Micro-scale vertebral features in postmenopausal women with alcohol-associated and metabolic-associated fatty liver disease: ex vivo bone quality analyses

PURPOSE

Although epidemiological studies indicate increased fracture risk in women with alcohol-associated liver disease (AALD) and metabolic-associated fatty liver disease (MAFLD), data about their micro-scale bone features are still limited. We aimed to characterize bone quality changes in the anterior mid-transverse part of the first lumbar vertebral body collected from 32 adult postmenopausal females. Based on pathohistological assessment of the liver tissue, individuals were divided into AALD (n = 13), MAFLD (n = 9), and control group (n = 10).

METHODS

We analyzed trabecular and cortical micro-architecture (using micro-computed tomography), bone mechanical properties (using Vickers microhardness tester), osteocyte lacunar network and bone marrow adiposity morphology (using optic microscopy). Data were adjusted to elude the covariant effects of advanced age and body mass index on our results.

RESULTS

Our data indicated a minor trend toward deteriorated bone quality in MAFLD women, presented in impaired trabecular and cortical micro-architectural integrity, which could be associated with bone marrow adiposity alterations noted in these women. Additionally, we observed a significant decline in micro-architectural, mechanical, and osteocyte lacunar features in lumbar vertebrae collected from the AALD group. Lastly, our data indicated that vertebral bone deterioration was more prominent in the AALD group than in the MAFLD group.

CONCLUSION

Our data suggested that MAFLD and AALD are factors that could play a part in compromised vertebral strength of postmenopausal women. Also, our data contribute to understanding the multifactorial nature of bone fragility in these patients and highlight the necessity for developing more effective patient-specific diagnostic, preventive, and therapeutic strategies.

The micro-structural analysis of lumbar vertebrae in alcoholic liver cirrhosis

Although vertebral fracture is more common among alcoholic liver cirrhosis patients when compared to general population, current data on three-dimensional micro-architecture are scarce. Our study showed significant trabecular deterioration in lumbar vertebrae obtained from alcoholic liver cirrhosis donors, suggesting that they should be advised to undergo early-stage screening for osteoporosis.

PURPOSE

Recent studies showed an increased incidence of vertebral fractures in alcoholic liver cirrhosis (ALC) patients, while data about vertebral micro-structure are still limited. The aim of this study was to compare trabecular and cortical micro-architecture of lumbar vertebrae between ALC patients and healthy age- and sex-matched controls.

METHODS

Our study included lumbar vertebral samples of male cadaveric donors, divided into ALC (n = 20, age: 59 ± 6 years) and control group (n = 20, age: 59 ± 8 years). Following pathohistological verification of liver cirrhosis, trabecular and cortical bone micro-architecture was analyzed by micro-computed tomography (micro-CT).

RESULTS

Micro-CT evaluation of the trabecular bone in lumbar vertebrae showed a significant decrease in bone volume fraction, trabecular thickness, trabecular number, and connectivity (p < 0.01). In contrast to trabecular deterioration, prominent alteration in cortical parameters was not observed in lumbar vertebrae of ALC patients (p > 0.05).

CONCLUSIONS

Our data indicate that susceptibility to non-traumatic fractures in ALC patients could be explained by alterations in trabecular bone micro-architecture. Thus, we genuinely recommend osteological screening of the lumbar spine for all ALC patients in order to evaluate individual fracture risk. Graphical abstract.

Folate and pyridoxine to ssri in major depression and residual cognitive Decline

Introduction

Depressive disorders are very common conditions, lifetime risk for experiencing major depression is approximately 15%.

Objective

Patients with major depression having an insufficient response to SSRI may benefit from addition of methylfolate and pyridoxine.

Aim

The aim of our study was to determine the effect of folate and pyridoxine augmentation to SSRI on emotional, physical and cognitive symptoms in major depression.

Methods

Eighteen patients with MDD were enrolled, were on citalopram 20 mg/day when folate/15 mg per day/and pyridoxine/40 mg per day/were added. They have been monitored for three months using standard scales for depression and assessment by interview.

Results

After three months of using folate and pyridoxine to SSRI there was a significant improvement in depression as measured by the scales. In 8 patients were recorded improvements of 30–50%. The most prominent changes were in cognitive sphere of depression such as attention, reasoning and problem solving, working memory and speed of processing.

