Colostomy Reversal following Hartmann’s Procedure: The Importance of Timing in Short- and Long-Term Complications: A Retrospective Multicentric Study

The restoration of bowel continuity following Hartmann’s Procedure (HP) has been reported hitherto with high morbidity and mortality rates. No clear guidelines exist about timing in Hartmann’s Reversal (HR), the literature data being conflicting. We have sought to investigate the effect of the interval time between HP and HR in short- and long-term HR outcomes through a retrospective study based on consecutive patients undergoing HR between 2009 and 2017 in two regional hospitals in Italy. Demographic characteristics, comorbidities, intra- and post-operative data, as well as early complications, were recorded. Long-term data were collected on the surgical site occurrences of Incisional Ventral Hernia (IVH). One hundred and five patients were recruited for the study. Late HR, female gender, and long operating time were related to the highest incidence of peri-operative complications. Patients who developed IVH had undergone HR at significantly shorter times and had a higher Body Mass Index (BMI). The timing of HR seems to be an important variable linked to the onset of early and late post-operative complications. The patients submitted to early HR show a significantly lower complication rate but, at the same time, a higher rate of IVH incidence after restorative surgery. These data, in our opinion, reflect the need for planning, where possible, an early restoration of bowel continuity after HP.

Virulence and antibiotic resistance of Klebsiella pneumoniae strains isolated from wastewater

Background

Multidrug-resistant Klebsiella pneumoniae (Kp) strains are considered a global public health threat. The aim of the present study was to assess the occurrence of resistant and virulent Kp in Italian environmental wastewater, in order to evaluate the contribution of wastewater as reservoir of virulent and multidrug-resistant bacteria.

Methods

Forty samples of wastewater were collected in six sampling sessions from June to November 2018 in Central Italy and processed to detect Kp. All the presumptive Kp colonies isolated were identified by MALDI-TOF MS (Bruker Daltonics, Germany), then the genome sequences of all the confirmed Kp were obtained using Illumina Sequencing. Finally, characterization of virulence and resistance genes was performed in silico using the BIGSdb-Kp database provided by the Institut Pasteur (http://bigsdb.web.pasteur.fr).

Results

Kp was detected in 32 out of 40 samples (80%) and all strains were confirmed as Kp by MALDI-TOF MS. Genotyping analysis showed that besides the native bla-SHV, bla-LEN, bla-OKP genes linked to β-lactams resistance, gyr and par genes, involved in quinolone resistance, and no other resistance genes were detected. Regarding virulence, all strains carried the fimbriae encoding gene mrk, associated with adhesion and biofilm formation. The ferric aerobactin receptor iutA was harbored by 3 strains (9.4%). The siderophore Yersiniabactin locus (ybtS, ybtX, ybtQ, ybtP, ybtA, irp2 irp1, ybtU, ybtT, ybtE, fyuA), essential for iron scavenging, is carried by 7 out of 32 strains (21.9%).

Conclusions

Our results showed a high prevalence of Kp in wastewater that also harbored several resistance and virulence genes. These results make interesting to investigate more about wastewater as hot spots of enrichment, recombination, genetic exchange and selection of antibiotic resistant “super-bugs” that persisting and surviving in the environment could be a health risk for humans and animals.

Key messages

Wastewater could play a role as Klebsiella pneumoniae reservoir of virulence and resistance genes that can disseminate into wildlife and reach humans. It’s necessary a “one health” approach to deeply investigate about the presence of superbugs bacteria in the environment and the possible risks for human health.

Fast WGS source attribution of Listeria monocytogenes outbreak in a sheep flock in Abruzzo region

Background

Listeriosis is a life-threatening disease in human as well as animals, cows and sheep are the most sensible to the disease. Correlation to feed is well documented (silage). Some clonal complexes (CCs) are more virulent than others and frequently involved in animal and human listeriosis. Whole genome sequencing (WGS) and in silico CCs identification and core genome multilocus sequence typing (cgMLST) determination are the best way to characterize isolates and confirm connection between clinical strains and source of contamination. This work aimed to demonstrate the advantages of using WGS to find the source of Listeria monocytogenes (Lm), causing an outbreak in an ovine farm in Abruzzo region.

