The multidisciplinary Heart Team approach for patients with cardiovascular disease: a step towards personalized medicine

AIMS

Despite general agreement on the benefits of the Heart Team approach for patients with cardiac diseases, few data are available on its real impact on the decision-making process. The aim of the study is to define the evolution over time of the level of agreement with the systematic discussion of patients in the Heart Team and to evaluate the adherence to the Heart Team recommendations and the impact of the Heart Team on the clinical outcome of the patients.

METHODS

In 2015--2016, an experienced cardiac surgeon and a cardiologist independently reviewed clinical data of a series of 100 patients (Group 1, G1) and subsequently for each patient recommended treatment (surgical, percutaneous, hybrid or medical therapy) or further diagnostic investigations. The next day, each case was discussed by the Hospital Heart Team. The Heart Team recommendation, the subsequent treatment received by the patient and the in-hospital outcome were recorded. The same study procedure was repeated in 2017 in a second (G2) and in 2018 in a third (G3) group, both of them including 100 patients.

RESULTS

Complete agreement in treatment selection by the cardiac surgeon, cardiologist and the Heart Team was observed in 43% of cases in G1 and in 70% and 68% in G2 and G3, respectively (G1 vs. G2: P  < 0.001, G1 vs. G3: P  = 0.01, G2 vs. G3: P  = 0.30). Agreement was less frequent in patients with a higher risk profile and in patients with aortic valve stenosis. The Heart Team decision was implemented in 95% of cases with a 30-day mortality of 0.67%.

CONCLUSION

Agreement in treatment selection among the cardiac surgeon, cardiologist and Heart Team appears to be low in the initial experience. Subsequently, it seems to steadily increase over time up to a limit, when it reaches a plateau of stable results. Heart Team clinical cases discussion, based on both guidelines and multidisciplinary experience, represents a key step in defining the best patient treatment pathway, potentially improving the decision-making process and clinical results.

Global longitudinal strain for prediction of mortality in ST-segment elevation myocardial infarction and aortic stenosis patients: two sides of the same coin

OBJECTIVE

Global longitudinal strain (GLS) predicts major adverse events in ST-segment elevation myocardial infarction (STEMI) and aortic stenosis (AS). Different cut-off values and different end-points have been proposed for prognostic stratification. We aimed to verify whether a single GLS cut-off value can be used to identify increased risk of all-cause death in STEMI and AS.

PATIENTS AND METHODS

One-hundred- seventeen successfully treated first STEMI (age 63.8±12.5 yrs, 70% men) and 64 AS (age 80.3±6.9 yrs, 44% men) patients, undergoing echocardiography before discharge and before AS treatment, respectively, were retrospectively analyzed. GLS was analyzed, together with pulmonary artery systolic pressure (PASP), Killip class and Genereux stage. End-point was all-cause death at 6-month follow-up.

RESULTS

All-cause death occurred in 4 (3.4%) STEMI and 5 (7.8%) AS patients (p=ns). AS patients who died had GLS similar to died STEMI patients (9.7±2.1 vs. 11.3±1.7, p=ns). GLS cut-off ≤12% predicted death with 89% sensitivity and 70% specificity (AUC 0.84, p=0.001): STEMI and AS patients with GLS ≤12% had worse survival than STEMI and AS patients with GLS >12% (log-rank p=0.001). At multivariate Cox regression analysis, lower GLS values independently predicted death (HR 0.667, 95% CI 0.451-0.986, p=0.042), and the prediction model was improved when GLS was added to old age, significant comorbidities, PASP and Killip/Genereux stage (χ2 6.691 vs. 1.364, p=0.010).

CONCLUSIONS

Died patients with STEMI and AS show similar values of GLS. A unique cut-off value of GLS can reliably be used to stratify the risk of all-cause death at 6-month follow-up in both two clinical settings.

