Reducing the burden of travel and environmental impact through decentralization of cancer care

Life expectancy, quality of life and satisfaction of oncologic patients highly depend on access to adequate specialized services, that consider their conditions in a holistic way. The present study aims to evaluate the introduction of oncology services in an outpatient setting in a mountain village in Northern Italy. The initiative is evaluated using the three pillars of sustainability (social, economic and environmental) as dimensions that are often overlooked by healthcare policy makers. Using micro data on 18,625 interventions, we estimate the number of kilometers saved by patients (reduction of "travel burden" as indicator of social sustainability), the additional travel costs for the NHS (indicator of economic sustainability) and the implied reduction of CO2 emissions (indicator of environmental sustainability). Over the period July 2016-2021, the decentralized health center delivered 2,292 interventions saving 218,566 km for a corresponding value of €131,140. The additional costs for the NHS was €26,152. The reduction of CO2 emissions was 32.37 Tons (€5,989). Overall, the socio-economic benefit of reducing travel of care for the patients residing in this remote valley was €110,976. This study adds original understanding of the benefits of decentralizing oncologic care and shows its operational feasibility conditions. Given the modest number of similar projects, it provides evidence to policy makers and, especially, managers who are faced with the challenge to implement the decentralization of specialized services.

An overview of reviews: what do we know about task shifting and skill mix change in healthcare?

Key messages

• Task shifting is a globally recognized strategy to respond to healthcare challenges. This research contributes to the academic providing a comprehensive overview of the current knowledge on the topic.

• Task shifting can be performed by different categories of professionals, being applicable to many care services. It should be designed according to the specific context and professionals involved.

Nerves, H2O2 and Shh: Three players in the game of regeneration

The tight control of reactive oxygen species (ROS) levels is required during regeneration. H₂O₂ in particular assumes clear signalling functions at different steps in this process. Injured nerves induce high levels of H₂O₂ through the activation of the Hedgehog (Shh) pathway, providing an environment that promotes cell plasticity, progenitor recruitment and blastema formation. In turn, high H₂O₂ levels contribute to growing axon attraction. Once re-innervation is completed, nerves subsequently downregulate H₂O₂ levels to their original state. A similar regulatory loop between H₂O₂ levels and nerves also exists during development. This suggests that redox signalling is a major actor in cell plasticity.

Hydrogen peroxide (H2O2) controls axon pathfinding during zebrafish development

It is now becoming evident that hydrogen peroxide (H2O2), which is constantly produced by nearly all cells, contributes to bona fide physiological processes. However, little is known regarding the distribution and functions of H2O2 during embryonic development. To address this question, we used a dedicated genetic sensor and revealed a highly dynamic spatio-temporal pattern of H2O2 levels during zebrafish morphogenesis. The highest H2O2 levels are observed during somitogenesis and organogenesis, and these levels gradually decrease in the mature tissues. Biochemical and pharmacological approaches revealed that H2O2 distribution is mainly controlled by its enzymatic degradation. Here we show that H2O2 is enriched in different regions of the developing brain and demonstrate that it participates to axonal guidance. Retinal ganglion cell axonal projections are impaired upon H2O2 depletion and this defect is rescued by H2O2 or ectopic activation of the Hedgehog pathway. We further show that ex vivo, H2O2 directly modifies Hedgehog secretion. We propose that physiological levels of H2O2 regulate RGCs axonal growth through the modulation of Hedgehog pathway.

Nerves Control Redox Levels in Mature Tissues Through Schwann Cells and Hedgehog Signaling

AIMS

Recent advances in redox biology have emphasized the role of hydrogen peroxide (H2O2) in the modulation of signaling pathways and revealed that H2O2 plays a role in cellular remodeling in adults. Thus, an understanding of the mechanisms that control H2O2 levels in mature tissue would be of great interest.

RESULTS

We used a denervation strategy to demonstrate that sensory neurons are responsible for controlling H2O2 levels under normal conditions and after being lesioned. Moreover, we demonstrate that severed nerves respond to appendage amputation via the induction of Hedgehog signaling and that this signaling is responsible for H2O2 production in the wounded epidermis. Finally, we show that H2O2 and nerve growth are regulated via reciprocal action in adults.

INNOVATION AND CONCLUSION

These data support a new paradigm for the regulation of tissue homeostasis: H2O2 attracts nerves and nerves control H2O2 levels in a positive feedback loop. This finding suggests that the peripheral nerve redox environment could be a target for manipulating cell plasticity in adults.

