Micro-mechanical fingerprints of the rat bladder change in actinic cystitis and tumor presence

Tissue mechanics determines tissue homeostasis, disease development and progression. Bladder strongly relies on its mechanical properties to perform its physiological function, but these are poorly unveiled under normal and pathological conditions. Here we characterize the mechanical fingerprints at the micro-scale level of the three tissue layers which compose the healthy bladder wall, and identify modifications associated with the onset and progression of pathological conditions (i.e., actinic cystitis and bladder cancer). We use two indentation-based instruments (an Atomic Force Microscope and a nanoindenter) and compare the micromechanical maps with a comprehensive histological analysis. We find that the healthy bladder wall is a mechanically inhomogeneous tissue, with a gradient of increasing stiffness from the urothelium to the lamina propria, which gradually decreases when reaching the muscle outer layer. Stiffening in fibrotic tissues correlate with increased deposition of dense extracellular matrix in the lamina propria. An increase in tissue compliance is observed before the onset and invasion of the tumor. By providing high resolution micromechanical investigation of each tissue layer of the bladder, we depict the intrinsic mechanical heterogeneity of the layers of a healthy bladder as compared with the mechanical properties alterations associated with either actinic cystitis or bladder tumor.

Open surgery versus TEVAR in complicated type B acute aortic syndromes: outcomes of a single referral center

Background

While patients with uncomplicated acute Type B aortic syndromes (ATBAS) are usually managed with optimal medical therapy, complicated ATBAS require a quick intervention to prevent life-threatening complications. If anatomical features are favorable, TEVAR is the preferred treatment option. Nevertheless, open surgery still plays a significant role in selected cases. The optimal approach to complicated ATBAS remains matter of debate.

Purpose

We retrospectively evaluated our seventeen-years' experience as regional referral center for acute aortic syndromes to analyze the outcomes of TEVAR and open surgery in cases of complicated ATBAS.

Methods

Between January 2000 and December 2016, 199 patients with ATBAS were referred to our hospital: 133 aortic dissections, 53 intramural hematomas, 13 penetrating ulcers. All patients were evaluated by a multidisciplinary aortic team. 113 patients (56.8%) received the optimal medical therapy being uncomplicated, while 86 (43.2%) patients admitted with or developing a complicated form of ATBAS underwent TEVAR or open surgery during the same hospital admission. Open surgical repair was performed in cases of unsuitable anatomy for TEVAR, retrograde involvement of the arch, ascending aorta ectasia or aneurysm. In-hospital outcomes, long term survival and freedom from reoperation were analyzed and compared between the groups.

Results

No differences were observed in terms of in-hospital mortality between uncomplicated and complicated ATBAS (13.3% versus 14.0% respectively [p=0.890]). Complicated ATBAS were treated for unstable anatomical evolution (34 patients), refractory pain or uncontrollable hypertension (19 patients), visceral or peripheral malperfusion (18 patients) or impending rupture in 15 patients. Sixty-eight patients (79%) underwent TEVAR while 18 underwent open surgery (16 frozen elephant trunk [FET] and 2 descending thoracic aorta replacement). Operative timing from the onset of symptoms did not differ between two groups (9+10 (TEVAR) versus 14+16 (Open) days [p=0.233]). In-hospital mortality was 13.2% in TEVAR group versus 16.7% in open surgery (p=0.709). Postoperative myocardial infarction, visceral and peripheral ischemia and neurological outcomes were similar in two groups (p>0.05), but acute kidney injury was higher in open surgery cohort (p=0.027). One, 5 and 10-years survival of uncomplicated ATBAS (medical therapy) were 75%, 58%, 34% vs. 76%, 65%, 58% in TEVAR and 83%, 76%, 76% in open surgery groups (Log rank p=0.329). Comparing TEVAR and open surgery, freedom from endovascular reoperation at 1 and 5 years was 86%, 78% vs. 66%, 60% respectively (Log rank p=0.091).

Conclusions

Surgical treatment options (open and TEVAR) modify the natural history of complicated acute type B aortic syndromes. Open surgery represents a good option in selected cases with in-hospital and long-term survival at least comparable to TEVAR.