Conclusion

Low levels of folate and pyridoxine have been associated with the presence of depression and residual poor cognitive function. Our study confirms that folate and pyridoxine as adjunctive therapy to SSRI-partially refractory major depression is useful in particular to issues of residual cognitive interference conditions such as impaired concentration and memory, slow mentation, attention/vigilance, problem solving, working memory and speed of processing.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Vitamin D status, bone metabolism and bone mass in patients with alcoholic liver cirrhosis

INTRODUCTION

Osteoporosis is seen in some 12-50 % patients with liver cirrhosis. Detrimental effects of alcohol are exerted directly on the bone cells and indirectly on hormones. Vitamin D is involved in osteoblast differentiation, bone matrix synthesis and bone mineralization, as well as in its decomposition. Vitamin D deficiency has been reported in about 2/3 patients with liver cirrhosis.

OBJECTIVE

Determination of vitamin D status, bone metabolic activity and bone mass in patients with alcoholic liver cirrhosis (ALC).

METHODS

Thirty male patients with ALC were investigated in the period October 2011- March 2012. Total vitamin D, parathormone, osteocalcin and CrossLaps were determined by the ECLIA method (electrochemiluminiscence immunoassay) using Elecsys 2010 analyzer. Bone mineral density was measured by means of dual-energy x-ray absorptiometry (DXA) using the Lunar Prodigy. Result analysis was performed using descriptive statistics and hypothesis testing, as well as nonparametric one-way analysis of variance, Kruskal-Wallis test, Mann-Whitney U-test, Pearson correlation coefficient.

RESULTS

Deficiency in vitamin D (< 50 nmol/l) was noted in 66.66 % patients, with highest prevalence in Child-Pugh C class patients (chi-square = 5.878, p < 0.05). Osteocalcin levels were below the lower limit of normal in 86.7 % patients. CrossLaps was increased in only 20 % patients, but a significant increase was noted in Child-Pugh C class patients. Osteoporosis was diagnosed in 20 % of patients, with no correlation with disease severity and vitamin D status.

CONCLUSIONS

Vitamin D deficiency is present in patients with ALC. Decrease in bone formation and bone mass is most probably multicausal (Tab. 2, Fig. 1, Ref. 30).

Prognostic factors for longer disease free survival and overall survival after surgical resection of isolated liver metastasis from breast cancer

PURPOSE

Isolated liver metastases (LMs) from breast cancer (BC) occur in only 1-3% of the cases. Resection of isolated LMs improves survival. We examined the prognostic factors for time to LM development, disease free survival (DFS) and overall survival (OS) after BCLM resection.

METHODS

From 2006 to 2009, 32 patients underwent LM resection. All of them had breast cancer surgery for their primary tumor and developed resectable LMs as the first and only site of disease progression.

RESULTS

LMs developed after a median of 25 months. With a median follow up of 37 months (range 7-66) after metastases resection, median DFS and OS (with 95% CI) were 22.5 (12-40) and 37 (≥23) months, respectively. Tumor size ≥3 vs <3 cm and adjuvant chemotherapy vs no adjuvant chemotherapy correlated with shorter time to LM development (p<0.01 for both parameters). These parameters and BC negative estrogen (ER)/ progesterone receptors (PR) (ER?/PR? vs other) were related with shorter DFS. Positive (vs negative) axillary lymph nodes and BC negative ER/ PR (ER?/PR? vs other) status correlated with shorter OS (p<0.01 for both parameters). A period to metastases development ≥ 24 months (vs ≤24) and single (vs multiple) metastases were related with longer DFS and OS (p<0.01 for both conditions).

CONCLUSION

Despite the relatively small number of patients in this study, we believe that positive ER/PR status for both BC and LMs, negative axillary lymph nodes, time to liver metastases development >24 months and single liver metastases predict longer DFS and OS after LM resection.