Control of brain patterning by Engrailed paracrine transfer: a new function of the Pbx interaction domain

Homeoproteins of the Engrailed family are involved in the patterning of mesencephalic boundaries through a mechanism classically ascribed to their transcriptional functions. In light of recent reports on the paracrine activity of homeoproteins, including Engrailed, we asked whether Engrailed intercellular transfer was also involved in brain patterning and boundary formation. Using time-controlled activation of Engrailed combined with tools that block its transfer, we show that the positioning of the diencephalic-mesencephalic boundary (DMB) requires Engrailed paracrine activity. Both zebrafish Eng2a and Eng2b are competent for intercellular transfer in vivo, but only extracellular endogenous Eng2b, and not Eng2a, participates in DMB positioning. In addition, disruption of the Pbx-interacting motif in Engrailed, known to strongly reduce the gain-of-function phenotype, also downregulates Engrailed transfer, thus revealing an unsuspected participation of the Pbx interaction domain in this pathway.

Adenosine enhances progenitor cell recruitment and nerve growth via its A2B receptor during adult fin regeneration

A major issue in regenerative medicine is the control of progenitor cell mobilisation. Apoptosis has been reported as playing a role in cell plasticity, and it has been recently shown that apoptosis is necessary for organ and appendage regeneration. In this context, we explore its possible mode of action in progenitor cell recruitment during adult regeneration in zebrafish. Here, we show that apoptosis inhibition impairs blastema formation and nerve growth, both of which can be restored by exogenous adenosine acting through its A2B receptor. Moreover, adenosine increases the number of progenitor cells. Purinergic signalling is therefore an early and essential event in the pathway from lesion to blastema formation and provides new targets for manipulating cell plasticity in the adult.

Genome-wide analysis of DNA methylation, copy number variation, and gene expression in monozygotic twins discordant for primary biliary cirrhosis

Primary biliary cirrhosis (PBC) is an uncommon autoimmune disease with a homogeneous clinical phenotype that reflects incomplete disease concordance in monozygotic (MZ) twins. We have taken advantage of a unique collection consisting of genomic DNA and mRNA from peripheral blood cells of female MZ twins (n = 3 sets) and sisters of similar age (n = 8 pairs) discordant for disease. We performed a genome-wide study to investigate differences in (i) DNA methylation (using a custom tiled four-plex array containing tiled 50-mers 19,084 randomly chosen methylation sites), (ii) copy number variation (CNV) (with a chip including markers derived from the 1000 Genomes Project, all three HapMap phases, and recently published studies), and/or (iii) gene expression (by whole-genome expression arrays). Based on the results obtained from these three approaches we utilized quantitative PCR to compare the expression of candidate genes. Importantly, our data support consistent differences in discordant twins and siblings for the (i) methylation profiles of 60 gene regions, (ii) CNV of 10 genes, and (iii) the expression of 2 interferon-dependent genes. Quantitative PCR analysis showed that 17 of these genes are differentially expressed in discordant sibling pairs. In conclusion, we report that MZ twins and sisters discordant for PBC manifest particular epigenetic differences and highlight the value of the epigenetic study of twins.

Genome-wide analysis of DNA methylation, copy number variation, and gene expression in monozygotic twins discordant for primary biliary cirrhosis

Primary biliary cirrhosis (PBC) is an uncommon autoimmune disease with a homogeneous clinical phenotype that reflects incomplete disease concordance in monozygotic (MZ) twins. We have taken advantage of a unique collection consisting of genomic DNA and mRNA from peripheral blood cells of female MZ twins (n = 3 sets) and sisters of similar age (n = 8 pairs) discordant for disease. We performed a genome-wide study to investigate differences in (i) DNA methylation (using a custom tiled four-plex array containing tiled 50-mers 19,084 randomly chosen methylation sites), (ii) copy number variation (CNV) (with a chip including markers derived from the 1000 Genomes Project, all three HapMap phases, and recently published studies), and/or (iii) gene expression (by whole-genome expression arrays). Based on the results obtained from these three approaches we utilized quantitative PCR to compare the expression of candidate genes. Importantly, our data support consistent differences in discordant twins and siblings for the (i) methylation profiles of 60 gene regions, (ii) CNV of 10 genes, and (iii) the expression of 2 interferon-dependent genes. Quantitative PCR analysis showed that 17 of these genes are differentially expressed in discordant sibling pairs. In conclusion, we report that MZ twins and sisters discordant for PBC manifest particular epigenetic differences and highlight the value of the epigenetic study of twins.