Microscale Neuronal Activity Collectively Drives Chaotic and Inflexible Dynamics at the Macroscale in Seizures

Neuronal activity propagates through the network during seizures, engaging brain dynamics at multiple scales. Such propagating events can be described through the avalanches framework, which can relate spatiotemporal activity at the microscale with global network properties. Interestingly, propagating avalanches in healthy networks are indicative of critical dynamics, where the network is organised to a phase transition, which optimises certain computational properties. Some have hypothesised that the pathological brain dynamics of epileptic seizures are an emergent property of microscale neuronal networks collectively driving the brain away from criticality. Demonstrating this would provide a unifying mechanism linking microscale spatiotemporal activity with emergent brain dysfunction during seizures. Here, we investigated the effect of drug-induced seizures on critical avalanche dynamics, using in vivo whole-brain 2-photon imaging of GCaMP6s larval zebrafish (males and females) at single neuron resolution. We demonstrate that single neuron activity across the whole brain exhibits a loss of critical statistics during seizures, suggesting that microscale activity collectively drives macroscale dynamics away from criticality. We also construct spiking network models at the scale of the larval zebrafish brain, to demonstrate that only densely connected networks can drive brain-wide seizure dynamics away from criticality. Importantly, such dense networks also disrupt the optimal computational capacities of critical networks, leading to chaotic dynamics, impaired network response properties and sticky states, thus helping to explain functional impairments during seizures. This study bridges the gap between microscale neuronal activity and emergent macroscale dynamics and cognitive dysfunction during seizures.Significance StatementEpileptic seizures are debilitating and impair normal brain function. It is unclear how the coordinated behaviour of neurons collectively impairs brain function during seizures. To investigate this we perform fluorescence microscopy in larval zebrafish, which allows for the recording of whole-brain activity at single-neuron resolution. Using techniques from physics, we show that neuronal activity during seizures drives the brain away from criticality, a regime that enables both high and low activity states, into an inflexible regime that drives high activity states. Importantly, this change is caused by more connections in the network, which we show disrupts the ability of the brain to respond appropriately to its environment. Therefore, we identify key neuronal network mechanisms driving seizures and concurrent cognitive dysfunction.

Incidence of cerebrovascular accident following head and neck free tissue transfer surgery

The aim of this study was to determine the incidence of postoperative cerebrovascular accident (CVA) following head and neck free tissue transfer and to identify predictive risk factors. A retrospective audit was performed of patients who underwent head and neck reconstructive surgery at Queen Elizabeth University Hospital between 2009 and 2020. The patient records were analysed to identify those who developed CVA within 30 days after surgery. A total of 1109 patients underwent head and neck free tissue transfer surgery, including 1048 neck dissection procedures. Of these, 78.6% had one or more identified risk factors for perioperative stroke. Five patients (0.45%) developed postoperative CVA. The results showed that CVA correlated to patients with hypercholesterolemia (P = 0.007). This study demonstrates the safety of free tissue transfer. Despite underlying co-morbidities and risk factors, the incidence of CVA is low following surgery and manipulation of the major vasculature of the neck.

Topographically Localized Modulation of Tectal Cell Spatial Tuning by Complex Natural Scenes

The tuning properties of neurons in the visual system can be contextually modulated by the statistics of the area surrounding their receptive field (RF), particularly when the surround contains natural features. However, stimuli presented in specific egocentric locations may have greater behavioral relevance, raising the possibility that the extent of contextual modulation may vary with position in visual space. To explore this possibility, we utilized the small size and optical transparency of the larval zebrafish to describe the form and spatial arrangement of contextually modulated cells throughout an entire tectal hemisphere. We found that the spatial tuning of tectal neurons to a prey-like stimulus sharpens when the stimulus is presented against a background with the statistics of complex natural scenes, relative to a featureless background. These neurons are confined to a spatially restricted region of the tectum and have receptive fields centered within a region of visual space in which the presence of prey preferentially triggers hunting behavior. Our results suggest that contextual modulation of tectal neurons by complex backgrounds may facilitate prey-localization in cluttered visual environments.

Subclinical dysfunction of remote myocardium is related to high NT-proBNP and affects global contractility at follow-up, independently of infarct area

Background

In ST-segment elevation myocardial infarction (STEMI), predictors of subclinical dysfunction of remote myocardium are unknown. We prospectively aimed at identifying clinical and biochemical correlates of remote subclinical dysfunction and its impact on left ventricular ejection fraction (LVEF).

Methods

One-hundred thirty-three patients (63.9 ± 12.1 years, 68% male) with first successfully treated (54% anterior, 46% non-anterior, p = 0.19) STEMI underwent echocardiography at 5 ± 2 days after onset and at 8 ± 2-month follow-up, and were compared to 13 age and sex-matched (63.3 ± 11.4) healthy controls. All 16 left ventricular (LV) segments were grouped into ischemic, border, and remote myocardium: mean value of longitudinal strain (LS) within grouped segments were expressed as iLS, bLS, rLS, respectively. LV end-diastolic (EDV), end-systolic (ESV) volumes indexed for body surface area (EDVi, ESVi, respectively), LVEF and global LS (GLS) were determined. Creatinine, glomerular filtration rate, admission level of NT-pro-brain-natriuretic peptide (NT-proBNP) and troponin peaks were considered for the analysis.