A case of pregabalin intoxication

Pregabalin, or S-(+)-3-isobutylgaba, is a lipophilic analogue of GABA. Although pregabalin is structurally related to GABA, it is inactive at GABA receptors and does not appear to mimic GABA physiologically. Pregabalin is a potent ligand for the alpha-2-delta subunit of voltage-gated calcium channels in the central nervous system. It is currently being licensed for epilepsy, neuropathic pain, and generalized anxiety disorder. There are few case reports that have demonstrated safety of pregabalin in case of intoxication. We report here a case of pregabalin toxicity with a moderate pregabalin concentration that was successfully managed with conservative treatment only. The case report describes a 54-year-old man who was treated with pregabalin for generalized anxiety disorder. After having experienced a significant stress on a job the patient ingested huge amount of pregabalin (4,2 r) together with bromazepam (21 mg) and chlorimipramine (125 mg). On presentation he was conscious and alert with a stable condition of cardiovascular and respiratory systems. The serum pregabalin concentration was 20.8 mg/L but the patient did not have any signs of toxicity. Thanks to his good and stable somatic condition the patient was managed with supportive treatment only. Although anecdotal, our case report points toward safety of pregabalin following deliberate self-poisoning. Our observation is in accordance with the recent international literature underlining that pregabalin was listed as the drug ingested in only 1% of fatalities, usually in combination with other drugs.

Ultraradical surgery and heated intraperitoneal chemotherapy (HIPEC) as multimodal treatment of advanced colorectal cancer

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Background: Examin does agressive surgical treatment in combination with HIPEC (oxaliplatin) could increase median survial in patients with advanced stage of colorectal cancer.

Methods: Ultraradical surgery and HIPEC was applied in patients who were initialy with peritoneal carcinomatosis or infiltration in around organs. We evaluated the patients during the period 2000-2010 in this retrospective study.

Results: During 2000 and 2010 we peformed 132 ultraradical surgical procedure. All patients were treated with HIPEC (40C) using oxaliplatin (410mg/m2) in 3l of perfusat during 90 minutes. The average duration of the procedure was 5h 57 minutes.The follow up period was 72 months. 120 had Ro and 12 had R1 resection. One year survival rate was 81.25% and three year survival rate was 56.25%, six year survival rate is 40.6%.

Conclusions: Ultraradical surgery combined with HIPEC prolongs patient's survival and is considered to be a safe procedure if performed by the experience team of oncological surgeons.

No significant financial relationships to disclose.

Comparison between Steroid Receptors and Her2 Status in Primary Breast Carcinoma and Completely Resected Breast Carcinoma Metastases from Different Visceral Organ Sites

Background: Metastases biopsy are seldom performed in metastatic breast carcinoma (MBC) and hormonal, and anti-Her2 therapy are given upon biological markers of the primary breast cancer (PBC).However, there are reports about discrepancies in biological markers between PBC and MBC that could significantly influence treatment outcome.Aim: The aim of this paper is to compare steroid receptors and Her2 status of the PBC and of resected metastases (MBC) Patients and methods: Pathology reports were analyzed for all patients who underwent resection of PBC and resection of liver, brain or lung metastases. Rationale for this patients selection is the assumption that BC, as a heterogeneous malignancy might have differently expressed biological markers in different parts of metastases and therefore, biopsy only might not be completely informative about biological marker status of MBC. Results: 36 pts were identified: 27 with liver metastasis resection; 8 with brain metastasis resection; and 1 patient with lung metastasis resection. Median age was 51,5 years (31-73) Median DFI was 36 months (0-144) ER/PGR status of PBC was known for 32/36 pts and for 30/36 pts in metastasis (MBC). HER2 status of PBC was known for 30/36 pts and for 29/36 in MBC. To facilitate results interpretation, steroid receptor status is divided in 2 groups upon indication for hormonal treatment: A. hormone dependent, (one or both receptors score ≥ 4): B. hormone independent, (both receptors ≤ score 3). Her2 status is also divided in 2 groups upon indication for trastuzumab as: C. Her2 negative if IHC Her 2 was 0+,1+, or 2 + D. Her2 positive, if IHC was 3+ or CISH +; E. Triple negative if both steroid receptors were score 0 and Her2 0+ Results are presented at table 1.ResultsInitial biological markers status in PBCNo of pts (%)Changed biological markers status in MBC (%)CommentA. ER or PGR ≥ 421 (65,6%)12 (57%)12/21 (57%) hormone dependent PBC become hormone independent in MBCB.ER and PGR ≤ 311 (34,3%)1 (9 %)1/11 (9%) hormone independent PBC become hormone dependent in MBCC. Her2 0+,1+,2+24 (80%)0 (0%)0/24 (0%) Her2 0+,1+,2+ PBC has changed status to Her2 3+ in MBCD.Her2 3+6 (20%)1 (16,6%)1/6 (16,6%) Her2 3+ PBC has changed status in Her2 1+ in MBCE.Triple negative3 (10%)0 (0%)0/3 (0%) triple negative PBC has changed status in MBC     Conclusion: Biological markers, that are considered as poor prognostic factors are more stable characteristics of BC hence they tends to change in MBC in much lesser degree than biological markers that are considered as good prognostic factors. Although obtained in selected subgroup of BC patients who developed resectable BC metastases, these results could be implemented in every day clinical practice, hence triple negative, steroid receptor negative and Her2 positive PBC almost always retains these characteristics in MBC.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4048.