Serum autoantibodies for the diagnosis and management of autoimmune liver diseases

The spectrum of autoimmune liver diseases (AILD) includes primary biliary cirrhosis, primary sclerosing cholangitis and autoimmune hepatitis. The immunological mechanisms triggering the initiation and perpetuation of AILD remains unknown, while autoantigens are now recognized in most cases, and are generally nontraditional in their widespread distribution. Sensitive and specific methods for the detection of serum autoantibodies in patients affected by AILD represent a challenge for researchers and clinicians who desire to obtain an early and certain diagnosis as well as markers of disease control. To this regard, the use and interpretation of serum autoantibodies in AILD may be seen as paradigmatic for the large gaps in our knowledge based on the lack of true population-based studies. The present review article will critically discuss the available evidence on the use of autoantibody findings in the diagnosis or management of autoimmune liver disease.

Cutting-edge issues in primary biliary cirrhosis

Several crucial issues remain open in our understanding of primary biliary cirrhosis (PBC), an autoimmune liver disease targeting the small- and medium-sized intrahepatic bile ducts. These issues include the high tissue specificity of the autoimmune injury despite the nontraditional autoantigens found in all mitochondria recognized by PBC-associated autoantibodies, the causes of the commonly observed pruritus, and the disease etiology per se. In all these fields, there has been recent interest secondary to the use of large-scale efforts (such as genome-wide association studies) that were previously considered poorly feasible in a rare disease such as PBC as well as other intuitions. Accordingly, there are now fascinating theories to explain the onset and severity of pruritus due to elevated autotaxin levels, the peculiar apoptotic features of bile duct cells to explain the tissue specificity, and genomic and epigenetic associations contributing to disease susceptibility. We have arbitrarily chosen these four aspects as the most promising in the PBC recent literature and will provide herein a discussion of the recent data and their potential implications.

The epigenetics of autoimmunity

The etiology of autoimmune diseases remains largely unknown. Concordance rates in monozygotic twins are lower than 50% while genome-wide association studies propose numerous significant associations representing only a minority of patients. These lines of evidence strongly support other complementary mechanisms involved in the regulation of genes expression ultimately causing overt autoimmunity. Alterations in the post-translational modification of histones and DNA methylation are the two major epigenetic mechanisms that may potentially cause a breakdown of immune tolerance and the perpetuation of autoimmune diseases. In recent years, several studies both in clinical settings and experimental models proposed that the epigenome may hold the key to a better understanding of autoimmunity initiation and perpetuation. More specifically, data support the impact of epigenetic changes in systemic lupus erythematosus, rheumatoid arthritis, multiple sclerosis and other autoimmune diseases, in some cases based on mechanistical observations. We herein discuss what we currently know and what we expect will come in the next future. Ultimately, epigenetic treatments already being used in oncology may soon prove beneficial also in autoimmune diseases.

Experimental evidence on the immunopathogenesis of primary biliary cirrhosis

Primary biliary cirrhosis (PBC) is a chronic cholestatic liver disease for which an autoimmune pathogenesis is supported by clinical and experimental data, including the presence of autoantibodies and autoreactive T cells. The etiology remains to be determined, yet data suggest that both a susceptible genetic background and unknown environmental factors determine disease onset. Multiple infectious and chemical candidates have been proposed to trigger the disease in a genetically susceptible host, mostly by molecular mimicry. Most recently, several murine models have been reported, including genetically determined models as well as models induced by immunization with xenobiotics and bacteria.

Expansion and de novo generation of potentially therapeutic regulatory T cells in patients with autoimmune hepatitis

CD4+CD25+ regulatory T cells (T-regs) are central to the maintenance of immune tolerance and represent an immune intervention candidate in autoimmune hepatitis (AIH), a condition characterized by impaired T-reg number and function. We investigated whether T-regs can be expanded from the existing CD4+CD25+ T cell pool and generated de novo from CD4+CD25- T cells in AIH patients and healthy controls. Purified CD4+CD25+ and CD4+CD25- T cells from 24 patients with type 1 AIH and 22 healthy controls were cultured for up to 5 weeks with anti-CD3/anti-CD28 T cell expander and high-dose interleukin-2 (IL-2). Cell phenotypes, suppressor ability, forkhead winged/helix transcription factor box P3 (FOXP3) gene, and protein expression were assessed weekly by cytofluorimetry, proliferation assay, real-time polymerase chain reaction (PCR), and immunoblot. During culture, the number of CD4+CD25+ T cells derived from the existing T-reg pool (expanded T-regs) and generated de novo from CD4+CD25- T cells (newly generated T-regs) increased constantly up to week 4 in both healthy controls and, to a lesser extent, in AIH patients. Expanded T-regs retained conventional T-reg phenotype and, compared with baseline, demonstrated more vigorous suppressive function and increased FOXP3 gene and protein expression. Newly generated T-regs not only acquired T-reg phenotype but underwent greater growth and were more resistant to apoptosis than expanded T-regs. Their suppressive function augmented throughout culture, reaching a peak at week 4, preceded by a peak FOXP3 gene and protein expression at week 2. Suppressor function and FOXP3 expression of both expanded and newly generated T-regs were higher in normal controls than in AIH patients.