Methods

Lm was detected according to ISO 11290-1:2017. Serogroup was determined by multiplex PCR. WGS data were obtained using Illumina platform. Sequences were used to assess CCs and cgMLST according to BIGSdb Pasteur platform. Two brain samples and 1 lymph node from 2 sheep, one sample of silage (15 analytical portion), and 1 sample of hay were tested.

Results

Lm was detected in all animal specimens and in 2 analytical portions of feed (silage) tested. Out of 35 colonies detected 28 were identified as Lm (27 serogoup IVb and 1 sample of silage serogroup IIa). Five colonies were selected for WGS (one from each animal brain, one from the lymph node and one from each positive analytical portion of silage), among them only one colony from the silage showed the same CC of the strains isolated from sheep (CC1). cgMLST revealed no allelic distances between these strains.

Conclusions

CC1 is the main virulent clone among Lm isolates often involved in human and animal outbreak. Feed may be a vehicle for Lm and could be the outbreak source. Cases ceased after removing the silage. Use of WGS is a definitive help in source attribution when feed is available and the sampling is done in a correct manner.

Key messages

Silage can be cause of listeriosis in livestock. WGS can improve source attribution of outbreaks detecting the relatedness of the strains and improving the epidemiological investigation in case of outbreak.

Shiga-toxin producing Escherichia coli detection in samples from Abruzzo and Molise regions, Italy

Background

Top five serogroups (O157, O111, O26, O103 and O145) of Shiga-toxin producing Escherichia coli (STEC) represent the third most important increasing zoonosis reported in European Union. The ISO methods of analysis, used in foods and environmental samples, quite often does not confirm the molecular detection of STEC genes (stx1 and stx2) in enrichment broth. The aim of this study was to summarize the results of the tests carried out at Istituto Zooprofilattico Sperimentale dell'Abruzzo e del Molise in the last six years (2016-2021), comparing genes detection in enrichment broth and in colonies grown on agar plates.

Methods

Along the 2016-2021, a total of 1716 foods and environmental samples from Abruzzo and Molise regions were tested, according to ISO/TS 13136:2012.

Results

Out of 1716 samples, 16 (0.9%) shown presumptive positive presence of STEC (stx1 and/or stx2) in broth. In spite of that, the presence of STEC (positive colonies for stx1 and/or stx2) was confirmed only in 4 out of 16 samples (one sample of cheese and 3 of minced meat). Then, eae gene was found in 54 samples in broth and only in 3 samples from colonies, during a foodborne outbreak investigation. Serogroup specific targets were detected in 6 broth samples (O26, O145 and O157) and confirmed in colonies only in 2 minced meat samples (O157).

Conclusions

STEC are a heavy hazard for the consumers and the number of cases is slightly increasing since 2015. Our results highlight a low number of presumptive positive samples and even lower number of STEC detection obtained with the ISO classical method. Furthermore, detection of the target genes in broth was rarely confirmed after plating, highlighting a weak point of the analytical method that needs to be investigated. Efforts are necessary to improve the method and the STEC confirmation from colonies. Immunomagnetic beads targeting the top five serogroups and digital PCR could help in increasing the recovery rate of cultivable STEC.

Key messages

The presumptive positive samples for STEC genes in foodstuffs from the Abruzzo and Molise regions are quite rare, even lower is the number of confirmed colonies by agar plate isolation. Specific immunomagnetic beads for the top five STEC serogroups could improve the method and the STEC colonies detection, increasing the recovery rate of cultivable strains.

Klebsiella pneumoniae in vegetable products: antimicrobial resistance and consumer health risk

Background

Klebsiella pneumoniae (Kp) is considered one of the major causes of human hospital infections. Moreover, Kp is often present in several food products and it could be a potential health hazard for the consumers through the increase of Kp antimicrobial resistance (AMR) to the main routinely used antibiotics classes. The aim of this study was to evaluate the AMR profile of Kp strains isolated from vegetable food products.

