Tumor enlargement in adrenal incidentaloma is related to glaucoma: a new prognostic feature?

PURPOSE

The uncertainty on the management of small adrenal incidentalomas (AIs) still represents a challenge in real clinical practice. Considering the lack of knowledge on risk factors implicated in tumour enlargement, the aim of this study was to identify risk factors for morphological changes during follow-up of adrenal incidentalomas (AIs).

METHODS

We retrospectively evaluated demographic, clinical, radiological and biochemical parameters of 153 AIs (2007-2021). Patients with histological diagnosis of metastases or pheochromocytoma were excluded. To detect risk factors for tumor enlargement, diseases associated with AIs were included if their prevalence was higher than 2%. Patients were divided into two groups (A: radiological stability; B: tumor enlargement defined as > 5 mm/year in the main diameter).

RESULTS

Group A: 89.5% and group B: 10.5%, mean follow-up 38.6 ± 6.9 months (range 6-240). Tumor enlargement when occurred was within 36 months of follow-up. In group B high body weight (p < 0.03), dehydroepiandrosterone sulfate (DHEAS) (p < 0.05) and direct renin concentration (DRC) (p < 0.04) were higher than group A, while aldosterone levels were lower; moreover, considering comorbidities, glaucoma and dysglycemia (p < 0.01 for both) had higher prevalence in group B. Glaucoma and dysglycemia were independent predictors of enlargement. Patients affected by glaucoma, atrial fibrillation, dysglycemia had a lower dimensional change-free survival than non-affected.

CONCLUSIONS

Glaucoma might be a novel risk factor for AI enlargement. If subtle undetectable cortisol hypersecretion has a role is a topic for further research.

A method to generate perfusable physiologic-like vascular channels within a liver-on-chip model

The human vasculature is essential in organs and tissues for the transport of nutrients, metabolic waste products, and the maintenance of homeostasis. The integration of vessels in in vitro organs-on-chip may, therefore, improve the similarity to the native organ microenvironment, ensuring proper physiological functions and reducing the gap between experimental research and clinical outcomes. This gap is particularly evident in drug testing and the use of vascularized models may provide more realistic insights into human responses to drugs in the pre-clinical phases of the drug development pipeline. In this context, different vascularized liver models have been developed to recapitulate the architecture of the hepatic sinusoid, exploiting either porous membranes or bioprinting techniques. In this work, we developed a method to generate perfusable vascular channels with a circular cross section within organs-on-chip without any interposing material between the parenchyma and the surrounding environment. Through this technique, vascularized liver sinusoid-on-chip systems with and without the inclusion of the space of Disse were designed and developed. The recapitulation of the Disse layer, therefore, a gap between hepatocytes and endothelial cells physiologically present in the native liver milieu, seems to enhance hepatic functionality (e.g., albumin production) compared to when hepatocytes are in close contact with endothelial cells. These findings pave the way to numerous further uses of microfluidic technologies coupled with vascularized tissue models (e.g., immune system perfusion) as well as the integration within multiorgan-on-chip settings.

Diagnostic pathways to wild-type transthyretin amyloid cardiomyopathy: a multicentre network study

AIM

Epidemiology of wild-type transthyretin cardiac amyloidosis (ATTRwt-CA) remains poorly defined. A better characterization of pathways leading to ATTRwt-CA diagnosis is of key importance, and potentially informative of disease course and prognosis. The aim of this study was to describe the characteristics of contemporary pathways leading to ATTRwt-CA diagnosis, and their potential association with survival.

METHODS AND RESULTS

This was a retrospective study of patients diagnosed with ATTRwt-CA at 17 Italian referral centres for CA. Patients were categorized into different 'pathways' according to the medical reason that triggered the diagnosis of ATTRwt-CA (hypertrophic cardiomyopathy [HCM] pathway, heart failure [HF] pathway, incidental imaging or incidental clinical pathway). Prognosis was investigated with all-cause mortality as endpoint. Overall, 1281 ATTRwt-CA patients were included in the study. The diagnostic pathway leading to ATTRwt-CA diagnosis was HCM in 7% of patients, HF in 51%, incidental imaging in 23%, incidental clinical in 19%. Patients in the HF pathway, as compared to the others, were older and had a greater prevalence of New York Heart Association (NYHA) class III-IV and chronic kidney disease. Survival was significantly worse in the HF versus other pathways, but similar among the three others. In multivariate model, older age at diagnosis, NYHA class III-IV and some comorbidities but not the HF pathway were independently associated with worse survival.

CONCLUSIONS

Half of contemporary ATTRwt-CA diagnoses occur in a HF setting. These patients had worse clinical profile and outcome than those diagnosed either due to suspected HCM or incidentally, although prognosis remained primarily related to age, NYHA functional class and comorbidities rather than the diagnostic pathway itself.

V-046 LAPAROSCOPIC SURGICAL MANAGEMENT OF AN HUGE DIAPHRAGMATIC HERNIA

Introduction

Diaphragmatic hernias (DH) in most cases are the consequence of a diaphragmatic trauma causing a missed injury. Less frequently, DHs are congenital.

Case Presentation

A 52 years old patient came to our attention due to a worsening severe dyspnea. A chest CT scan were performed, showing an extensive left-side DH. We present the video of the surgical procedure.

The patient mentioned a severe left hemithorax trauma occurred almost twenty years before due to a motorbike accident. Possibly, a diaphragmatic injury was not diagnosed at the time. Subsequently, a Covid-19-related chronic cough resulting in a persistently increased intra abdominal pressure may have caused the herniation of abdominal viscera.