CONCLUSION

Functionally enhanced T-regs can be expanded and generated de novo in patients with AIH. This finding may assist in reconstituting impaired immune regulation and restoring peripheral tolerance through T-reg infusion in this condition.

Serum autoantibodies: a road map for the clinical hepatologist

The widespread use of serum autoantibodies in the practice of clinical hepatology has led to novel challenges in the interpretation of results obtained with routine techniques, such as indirect immunofluorescence (IIF) or with recombinant antigens. In fact, the laboratory methods are often overlooked factors in the interpretation of data by the bedside clinician despite being critical in the interpretation of data. Importantly, the sensitivity and specificity of these serum hallmarks are not defined in all cases. Taken altogether, these observations point towards the need for a systematic discussion of autoimmune serology in the clinical setting of everyday practice. The target of this review article is therefore, to illustrate the current knowledge and available experimental evidence to guide the diagnostic and prognostic decision making in autoimmune and viral chronic liver diseases.

Genetic variants of endothelial nitric oxide synthase in patients with primary biliary cirrhosis: association with disease severity

BACKGROUND AND AIMS

Primary biliary cirrhosis (PBC) presents a wide spectrum of clinical manifestations. In experimental models of liver cirrhosis and cholestasis it has been suggested that altered nitric oxide production is involved in liver injury and portal hypertension development. The present study investigated endothelial nitric oxide synthase (eNOS) genetic polymorphisms (894G/T, -786T/C) in patients with PBC and in controls to verify whether disease susceptibility and progression are associated with a particular genotype.

METHODS

Genomic DNA from 109 Italian PBC patients (65 with advanced disease, i.e. liver transplantation or histological stage III-IV) was obtained and polymorphisms determined by fluorescent probe analysis. Healthy subjects (n = 242) were used as a control group.

RESULTS

The allelic frequencies of both polymorphisms did not differ significantly between PBC patients and controls. When the association between genotypes and disease severity was addressed, both the 894T and the -786T alleles were more frequently found in the 22 patients with progressing disease (894T, frequency 0.455 compared with 0.240; P = 0.032; -786T, frequency 0.682 compared with 0.460; P = 0.038). Patients with 894TT presented higher Mayo score values (6.1 +/- 1.2 compared with 5.4 +/- 1.3 in 894G/G patients; P = 0.030) but similar age and disease duration values.

CONCLUSIONS

The authors suggest that genetic variants of eNOS are not associated with susceptibility to PBC, although the genotypes may lead to differences in disease severity and progression.

Extracorporeal circulation in sheep with normal bleeding time using a surface heparinized circuit

Bleeding due to systemic heparinization represents the major side effect of extracorporeal respiratory support. In the present animal study, a surface heparinized system (Carmeda Biological Active Surface) was applied to assess the feasibility of prolonged perfusion at low circulating heparin levels. Eight sheep divided into two groups: group A (5 animals) and group B (3 animals) underwent venovenous bypass using a heparin coated surface circuit. The following protocol was used: a) 24 hours at high heparin dose (30 to 100 U/kg/hr with an ACT [activated coagulation time] three to four times normal); b) 24 hours at low heparin dose (3 to 8 U/kg/hr with an ACT within the normal range); c) 24 hours at high heparin dose. Group B animals also received fresh frozen sheep plasma (14 ml/kg/day). During Period b, the clotting times were within baseline range. The bleeding time showed a dramatic decrease after change from a to b (27.9 +/- 3 minutes vs. 10.2 +/- 5.6 minutes). There was a negative relationship between antithrombin III (AT III) and thrombin coagulase time (TC); the latter is considered to be an aspecific indicator of circulating fibrin(ogen) degradation products. Maintaining AT III over 70%, TC changes were only minor. The use of the bioactive heparin surface allowed the performance of a 24 hour bypass, with normal coagulation times, at low circulating heparin levels.