Modeling Glutaric Aciduria Type I in human neuroblastoma cells recapitulates neuronal damage that can be rescued by gene replacement

Glutaric Aciduria type I (GA1) is a rare neurometabolic disorder caused by mutations in the GDCH gene encoding for glutaryl-CoA dehydrogenase (GCDH) in the catabolic pathway of lysine, hydroxylysine and tryptophan. GCDH deficiency leads to increased concentrations of glutaric acid (GA) and 3-hydroxyglutaric acid (3-OHGA) in body fluids and tissues. These metabolites are the main triggers of brain damage. Mechanistic studies supporting neurotoxicity in mouse models have been conducted. However, the different vulnerability to some stressors between mouse and human brain cells reveals the need to have a reliable human neuronal model to study GA1 pathogenesis. In the present work we generated a GCDH knockout (KO) in the human neuroblastoma cell line SH-SY5Y by CRISPR/Cas9 technology. SH-SY5Y-GCDH KO cells accumulate GA, 3-OHGA, and glutarylcarnitine when exposed to lysine overload. GA or lysine treatment triggered neuronal damage in GCDH deficient cells. SH-SY5Y-GCDH KO cells also displayed features of GA1 pathogenesis such as increased oxidative stress vulnerability. Restoration of the GCDH activity by gene replacement rescued neuronal alterations. Thus, our findings provide a human neuronal cellular model of GA1 to study this disease and show the potential of gene therapy to rescue GCDH deficiency.

A ring-like accretion structure in M87 connecting its black hole and jet

The nearby radio galaxy M87 is a prime target for studying black hole accretion and jet formation1,2. Event Horizon Telescope observations of M87 in 2017, at a wavelength of 1.3 mm, revealed a ring-like structure, which was interpreted as gravitationally lensed emission around a central black hole3. Here we report images of M87 obtained in 2018, at a wavelength of 3.5 mm, showing that the compact radio core is spatially resolved. High-resolution imaging shows a ring-like structure of [Formula: see text] Schwarzschild radii in diameter, approximately 50% larger than that seen at 1.3 mm. The outer edge at 3.5 mm is also larger than that at 1.3 mm. This larger and thicker ring indicates a substantial contribution from the accretion flow with absorption effects, in addition to the gravitationally lensed ring-like emission. The images show that the edge-brightened jet connects to the accretion flow of the black hole. Close to the black hole, the emission profile of the jet-launching region is wider than the expected profile of a black-hole-driven jet, suggesting the possible presence of a wind associated with the accretion flow.

OSNA Total Tumor Load for the Prediction of Axillary Involvement in Breast Cancer Patients: Should We use Different Thresholds According to the Intrinsic Molecular Subtype? MOTTO Study

Aims

To assess the impact of the molecular subtype (MS) on the total number of CK19 mRNA copies in all positive SLN (TTL) threshold, to predict non-SLN affectation, and to compare 5 years progression-free survival (PFS) according to the risk of recurrence (ROR) group by PAM50.

Methods

Cohort with infiltrating breast cancer with intra-operative metastatic SLN detected by one-step nucleic acid amplification (OSNA) assay who underwent subsequent ALND. Logistic regression was used to assess a possible interaction between TTL and MS(Triple Negative, Her-2-Enriched, Luminal A, or Luminal B), or hormone receptors (HR: positive or negative) by immunohistochemistry (IMH). Cox regression was used to compare PFS and OS in the 3 ROR groups (high, medium, or low).

Results

TTL was predictive of non-SLN affectation in both univariate (OR [95% CI]: 1.72 [1.43, 2.05], P < .001) and multivariate (1.55 [95% CI: 1.04, 2.32], P = .030) models, but MS-IMH or HR-IMH, and their interactions with TTL were not (best multivariate model: HR + main effect OR 1.16 [95% CI: 0.18, 7.64], P = .874; interaction OR: 1.04 [0.7, 1.55], P = .835; univariate model: HR + main effect OR: 1.44 [95% CI: 0.85, 2.44], P = .180). PFS was lower in the high-risk ROR group (81.1%) than in the low-risk group (93.9%) (HR: 3.68 [95 CI: 1.70, 7.94], P < .001).

Conclusions

our results do not provide evidence to support the utilization of subtype-specific thresholds for TTL values to make therapeutic decisions on the axilla. The ROR group was predictive of 5 years-PFS.

Removal of emerging pollutants by a 3-step system: Hybrid digester, vertical flow constructed wetland and photodegradation post-treatments