Results

At baseline, rLS (15.5 ± 4.4) was better than iLS (12.9 ± 4.8, p < 0.001), but lower than that in controls (19.1 ± 2.7, p < 0.001) and similar to bLS (15 ± 5.4, p = ns), and did not differ between patients with single or multivessel coronary artery disease (CAD). At multivariate regression analysis, only admission NT-proBNP levels but not peak Tn levels independently predicted rLS (β = -0.58, p = 0.001), as well as iLS (β = -0.52, p = 0.001). Both at baseline and at follow-up, rLS correlated to LVEF similarly to iLS and bLS (p < 0.001 for all). Median value of rLS at baseline was 15%: compared to patients with rLS ≥ 15% at baseline, patients with rLS < 15% showed lower LVEF (52.3 ± 9.4 vs. 58.6 ± 7.6, p < 0.001) and GLS (16.3 ± 3.9 vs. 19.9 ± 3.2), and higher EDVi (62.3 ± 19.9 vs. 54 ± 12, p = 0.009) and ESVi (30.6 ± 15.5 vs. 22.3 ± 7.6, p < 0.001) at follow-up.

Conclusion

In optimally treated STEMI, dysfunction of remote myocardium assessed by LS: (1) is predicted by elevated NT-proBNP; (2) could be independent of CAD extent and infarct size; (3) is associated to worse LV morphological and functional indexes at follow-up.

809 A CASE OF CASEOUS MITRAL ANNULUS CALCIFICATION

Caseous mitral annular calcification (CMAC) is a rare variant of degenerative mitral annular calcification (MAC) with an echocardiographic prevalence of 0.6% of all MACs and an overall prevalence of up to 0.07% in the general population. It primarily affects older patients with hypertension and chronic kidney disease. Due to the general benign prognosis, conservative management of this lesion is recommended in most cases.

Herein we describe the case of a 78-year-old female patient admitted for sustained ventricular tachycardia treated with Amiodaron infusion followed by electrical cardioversion for hemodynamically instability. Her past medical history was remarkable for hypertension, HFpEF and chronic kidney disease. Trans-thoracic echocardiogram showed the presence of an echo-dense mass with central echo-lucency surrounded by calcifications at the posterior peri-annular and leaflet region of the mitral valve, not associated with valvular disfunction.

To define the etiology of the arrythmia, a coronary angiography was performed and excluded significant coronary artery disease. Nevertheless, a round-shape hyperdense mass was observed in the left atrium near the atrio-ventricular groove (figure 1): during injection through coronary vessels the contrast was not visible in the lesion. In order to better define the nature of the mass, a Trans-esophageal Echocardiogram was performed and showed a “toothpaste-like” echo-dense mass with central echo-lucency surrounded by a calcified envelope at the posterior peri-annular region of the mitral valve suggestive for CMAC (figure 2); 3D zoom imaging clarified its relationship with P2 scallop of posterior mitral valve leaflet (figure 3). For the best tissue characterization and to definitely exclude other mass-like lesions, such as myxoma, papillary fibroelastoma, myocardial abscess, vegetations, lipomatous hypertrophy, Cardiac Magnetic Resonance was performed and showed low-signal intensity in both T1- and T2-weighted sequences, reflecting its calcium content. First-pass perfusion sequence reveals no contrast enhancement, whereas late gadolinium enhancement depicts a peripheral rim of enhancement confirming our suspect.

In Conclusion, CMAC is a rare disorder requiring a multimodal imaging approach to differentiate it with other intra-cardiac masses. Its course is generally benign and whether not associated with valvular or hemodynamic significance, it could be considered as a bystander.