The surgical procedure was laparoscopic. The whole greater omentum and most of the transverse colon were herniated and, after a thorough adhesiolysis between the herniated tissues and the left diaphragmatic crus, the DH was reduced. It was confirmed the presence of a 8 cm defect of the left hemidiaphragm, it was repaired with a absorbable continuous suture. A 08×10 cm Bio-A patch was positioned over. The herniated tissues were meticulously examined and showed no signs of damage.

Conclusions

Diaphragm's injuries are unfortunately difficult to diagnose in an acute setting, thus remaining often unbeknownst to the surgeon. Some patients never develop any symptoms because of such missed diaphragmatic injuries. Some others instead, due to an increase in the intra abdominal pressure, may develop symptomatic DHs. In the latter case, surgical management becomes mandatory.

V-045 SAFENESS OF LIQUIBAND FIX8® IN T.A.P.P. PROCEDURE: ANALYSIS OF COSTS, POST-OPERATIVE COMPLICATIONS AND RECURRENCES

Aims

We tested the use of LiquiBand®FIX8™ versus standard TAPP procedure comparing costs, surgical time, complications, recurrence rate, chronic pain to check the feasibility of the procedure.

Materials and Methods

LiquiBand®FIX8™is a cyanoacrylic adhesive used to fix the mesh during laparoscopic procedures. It consents the avoidance of plastic or metallic fixing materials that can causes post-operative chronic pain or vascular damage

Discussion

We performer 54 TAPP procedures, 48 with standardized tack technique and 6 with LiquiBand®FIX8™. We checked the results after a 6 months follow-up and we found no difference in recurrence rate or chronic pain between the two techniques. Costs and surgical time were inferior in LiquiBand®FIX8™ group.

Conclusions

The use of LiquiBand®FIX8™is a safe and feasible procedure during TAPP to reduce the surgical time, to limit costs and to avoid intraoperative and postoperative complications that can occur with mechanical fixing materials.

V-056 LAPAROSCOPIC VENTRAL HERNIA REPAIR WITH GORE SINECOR INTRAPERITONEAL BIOMATERIAL: OUR CENTER EXPERIENCE

Aim

Ventral hernias including incisional ones are very common in our population. Mesh reinforcement options for ventral/incisional hernia repair continue to evolve with advances in polymer science and better understanding of the extracellular matrix. Consensus on the safety and efficacy of these various types of synthetic and biologic mesh has yet to be reached.

Intraperitoneal onlay mesh (IPOM) is the laparoscopic technique most frequently used in our center to treat umbilical and abdominal ventral defects sized 3 cm to 8 cm. Our equipe built an expertise with Gore DualMesh prosthesis (2% recurrence ratio in our center); we used the Gore Sinecor Intraperitoneal Biomaterial for the first time here.

Methods

Symptomatic supraumbilical incisional hernia in a 74 years old man; parietal defect sized 7×8 cm. We performed an Ipom repair procedure using a 20×25 cm Gore Sinecor Intraperitoneal Biomaterial, trimmed to 18×20 cm. Follow-up at one and six months from surgery.

Results

The patient was discharged the day after surgery. He did not complain severe pain in the first week after surgery and he only use Paracetamolo 1g die as antalgic therapy. After seven days he resumed his daily activities.

He did not experience any short-term sieroma nor long-term complication at follow up.

Conclusions

The Gore Sinecor Intraperitoneal Biomaterial, while maintaining a firm peritoneal adhesivity, has a better handling and feels lighter than the Gore DualMesh we routinely use. The transparency makes it possible to visualize the overlying abdominal wall, allowing a safer tacs positioning.

P242 ADVANCED HEART FAILURE: ENHANCEMENT OF INTEGRATED MANAGEMENT IN THE METROPOLITAN AREA OF FORLÌ

 

The aim of this study is to assess the effectiveness of a multi–professional home care (HC) model – cardiologist, general practitioner, cardiology nurse – which has been active in the metropolitan area of Forlì since 1999. In May 2021, 14 patients were enrolled (mean age=75.43). Inclusion criteria: heart failure (HF) in NYHA class III–IV, recurrent hospitalizations for HF and difficulties to reach the clinic. 4 out of 14 patients had been followed by the cardiologic HC program since 2016, 3 patients since 2018, 1 patient since 2019, 1 patient since 2020, 5 patients since 2021.

Outcome Measures

Rate of hospital admissions for HF 6 and 12 months before and after admission in HC pathway, quality of life (Minnesota Test), functional residual capacity (Palliative Performance Scale, PPS), compliance to the therapeutic program (Morisky Test). Questionnaires were administered when patients were included in HC and repeated at the time of enrollment and after 6 months. 3 patients were excluded from the analysis after enrollment because they died (n = 2) or were admitted in nursing homes (n = 1). It was observed that hospitalizations due to HF decreased from 1.64 during the 6 months preceding the admission in HC to 0.36 in the following 6 months (–78.05%, p = .002); furthermore, patients included in HC for more than 12 months (n = 9) decreased their hospitalizations from 1.78 in the year before their inclusion in the HC pathway to 0.33 in the year after (81.46%, p = .012). Since the cost of an average hospitalization for HF has been evaluated to be € 3,265.90 (DRG 127 Emilia–Romagna Region 2020), it was estimated a reduction in costs per patient of € 4,180.36 in 6 months and € 4,735.55 in 12 months. During the follow–up period, patients experienced a clinically significant improvement in psychophysical and social well–being and in the performance of daily activities. The mean Minnesota Test score improved (p = .001) from 62.86 (at the admission in HC) to 44.21 (at the enrollment) and 40.09 (at 6 months); the PPS score increased (p = .0021) from 56.43% (at the admission in HC) to 61.43% (at the enrollment) and 67.27% (at 6 months). Good therapeutic adherence was maintained, with a Morisky Test score ≥ 10.