The removal of emerging pollutants from municipal wastewater was studied for the first time using a three-step pilot-scale system: 1) hybrid digester (HD) as first step, 2) subsurface vertical flow constructed wetland (VF) as second step, and 3) photodegradation (PD) unit as third step or post-treatment. The HD and VF units were built and operated in series with effluent recirculation at pilot scale. For the PD post-treatment, three alternatives were studied at lab-scale, i) UVC irradiation at 254 nm (0.5 h exposure time), ii) UVA irradiation at 365 nm using a TiO₂-based photocatalyst and iii) sunlight irradiation using a TiO₂-based photocatalyst, the last two for 1 and 2 h. Alternative iii) was also tested at pilot-scale. Degradation of nine compounds was evaluated: acetaminophen (ACE), caffeine (CAF), carbamazepine (CBZ), ketoprofen (KET), ibuprofen (IBU), diclofenac (DCL), clofibric acid (ACB), bisphenol A (BPA), and sotalol (SOT). Overall, the HD-VF-UVC system completely removed (>99.5 %) ACE, CAF, KET, IBU, DCL and ACB, and to a lesser extent SOT (98 %), BPA (83 %) and CBZ (51 %). On the other hand, the HD-VF-UVA/TiO₂ system (at 2 h) achieved >99.5 % removal of ACE, CAF, KET, IBU and DCL while ACB, BPA, CBZ and SOT were degraded by 83 %, 81 %, 78 % and 68 %, respectively. Working also at 2 h of exposure time, in summer conditions, the HD-VF-Sol/TiO₂ system achieved >99.5 % removal of ACE, CAF, KET, IBU, DCL and ACB, and to a minor extent BPA (80 %), SOT (74 %) and CBZ (69 %). Similar results, although slightly lower for SOT (60 %) and CBZ (59 %), were obtained in the pilot sunlight plus TiO₂ catalyst unit. However, the use of sunlight irradiation with a TiO₂-based photocatalyst clearly showed lower removal efficiency in autumn conditions (i.e., 47 % SOT, 31 % CBZ).

Use of micafungin as antifungal prophylaxis in patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT) in Spain (GETH-MIC)

Introduction

The fungal infections remain an important problem in the allogeneic stem cell trasnsplantation (allo-SCT) setting and thus, anti-fungal prophylaxis is commonly used. The antifungal drug should offer activity, at least against Candida and Aspergillus spp., a good safety profile and low probability interactions. Micafungin could theoretically fulfill these requisites. The aim of the study was to describe the experience with micafungin as primary prophylaxis in patients undergoing allo-SCT in a cohort of Spanish centres, and to evaluate its efficacy and tolerability in this population.

Material and methods

Retrospective multicentre observational study including all consecutive adult patients admitted for allo-SCT in participating centres of the Grupo Español de Trasplante Hematopoyético (GETH), from January 2010 to December 2013, who received micafungin as primary prophylaxis during the neutropenic period.

Results

A total of 240 patients from 13 centres were identified and 159 patients were included for the analysis. Most patients (95.6%) received 50 mg/day of micafungin. During the follow-up, 7 (4.4%) patients developed breakthrough invasive fungal disease, 1 proven and 6 probable; one patient discontinued the drug because of serious drug interactions. Prophylaxis with micafungin was considered effective in 151 (94.9%) patients.

Conclusions

According to our experience, micafungin is an appropriate alternative for antifungal prophylaxis in patients undergoing an allo-HSCT, because its efficacy, its low profile of drug interactions and side-effects.

Reason for immigration and immigrants' health

OBJECTIVES

The existing literature on the health trajectories of the UK immigrants has mainly focussed on the relationship between ethnicity and health. There is little information on the role of immigration status and no previous information on the role of reason for immigration to the country. This study fills this gap in the literature by analysing the heterogeneity of immigrant-native differences in health by reason for immigration.

STUDY DESIGN

Analysis of cross-sectional quarterly data from the UK Labour Force Survey covering the period of 2010 (quarter 1) to 2017 (quarter 2). The sample includes 345,086 observations. The dependent variables of interest include suffering from a long-lasting condition, the link between long-lasting conditions and labour market performance and the prevalence of 12 specific health conditions.

METHODS

Data were analysed using linear probability models to adjust for differences in age, education, gender, ethnicity, local authority of residence and year of survey. The analysis also explores the role of length of stay in the UK and the percentage of current lifetime spent in the UK (duration in the UK/age).

RESULTS

Results indicate that, in general, immigrants are less likely than natives to report suffering from a long-lasting (1 year or more) health problem. This pattern generally remains the same when we consider the specificity of the long-lasting health problem. However, there are key differences across the immigrant groups by reason for immigration. Those who migrated for employment, family and study reasons report better health outcomes than natives, while those who migrated to seek asylum report worse health outcomes than natives. There is convergence to natives' health outcomes over time for those who migrated for non-asylum reasons, but not for those who migrated to seek asylum.

CONCLUSIONS

The findings show that the prevalence of health problems differs not only between natives and immigrants but also across groups of immigrants who moved to the UK for different reasons.

Viral kinetics analysis and virological characterization of treatment failures in patients with chronic hepatitis C treated with sofosbuvir and an NS5A inhibitor

BACKGROUND

The combination of sofosbuvir (SOF) plus an NS5A inhibitor for 12 weeks is highly efficacious in patients with chronic hepatitis C. As the costs of generic production of sofosbuvir and NS5A inhibitor are rapidly decreasing, the combination of these DAAs will be the standard treatment in most low- to middle-income countries in the future.

AIM

To identify key predictors of response that can be used to tailor treatment decisions.

METHODS

A cohort of 216 consecutive patients infected with HCV genotype 1 (1a: n = 57; 1b: n = 77), 2 (n = 4), 3 (n = 33) or 4 (n = 44) were treated with sofosbuvir (SOF) + daclatasvir (n = 176) or SOF + ledipasvir (n = 40) for 12 weeks. The viral kinetics was analysed using the biphasic model and the cure boundary was used to predict time to clear HCV.