Funding Acknowledgement

Type of funding source: None

Routine coagulation testing in Vacutainer® Citrate Plus tubes filled at minimum or optimal volume

Background Filling of citrate tubes with appropriate amount of blood is essential for obtaining reliable results of coagulation testing. This study aimed to verify whether results of routine coagulation tests are comparable when the new Becton Dickinson Vacutainer® Citrate Plus tubes are filled at minimum or optimal volume. Methods The study population consisted of 133 patients (40 on oral anticoagulant therapy), who had blood collected for routine coagulation testing. Two sequential Vacutainer® Citrate Plus tubes of the same type and lot were drawn. The first tube was collected after a butterfly needle was inserted into the vein, so that the air in the tubing was aspirated into the tube before blood (minimum fill volume), whilst the second was drawn at optimal fill volume. Experiments were repeated using 2.7-mL (n = 86) and 1.8-mL (n = 47) tubes. Results Prothrombin time (PT) and fibrinogen values were slightly but significantly decreased in tubes with minimum than in those with optimal fill volume. The activated partial thromboplastin time (APTT) was slightly prolonged in tubes with minimum than in those with optimal fill volume, but the difference was not statistically significant. An identical trend was noted in separate analyses for the 2.7-mL and 1.8-mL tubes. Spearman's correlations between the two fill volumes were always >0.94 and bias was always within the quality specifications. Conclusions Blood drawing into Vacutainer® Citrate Plus tubes at minimum fill volume does not clinically bias routine coagulation testing.

Assessment of the InSiGHT Interpretation Criteria for the Clinical Classification of 24 MLH1 and MSH2 Gene Variants

Pathogenicity assessment of DNA variants in disease genes to explain their clinical consequences is an integral component of diagnostic molecular testing. The International Society for Gastrointestinal Hereditary Tumors (InSiGHT) has developed specific criteria for the interpretation of mismatch repair (MMR) gene variants. Here, we performed a systematic investigation of 24 MLH1 and MSH2 variants. The assessments were done by analyzing population frequency, segregation, tumor molecular characteristics, RNA effects, protein expression levels, and in vitro MMR activity. Classifications were confirmed for 15 variants and changed for three, and for the first time determined for six novel variants. Overall, based on our results, we propose the introduction of some refinements to the InSiGHT classification rules. The proposed changes have the advantage of homogenizing the InSIGHT interpretation criteria with those set out by the Evidence-based Network for the Interpretation of Germline Mutant Alleles (ENIGMA) consortium for the BRCA1/BRCA2 genes. We also observed that the addition of only few clinical data was sufficient to obtain a more stable classification for variants considered as "likely pathogenic" or "likely nonpathogenic." This shows the importance of obtaining as many as possible points of evidence for variant interpretation, especially from the clinical setting.

Hemodialysis with High Cut-Off Hemodialyzers in Patients with Multi-Drug Resistant Gram-Negative Sepsis and Acute Kidney Injury: A Retrospective, Case-Control Study

BACKGROUND

Hemodialysis with high cut-off continuous veno-venous hemodialyzer (HCO-CVVHD) removes mediators of organ dysfunction during sepsis. This study assessed the clinical effects of HCO-CVVHD as compared to high-flux (HF) membranes during gram-negative sepsis.

METHODS

Intensive care unit (ICU), septic patients treated with HCO-CVVHD or HF-CVVHDF for AKI were retrospectively observed (January 2013-December 2014). Mechanical ventilation, vasopressors' requirements, ICU length of stay (LOS) and ICU in-hospital mortality were compared between groups.

RESULTS

Sixteen HCO and 8 HF patients were observed. Isolated pathogens included Klebsiella pneumoniae, Acinetobacter baumannii, Escherichia coli and Pseudomonas aeruginosa. Median ratios of days-on-vasopressors and days-on-mechanical ventilation/ICU-LOS were 0.5, 1 and 0.8, 1 for HCO and HF groups (p < 0.03), respectively. ICU-LOS was 16 and 9 days (HCO- and HF-group, p = 0.03). ICU mortality rates were 37.5 and 87.5% for HCO and HF groups, respectively (p = 0.03). No statistical difference was found in in-hospital morality.

CONCLUSION

Patients in HCO-CVVHD group spent lesser number of days on vasopressors and mechanical ventilation as a ratio to total ICU-LOS. In the same group, a reduction in ICU mortality was observed.