Methods

The whole genome sequences of 10 Kp strains, previously isolated from carrots (n. 4), salads (n. 3), tomatoes (n. 2) and pumpkin (n. 1) samples, were obtained by next generation sequencing technique, using Illumina platform. Phenotypic and genotypic AMR profiles, with particular attention to β-lactams, quinolones and aminoglycosides resistances, were acquired by both agar diffusion and micro-dilution susceptibility testing and uploading the Kp sequences to Institut Pasteur platform (https://bigsdb.pasteur.fr/), respectively.

Results

Most of Kp strains (9 of 10) resulted susceptible to the main antibiotics tested and few AMR genes were detected in silico besides the native blaSHV, blaOKP and blaLEN. Only one Kp harboured blaAMPC and blaCMY, showing resistance to 5 β-lactams (amoxicillin/clavulanate, cefoxitin, cefpodoxime, cefpodoxime/clavulanate, ceftobiprole). Regarding the quinolone resistances, all the Kp strains carried gyr and par genes. No aminoglycoside resistance genes were highlighted in the 10 Kp strains studied.

Conclusions

These preliminary results showed the presence, in vegetable foods, mainly in ready to eat raw products, of Kp strains, harbouring no or few AMR genes. Good hygiene practices should be properly applied during the entire food processing chain, to avoid hazardous implications for the consumer. Further studies are needed in order to: analyse more vegetable samples, deeply evaluate the phenotypic and genotypic AMR profile of the Kp strains and their possible transmission from food products to consumer.

Key messages

Klebsiella pneumoniae is often isolated in food, as ready to eat vegetables, and it could be a potential public health risk due to the antimicrobial resistance increase to main antibiotics. The presence of Klebsiella pneumoniae in food implies the correct application of good hygiene practices in the entire food processing chain, in order to avoid dangerous effects for consumers.

Multidrug-resistant Klebsiella pneumoniae: risks to food safety and public health

Background

Klebsiella pneumoniae (Kp) is a Gram-negative hospital-acquired pathogen. Kp also poses a potential food safety hazard, since a significant increase of multidrug-resistant (MDR) Kp was observed in foods. The purpose of this study was to characterize MDR Kp strains in order to evaluate the presence of beta-lactams, quinolones and aminoglycosides resistance genes.

Methods

A total of 13 Kp strains, isolated from chicken (n.8), raw milk (n.2), waste water (n.2), human faeces (n.1), and identified as MDR by microdilution test, were selected to evaluate antimicrobial resistance profiles, focusing on beta-lactams, quinolones and aminoglycosides. Next Generation Sequencing (NGS), with NextSeq 500 Illumina platform, was performed to acquire genome sequences. The antimicrobial resistance profiles were obtained using ResFinder (https://cge.cbs.dtu.dk/services/ResFinder/).

Results

From the 13 Kp considered, 6 strains (46.2 %) showed the presence of several beta-lactam genes. The blaSHV gene was carried by 12 Kp (92.3%); of these strains, 5 also carried blaTEM (41.7%) and 3 also blaCTX-M (25.0%) genes. Only 1 Kp strain showed the presence of blaOKP-A gene. All the 13 Kp carried the oqxA and oqxB genes. Of these strains, 4 also highlighted the presence of qnrB or qnrS plasmid-mediated gene for quinolone resistance. Regarding aminoglycoside resistance, 6 Kp strains (46.2%) carried aph, aadA and aaC genes, linked to gentamicin and streptomycin resistance protein.

Conclusions

These preliminary results emphasize the need of further studies on more several samples, to better understand the antimicrobial resistance of Kp strains, the hypothetical transmission of MDR Kp from foods to consumers and the potential risk posed to food safety, environmental and public health.

Key messages

The increasing prevalence of multidrug-resistant Klebsiella pneumoniae requires the need to investigate more foods and environmental samples to ensure consumer safety and public health. Public health safety requires a major knowledge of the hypothetical mechanisms and routes of transmission of multidrug-resistant Klebsiella pneumoniae.