Profile of handicap situations in cancer patients

PURPOSE

The aim of this study was to assess the level of difficulty when performing a life habit, the type of assistance required and the person's level of satisfaction in relation to the accomplishment of each life habit, to establish a profile of handicap situation in cancer patients and to assess the relationship between the level of accomplishment and the level of satisfaction.

PATIENTS AND METHODS

The study sample consisted of 100 cancer patients. The Life Habits Assessment was used to measure the degree of accomplishment in 12 categories of life habits - daily living and social roles.

RESULTS

Disruptions in the accomplishment of all life habit categories were revealed. The highest disruptions were observed in the following categories: education, recreation, and employment. The highest accomplishments were observed in communication, personal care, and fitness. Human assistance was required in the accomplishment of responsibility, community, employment and recreation. The highest person's level of satisfaction was observed in communication, personal care and interpersonal relations. The highest correlation between the level of accomplishment and the level of satisfaction were in mobility and residence, and the lowest correlation was in communication.

CONCLUSION

The established profile of handicap situation in cancer patients should help specify rehabilitation objectives and may be a frame for individual treatment plan in accomplishing better social participation of cancer patients.

[Fatal therapeutic event after an injection of chlorpromazine]

Accidental deaths after parenteral use of medicaments are usually very rare. The most common cause of death is allergic reaction. In literature, the most menacing medicaments are antibiotics. Taking into account that macroscopic and microscopic autopsy findings are uncharacteristic and poor clinical features and circumstances are more or less characteristic and objective, and that the establishing of cause and mode of death could be a problem for dissectors. Later, in forensic expertise, the questions about medical malpractice could arise. In this paper the authors report on the case of a male, aged 46, a chronic psychiatric patient with schizophrenia, treated by neuroleptics, who died about half an hour after intramuscular injection of chlorpromazine. On the basis of the autopsy, microscopical and toxicological findings, clinical features and circumstances, as well as exclusion of other possible violent and morbid causes of death, it was established that the unexpected and sudden death was caused by anaphylactic allergic reaction due to injected medicament--chlorpromazine.

Significant increase of aortic root volume and commissural area occurs prior to aortic valve opening

BACKGROUND AND AIM OF THE STUDY

The increased use of autologous, homologous or heterologous aortic root demands a detailed knowledge of its anatomy and function. The advent of 3-D digital sonomicrometry offered the opportunity to acquire precise information on the root and leaflet movements during the cardiac cycle.

METHODS

Under cardiopulmonary bypass, sonomicrometry crystals were implanted in the aortic root and valve of eight sheep. Crystals were sutured at each commissure (n = 3), the top of the sinotubular junction (n = 3), lowest point of the annulus (n = 3), and leaflet tip (n = 3). 3-D coordinates of each crystal were recorded, together with left ventricular and aortic root pressures and ECG. When the animal had returned to a stable hemodynamic condition, the maximum and minimum distances between two crystals, and areas between three crystals, were calculated. Changes in root volume and leaflet position were time-related to the pressure changes.

RESULTS

The most significant change between maximum and minimum distance between crystals during the cardiac cycle occurred at the commissural level. Similarly, the triangle defined by the three commissural crystals showed the greatest change in area (47%). The root volume increased by an average of 22%; about 40% of this increase occurred during the isovolumic phase. The aortic leaflets began to open before ejection.

CONCLUSION

We postulate that aortic valve opening is initiated by the outward pull of the commissures. These findings should impact on aortic root surgery.