RESULTS

The overall SVR rate was high (94.4%; n = 204), regardless of the time to viral suppression or low-level viraemia at the end of treatment. The model-based predicted HCV RNA levels at the end of treatment could not differentiate patients who did from those who did not achieve SVR. The presence of NS5A resistance-associated substitutions [position 28 (OR = 70.3, P<.001) and/or 31 (OR = 61.6, P = .002)] at baseline was predictive of virological failure in cirrhotic patients but was not associated with on-treatment viral kinetics.

CONCLUSION

This real-world study confirms the excellent results of clinical trials with therapies based on a combination of SOF plus an NS5A inhibitor. It suggests that a personalized approach including baseline NS5A inhibitor resistance testing may inform treatment decisions in cirrhotic patients.

Integrating pretreatment and denitrification in constructed wetland systems

The aim of this work was to study the operational characteristics and the efficiency of a compact constructed wetland system for municipal wastewater treatment that integrates denitrification in the pre-treatment unit. The proposed system was simulated by two units in series with effluent recirculation, the first one being an anoxic digester, conceived as a hydrolytic up flow sludge bed for solids hydrolysis and denitrification, and the second one a sand column that simulated the operation of a vertical flow constructed wetland. The hybrid system consisted of two small columns of 4 and 10.2cm in diameter (anoxic digester and vertical flow unit, respectively). The unplanted system was operated successively with synthetic and real municipal wastewater over a period of 136days. Hydraulic loading rate ranged from 212 to 318mm/day and surface loading rate from 122 to 145g/m²·day of chemical oxygen demand and 10-15g/m²·day of total nitrogen for the overall system. The overall system reached removals of 91% to 99% for total suspended solids, chemical oxygen demand and biochemical oxygen demand whilst total nitrogen removal ranged from 43% to 61%. In addition to suspended solids removal (up to 78%), the anoxic digester provided high denitrification rates (3-12gN/m²·day) whilst the vertical flow unit provided high nitrification rates (8-15gN/m²·day). Organic matter was mainly removed in the anoxic digester (63-82% chemical oxygen demand) and used for denitrification. Final effluent concentration was lower for ammonia (7.4±2.4mgN/L on average) than for nitrate (19.8±4.4mgN/L), denitrification appearing as the limiting step in nitrogen removal in the system. CH₄ or N₂O emissions were not detected in any of the units of the system indicating very low greenhouse gas emissions.

Abstract P4-21-05: Neoadjuvant non-pegylated liposomal doxorubicin plus paclitaxel, trastuzumab and pertuzumab in patients with HER2+ breast cancer – Final results of the SOLTI OPTI-HER HEART study

INTRODUCTION

Targeting HER2 by dual blockade with trastuzumab (T) and pertuzumab (P) in a taxane-based regimen is an active neoadjuvant treatment (NAT) of HER2+ early breast cancer (EBC). Addition of an anthracycline could further enhance this response, but potential cardiac toxicity is a concern. The Opti-HER HEART trial (NCT01669239) aims to optimize neoadjuvant treatment while minimizing cardiac risk, by combining T+P with a taxane and non-pegylated liposomal doxorubicin (NPLD).

MATERIAL AND METHODS

Phase II open-label, single-arm study of six 21-day cycles of NPLD (50mg/m2 D1), paclitaxel (80mg/m2 D1,8,15), T (4mg/kg C1D1, followed by 2mg/kg weekly), and P (840mg C1D1, followed by 420mg C2-6D1) as NAT for patients (pts) with stage II-IIIB HER2+ BC. Primary objective was to evaluate cardiac safety of the combination, measured by the incidence of type A (symptomatic congestive heart failure ) or type B [asymptomatic reduction of Left Ventricular Ejection Fraction (LVEF) value: ≥10% absolute decrease and LVEF&lt;50%, LVEF&lt;40% or any absolute decrease ≥20%] events, during NAT. Eighty-three pts were required to reject with 80% confidence the null hypothesis that the combination increases the incidence of cardiac events above the historical control of 18% (3% type A; 15% type B).

RESULTS

Between June 2013 and January 2015, 83 pts with HER2+ EBC (stage II 78%, stage III 22%) and adequate cardiac function (LVEF≥55%) were enrolled. Mean age was 50 years, N+ 47%, hormone receptor (HR) positive 71% and median baseline LVEF 66%. Eighty-five percent of pts completed 6 cycles of NAT, whereas 15% discontinued NAT due to toxicity. Adverse events (AEs) leading to dose adjustments/temporary interruptions and discontinuation of at least 1 drug occurred in 70% and 21% of pts, respectively. Primary objective was met with an incidence of cardiac events during NAT of 4% (95%CI 1-10, 3pts, all type B). Cardiac events until study completion (1 year) were 8% (all type B). All (but 2 cases with no follow-up data) were reversible and only 1 pt presented an asymptomatic LVEF&lt;40%. Neutropenia (45%) was the most frequent hematological toxicity (G3/4 34%; febrile neutropenia 6%), less frequent in the 71% of pts that received primary G-CSF prophylaxis (G3/4 25% vs. 67%). Common non-hematological toxicities were diarrhea (74%; G3 7%), asthenia (78%; G3 11%) and neurotoxicity (52%; G3/4 10%). Pathological complete response (pCR) in breast+axilla (ypT0/is ypN0) was 60% (87% in HR-) and 69% in breast (91% in HR-).