In conclusion, these preliminary results are consistent with recent ESC guidelines for the multi–professional care of patients with chronic HF and show the efficacy of this approach in order to prevent hospital admissions and to improve quality of life.

Abnormal Vasculature Development in Zebrafish Embryos with Reduced Expression of Pantothenate Kinase 2 Gene

Mutations in pank2 gene encoding pantothenate kinase 2 determine a pantothenate kinase-associated neurodegeneration, a rare disorder characterized by iron deposition in the globus pallidus. To extend our previous work, we performed microinjections of a new pank2-specific morpholino to zebrafish embryos and thoroughly analyzed vasculature development. Vessels development was severely perturbed in the head, trunk, and tail, where blood accumulation was remarkable and associated with dilation of the posterior cardinal vein. This phenotype was specific as confirmed by p53 expression analysis and injection of the same morpholino in pank2-mutant embryos. We can conclude that pank2 gene is involved in vasculature development in zebrafish embryos. The comprehension of the underlining mechanisms could be of relevance for understanding of pantothenate kinase-associated neurodegeneration.

Morbidity following thyroid surgery: acceptable rates and how to manage complicated patients

PURPOSE

The endocrine surgeon and the endocrinologist should standardize how they deal with patients with an indication for thyroidectomy, as the road to surgery starts well before the operation itself. The patient should be thoroughly informed about where and how surgery will be performed, the postoperative improvements that can be expected, and the possibility and incidence of relevant complications. This short review aims at identifying the most common postoperative issues after thyroidectomy, with the relevant therapeutic suggestions.

METHODS

A revision of studies reporting the morbidity of thyroid surgery, involving the largest numbers of patients.

RESULTS

It has been clearly demonstrated that the outcome of thyroid surgery is significantly better when the procedure is performed by an experienced surgeon. Thus, the number of thyroidectomies performed by a surgeon should drive the endocrinologist when referring a patient.

CONCLUSIONS

Despite the surgeon's experience, thyroidectomy is burdened by a relatively high rate of postoperative issues ranging from less severe ones to others causing significant changes in the patient's quality of life. Minor, non-invalidating symptoms have been described in 40% of patients after thyroidectomy (e.g. hoarseness, mild dysphagia, some degree of voice alteration); however, these symptoms usually resolve within a few months of surgery, with or without early treatment. On the other hand, major postoperative complications are observed in a limited number of patients, but in these cases early diagnosis is important to provide the most appropriate postoperative treatment, and thus hasten full recovery or at least achieve the greatest possible improvement.

Relationship between Doxorubicin-Induced Ecg Changes and Myocardial Alterations in Rats

The aim of the present study was to evaluate the dose- and time-dependence of the effect displayed by doxorubicin (DXR) on the electrocardiogram (ECG) and to establish the relationship between structural alterations of the myocardium and ECG changes in rats administered DXR, at a dose of 1.5 or 3.0 mg/kg, every 3 days for a total of three administrations. The most interesting findings consisted of a dose-dependent, but reversible prolongation of the QRS complex, and in a dose-dependent and progressive irreversible increase in QaT and, in particular, in SaT duration. Furthermore, animals treated with the higher DXR dose showed a slight increase in serum K+ concentration and a significant decrease in serum Ca2+ levels. A good correlation was found between the morphologic score indicating the degree of observed tissue damage and SaT prolongation. These results therefore support the usefulness of measuring this ECG parameter for monitoring the development of DXR-induced cardiotoxicity in rats.

Evaluation of adequacy of levo-thyroxine dosage in patients with differentiated thyroid carcinoma: correlation between morning and afternoon TSH determination

PURPOSE

The aim of this study was to judge the reliability of evaluating thyroid-stimulating hormone (TSH) and free thyroxine (f-T4) in the morning and afternoon in differentiated thyroid carcinoma (DTC) patients.

METHODS

We evaluated 153 DTC patients, aged 61 ± 13 years, in active follow-up in our center after primary treatments and under stabilized levo-thyroxine (L-T4) posology. In each patient, morning and afternoon examinations were performed 1-3 months apart. Blood samples were collected at 08:00-09:00 h and 15:00-16:00 h. TSH and f-T4 were evaluated in both samples. Thyroglobulin (Tg), Tg-antibodies and neck ultrasonography were also evaluated.

RESULTS

According to clinical and laboratory examinations, 92% of patients were disease-free, 6% had biochemical disease, and 2% structural disease. L-T4 dosages (1.64 ± 0.38 µg/kg b.w.) proved the same on both occasions, despite slight changes in body weight or L-T4 posology in 15% of patients. Free-T4 values were significantly higher in the afternoon (21.5 ± 0.3 pmol/L) than in the morning (18.8 ± 0.4 pmol/L; P < 0.0001), whereas TSH values were statistically unchanged (morning 0.85 ± 0.25 mIU/L; afternoon 0.72 ± 0.20 mIU/L). There was a significant correlation (P < 0.0001) between the two TSH determinations in the same patients.