Detection of Klebsiella pneumoniae complex in carrots

Background

Klebsiella pneumoniae (Kp) is an opportunistic pathogen now acknowledged as an urgent threat to human health because it is multi-drug resistant bacteria. The role of food as reservoir or carrier of Kp is under investigation, at the same time the optimization of the method to detect Kp in food is ongoing. The study was aimed to detect Kp in carrots using conventional method and to screen Real-time PCR performances, targeting intergenic sequence between zur and khe, based on INRA and Pasteur Institute method

Methods

A total of 60 samples of carrots were tested. The samples (25 g) were added to 225 ml of Buffered peptone water and incubated at 37 °C and at 44 °C for 24h. After incubation broths were subjected to Real-Time PCR, and one loop streaked on SCAI + inositol agar. Plates were then incubated at 37 °C and at 44 °C for 48 h. After incubation a maximum of 5 typical colonies were selected, subcultered on Nutritive agar and identified by MALDI-TOF MS.

Results

The RT PCR gave 29 positive samples, according to the presence of Kp detected at least in one of the two temperature conditions of broths incubation and 31 negative samples. Conventional culture gave, instead, 13 positive and 47 negative samples. Discordance was highlighted in 16 samples, all positives in RT-PCR and negatives with culture method.

Conclusions

Real-Time PCR gave not false negative results, then PCR decrease the time needed to perform the detection in negative samples. The discordance of results could be linked to lack of selectivity of the SCAI agar + inositol, not able to distinguish colonies of Klebsiella spp. Vs similar colonies not Klebsiella spp., the presence of DNA and not viable cells. The process of validation of the detection method is still ongoing, trying to improve selectivity using two selective media for plating. It's necessary to do new trials and to select more typical colonies to increase the probability to detect Kp colonies.

Key messages

Real-Time PCR is able to detect all positive samples, and to shorten the length of the analytical method. To improve sensibility of the analytical method more selective media need to be used.

Acute chest pain and esophageal mucosal injury following an extreme yoga position Case report

A young lady complained of the sudden onset of intense chest pain, in consequence of an extreme hyperextension of the back in a yoga position. At endoscopy a large lesion of the esophageal epithelium was detected, involving the middle third of the anterior wall of the esophagus. Other symptoms reported by the patient were dysphagia and odynophagia, depicting the typical features of intramural hematoma, also known as intramural dissection or intramural perforation of the oesophagus. The patient was managed conservatively and symptoms disappeared within a week. A barium swallow at six months reported normal findings. Different types of accidents occurring during yoga practice are reported in the literature, mainly involving musculoskeletal or nervous systems. Visceral lesions are exceptional and no similar cases have been reported in the literature. KEYWORDS: Acute chest pain, Esophageal lesion, Intramural hematoma, Management of esophageal lesion.

Extensive surgery and lymphadenectomy do not improve survival in primary melanoma of the anorectum: results from analysis of a large database (SEER)

AIM

Primary anorectal melanoma is a rare disease with a dismal prognosis due to early distant metastasis. The prognostic value of positive loco-regional lymph nodes and the impact of lymphadenectomy on overall survival are unclear. We have investigated this by analysis of data obtained from a national representative database, controlling for potential confounders.

METHODS

Data were retrieved from the Surveillance, Epidemiology and End Results (SEER) database. Multiple imputation analysis was performed to deal with missing data. Cox regression models were formulated using different prognostic factors including site of origin, gender, size, race, rate of lymph node metastasis (ratio between positive lymph node count and total lymph nodes harvested), extent of lymphadenectomy (none, level I etc.), age, type of surgery, stage of disease and administration of radiotherapy.

RESULTS

Our population was composed of 208 patients who underwent surgery between 1998 and 2012. Rate of lymph node metastasis (P = 0.027; hazard ratio 1.873, 95% CI 1.076-3.261) and race (P = 0.019; hazard ratio 2.291, 95% CI 1.148-4.575) were found to be independent predictors of survival.

CONCLUSION

Based on the data retrieved from the SEER database, metastasis to loco-regional lymph nodes is an important prognostic factor, but lymphadenectomy does not improve survival.