 TOTALHR-HR+% ypT0/is (95% CI)69 (58-79)91 (72-99)61 (47-74)% ypT0/is ypN0 (95% CI)60 (46-71)87 (66-97)50 (36-64)

CONCLUSIONS

The neoadjuvant combination of T+P, paclitaxel and NPLD does not increase the risk for cardiac events in HER2+ BC pts. Since cardiac toxicities may present later, long-term cardiac monitoring is essential. Efficacy in terms of pCR was remarkable, being higher to historical values of combinations with dual anti-HER2 blockade and one of the highest reported among HR-HER2+ BC. This regimen administered with primary G-CSF prophylaxis and cardiac function monitoring may be an effective and secure option for early and locally advanced HER2+ pts with good cardiac function.

Citation Format: Gavilá J, Perez-Garcia J, Calvo I, Ciruelos E, Muñoz M, Virizuela JA, Ruiz I, Andrés R, Morales S, Perelló A, Sánchez P, Garcia-Saenz JA, Quero Guillen JC, González-Santiago S, Garau Llinas I, González-Martín A, Cantos Sánchez de Ibargüen B, Zaragoza K, de la Peña L, Llombart-Cussac A, Oliveira M. Neoadjuvant non-pegylated liposomal doxorubicin plus paclitaxel, trastuzumab and pertuzumab in patients with HER2+ breast cancer – Final results of the SOLTI OPTI-HER HEART study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-21-05.

Overexpression of kynurenic acid in stroke: An endogenous neuroprotector?

It is known that kynurenic acid (KYNA) exerts a neuroprotective effect against the neuronal loss induced by ischemia; acting as a scavenger, and exerting antioxidant action. In order to study the distribution of KYNA, a highly specific monoclonal antibody directed against KYNA was developed. This distribution was studied in control rats and in animals in which a middle cerebral artery occlusion (stroke model) was induced. By double immunohistochemistry, astrocytes containing KYNA and GFAP were exclusively found in the ipsilateral cerebral cortex and/or striatum, at 2, 5 and 21days after the induction of stroke. In control animals and in the contralateral side of the stroke animals, no immunoreactivity for KYNA was found. Under pathological conditions, the presence of KYNA is reported for the first time in the mammalian brain from early phases of stroke. The distribution of KYNA matches perfectly with the infarcted regions suggesting that, in stroke, this overexpressed molecule could be involved in neuroprotective/scavenger/antioxidant mechanisms.

3-hydroxi-anthranilic acid is early expressed in stroke

Using an immunohistochemical technique, we have studied the distribution of 3-OH-anthranilic acid (3-HAA) in the rat brain. Our study was carried out in control animals and in rats in which a stroke model (single transient middle cerebral artery occlusion) was performed. A monoclonal antibody directed against 3-HAA was also developed. 3-HAA was exclusively observed in the infarcted regions (ipsilateral striatum/cerebral cortex), 2, 5 and 21 days after the induction of stroke. In control rats and in the contralateral side of the stroke animals, no immunoreactivity for 3-HAA was visualized. Under pathological conditions (from early phases of stroke), we reported for the first time the presence of 3-HAA in the mammalian brain. By double immunohistochemistry, the coexistence of 3-HAA and GFAP was observed in astrocytes. The distribution of 3-HAA matched perfectly with the infarcted regions. Our findings suggest that, in stroke, 3-HAA could be involved in the tissue damage observed in the infarcted regions, since it is well known that 3-HAA exerts cytotoxic effects.

Effect of by-pass and effluent recirculation on nitrogen removal in hybrid constructed wetlands for domestic and industrial wastewater treatment

Hybrid constructed wetlands (CWs) including subsurface horizontal flow (HF) and vertical flow (VF) steps look for effective nitrification and denitrification through the combination of anaerobic/anoxic and aerobic conditions. Several CW configurations including several configurations of single pass systems (HF + HF, VF + VF, VF + HF), the Bp(VF + HF) arrangement (with feeding by-pass) and the R(HF + VF) system (with effluent recirculation) were tested treating synthetic domestic wastewater. Two HF/VF area ratios (AR) were tested for the VF + HF and Bp(VF + HF) systems. In addition, a R(VF + VF) system was tested for the treatment of a high strength industrial wastewater. The percentage removal of TSS, COD and BOD5 was usually higher than 95% in all systems. The single pass systems showed TN removal below the threshold of 50% and low removal rates (0.6-1.2 g TN/m(2) d), except the VF + VF system which reached 63% and 3.5 g TN/m(2) d removal but only at high loading rates. Bp(VF + HF) systems required by-pass ratios of 40-50% and increased TN removal rates to approximately 50-60% in a sustainable manner. Removal rates depended on the AR value, increasing from 1.6 (AR 2.0) to 5.2 g TN/m(2) d (AR 0.5), both working with synthetic domestic wastewater. On real domestic wastewater the Bp (VF + HF) (AR 0.5 and 30% by-pass) reached 2.5 g TN/m(2) d removal rate. Effluent recirculation significantly improved the TN removal efficiency and rate. The R(HF + VF) system showed stable TN removals of approximately 80% at loading rates ranging from 2 to 8 g TN/m(2) d. High TN removal rates (up to 73% TN and 8.4 g TN/m(2) d) were also obtained for the R(VF + VF) system treating industrial wastewater.