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384 Morpho-functional analysis of subvalvular apparatus in mitral valve prolapse and response to dipyridamole stress echocardiography. A pilot study

Aims

Myocardial fibrosis has been found in papillary muscles (PM) and basal segment of left ventricular (LV) inferior-lateral wall in patients with mitral valve prolapse (MVP), which may be due to stretch from valve. Moreover, ST-segment depression is common in patients with MVP, despite low prevalence of epicardial coronary artery disease, and it is attributed to microvascular dysfunction or myocardial stretch. Longitudinal strain (LS) correlates with myocardial fibrosis, while dipyridamole stress echocardiography (DSE) identifies microvascular dysfunction. We aimed at assessing morphology and function of PM and left ventricular walls at rest and during DSE by LS, and at determining prevalence of microvascular dysfunction in patients with MVP.

Methods and results

Seven consecutive patients with MVP (age 55.4 ± 15.7 years, 57% female) and LV ejection fraction 64 ± 5% underwent DSE. Length and LS of PM were measured at rest and retrospectively compared with those of patients with ischaemic heart disease (n = 8, age 67.1 ± 10.1 years, 37% female) and healthy controls (n = 8, age 39.6 ± 13.3 years, 50% female). LS of PM and LV was also determined at rest and during stress in MVP. Length of PM did not differ among groups, but in MVP, posterior PM was longer than the anterior PM (24 ± 3.8 vs. 20.6 ± 3.6 mm, P = 0.028). Significant difference in resting PM LS was found among groups (overall P = 0.04), with PM LS value in MVP (16.7 ± 7.1%) intermediate between ischaemic (14.2 ± 3.2%) and controls (20.5 ± 2.7%). No difference was found between rest and stress LS of PM in MVP. Global LS tended to increase in MVP during DSE compared to rest (23.1 ± 3.8% vs. 21.1 ± 2.6%, respectively, P = 0.07), while no significant difference between rest and stress LS was found in every LV myocardial segments. Nevertheless, in MVP, LS of LV inferior-lateral wall tended to improve under DSE in patients with mild regurgitation (19.7 ± 4.6 vs. 14.2 ± 5 at rest), but to decrease (16 ± 6.1 vs. 20.3 ± 2.3 at rest) in patients with severe mitral regurgitation (P = 0.006 for interaction). ST-segment depression was elicited by DSE in 29% of MVP. No significant difference in echocardiographic parameters was found between patients with and without ST-segment depression.

Conclusions

In MVP, sub-valvular apparatus may have peculiar morpho-functional features. DSE does not alter LS of PM, neither of LV walls, except for inferior-lateral wall, which impairs in severe mitral regurgitation. Prevalence of microvascular dysfunction is comparable to that of the general population.

786 A case of end-stage mitochondrial cardiomyopathy undergoing heart and kidney transplantation

Male, 46 year old. Family history: brother affected by deafness and repeated episodes of stroke at a young age. Pathological history: history of competitive sporting activity in which he underwent periodic outpatient checks and reported sporadic myalgic episodes. The patient was suffering from bilateral keratoconus. For the purpose of discovering Wolf–Parkinson–White syndrome with the presence of a right antero-septal accessory pathway, he underwent an electrophysiological study (2003) negative for inducible arrhythmias. During a routine checkup, a renal biopsy was performed to search for elevated blood creatinine, which concluded with acute interstitial nephritis (2005), treated ineffectively with steroids and resulted in dialysis-dependent stage V renal failure (2020). Following light tiredness, he underwent an echocardiographic examination (2009) which revealed the presence of dilated heart disease with reduced left ventricular systolic function. He underwent a cardiac MRI which showed diffuse spots of subepicardial late enhancement as a possible post-myocarditis outcome. At subsequent clinical-echocardiographic checks, progressive biventricular dysfunction, and signs of congestive heart failure were highlighted, for which medical therapy was progressively increased and insertion of an implantable cardioverter defibrillator in primary prevention for sudden cardiac death. At the subsequent clinical re-evaluations, there was evidence of progressive bilateral hearing loss. In consideration of the clinical picture and family history, considering the syndromic nature of the polypathologies to be likely, genetic investigation was required for mitochondrial diseases. Mutations 3242 and 3271mt-RNA and 13513 mtND5, frequent in the MELAS Syndrome, were searched in peripheral venous samples and resulted as negative. In 2020 he underwent an orthotopic heart transplant sec. Shamway followed by a kidney transplant from a compatible donor. In order to perform further diagnostic investigations, the explanted heart was sent to the Pathological Anatomy laboratory of the Umberto I Hospital: macroscopic analysis showed foci of fat replacement at the level of the anterior and posterior wall of the right ventricle (Figure); under microscopy, marked myocardial hypertrophy was observed, associated with cytoplasmic vacuolization of the cardiomyocytes, fibro-adipose substitution of the right ventricle, and replacement fibrosis in minute foci in the left ventricular level. A widespread and marked reduction in the enzymatic activity of cytochrome oxidase in cardiomyocytes and mitochondrial proliferation was demonstrated using histo-enzymatic staining, by staining for succinate dehydrogenase, concluding with mitochondrial disease. Mitochondrial diseases represent a challenge not only from the prognostic–therapeutic point of view but, remarkably, also from a diagnostic one: the patient received a correct diagnosis of the pathology that afflicted him, with almost two decades of delay. The integrated and multidisciplinary approach is desirable in order to obtain an early diagnosis.