Cadherin-6 promotes EMT and cancer metastasis by restraining autophagy

The transdifferentiation of epithelial cells toward a mesenchymal condition (EMT) is a complex process that allows tumor cells to migrate to ectopic sites. Cadherins are not just structural proteins, but they act as sensors of the surrounding microenvironment and as signaling centers for cellular pathways. However, the molecular mechanisms underlying these signaling functions remain poorly characterized. Cadherin-6 (CDH6) is a type 2 cadherin, which drives EMT during embryonic development and it is aberrantly re-activated in cancer. We recently showed that CDH6 is a TGFβ target and an EMT marker in thyroid cancer, suggesting a role for this protein in the progression of this type of tumor. Papillary thyroid carcinomas (PTCs) are usually indolent lesions. However, metastatic spreading occurs in about 5% of the cases. The identification of molecular markers that could early predict the metastatic potential of these lesions would be strategic to design more tailored approaches and reduce patients overtreatment. In this work, we assessed the role of CDH6 in the metastatic progression of thyroid cancer. We showed that loss of CDH6 expression profoundly changes cellular architecture, alters the inter-cellular interaction modalities and attenuates EMT features in thyroid cancer cells. Using a yeast two-hybrid screening approach, based on a thyroid cancer patients library, we showed that CDH6 directly interacts with GABARAP, BNIP3 and BNIP3L, and that through these interactions CDH6 restrains autophagy and promotes re-organization of mitochondrial network through a DRP1-mediated mechanism. Analysis of the LIR domains suggests that the interaction with the autophagic machinery may be a common feature of many cadherin family members. Finally, the analysis of CDH6 expression in a unique cohort of human PTCs showed that CDH6 expression marks specifically EMT cells. and it is strongly associated with metastatic behavior and worse outcome of PTCs.

Laparoscopic versus open appendectomy in obese patients: A meta-analysis of prospective and retrospective studies

BACKGROUND:

A meta-analysis of different kinds of studies was performed to assess outcomes of laparoscopic versus open appendectomy in obese patients.

MATERIALS AND METHODS:

Retrospective and prospective studies enrolling patients with a body mass index greater than 30 kg/m² were included. Primary outcomes were days of hospital stay, surgical procedure duration, and overall post-operative complication rate. Secondary outcomes were wound infection and intra-abdominal abscesses formation rate, hospital charges.

RESULTS:

Laparoscopic appendectomy showed to be significantly associated with lower wound infection (P < 0.001) and post-operative complication rate (P < 0.001). Surgical time was considered as a hallmark of technical challenge and resulted diminished in the laparoscopic group (P = 0.018). Although not clinically relevant per se, the statistically significant shorter hospital stay (P < 0.001) was probably the reason of decreased hospital charges (P < 0.001). Intra-abdominal abscesses formation rate was higher in the open appendectomy group (P = 0.058), although slightly above the statistical significance threshold.

CONCLUSION:

Laparoscopic approach seemed to show relevant advantages compared to open appendectomy, but a large prospective trial is necessary to collect high quality data and investigate long-term outcomes.

Rectal versus non-rectal primary signet ring cell carcinoma of the colorectum: a retrospective survival analysis controlled for confounders

PURPOSE

Our objective was to compare the outcomes of rectal and non-rectal primary signet ring cell adenocarcinoma of the colorectum.

METHODS

A retrospective survival analysis was performed using the Surveillance, Epidemiology, and End Results Program database between 2004 and 2009 on subjects who were diagnosed as having a primary signet ring cell carcinoma of the colorectum. Cox proportional hazard regression analysis controlled for confounders was used to assess overall survival comparing rectal and non-rectal cancers.

RESULTS

Our population was composed of 1,484 patients: 200 affected by rectal cancer and 1,284 by non-rectal cancer. Unadjusted survival curves resulted to be almost superimposable (P = 0.916). After controlling for age, gender, race, tumor stage, grade, and size, tumor location demonstrated a statistically significant impact on overall survival (P = 0.032; 95% confidence interval 0.640-0.980; hazard ratio 0.792).

CONCLUSION

On the basis of analysis of information from the SEER database, the signet ring cell carcinoma of the rectum was associated to a worse prognosis as compared to non-rectal cancer.