CONCLUSIONS

In DTC patients, follow-up examination consists of clinical and laboratory evaluations. The majority of patients have good disease control. Our study suggests that the adequacy of L-T4 therapy can be monitored equally well either in the morning or in the afternoon. Afternoon examinations can alleviate crowding in hospital ambulatories in the morning.

The Rat Model in the Comparative Evaluation of Anthracyclines Cardiotoxicity

In the present investigation, the cardiotoxic effects of three anthracycline analogs (doxorubicin, 4′-epi-doxorubicin and 4′-deoxy-doxorubicin) were compared. For this purpose, 9.0 mg/kg of doxorubicin, divided into three closely spaced sub-doses, were injected intravenously in rats. The two derivatives were administered according to the same time schedule and their doses were chosen on the basis of the clinically adopted ratio, doxorubicin : 4′-epidoxorubicin : 4′-deoxy-doxorubicin = 1:1: 0.5. The degree of cardiomyopathy induced by the three anthracyclines was evaluated by ECG changes and morphological alterations. Doxorubicin was found to produce a significant degree of cardiotoxicity, thus confirming the validity of the experimental model adopted. Both 4′-substituted derivatives proved to be less cardiotoxic than the parent compound, although not completely devoid of this side effect.

Interaction between Doxorubicin and Mitomycin C on Mortality and Myocardial Contractility in Guinea PIG

The present investigations were carried out in guinea pig to ascertain whether mitomycin C has a direct cardiotoxic effect or interacts with doxorubicin-induced cardiotoxicity. I.p. administration of mitomycin C did not modify the survival rate up to 30 days, whereas the combined administration of doxorubicin and mitomycin C significantly decreased the survival time in comparison to the doxorubicin-treated group. On isolated atria, mitomycin C did not cause significant inhibition of the contractile force or an enhancement of the doxorubicin-induced negative inotropic effect. These results do not support the possibility that mitomycin C potentiates the acute cardiotoxic effects produced by doxorubicin.

In vitro sensitivity to methyl-prednisolone is associated with clinical response in pediatric idiopathic nephrotic syndrome

The aim of this study was to evaluate the in vitro steroid sensitivity as a predictor of clinical response to glucocorticoids in childhood idiopathic nephrotic syndrome (INS). Seventy-four patients (median age 4.33, interquartile range [IQR] 2.82-7.23; 63.5% male) were enrolled in a prospective multicenter study: in vitro steroid inhibition of patients' peripheral blood mononuclear cell proliferation was evaluated by [methyl-(3) H] thymidine incorporation assay at disease onset (T0) and after 4 weeks (T4) of treatment. Steroid dependence was associated with increased in vitro sensitivity at T4 assessed both as drug concentration inducing 50% of inhibition (IC50 ; odds ratio [OR] = 0.48, 95% confidence interval [CI] = 0.24-0.85; P = 0.0094) and maximum inhibition at the highest drug concentration (Imax ; OR = 1.13, 95% CI = 1.02-1.31; P = 0.017). IC50 > 4.4 nM and Imax < 92% at T4 were good predictors for optimal clinical response. These results suggest that this test may be useful for predicting the response to glucocorticoid therapy in pediatric INS.

Combining bosentan and sildenafil in pulmonary arterial hypertension patients failing monotherapy: real-world insights

Pulmonary arterial hypertension is a severe disease with a complex pathogenesis, for which combination therapy is an attractive option.

This study aimed to assess the impact of sequential combination therapy on both short-term responses and long-term outcomes in a real-world setting.

Patients with idiopathic/heritable pulmonary arterial hypertension, or pulmonary arterial hypertension associated with congenital heart disease or connective tissue disease and who were not meeting treatment goals on either first-line bosentan or sildenafil monotherapy, were given additional sildenafil or bosentan and assessed after 3–4 months. Double combination therapy significantly improved clinical and haemodynamic parameters, independent of aetiology or the order of drug administration. Significant improvements in functional class were observed in patients with idiopathic/heritable pulmonary arterial hypertension. The 1-, 3- and 5-year overall survival estimates were 91%, 69% and 59%, respectively. Patients with pulmonary arterial hypertension associated with connective tissue disease had significantly poorer survival rates compared to other aetiologies (p<0.003).

The favourable short-term haemodynamic results and good survival rates, observed in patients receiving both bosentan and sildenafil, supports the use of sequential combination therapy in patients failing on monotherapy in a real-world setting.

Significant association among growing pains, vitamin D supplementation, and bone mineral status: results from a pilot cohort study

The aim of our study was to analyze the possible relationship between growing pains, vitamin D levels, and bone mineral status. We enrolled 33 children affected by growing pains. Their pain intensity was evaluated through a questionnaire using the Wong-Baker Faces Pain Rating Scale for pain assessment. Serum 25-hydroxyvitamin D (25-OH-D), parathyroid hormone (PTH), and alkaline phosphatase levels were measured as well. A quantitative ultrasound assessment (QUS) was also done, measuring both the amplitude-dependent speed of sound (AD-SOS) and the bone transmission time (BTT), correlating, respectively, with bone density and with cortical thickness. After 3 and 24 months of vitamin D supplementation, we re-evaluated pain intensity and laboratory results. After 24 months we re-assessed QUS parameters. At the beginning of the study the children reported a mean growing pain intensity of 7.5 ± 1.6 SD. The mean values of 25-OH-D and PTH levels were 15.7 ± 6.9 ng/ml and 57.3 ± 27.3 pg/ml, respectively. The AD-SOS Z score was -0.53 ± 1.19 SD, and the mean value of the BTT Z score was -0.72 ± 0.96 SD. After the first 3 months of vitamin D supplementation we observed an increase in 25-OH-D levels (34.1 ± 17.8, p < 0.001) and a reduction in both PTH levels (47.3 ± 30.6, p = 0.135) and pain intensity (2.7 ± 2.2, p < 0.001). After 24 months we observed a further significant reduction in the pain intensity (3.9 ± 3.4, p < 0.001) and in PTH levels (43.7 ± 28.5, p = 0.004) and an improvement in the QUS parameters, in particular in BTT Z scores (p = 0.014). Our study suggests an interesting relationship between growing pains, vitamin D levels and bone mineral status.