Blood and tissue distribution of posaconazole in a rat model of invasive pulmonary aspergillosis

Posaconazole is the recommended prophylactic agent in patients at high risk of invasive fungal infection, since adequate drug levels seem to be reached in target sites despite the relatively low levels detected in blood. The objective of this study is to obtain pharmacokinetic (PK) information associated to blood and tissue distribution of posaconazole in an animal model of invasive pulmonary aspergillosis. The PK parameters in lung samples were systematically higher than in serum. After multiple-dose administration of posaconazole, a significant accumulation of the drug was evident in lung tissue. The PK behavior of posaconazole in this particular experimental model is similar to that observed in humans. Thus, we believe this model could be a valid tool to evaluate posaconazole exposure-response relationship.

Indirect costs associated with glioblastoma: Experience at one hospital

INTRODUCTION

Glioblastoma is the most common primary brain tumour. Despite advances in treatment, its prognosis remains dismal, with a mean survival time of about 14 months. Many articles have addressed direct costs, those associated with the diagnosis and treatment of the disease. Indirect costs, those associated with loss of productivity due to the disease, have seldom been described.

MATERIAL AND METHOD

We conducted a retrospective study in patients diagnosed with glioblastoma at Hospital Universitario Donostia between January 1, 2010 and December 31, 2013. We collected demographics, data regarding the treatment received, and survival times. We calculated the indirect costs with the human capital approach, adjusting the mean salaries of comparable individuals by sex and age and obtaining mortality data for the general population from the Spanish National Statistics Institute. Past salaries were updated to 2015 euros according to the annual inflation rate and we applied a discount of 3.5% compounded yearly to future salaries.

RESULTS

We reviewed the records of 99 patients: 46 women (mean age 63.53) and 53 men (mean age 59.94); 29 patients underwent a biopsy and the remaining 70 underwent excisional surgery. Mean survival was 18.092 months for the whole series. The total indirect cost for the series was €11 080 762 (2015). Mean indirect cost per patient was €111 926 (2015).

DISCUSSION

Although glioblastoma is a relatively uncommon type of tumour, accounting for only 4% of all cancers, its poor prognosis and potential sequelae generate disproportionately large morbidity and mortality rates which translate to high indirect costs. Clinicians should be aware of the societal impact of glioblastoma and indirect costs should be taken into account when cost effectiveness studies are performed to better illustrate the overall consequences of this disease.

Methane and carbon dioxide emissions from constructed wetlands receiving anaerobically pretreated sewage

The aim of this research was to determine methane and carbon dioxide emissions from a hybrid constructed wetland (CW) treating anaerobically pre-treated sewage. The CW was constituted of two horizontal flow (free water surface followed by a subsurface) units. A long-term study was carried out as both CW units were monitored for three campaigns in Period 1 (0.9-1.5years after start-up), and four campaigns in Period 2 (4.5-5.8years after start-up). The closed chamber method with collecting surfaces of 1810cm(2) was used. For this system, variability due to position in the transverse section of CW, plant presence or absence and recommended sampling period was determined. Overall methane emissions ranged from 96 to 966mgCH4m(-2) d(-1), depending on several factors as the operation time, the season of the year and the position in the system. Methane emissions increased from 267±188mgCH4m(-2)d(-1) during the second year of operation to 543±161mgCH4m(-2)d(-1) in the sixth year of operation. Methane emissions were related to the age of the CW and the season of the year, being high in spring and becoming lower from spring to winter. Total CO2 emissions ranged mostly from 3500 to 5800mgCO2m(-2)d(-1) during the sixth year of operation, while nitrous oxide emissions were below the detection limit of the method.

[Current management of hepatocellular carcinoma]

Hepatocellular carcinoma is the major complication of chronic liver diseases and particularly of cirrhosis whatever its etiology. Once encountered mainly in the endemic countries of hepatitis B and C, the incidence of hepatocellular carcinoma (6/100,000) is parallel to the global development of diabetes, overweight and alcohol consumption. Little progress has been made for this cancer, whose mortality is 100 % at 10 years. Liver transplantation is the only truly curative treatment (survival more than 50 % at 10 years) since it allows the eradication of hepatocellular carcinoma and its essential cause, cirrhotic liver. This is the only possible therapy when liver function is impaired. It has little impact since in the richest countries, less than 10 % of cases can be transplanted. Surgical resection and percutaneous destruction methods (uni- and multipolar radiofrequency, microwave, cryotherapy, electroporation) are the preferred treatments (survival less than 50 % at 5 years) but are only applicable for moderate tumour masses and in the absence of adjuvant therapy, are effective only in the medium term. Most patients received chemoembolization through hepatic artery, whose action is modest. Radiotherapy is widely used in Asia but almost non-existent in Western countries in this indication. Sorafenib is the only effective drug but its impact is modest. Therapies combining two modalities (embolization and radiotherapy; embolization and radiofrequency) seem promising and deserve wider testing. Screening and monitoring of cirrhosis is probably the major measure for potentially curative therapies.

[Multiple extraneural metastasis of glioblastoma multiforme]

INTRODUCTION

Glioblastoma multiforme is the most frequent primary tumor in the brain. Despite improvements in its surgical, chemotherapy and radiotherapy treatment, prognosis remains poor. Extracranial metastases of glioblastoma are a rare complication in this disease. Its appearance has been described in lung, liver, bone or lymph nodes.