Sporadic carcinoma of the colon-rectum in young patients: a distinct disease? A critical review

INTRODUCTION

Colon carcinoma is rare in patients under 40 years but incidence is increasing. Results regarding outcome of this age group have been controversial and difficult to interpret. Some authors have reported a worse prognosis related to advanced stage at diagnosis and cancer-aggressive behavior. We tried to assess whether sporadic colon carcinoma in young patients is a distinct disease with different etiology and how this reflects on outcome.

METHODS

Most relevant papers published and indexed on PubMed in the last 20 years were reviewed. Epidemiological data were retrieved from the Surveillance, Epidemiology and End Results database and discussed.

DISCUSSION

Stage-specific analyses adjusted for age have demonstrated that prognosis is related to tumor stage regardless of age. Advanced stage is partly due to tumor biology and to delayed diagnosis. Younger patients show a better performance status that allows aggressive multimodal treatment.

CONCLUSION

Colon carcinoma in young adults appears to be a distinct disease characterized by biological aggressiveness, but prognosis is not worse due to a better performance status at time of surgical intervention.

A novel BRAF mutation in association with primary amelanotic melanoma with oral metastases

BACKGROUND

In the context of amelanotic melanoma, little is known on the genetic or molecular background that determines the onset of this peculiar phenotype of melanoma and its sites of metastatic spread. However, it appears that amelanotic melanomas frequently lack BRAF mutations.

OBJECTIVE

To report the genetical analysis of one case amelanotic melanoma developing oral metastasis.

METHODS

The BRAF mutational status of the primary lesion was assessed by both Sanger sequencing and pyrosequencing.

RESULTS

Both methodologies showed changes in three nucleotides: C1796T; G1798A and T1799A. These mutations should result in a rare double aminoacid substitution in codons 599 and 600 of the BRAF protein (BRAF T599I/V600K).

CONCLUSION

This unusual mutation was associated with an uncommon clinical phenotype of the primary tumour and with an unusual site of metastatic spread. In the lack of comparable data, a potential association between the unusual mutation and clinical findings remains a matter of further studies.

Induction of complete regressions of oncogene-induced breast tumors in mice

Over the past decade, mouse models of cancer have come to resemble human disease much more closely than simple subcutaneous or orthotopic systems. Intervention strategies that work on these new model systems are more likely to have an impact clinically. We have shown recently that antiangiogenic stress imposed by loss of Id protein in endothelial progenitor cells results in dramatic central necrosis in breast tumors initiated in mice by overexpression of the her2/neu oncogene. Tumor cells remain viable at the periphery, perhaps via the hypoxic response pathway which allows the lesions to expand. Inhibition of this pathway by the inactivation of the Hif-1alpha chaperone Hsp90 in combination with antiangiogenic stress leads to the first reported complete regression of these aggressive breast tumors.

Plasma lipoprotein(a) concentration in familial hypercholesterolemic patients without coronary artery disease

Familial Hypercholesterolemia (FH) is a condition characterized by markedly elevated blood cholesterol, low-density lipoproteins (LDL), and apolipoprotein B-100 (apo B). The molecular basis of this monogenic disease is the defective functioning of the cellular receptor for LDL that recognizes apo B. Lipoprotein(a) [Lp(a)] is a circulating lipoprotein that is structurally related to LDL, as it also contains apo B. To assess the impact of the LDL receptor deficiency on the plasma Lp(a) concentration, we measured Lp(a) in 28 FH patients and in 31 unaffected relatives. Because elevation of Lp(a) concentration in plasma of patients with coronary artery disease (CAD) appears to occur independently from plasma cholesterol levels, to avoid potentially confounding problems, members of the families chosen had no history for the disease. Whereas apo B clearly showed a bimodality of distribution by being significantly higher in the FH patients (166 +/- 38 mg/dL) than in the unaffected relatives (92 +/- 18 mg/dL), Lp(a) concentration did not differ in the two groups of patients (30 +/- 24 mg/dL in the FH patients v 31 +/- 23 in the normolipidemic relatives). Similar results were obtained when only siblings were further considered. We conclude that although Lp(a) is closely related to LDL structurally, its level in plasma is not significantly affected by the LDL receptor activity.