Efficacy of sorafenib and impact on cardiac function in patients with thyroid cancer: a retrospective analysis

PURPOSE

Sorafenib has recently been recognized as an important standard option for the management of patients with differentiated thyroid cancer. Although data concerning cardiac safety are available in pan-tumor studies, no data are available on its use in everyday clinical practice in patients with thyroid cancer.

METHODS

In the off-label program of our institution, we enrolled 14 patients with different histological types of thyroid cancer suitable for treatment with sorafenib. Our aims were to evaluate cardiac safety factors-LVEF (left ventricular ejection fraction), heart rate and blood pressure-the cardiac markers NT-proBNP and troponin I, radiological response evaluated by CT and (18)FDG-PET (according to RECIST 1.1 criteria) and biomarker reduction (Eastern Cooperative Oncology Group Performance Status: ECOG PS) 0-2.

RESULTS

Patients with ECOG PS 2 accounted for 36%. After starting sorafenib, many patients displayed reduced or stabilized metabolic activity in target lesions (clinical benefit = 44%), radiologic reduction or stabilization (74%) and decreased cancer markers (90%). Lung metastases displayed the largest reductions in size. Median overall survival (OS) was 7 months and median progression-free survival (PFS) was 3 months. No sign of cardiotoxicity was observed in almost all patients. LVEF was altered in two patients and proved symptomatic in one.

CONCLUSIONS

Sorafenib seems to be effective in reducing disease progression in the early stages of treatment (3-6 months). Responses varied considerably according to the criteria investigated. Cardiac toxicities did not raise concerns and were in line with data reported in other malignancies. However, cardiac monitoring is recommended.

Utility of a Liquid Formulation of Levo-thyroxine in Differentiated Thyroid Cancer Patients

The goal of levo-thyroxine (L-T4) administration in differentiated thyroid cancer (DTC) is to suppress thyroid stimulating hormone (TSH) levels. The tolerability and efficacy of a new formulation of liquid L-T4 vs. the previous tablet formulation was evaluated in a cohort of 59 patients with cured DTC. The correlation between breakfast modality and therapy was also monitored. Hormonal and clinical evaluations were performed before and 70 days after patients were switched from tablet to liquid L-T4 formulation, without changes in daily dose. Breakfast habits were evaluated. The interval between L-T4 therapy and breakfast was recorded. Patient approval of L-T4 formulations was evaluated. 8% of patients dropped out owing to adverse events. The modality of L-T4 administration proved adequate under tablet and liquid formulation in 64% and 68% of patients who fully complied with the protocol. While significantly more patients found the tablet formulation more agreeable, at the end of the protocol subjective symptoms had diminished significantly and 73% requested to remain on the liquid formulation. No change in TSH, thyroid hormones or thyroglobulin was noted during the study. A balanced breakfast containing less than 4 g of alimentary fibre did not interfere with L-T4 therapy. Liquid L-T4 seems to be a valid alternative formulation in DTC patients, its initial dislike being outweighed by a significant reduction in subjective symptoms. Both tablet and liquid L-T4 therapy require monitoring over time. A continental breakfast containing less than 4 g of alimentary fibres seems to favour the absorption of L-T4, whether in tablet or liquid formulation.

Inflammatory cues acting on the adult intestinal stem cells and the early onset of cancer (review)

The observation that cancer often arises at sites of chronic inflammation has prompted the idea that carcinogenesis and inflammation are deeply interwoven. In fact, the current literature highlights a role for chronic inflammation in virtually all the steps of carcinogenesis, including tumor initiation, promotion and progression. The aim of the present article is to review the current literature on the involvement of chronic inflammation in the initiation step and in the very early phases of tumorigenesis, in a type of cancer where adult stem cells are assumed to be the cells of origin of neoplasia. Since the gastrointestinal tract is regarded as the best-established model system to address the liaison between chronic inflammation and neoplasia, the focus of this article will be on intestinal cancer. In fact, the anatomy of the intestinal epithelial lining is uniquely suited to study adult stem cells in their niche, and the bowel crypt is an ideal developmental biology system, as proliferation, differentiation and cell migration are all distributed linearly along the long axis of the crypt. Moreover, crypt stem cells are regarded today as the most likely targets of neoplastic transformation in bowel cancer. More specifically, the present review addresses the molecular mechanisms whereby a state of chronic inflammation could trigger the neoplastic process in the intestine, focusing on the generation of inflammatory cues evoking enhanced proliferation in cells not initiated but at risk of neoplastic transformation because of their stemness. Novel experimental approaches, based on triggering an inflammatory stimulus in the neighbourhood of adult intestinal stem cells, are warranted to address some as yet unanswered questions. A possible approach, the targeted transgenesis of Paneth cells, may be aimed at 'hijacking' the crypt stem cell niche from a status characterized by the maintenance of homeostasis to local chronic inflammation, with the prospect of initiating neoplastic transformation in that site.