CASE REPORT

We describe the case of a 20 year-old patient who complained of a subacute-onset headache. In the MRI an enhancing right temporal lesion was detected suggesting a high grade glioma as first diagnosis. Surgery was performed, obtaining a gross total resection of the lesion. Our patient underwent adjuvant radiotherapy and chemotherapy treatment, according to our hospital's protocol. Five months after initial surgery our patient complained of chest pain and a hacking cough. A thoracic-abdominal-pelvic CT scan was obtained, which showed bilateral lung infiltrates with pleural effusion, a pancreatic nodule and several vertebral lytic lesions. The lung lesions were biopsied. The pathologic diagnosis was metastatic glioblastoma multiforme. The patient died eight months after initial diagnosis.

CONCLUSION

Extracranial metastases of glioblastoma remain a rare event although its incidence is increasing, probably due to the improvement in survival among these patients and better imaging techniques. The mechanisms for extracranial dissemination of glioblastoma are not entirely known, as several theories exist in this regard. Physicians must be aware of this complication and keep it in mind as a differential diagnosis to improve the quality of life of our patients.

Impact of Epstein Barr virus-related complications after high-risk allo-SCT in the era of pre-emptive rituximab

We monitored 133 high-risk allo-SCT recipients for 6 months after transplant for EBV reactivation by quantitative real-time PCR. Rituximab was given as pre-emptive therapy for viremia >1000 copies/mL. The 1-year cumulative incidence of EBV reactivation was 29.4% (95% confidence interval (CI): 18-40) in patients monitored due to initial high-risk characteristics (n=93) and 31.8% (95% CI: 19.7-44) in those followed because of the development of refractory GVHD (n=40). Overall response rate to Rituximab was 83%. Nine patients (9.6%) developed post-transplant lymphoproliferative disorder (PTLD) at a median of +62 days after SCT. Eight of them showed a concomitant CMV reactivation. Second SCT was the only risk factor associated with EBV infection and PTLD in multivariate analysis (hazard ratio (HR) 2.6 (95% CI: 1.1-6.4; P=0.04) and HR 6.4 (95%CI: 1.3-32; P=0.02)). The development of EBV reactivation was not associated with non-relapse mortality or OS (P=0.97 and P=0.84, respectively).

Wineries wastewater treatment by constructed wetlands: a review

The application of wetland systems for the treatment of wineries wastewater started in the early 1990s in the USA followed a few years later by France, Italy, Germany and Spain. Various studies demonstrated the efficiency of constructed wetlands (CWs) as a low cost, low maintenance and energy-saving technology for the treatment of wineries wastewater. Several of these experiences have also shown lessons to be learnt, such as some limits in the tolerance of the horizontal subsurface flow and vertical subsurface flow classic CWs to the strength of the wineries wastewater, especially in the first stage for the multistage systems. This paper is presenting an overview of all the reported experiences at worldwide level during the last 15 years, giving particular attention and provision of details to those systems that have proven to get reliable and constant performances in the long-term period and that have been designed and realized as optimized solutions for the application of CW technology to this particular kind of wastewater. The organic loading rates (OLRs) applied to the examined 13 CW systems ranged from about 30 up to about 5,000 gCOD/m² d (COD: chemical oxygen demand), with the 80th percentile of the reported values being below 297 gCOD/m² d and the median at 164 gCOD/m² d; the highest OLR values have in all cases been measured during the peak season (vintage) and often have been linked to lower surface removal rates (SRRs) in comparison to the other periods of the year. With such OLRs the SRRs have ranged from a minimum of 15 up to 4,700 gCOD/m² d, with the 80th percentile of the reported values being below 308 gCOD/m² d and the median at 112 gCOD/m² d.

Heavy metal removal in an UASB-CW system treating municipal wastewater

The objective of the present study was to investigate for the first time the long-term removal of heavy metals (HMs) in a combined UASB-CW system treating municipal wastewater. The research was carried out in a field pilot plant constituted for an up-flow anaerobic sludge bed (UASB) digester as a pretreatment, followed by a surface flow constructed wetland (CW) and finally by a subsurface flow CW. While the UASB showed (pseudo) steady state operational conditions and generated a periodical purge of sludge, CWs were characterised by the progressive accumulation and mineralisation of retained solids. This paper analyses the evolution of HM removal from the water stream over time (over a period of 4.7 year of operation) and the accumulation of HMs in UASB sludge and CW sediments at two horizons of 2.7 and 4.0 year of operation. High removal efficiencies were found for some metals in the following order: Sn > Cr > Cu > Pb > Zn > Fe (63-94%). Medium removal efficiencies were registered for Ni (49%), Hg (42%), and Ag (40%), and finally Mn and As showed negative percentage removals. Removal efficiencies of total HMs were higher in UASB and SF units and lower in the last SSF unit.