Mechanism of sustained mechanical alternans. Effect of variations in ventricular billing volume

This study investigations the phenomenon of sustained mechanical alternans (SMA) through the use of quantitative criteria. Discrete analysis is used to demonstrate that the hemodynamic variables during SMA are governed by a simple mathematical relation. The analysis shows that the value of the slope created by the two alternating beats on the stroke volume (SV)-end-diastolic volume (EDV) plane is gamma = (mu - 1) (1 + beta)/(mu - beta), where mu = SVs/SVw, and SVs and SVw denote the strong and weak beats, respectively, in the presence of one contractile state, and the beats associated with the higher and lower contractile states, respectively, in the presence of two alternating contractile states; beta = FVs/FVw, where FVs and FVw are the filling volumes after SVs and SVw, respectively. This equation is valid, whether SMA is exhibited in the presence of one or two contractile states and irrespective of the SV-EDV functional relation. Assuming constant afterload, a criterion based on this slope (gamma) is described to determine if SMA is caused by variations in EDV and FV. The slope of the SV-EDV curve in the presence of one contractile state (denoted as gamma) was determined directly (34 runs in eight dogs) by preventing FV in a beat, after a steady state, using a remote-controlled mitral valve. The slope gamma = 0.892 +/- 0.078 was found to agree with data in the literature. In 10 other dogs, mitral flow and aortic flow were measured in 55 series of SMA. In 51 series, gamma was greater than 1. Because the experimental slope in the presence of one contractile state, gamma, is smaller than or equal to 1, the possibility that one contractile state is involved in this series is rejected. On the other hand, when two contractile states are involved, the slope that the two successive beats create on the SV-EDV plane, gamma, is determined by connecting the two SV-EDV relations. This slope tends to be greater than 1. Thus, in these 51 series, SMA cannot be explained as a result of the Frank-Starling mechanism and variations in FV but as a result of two alternating contractile states. In the other four series, the value of gamma can be compatible either with the presence of one contractile state or with two alternating contractile states. This quantitative analysis enables the classification of the various types of SMA into subcategories with well-defined features. The quantitative analysis presented here shows that the common genesis of SMA is an alternating contractile state.

Effect of early diastolic loading on myocardial relaxation in the intact canine left ventricle

Early transmitral flow (MiF) patterns depend strongly on the rate of fall of measured left ventricular pressure (Pm) determined by both the active decay of pressure (Pa) due to myocardial relaxation and the increase in pressure due to stretch of passive elements during filling (Pp). This study was designed to uncouple passive forces from deactivation in order to reveal the instantaneous rate and duration of myocardial relaxation. We assumed a parallel combination of passive and active elements: Pm(t,V) = Pa(t) + Pp(V), with no constraints on the form of Pa(t), where t is time and V is ventricular volume. Pp(V) was determined by a retrospective analysis of data obtained in 11 anesthetized dogs instrumented for volume clamping with a remote-controlled mitral valve, with left atrial and left ventricular micromanometers, and with an electromagnetic probe to measure MiF. The passive pressure-volume relation (both positive and negative portions) was determined by clamping at end-systolic volume or after various filling volumes, and fit to logarithmic functions. Pp(t) was then calculated from Pp(V) and V(t) (integral of MiF). Time to end relaxation (Ter) was defined as time when Pa = 0. During isovolumic relaxation, when dPp/dt = 0, dPm/dt is equal to the relaxation rate, dPa/dt. In completely isovolumic relaxations, asymptote P infinity = -7 +/- 6 mm Hg (thus, Pa is 7 mm Hg greater than Pm) and Ter = 40 +/- 15 msec, compared with 175 +/- 53 msec during normal filling. In high versus low inotropic state, Pa at the beginning of filling was greater (18.1 +/- 6.1 vs. 12.2 +/- 3.9 mm Hg), and Ter was shorter (170 +/- 42 vs. 228 +/- 43 msec). Active pressure Pa(t) during filling is not an exponential function, and at any time, it was always greater after filling than in nonfilling beats, which indicates an increase in the relaxation duration. We conclude that myocardial relaxation is modulated by filling, which slows its rate and increases its duration, and is therefore a function of both ventricular volume and time. Such a mechanism may have an important role in regulating the diastolic pressure-volume relation.

Teaching stress management techniques to a schizophrenic patient

This paper describes a stress management training program used with a 26-year-old schizophrenic man attending an outpatient day care program. In a seven-session program the patient was taught to use various techniques in muscle relaxation and biofeedback to decrease anxiety and to cope with stress. The patient's improvement on 7 of the 20 items of the State-Trait Anxiety Inventory demonstrated the effectiveness of even a short-term stress management program.