Co-targeting the IGF system and HIF-1 inhibits migration and invasion by (triple-negative) breast cancer cells

Background:

Metastatic triple-negative breast cancer is mostly incurable, due to lack of suitable drug targets. The insulin-like growth factor (IGF) system could provide such a target, and IGF-1 receptor (IGF-1R)-directed agents are already available, but seem unable to control all the complexities of the system, including crosstalk with hypoxia-inducible pathways.

Methods:

Migration of triple-negative MDA-231 breast cancer cells and its modulation by IGFs, the IGF-1R inhibitor NVP-AEW541 and the IGF-2-sequestering monoclonal antibody MAB292 were assessed by the scratch wound healing and Boyden chamber assays; the effect of topotecan (inhibiting hypoxia-inducible factor-1 (HIF-1)) under hypoxia was also evaluated. Constitutive as well as drug-modulated levels of components of the IGF and HIF-1 pathways were evaluated by western blotting and qPCR.

Results:

IGF-induced migration of MDA-231 cells was not abrogated by the IGF-1R inhibitor NVP-AEW541, whereas IGF-2 sequestration by MAB292 significantly reduced cell migration. Under hypoxia, topotecan was also effective, likely by reducing HIF-1-induced IGF-2 release. Simultaneous targeting of IGF-1R and IGF-2 or HIF-1 completely abolished cell migration.

Conclusions:

IR activation may account for the failure of NVP-AEW541 to suppress MDA-231 cell migration. Ligand-targeting compounds, or co-inhibition of the IGF and HIF-1 systems, may prevent activation of compensatory signalling, thereby providing a valuable addition to IGF-1R inhibitor-based therapies.

Long-term outcome after radioiodine therapy with adjuvant rhTSH treatment: comparison between patients with non-toxic and pre-toxic large multinodular goitre

In multinodular goitre (MNG), low radioiodine (RAI) activity after recombinant human (rh) TSH is able to reduce thyroid volume (TV) and improve symptoms. Our aim was to evaluate the long-term outcome of RAI after rhTSH treatment in patients who were divided according to their baseline TSH levels. Eighteen patients (69.2 ± 6.1 year) presented non-toxic (TSH >0.3 mIU/l) MNG (TV: 61.0 ± 3.8 ml; group 1), while 13 patients (74.1 ± 7.9 year) had non-autoimmune pre-toxic (TSH <0.3 mIU/l) MNG (TV: 82.6 ± 14.4 ml; group 2). TSH, thyroid hormones, TV (by ultrasonography), body mass index (BMI), symptoms and quality of life (QoL) were evaluated. Treatment induced short-term thyrotoxicosis in both groups, but this was slightly more marked in group 2 than in group 1. The number and severity of adverse events were similar. The follow-up period was 55.3 ± 4.1 months in group 1 and 57.2 ± 5.1 months in group 2. The final TV reduction was similar in groups 1 (63.4 ± 3.6%) and 2 (57.2 ± 4.6%) and TV reduction positively correlated only with initial TV. At the last examination, 14 group-1 subjects were on L-T4 therapy, while 2 group-2 subjects were on methimazole. An increase in BMI was noted only in group 2. MNG-related symptoms were significantly reduced in both groups. Symptoms related to sub-clinical hyperthyroidism improved in group 2, while no significant changes in QoL were noted in either group. This study confirms the effectiveness of rhTSH adjuvant treatment in reducing TV after low RAI activities, irrespective of baseline thyroid status. TSH levels <0.3 mIU/l proved to be predictive of a more severe thyrotoxic phase after rhTSH and RAI, while initial TSH levels >0.3 mIU/l were more frequently followed by a need for L-T4 therapy. Compressive symptoms improved in the majority of subjects.

Spontaneous regression of low-grade cervical intraepithelial lesions is positively improved by topical bovine colostrum preparations (GINEDIE®). A multicentre, observational, italian pilot study

OBJECTIVES

Human papillomavirus (HPV) is the causal agent of cervical cancer. The great majority of abnormal Pap test results - almost 90% - is referrable to either atypical squamous intraepithelial lesion or CIN1. For these lesions, worldwide agreement exists concerning the high rate - ranging from 40% to 70% - of spontaneous regression over a period of 1-5 years. Host's immune response is a key point influencing the natural history of these conditions. Bovine colostrum is a natural agent positively promoting several immune activities against bacterial and viral agents. The aim of this report was to evaluate the potential positive effect of bovine colostrum-containing vaginal tablets administered to CIN1 diagnosed patients in a prospective trial in regards to spontaneous regression rate.

PATIENTS AND METHODS

A series of 256 consecutive patients with histologically proven CIN1 recruited in a multicentre, observational, Italian study. Patients have been enrolled in a 24-weeks protocol of treatment and re-tested at the end of the study. Rates of regression have been recorded.

RESULTS

Overall regression rate to a negative histology at the end of the 6 month follow up was 75.5%.

CONCLUSIONS

Regression to normal histology was observed in a very high rate of cases in a very short period compared to the natural history of these lesions. CIN1 patients could benefit from bovine colostrum topical administration in terms of significantly shortening the regression time.