New patterns of relapse in multiple myeloma: a case of “light chain escape” in which FLC predicted relapse earlier than urine and serum immunofixation

Multiple myeloma (MM) is characterized, in about 80% of cases, by the production of monoclonal intact immunoglobulin and more than 95% of them have elevated concentrations of involved (i.e. of the same class of intact immunoglobulin) free light chain (FLC). The introduction of novel therapeutic strategies has changed the natural history of the disease, leading to new manifestations of relapse. Light chain escape (LCE) is a pattern of relapse in which the FLC increase is not accompanied by a concomitant raise of the original monoclonal component (MC). Here we present a case of a 55-year-old man with an IgG kappa MM stage III diagnosed in September 2007. At presentation an IgG kappa MC and urine Bence Jones protein (BJP) kappa were present. Bone marrow biopsy (BMB) showed the presence of 80% monotypic kappa plasma cells (PCs). The patient received bortezomib, thalidomide, dexamethasone before undergoing a double autologous stem cell transplantation (ASCT) in October 2008 and April 2009. In May 2011 he relapsed showing the same pattern of presentation and treatment with lenalidomide and dexamethasone was started. ln May 2013 serum and urine immunofixation and FLC became negative. In September 2014, an increase of kappa FLC was observed, while serum and urine immunofixations remained negative until January 2015, when urine immunofixation became positive. Eventually, in February 2015, serum immunofixation revealed the presence of a free kappa MC. After a new BMB showing 80% of monotypic kappa PCs, a LCE relapse was diagnosed and the patient started the treatment with bendamustine, bortezomib and dexamethasone. In the present case, the increase of kappa FLC has indicated relapse 4 and 5 months earlier than urine and serum IFE, respectively. Our observation confirms that it is advisable to routinely perform FLC or BJP during follow up of MM patients undergoing ASCT and/or treatment with biological drugs to ensure that LCE is not missed.

Role of hemodialysis with high cut-off membranes in a patient with a non-recognized leishmaniasis

BACKGROUND

We report here a case of a woman affected by fever, weight loss, splenomegaly, and leucopenia associated with trombocytopenia, transferred to the intensive care unit with acute kidney injury and septic shock.

METHODS

Patient was treated with high cut-off continuous veno-venous hemodialysis (HCO-CVVHD).

RESULTS

During treatment, the patient experienced a stable improvement in the hemodynamic, pulmonary function and tissue perfusion parameters. After 48 h of treatment, significant reductions in SOFA score (from 12, before starting the procedure, to 6) and in serum inflammatory mediators (as IL-6, from 599-568 pg/ml) were observed. Leishmania infection was identified as responsible of the septic condition only 48 h after removing hemodialysis. Antiprotozoal therapy was begun and the patient discharged.

CONCLUSIONS

By supporting the renal function and reducing systemic inflammation, HCO-CVVHD could be a useful bridge therapy. This procedure allowed the medical team to gain sufficient time to diagnose the type of infection and begin an etiological therapy.

Is green tea a potential trigger for autoimmune hepatitis?

A case of autoimmune liver hepatitis is reported: the onset was triggered by consumption of green tea infusion in a patient taking oral contraceptives and irbesartan. We hypothesize that our patient, carrying genetic variant of hepatic metabolism making her particularly susceptible to oxidative stress, developed an abnormal response to a mild toxic insult, afforded by a combination of agents (oral contraceptives+irbesartan+green tea) that normally would not be able to cause damage. Her particular hepatic metabolism further increased the drugs' concentration, favoring the haptenization of liver proteins, eventually leading to the development of an autoimmune hepatitis.

The frequency of granulocytes with spontaneous somatic mutations: a wide distribution in a normal human population

Germ-line mutation rate has been regarded classically as a fundamental biological parameter, as it affects the prevalence of genetic disorders and the rate of evolution. Somatic mutation rate is also an important biological parameter, as it may influence the development and/or the course of acquired diseases, particularly of cancer. Estimates of this parameter have been previously obtained in few instances from dermal fibroblasts and lymphoblastoid cells. However, the methodology required has been laborious and did not lend itself to the analysis of large numbers of samples. We have previously shown that the X-linked gene PIG-A, since its product is required for glycosyl-phosphatidylinositol-anchored proteins to become surface bound, is a good sentinel gene for studying somatic mutations. We now show that by this approach we can accurately measure the proportion of PIG-A mutant peripheral blood granulocytes, which we call mutant frequency, ƒ. We found that the results are reproducible, with a variation coefficient (CV) of 45%. Repeat samples from 32 subjects also had a CV of 44%, indicating that ƒ is a relatively stable individual characteristic. From a study of 142 normal subjects we found that log ƒ is a normally distributed variable; ƒ variability spans a 80-fold range, from less than 1×10⁻⁶ to 37.5×10⁻⁶, with a median of 4.9×10⁻⁶. Unlike other techniques commonly employed in population studies, such as comet assay, this method can detect any kind of mutation, including point mutation, as long as it causes functional inactivation of PIG-A gene. Since the test is rapid and requires only a small sample of peripheral blood, this methodology will lend itself to investigating genetic factors that underlie the variation in the somatic mutation rate, as well as environmental factors that may affect it. It will be also possible to test whether ƒ is a determinant of the risk of cancer.