Extracellular RGD-binding proteins modulate cell adhesion

Cell/fibronectin adhesion in extracellular matrices is partly mediated by integrin receptor recognition of RGD domains in fibronectin. Since blood contains significant levels of soluble fibronectin we have now investigated the occurrence of extracellular RGD-binding proteins. Attachment assays indicate that extracellular RGD-binding proteins prevent cell adhesion, suggesting their potential as novel secreted modulators of blood-borne cell adhesive interactions. These extracellular RGD-binding proteins also showed electrophoretic changes with reducing agents, suggestive of intrachain disulphide bonds, like those found in RGD-binding integrins. However, they differed from the latter in their electrophoretic profile, which was greatly dependent on the presence of protease inhibitors. Plasma from tumor-bearing mice showed a greater proportion of fast-migrating RGD-binding species under reducing condition compared to similarly treated normal plasma, suggesting that tumor development is associated with a partial degradation of extracellular RGD-binding proteins.

Pravastatin in heterozygous familial hypercholesterolemia: low-density lipoprotein (LDL) cholesterol-lowering effect and LDL receptor activity on skin fibroblastS

The cholesterol-lowering effect of provastatin, a new competitive inhibitor of 3-hydroxy-3-methyl-glutaryl coenzyme A (HMG-CoA) reductase, was studied in 10 patients with heterozygous familial hypercholesterolemia (FH). Residual low-density lipoprotein receptor (LDL-R) activity was also evaluated in cultured skin fibroblasts prior to treatment, and showed a wide range of reduction from 30% to 70% of the normal value. Treatment with pravastatin 40 mg once daily reduced total and LDL cholesterol (LDL-C) after 6 months by 19.7% and 25.4%, respectively (P less than .001). Serum apolipoprotein (apo) B levels decreased significantly by 29.1% (P less than .001). No significant changes were observed in mean serum total triglycerides or high-density lipoprotein cholesterol (HDL-C) levels. A positive correlation between residual LDL-R activity and maximum percent reduction of LDL-C levels was observed (r = .676, P less than .05). No clinically important side effects were recorded and the treatment was well tolerated. Thus, pravastatin effectively reduces LDL in heterozygous FH, and this effect appears to be related to LDL-R status.

Dietary treatment for familial hypercholesterolemia--differential effects of dietary soy protein according to the apolipoprotein E phenotypes

Familial hypercholesterolemia, one form of type IIa hyperlipidemia, usually responds poorly to standard low-lipid diets. To define the responsiveness to a soy-protein diet in this disease, one homozygous and twenty heterozygous type IIa patients were submitted to a 4-wk traditional hypocholesterolemic diet followed by 4 wk in which animal protein was substituted with texturized soy protein. Soy was then withdrawn for a further 4 wk. No significant changes in plasma lipids were observed during low-lipid diets. The soy diet, however, caused a marked decrease in total (-20.8%) and low-density-lipoprotein (-25.8%) cholesterol and in apolipoprotein B (-14.1%). The plasma cholesterol reduction was higher in patients with apolipoprotein E3/E3 or E3/E4 vs an almost negligible effect on E3/E2. These results confirm that soy-protein diets can lower cholesterol in type IIa patients with familial disease. Data on the sensitivity of patients with different apo-E isoforms agree with recent hypotheses suggesting that soy proteins may activate B,E receptors.