Peripheral nerve stimulation: a percutaneous minimally invasive approach

We report on the use of a new percutaneous technique for peripheral nerve stimulation (PNS) treatment of chronic pain. A 56-year-old woman was diagnosed with algodystrophic syndrome, now called Complex Regional Pain Syndrome, type 2 (CRPS2), due to a lesion of the right medial nerve despite surgical revascularization, angioplasty and stent insertion. After a successful 10-day trial of PNS via a percutaneous quadripolar lead in the interscaline space, an implantable pulse generator was implanted in the abdominal subcutaneous tissue and connected to the subcutaneous lead via an extension. After one year of follow-up, the patient was still experiencing good pain relief. We conclude that this novel percutaneous PNS technique offers the advantage of being a minimally invasive approach that can be easily adopted for the management of chronic pain.

Antiproliferative effects of interleukin-1 alpha and nitric oxide release in a human ovarian carcinoma cell line

Interleukin-1 (IL-1) exerts direct antiproliferative effects on a number of human tumor cell lines, but the mechanisms involved are still poorly understood. Nitric oxide (NO) has been shown to mediate some of the actions of IL-1. Therefore, we investigated the role played by NO in the cytostatic effects of IL-1 alpha on NIH:OVCAR-3 cells, a cell line which has been shown to possess IL-1 receptors and to respond to the cytokine with growth arrest; the involvement of NO release in the synergistic interaction between IL-1 alpha and adriamycin (ADR) observed in this cell line was also studied. 72 h exposure to concentrations of IL-1 alpha similar to its IC50 value, were found to enhance NO release. This was significantly reduced by co-incubation with 1 mM L-NAME, which however did not significantly affect the IC50 values, either for IL-1 alpha or for the combination IL-1 alpha:ADR (1:20,000). We conclude that induction of NO synthesis in IL-1 alpha-treated cells is probably a side effect originating from transcription factor activation by the cytokine, and that neither the antiproliferative effects of IL-1 alpha nor its potentiation of ADR cytotoxicity depend on NO release.

Serum inhibin B levels before and after varicocelectomy in early adolescence

BACKGROUND

Whereas no clear relationship has been observed between varicocelectomy and serum inhibin B levels in men, in adolescents comparison between inhibin B levels before and after varicocelectomy is lacking.

AIM

To evaluate the effect of varicocele surgical treatment on inhibin B levels in adolescents at the beginning of puberty compared to a group of healthy adolescents.

SUBJECTS AND METHODS

We studied 28 adolescents in Tanner 2 pubertal stage with a grade III left-sided varicocele (patients) compared to 13 age and pubertal stage-matched healthy adolescents (controls). All patients underwent blood tests to determine serum inhibin B levels before and 6 months after varicocelectomy by Palomo procedure. For comparison we investigated inhibin B levels in controls and repeated this test 6 months later. Testicular ultrasound was performed for patients only.

RESULTS

Baseline inhibin B concentrations of patients and controls were 109.90 ± 40.26 and 109.33 ± 38.34 pg/ml, respectively. No significant changes were observed in patients' inhibin B concentrations after varicocelectomy (116.00 ± 42.65 pg/ml), or in controls during the 6 months' follow-up (99.12 ± 30.09 pg/ml). Doppler examination after treatment shows a complete resolution of varicocele in all the patients without alterations in testicular parenchyma.

CONCLUSIONS

Varicocelectomy performed on adolescents at T2 pubertal stage might be useful to avoid alteration in inhibin B production and consequently in testicular function. Further studies are necessary to confirm the prognostic value of inhibin B levels and the benefit of early varicocelectomy in preserving the fertility of these adolescents.

[Influence of thyroid morphology on psychomotor development in patients with congenital hypothyroidism during 8 year follow-up]

AIM

The aim of this paper was to evaluate the impact of thyroid morphology on auxological and neuropsychological development in children affected by congenital hypothyroidism (CH), treated with levothyroxine, up to 8 years of age.

METHODS

Fifty-three children affected by CH divided into 3 groups on the basis of thyroid morphology determined at birth: patients with athyreosis (N=17), with ectopic gland (N=23), with in situ thyroid (N=13). The developmental quotient (DQ) was evaluated by the Brunet-Lezine test up to 3 years, and intelligent quotient (IQ) by the Terman-Merril test after 3 years of age.

RESULTS

DQs at one year in athyreotic patients are lower (P<0,05) as compared to those determined in patients with other thyroid morphology. Later on these patients still showed lower DQ and IQ values than in other groups, although statistically not significant.

CONCLUSION

Thyroid morphology seems to be fundamental in psychomotor development, in fact patients with athyreosis show a transient impairment at one year of age. This difference could be transient or to have repercussions on adult. Individualization of the starting dose of levothyroxine on the basis of thyroid morphology, could be useful.

Long term follow-up of carpal tunnel syndrome during pregnancy: a cohort study and review of the literature

INTRODUCTION

Carpal tunnel syndrome (CTS) occurring during pregnancy is considered to have a short and benign course and very few cases required surgery, however there is no information in literature on long term follow-up. The aim of this study was a systematic review of the literature and to report 3-year follow-up after delivery in a sample of pregnant women with CTS.

PATIENTS AND METHODS

We enrolled 45 consecutive pregnant women with CTS (mean age 32 years). Diagnosis was based on clinical and neurographic findings. Clinical and electrophysiological severity of CTS were scored according to an ordinal scale and the self-administered Boston questionnaires on symptoms (BQ-SYMPT) and functional status (BQ-FUNCT) of the hand during pregnancy and one-year after delivery. Symptoms were evaluated again by BQ over the telephone three years after delivery.