[Intolerance to food additives: an update]

Contrary to common believing, the prevalence of the intolerance to food additives in the general population is rather low. Nowadays many doubts persist with regard both to the pathogenetic mechanisms and to the clinical and diagnostic aspects in this field. Symptoms due to, or exacerbated from, food additives usually involve non-IgE-mediate mechanisms (pseudo-allergic reactions, PAR) and are usually less severe of those induced by food allergy. The most frequent clinical feature of the intolerance to food additives still remains the urticaria-angioedema syndrome, although these substances are really involved only in a minority of patients. Other possible clinical features include anaphylaxis, atopic eczema, behaviour disturbances, asthma and non-allergic rhinitis. The diagnostic approach consists in diary cards, reporting symptoms and food habits, elimination diet and double blinded placebo-controlled oral challenge with suspected additives. However, such procedure still remains poorly standardized and numerous uncertainties persist with regard to optimal conditions for performing and interpret the challenge results. The therapeutic approach consists in the exclusion of foods and products containing the additive involved, and, in patients not compliant to the diet, in treatment with symptomatic drugs.

The inflammatory network

In the last few years the findings on allergic inflammation have improved, particularly in cellular signaling. Now we know that cytokines and other mediators are a network able to regulate the allergic inflammation (and inflammation in general). The new findings are important not only for basic science but also for the development of new therapeutic approaches to allergic diseases.

L1 and laminin: their expression during rat hypophysis ontogenesis and in adult neurohemal areas

L1 is a murine multidomain glycoprotein implicated in cell aggregation, fasciculation. neurite outgrowth and synaptogenesis. Laminin, a trimeric polypeptide, is implicated in neuronal survival, growth cone guidance, neurite outgrowth and cell differentiation. Laminin can also interact with the cell adhesion molecule L1. Their expressions were investigated from embryonic day 15 (E15) to adult in the rat hypophysis, and in adult neurohemal zones. Detected in the neural lobe from E17, the L1 immunoreactivity increased during prenatal development and persisted in adulthood mainly related to the neuropeptidergic fibers. Pituicytes were only labelled on the plasmalemma apposed to axons. In the intermediate lobe, L1 appeared at birth on folliculo-stellate cells extensions, constituting a network which densified during postnatal development. L1 is also expressed in all neurohemal areas on neuronal profiles. Laminin was clearly detectable in the hypophysis at E15 before the first blood vessels penetrate the Rathke pouch. At E20, all the basal membranes of the blood vessels were stained. In the intermediate lobe, a spotted laminin immunoreactivity was detected at E21. At this stage, we observed the staining of intercellular spaces and the intracellular labelling of melanotrophs, concerning reticulum or vesicles. The staining of melanotrophs seemed to maintain during adulthood. In contrast with blood vessels of the adult cerebral tissue, adult capillaries of the neural lobe and the others neuro-hemal zones were intensely labelled with the anti-laminin antibody. These results suggest that neurite outgrowth and neurite guidance could be promoted by L1 and laminin in the neurointermediate lobe. The "intercellular tunnels" could also be an important guidance cue for migrating cells in the intermediate lobe. These data also demonstrate that melanotrophic cells. secreting the laminin, have a role in the ontogenesis of the gland. Finally, we suggest that L1 and laminin can collaborate to reinforce "neurons-capillaries" interactions in neurohemal zones.

[Diverticular disease of the colon: its epidemiology and etiology]

Epidemiology for diverticular disease of the colon is rather difficult to assess because of the almost regularly selection of the patients submitted to analysis and described in literature. Therefore data extracted from different experiences are useful only for orientative epidemiologic implications. In the meanwhile these studies have been very useful to understand the possible reasons of its insurgence and evolution. Actually for etiopathogenesis the more diffuse opinion is to give importance to low fibre diet and to intrinsic motor derangement of the colon.