Characterization of three mutations of the low density lipoprotein receptor gene in Italian patients with familial hypercholesterolemia

Three gross rearrangements of the low density lipoprotein receptor (LDL-R) gene were recognized during a survey of 23 unrelated Italian subjects with familial hypercholesterolemia (FH). Restriction endonuclease data were obtained by Southern blotting and hybridization with exon-specific probes. Proband FH-29 is heterozygous for a 4-kb deletion, which eliminates exons 13 and 14. This mutation is similar to that previously reported by other investigators in one Italian homozygous and two British and Canadian heterozygous patients. Proband FH-30 is homozygous for a 5.5-kb insertion caused by a duplication of exons 16 and 17 of the LDL-R gene. LDL-R mRNA isolated from skin fibroblasts of FH-30 was found to be larger than normal mRNA (5.6 versus 5.3 kb), in concordance with the insertion of the 236 nucleotides corresponding to exons 16 and 17. Proband FH-44 was found to have greater than 25-kb deletion, which eliminates the first six exons and the promoter region of the gene. This is the first example of a deletion that eliminates the promoter as well as the ligand-binding domain of the LDL-R gene. In the skin fibroblasts of this patient, the level of LDL-R mRNA was approximately half that found in control fibroblasts. We designate the new mutations found in FH-30 and FH-44 as FHviterbo and FHBologna-1, respectively, after the names of the Italian cities where the two patients were born.

Duplication of exons 13, 14 and 15 of the LDL-receptor gene in a patient with heterozygous familial hypercholesterolemia

During a survey of Italian patients with familial hypercholesterolemia (FH), we identified an FH heterozygous patient with a gross rearrangement of the low density lipoprotein (LDL) receptor gene. Southern blot analysis of the proband's DNA digested with restriction enzymes PvuII, BamHI, BglII and XbaI and hybridization with cDNA probes complementary to the 3' end of the gene revealed the presence of abnormal fragments that were approximately 7 kb larger than their normal counterparts. DNA digestion with other enzymes (EcoRV, NcoI, KpnI and StuI) and hybridization with probes complementary to exons 13-17 generated normal fragments and an abnormal fragment of 6.3-6.8 kb. These results are consistent with the presence of an insertion of approximately 7 kb caused by a duplication of exons 13, 14 and 15. This is a novel mutation that is most probably the result of an unequal crossing-over between repetitive sequences located in intron 12 and intron 15. This novel mutation has been designated FHBologna 2.

Role of Ca2+ in H+ transport by rabbit gastric glands studied with A23187 and BAPTA, an incorporated Ca2+ chelator

The role of Ca2+ in stimulation of H+ gastric secretion by cAMP-dependent and -independent secretagogues was studied in isolated rabbit glands using Ca2+ ionophore, A23187, and an intracellular Ca2+ chelator (BAPTA, 1,2-bis(2-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid) incorporated as its acetoxymethyl ester (BAPTA-AM). Acetylcholine (ACh), tetragastrin (TG), histamine and forskolin induced a transitory increase of intracellular Ca2+ concentration, [Ca2+]i, measured in gastric glands loaded with Ca2+-sensitive dye fura-2, and provoked an acid secretory response evaluated with aminopyrine accumulation ratio (AP ratio). The Ca2+-ionophore A23187 also induced an increase in [Ca2+]i and in AP ratio. cAMP-dependent secretagogues were more potent stimulants of acid secretion than cAMP-independent secretagogues. cAMP analogue, 8-bromo-adenosine 3',5'-cyclic monophosphate (8-BR-cAMP) induced an increase in AP ratio without modifying [Ca2+]i. BAPTA-AM (5-25 microM) induced a transient decrease of resting [Ca2+]i which returned to basal level due to extracellular Ca2+ entry. Increases in [Ca2+]i produced by ACh and TG were abolished by BAPTA and those produced by Ca2+ ionophore A23187 were partially buffered. BAPTA inhibited in a dose-dependent manner H+ secretion induced by cholinergic and gastrinergic stimulants in the presence of cimetidine. A23187 increased the AP ratio to values similar to those obtained with ACh or TG and was not inhibited by BAPTA. BAPTA partially inhibited (40%) the increase in AP ratio induced by forskolin and histamine inspite of the complete inhibition of the Ca2+ response. BAPTA did not inhibit the response to 8-BR-cAMP. BAPTA inhibition of forskolin stimulation was reversed by A23187 and the response was potentiated. These results indicate that ACh and TG response are completely dependent on an increase of [Ca2+]i. The response to cAMP-dependent agonists histamine and forskolin depend both on Ca2+ and cAMP. For forskolin stimulation the response may be the result of a potentiation between Ca2+ and cAMP.