RESULTS

At one-year follow-up BQ-SYMPT and BQ-FUNCT scores improved in 40% of women, did not change in 46.7% and 55.6% and worsened in 13.3% and 4.4%, respectively. Clinical severity was stage 0 (i. e. without symptoms) in 26.7% of women, improved in 6.7%, unchanged in 60% and worse in 6.7%. Electrophysiological severity was stage 0 (i.e. no delay in median nerve conduction) in 17.8%, improved in 20%, unchanged in 57.8% and worse in 4.4%. Only one woman underwent surgery (5 months after delivery), three were treated with local steroid injection before delivery and 18 used a splint, 8 of whom continued to do so periodically after one year. At 3-year follow-up 51% were symptom-free and 49% had anomalous ( > 1) BQ scores, but mean BQ scores improved with respect to those at baseline and one-year follow-up.

CONCLUSION

A Pubmed search identified 20 papers in which therapy and follow-up could be deduced. Almost all reported a short follow-up with disappearance of symptoms. Our study confirms that pregnancy-related CTS has a benign course: improvement of symptoms was evident at one- and 3-year follow-up, but about half the women still complained of symptoms 3 years after delivery. Only one woman underwent surgery and 11% still sometimes wore a splint at night. Despite improvement of symptoms, distal sensory conduction velocity of the median nerve improved but remained delayed in 84% of women one year after delivery.

Overexpression of wild-type and mutant mucolipin proteins in mammalian cells: effects on the late endocytic compartment organization

Mucolipin-1 is a 65-kDa membrane protein encoded by the MCOLN1 gene, which is mutated in patients with mucolipidosis type IV (MLIV), a rare neurodegenerative lysosomal storage disorder. We studied the subcellular localization of wild-type and three different mutant forms (T232P, F408del and F465L) of mucolipin by expressing Myc-tagged proteins in HeLa cells. The overexpressed wild-type mucolipin colocalizes to late endocytic structures and induces an aberrant distribution of these compartments. F408del and F465L MLIV mutant proteins show a distribution similar to the wild-type protein, whereas T232P is retained in the endoplasmic reticulum. Among the mutants, only F408del induces a redistribution of the late endocytic compartment. These findings suggest that the overexpression of the mucolipin cation channel influences the dynamic equilibrium of late endocytic compartments.

Molecular cloning and characterization of NEU4, the fourth member of the human sialidase gene family

Several mammalian sialidases have been cloned so far and here we describe the identification and expression of a new member of the human sialidase gene family. The NEU4 gene, identified by searching sequence databases for entries showing homologies to the human cytosolic sialidase NEU2, maps in 2q37 and encodes a 484-residue protein. The polypeptide contains all the typical sialidase amino acid motifs and, apart from an amino acid stretch that appears unique among mammalian sialidases, shows a high degree of homology for NEU2 and the plasma membrane-associated (NEU3) sialidases. RNA dot-blot analysis showed a low but wide expression pattern, with the highest level in liver. Transient transfection in COS7 cells allowed the detection of a sialidase activity toward the artificial substrate 4MU-NeuAc in the acidic range of pH. Immunofluorescence staining and Western blot analysis demonstrated the association of NEU4 with the inner cell membranes.

Study of in vitro and in vivo effects of the piperidine nitroxide Tempol--a potential new therapeutic agent for gliomas

The identification of novel therapeutic agents for the management of malignant gliomas represents an area of active research. Here, we show that Tempol (4-hydroxy-2,2,6,6-tetramethylpiperidine-1-oxyl; TPL), a stable nitroxide free radical, inhibits the growth of C6 glioma cells both in vitro and in vivo. Morphological features of apoptosis were apparent in C6 cells following in vitro treatment with TPL. Cell death was preceded by dose-dependent increase in p21(WAF1/CIP1) expression, without apparent stabilisation of the TP53 gene product. When C6 cells were grown as xenografts in nude mice, treatment with TPL induced a significant dose-dependent decrease in tumour growth, without signs of general or organ toxicity. Tumours from treated mice showed an increase in the number of apoptotic cells and a decrease in the rate of neo-vascularisation compared with tumours from control mice. Our findings suggest a potential use for TPL as a novel antiproliferative agent for the treatment of malignant gliomas.

Role of the lung resistance-related protein (LRP) in the drug sensitivity of cultured tumor cells

Drug resistance, one of the major obstacle in the successful anticancer therapy, can be observed at the outset of therapy (intrinsic resistance) or after exposure to the antitumor agent (acquired resistance). To gain a better insight into the mechanisms of intrinsic resistance we have analyzed two human cell types derived from untreated tumors: MCF-7 breast cancer and A549 non small cell lung cancer (NSCLC). We have examined: the cytotoxic effect induced by doxorubicin (DOX); the time course of drug accumulation by flow cytometry and intracellular drug distribution by confocal microscopy; the expression and distribution of proteins related to anthracycline resistance, such as P-gp (P-glycoprotein), MRP1 (multidrug resistance-associated protein) and LRP (lung resistance-related protein). The cytotoxicity assays showed that A549 cells were less sensitive than MCF-7 cells to the DOX treatment in agreement with the different DOX uptake. Moreover, while in A549 cells DOX was mostly located in well defined intracytoplasmic vesicles, in MCF-7 cells it was mainly revealed inside the nuclei. The analysis of P-gp and MRP expression did not show significant differences between the two cell lines while a high expression of LRP was detected at the nuclear envelope and cytoplasmic levels in A549 cells. These findings suggest that the lower sensitivity to DOX treatment showed by lung carcinoma cells could be ascribed to drug sequestration by LRP inside the cytoplasmic compartments.