Expression of neural cell adhesion molecules, NCAMs, and their polysialylated forms, PSA-NCAMs, in the developing rat pituitary gland

Neural cell adhesion molecules (NCAMs) can undergo post-translational modifications, such as the addition of polysialic acid chains, thus generating PSA-NCAMs, which are expressed mainly during development. Since polysialylation considerably modifies NCAM adhesivity, expression of NCAMs and PSA-NCAMs has been investigated in the developing hypophysis by immunohistochemistry. At embryonic day 13 (E13), an antibody against NCAM outlined all cellular profiles in the entire Rathke's pouch; this labelling persisted until adulthood. NCAM expression increased in all lobes during development and concerned all pituitary cell types. In contrast, at E13, PSA-NCAMs were only detected in the neural lobe, solely constituted of pituicytes at this stage, and the tuberal lobe, the only lobe expressing hormonal mRNA at the same stage. PSA-NCAMs expression increased in the neural lobe at E17 with the arrival of the neurosecretory fibres and persisted into adulthood. In the anterior lobe, PSA-NCAMs appeared at E15 where their distribution was similar to that of the differentiating corticotrophic cells; at subsequent stages, their expression extended to the whole anterior lobe. Only two cell types, corticotrophic and somatotrophic cells, remained labelled in the adult gland. In the intermediate lobe, melanotrophic cells never expressed PSA-NCAMs but these were expressed on folliculo-stellate cells at birth, preceding the onset of innervation. These results suggest that NCAMs and PSA-NCAMs play a role in pituitary histogenesis, cell differentiation and neurointermediate lobe innervation.

[Surgical therapy of obstructive tumors of the large intestine]

Current option in managing obstructive colorectal carcinoma is a one stage procedure. Between 1987 and 1991, 47 cases of obstructive colorectal cancer were managed. A statistical analysis showed no significant difference in mortality, morbidity and hospital stay when comparing elective and emergency one staged resection and reconstruction.

[Low colorectal anastomosis: a comparison of manual and mechanical sutures]

Sixty-three carcinomas of the lower third of the rectum operated of anterior resection with low colorectal or coloanal anastomosis are presented. Handsewn anastomoses were performed in 33 patients, while staplers were used in 30 cases. The average distance of the tumor from the anal verge is 10.8 cm. in hand sutured anastomoses and 7.8 cm. in stapled ones. Dehiscences, stenosis and temporary incontinence are observed more frequently after stapled anastomosis, while the incidence of neoplastic recurrences is higher in sutured anastomosis; hospital stay and mortality are similar in the two series. Our results and literature review show that both techniques are comparable though maintaining their own specific identity and precise indication.

Clinical and pharmacokinetic study of nimesulide in children

The pharmacokinetic profile and efficacy of nimesulide were assessed in 2 separate studies that recruited children with hypoglycaemia or upper respiratory tract infection and fever, respectively. A single dose of nimesulide 50mg (granules) administered orally to 14 hypoglycaemic children was rapidly absorbed. A mean maximum nimesulide plasma concentration of 3.5 mg/L was achieved within 2 hours of administration, which subsequently declined over the following 12 hours. Nimesulide was metabolised to its principal hydroxy metabolite, which was detectable in samples obtained 0.5 hours after giving the parent drug. Levels of this metabolite steadily increased, surpassing those of intact nimesulide at the 9-hour sampling point. In a randomised nonblind clinical investigation, 100 hospitalised children with acute upper respiratory infections and fever received nimesulide oral suspension (5 mg/kg/day) or paracetamol (26 mg/kg/day) for 3 to 9 days. The antipyretic and anti-inflammatory effects of nimesulide were superior to those observed with paracetamol (p < 0.01) and both drugs were equally well tolerated.

Assessing equivalence of innovator and generic formulations of betamethasone dipropionate cream and ointment

A series of tests was used to compare two formulations of the topical steroid beta-methasone dipropionate, Diprolene (manufactured by the innovator, Schering Corp.) and Topilene (a generic formulation, manufactured by Technilab). Cream and ointment formulations produced by both manufacturers were compared with respect to physicochemical characteristics, skin sensitivity in rabbits, and a vasconstrictor assay indicative of topical availability in man. The physicochemical tests revealed no differences between innovator and generic ointment formulations, whereas excipients varied widely for the cream products. Similarly, the ointment formulations were comparable on the skin sensitivity tests in rabbits, whereas the generic cream product was much more irritating than the innovator cream in this test. On the vasoconstrictor assay in man the ointments were comparable, while the activity of the generic cream was much lower (approximately 30%) than that of the innovator cream; this difference was highly statistically significant. The difference in vasoconstrictor activity of the two cream products is discussed in relation to the differences in their physicochemical properties. It is concluded that the generic Topilene cream is not interchangeable with the innovator Diprolene cream, and that both pharmacists and physicians should be very careful when substituting one topical steroid formulation for another.