Evaluation of PPCPs removal in a combined anaerobic digester-constructed wetland pilot plant treating urban wastewater

The removal efficiency of 16 pharmaceuticals and personal care products (PPCPs) from urban wastewater (dissolved and particulate phases) was evaluated for the first time in a hybrid pilot plant consisting of an upflow anaerobic sludge blanket reactor followed by two sequentially connected horizontal flow constructed wetlands: a surface flow wetland (SF CW) and a subsurface flow wetland (SSF CW). Whereas the PPCP removal associated with the dissolved phase exhibited a seasonal pattern, the fraction associated with the suspended solids showed less seasonality. In the dissolved phase, the overall removal efficiency in summer ranged from 70% to 85% for salicylic acid (SAL), methyl dihydrojasmonate, caffeine (CAF), ketoprofen and triclosan, whereas in winter it declined for most of the PPCPs to between 30% and 50%, except for CAF and SAL (>80%) and carbamazepine and butylated hydroxyl toluene (11-18%). In the suspended solids, the removal exceeded 80% for most of the target PPCPs. The efficiency of the different treatment steps was also compound-dependent, but the SF CW generally exhibited the highest removal efficiency for most of the contaminants analyzed. The characterization of the organic matter retained in the wetland gravel beds revealed the occurrence of hydrophobic contaminants such as phthalate esters and fragrances at moderate concentrations (i.e., up to 3.5 μg kg(-1)), which declined strongly over the course of the different treatment steps. In the SF CW, the net mass accumulation rates of tonalide and galaxolide were 4 and 23 gy(-1) respectively, whereas in the SSF CW they were 0.3 and 1.8 gy(-1) respectively.

[New mutation in the Birt Hogg Dube gene]

Patients with Birt-Hogg-Dube syndrome have an increased risk of developing hamartomas of the pilosebaceous unit, renal tumors of various types, lung cysts, and spontaneous pneumothorax. We present the case of a 54-year-old woman with a long history of whitish papules in the central region of the face and a family history of similar lesions. Biopsy and genetic study revealed a new mutation of the gene involved in Birt-Hogg-Dube syndrome.

Longitudinal changes of insight in first episode psychosis and its relation to clinical symptoms, treatment adherence and global functioning: one-year follow-up from the Eiffel study

OBJECTIVES

The Eiffel study is a longitudinal, naturalistic study of patients with first episode psychosis (FEP) designed to evaluate the predictive value of defective insight on treatment adherence and global functioning.

METHODS

Five hundred seventy-seven patients with FEP were assessed at baseline and at a 1-year follow-up. They were compared in terms of sociodemographic factors, psychopathology, insight, treatment adherence and functional outcome. Longitudinal functionality was prospectively assessed with the clinical global impression (CGI) and global assessment of functioning (GAF) rating scales.

RESULTS

At baseline, up to 50% of our sample presented with a lack of insight. Most clinical symptoms, including insight, improved over the follow-up period. Insight, education and social withdrawal significantly predicted CGI and GAF at follow-up. Insight and level of education were predictive of treatment adherence.

CONCLUSIONS

Insight significantly predicted the general clinical course, treatment adherence and functional outcome in our FEP sample after 1 year. Only education additionally accounted for the longitudinal course. Since our results suggest that better insight improves treatment adherence and consequently clinical course and functional outcome, insight could be a specific target of treatment in early intervention programs.

New Mutation in the Birt Hogg Dube Gene

Patients with Birt-Hogg-Dube syndrome have an increased risk of developing hamartomas of the pilosebaceous unit, renal tumors of various types, lung cysts, and spontaneous pneumothorax. We present the case of a 54-year-old woman with a long history of whitish papules in the central region of the face and a family history of similar lesions. Biopsy and genetic study revealed a new mutation of the gene involved in Birt-Hogg-Dube syndrome.

Are hepatocellular carcinoma surveillance programs effective at improving the therapeutic options

AIM

to evaluate whether the current surveillance programs (ultrasonography and alpha-fetoprotein testing every six months) are successful in detecting patients in the early stages.

MATERIAL AND METHODS

the health records of all patients diagnosed with hepatocellular carcinoma in Donostia Hospital between 2003 and 2005 were reviewed retrospectively. Eighty-five patients (11 women and 74 men) were included in the study and demographic data, risk factors and clinical data were obtained. Patients were split into two groups according to whether or not they had been included in a surveillance program.

RESULTS

seventy per cent of patients of the surveillance group is diagnosed in early stage opposite to 26.7% of patients in no surveillance group (p < 0.05). Thirteen patients cannot receive curative treatment in spite of the diagnosis in early stage (9 in the surveillance group and 4 in the no surveillance group. The global sensibility of the surveillance program in our series is 95%.

CONCLUSIONS

current hepatocellular carcinoma surveillance programs, which comprise six-monthly ultrasonography and alpha-fetoprotein tests, are highly sensitive and effective. These programs result in the detection of hepatocellular carcinoma in its early-stages, when potentially curative treatment may be offered.

Glottal space segmentation from motion estimation and Gabor filtering

Obtaining the glottal space segmentation is essential to characterize morphological disorders of vocal folds. In this study, the tested images are been acquired by direct optical inspection of the glottis using an endoscope and most of them are very poor quality. The application of motion estimation is very useful to segment the vocal folds endoscopic videos without user interaction. This approach involves three process steps: 1) Wiener motion estimator--to shift the measurement the next frame regarding to the current frame, and look for similarities between them. The best matching will accurate a shift equal to the displacement vector of the object; 2) Segmentation using motion estimation results and applying Gabor filtering; 3) Experimental results to demonstrate that the proposed method is effective. Our proposal works correctly with 95% of database test videos and it shows a great advance in design, and in the nearby future, a complete method to diagnose vocal folds pathologies.

