherapy) by selecting patients who have been treated with surgery and/or radiotherapy and for whom 5 years follow up data was available. For this part of the project, paraffin embedded formalin fixed biopsies from HNSCC patients were used to construct tissue microarray blocks. The expression of a number of genes involved in the DNA damage repair pathway and tumour hypoxia including PTEN, Ku80, RadSl, XRCC1, ERCC1 and HEP-la was tested using immunohistochemistry staining IHC. The tested genes were found to be expressed at varying levels in HNSCC patients. Associations between the level of the expression and gender, site of origin, tumour differentiation, TNM stage, lymph node metastases, overall and disease free survival and treatment outcome were investigated using statistical analysis programme SPSS. Using univariate analysis, ERCC1 expression was significantly associated with poor outcome to treatment. HIF-la high expression was significantly associated with short disease free survival and poor treatment outcome. Using multivariate analysis, PTEN expression was significantly associated with poor treatment outcome. In summary, it could be concluded that HNSCC cell lines could be killed effectively using TRAIL and Smac59 and their sensitivity could be predicted by level of caspase-8, TNF-a, Bcl-2 and EGFR proteins. TRAIL and Smac59 induce caspase-dependent apoptosis in HNSCC cell lines which consequently results in depletion of XIAP. Smac59 induces TNF-a autocrine secretion in Smac59 sensitive cell lines and adding rhTNF-a sensitised Smac59 resistant cells to Smac59. miRNA expression could be a marker for sensitivity of HNSCC cell lines to TRAIL and Smac59, however more investigation is required to validate this finding. In conclusion, these findings suggest a potential molecular signature that may be able to predict response of head and neck cancers to TRAIL and Smac59 for the treatment of HNSCC. Expression of genes involved in DNA damage repair and tumour response to hypoxia could be potential biomarkers for patient’s prognosis and response to treatment.