Objective characterization of oesophageal voice supporting medical diagnosis, rehabilitation and monitoring

Otolaryngologists use computational tools in the objective diagnosis of vocal folds pathologies by means of a set of acoustic parameters among others. This can be achieved in the cases of slight pathologies, but it does not exist any commercial software suitable for severe degradations of speech, as they are the oesophageal voice of laryngectomees. The present article shows a high-accuracy algorithm for the detection of the periodicity cycles of both oesophageal and laryngeal voices with low quality which allows the accurate and automatic estimation of pitch, jitter and shimmer. As the proposed algorithm works also with slighter pathologies, it is a useful contribution which allows doctors to perform an objective control during rehabilitation and monitoring stages. Thus, a patient can be controlled during oesophageal voice learning stage and it can also be saved a medical record with the results of the acoustic parameters' measurements in order to detect possible relapses.

Methanogenic toxicity in anaerobic digesters treating municipal wastewater

In upflow anaerobic sludge blanket (UASB) digesters treating raw sewage at low temperatures, the sludge progressively lost methanogenic activity, indicating the possibility of methanogenic activity inhibition caused by wastewater constituents. To check this fact, batch and semi-continuous methanogenic toxicity assays were carried out with raw and centrifuged sewage. Permanent methanogenic toxicity on anaerobic sludge of approximately 50% was found when the sludge exposure to wastewater was renewed in a semi-continuous way. A stronger methanogenic inhibition of about 70-100% was observed when an active anaerobic sludge was exposed to mixed liquor from the UASB digester treating municipal wastewater. Suspended solids removal from sewage slightly reduced methanogenic toxicity. Effective concentration of municipal wastewater that caused a 50% reduction in methanogenic activity was estimated to be in the range of 150-200 mg CODl(-1). As methanogenic inhibition appeared to be related to remaining COD, higher methanogenic toxicity in digesters operating with low conversion efficiency will be expected.

Municipal wastewater treatment in an anaerobic digester-constructed wetland system

An experimental plant was constituted for an upflow anaerobic sludge blanket (UASB) reactor with an active volume of 25.5 m3 and two horizontal constructed wetlands of 75 m2 each. The first wetland was a superficial flow (SF) system and the second a subsurface flow (SSF) system. The UASB reactor was fed with 60-73 m3 d(-1) of raw domestic wastewater from the municipal treatment plant (MTP) of the city of Santiago de Compostela. Part of the effluent from the UASB reactor (15 m3 d(-1)) passed through the SF wetland and then went into the SSF. In the first ten months of operation, from July 2005 to April 2006, the hydraulic retention time for the UASB system was in the range of 7-14 hours and the organic loading rate (OLR) was between 0.3 and 1.1 g COD l(-1) d(-1). The organic load in the wetlands was in the range of 5-40 g BOD5 m(-2) d(-1). The global results achieved for total suspended solids (TSS), chemical oxygen demand (COD) and biological oxygen demand (BOD5) removal efficiencies were 85-96%, 65-90% and 69-93%, respectively. The average monthly concentrations in the final effluent were 8-73 mg BOD5 l(-1), 25-120 mg COD l(-1) and 6-20 mg TSS l(-1). The global balance of VSS in the UASB reactor shows that purge accounted for 19.6% and hydrolysis accounted for 47.7% of influent VSS. Data from suspended solids balance in the constructed wetlands, at the end of the operation period, show a TSS and VSS accumulation of 48% and 16%, respectively.

Cerebrotendinous xanthomatosis: neuropathological findings

Cerebrotendinous xanthomatosis is an inherited autosomal recessive lipid storage disease caused by a 27-hydroxylase enzyme deficiency, characterised clinically by tendon xanthomas, premature cataracts, chronic diarrhoea and progressive neurologic dysfunction. The disease is very uncommon and there are very few pathological descriptions. We report a 52-year-old male who presented with a neuropsychiatric disorder and cognitive decline. Despite treatment the patient developed optic atrophy, parkinsonism and dementia and died. The autopsy revealed a nonspecific brain and cerebellar atrophy. Under microscopic examination, lipid crystal clefts, neuronal loss, demyelination, reactive astrocytosis and perivascular macrophages were found. These findings suggest the limited reversibility of the disease, and its poor prognosis, specially if treatment is not started early.

[Mohs micrographic surgery: our first 100 patients]

INTRODUCTION

Mohs surgery was first described by Frederic Mohs in 1941 to eliminate high-risk cutaneous tumors. The technique involves histological examination of the margins.

OBJECTIVE

The aim of this study was to describe the clinical findings and compare the grade and subclinical extension of the tumor as measured by the number of Mohs stages needed for complete elimination according to whether the tumor presented high-risk factors.

METHODS

We included 100 patients with 105 tumors. In all cases, age, sex, tumor site, tumor type, histological subtype in the case of basal cell carcinoma, size, recurrences, number of Mohs stages, and reconstruction technique were recorded.

RESULTS

The study group comprised 44 men and 56 women aged between 28 and 88 years (mean, 72.6 years). Of the tumors, 80 % corresponded to basal cell carcinoma, 12.38 % to squamous cell carcinoma, 4.76 % to dermatofibrosarcoma protuberans, 0.95 % to Merkel cell carcinoma, 0.95 % to microcystic adnexal carcinoma, and 0.95 % to lentigo maligna melanoma. Most tumors were located on the head and 60 % required more than one Mohs stage for complete elimination.

CONCLUSION

This series is characterized by a high percentage of high-risk cutaneous tumors. After assessing the risk factors independently, we found that the size of the tumor is the risk factor most closely related to grade and subclinical extension in the case of basal cell carcinoma, although similar conclusions cannot be drawn for the other types of tumor studied.