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658 Impairment of strain reserve extends to remote myocardium in the sub-acute phase of ST-elevation myocardial infarction

Aims

In ST-elevation myocardial infarction (STEMI), subtle tissutal changes in remote myocardium predict long-term left ventricular (LV) remodelling and prognosis, independently of infarct size and microvascular obstruction. Whether there is a subclinical dysfunction of remote myocardium, detectable by longitudinal strain (LS) at echocardiography, and whether it varies in different locations of STEMI and with adenosine (ADO) challenge, is still unknown.

Methods and results

Fifty-three patients (age 65 ± 12.5 years, 44 male, 20 anterior and 33 non-anterior, P = 0.01) underwent rest/stress echocardiography at 7 ± 2 days after successfully treated STEMI, and at 6-months follow-up. Global LS (GLS), ischaemic and remote LS (iLS and rLS) were analysed in anterior and non-anterior STEMI. Both at rest and at follow-up, GLS was stratified by ejection fraction (EF) into three groups: EF &lt; 40%, 40–49%, and ≥50%. Normal subjects, undergoing ADO stress echo, represented controls. Anterior STEMI showed lower GLS than controls (P &lt; 0.001) and non-anterior STEMI (P &lt; 0.001). ADO increased GLS in controls (P = 0.05), but neither in anterior nor in non-anterior STEMI, GLS changed during ADO stress, although significantly improved at follow-up (P &lt; 0.001 and P = 0.002, respectively). In anterior STEMI, rLS was comparable to iLS at rest, during stress and at follow-up (P = ns), while in non-anterior STEMI rLS was higher than iLS throughout the study (P &lt; 0.001). Patients with EF &lt; 40% and 40–49% had similar values of GLS, iLS, and rLS, which were, both at rest and at follow-up, lower than those of patients with EF ≥ 50% (P &lt; 0.001).

Conclusions

In the subacute phase, anterior STEMI shows the worst impairment of LS in both ischaemic and remote regions. Strain reserve to ADO is absent in remote myocardium, as well as in ischaemic zone, regardless of MI location. Global, ischaemic and remote LS may improve at follow-up.

665 Longitudinal strain impairment in organic mitral regurgitation: look beyond the valve

Aims

Global longitudinal strain (GLS) is a hallmark of cardiac damage in mitral regurgitation (MR). GLS &gt; −18% in patients with severe organic MR (OMR) and normal LV ejection fraction (LVEF) is an independent predictor of postoperative LV dysfunction. While it is known that GLS is impaired in less than severe functional ischaemic MR (FMR), the value of GLS in less than severe OMR is not known. We aimed to determine prevalence and determinants of any GLS impairment in OMR, in comparison to FMR.

Methods

We retrospectively evaluated 51 consecutive patients (33 OMR and 18 FMR) with mild-to-moderate, moderate and moderate-to-severe MR (Table*). Overall, GLS was higher in OMR than FMR (17.9±4.5 vs. 10.3±5.3, P&lt;0.001), with rate of impairment of 45% in OMR and 89% in FMR (P= 0.0024).

Results

However, no significant difference was found in GLS between mild-to-moderate, moderate and moderate-to-severe MR patients within OMR (17.7±4.7 vs. 16.9±3.9 vs. 22.4±3, respectively, P&gt;0.05), as well as FMR (9.8±6.6 vs. 10.7±5.3 vs. 10.4±5.3, respectively, P&gt;0.05) groups. GLS correlated directly with left ventricular (LV) ejection fraction (EF) in both OMR (r=0.69, P&lt;0.001) and FMR (r=0.90, P&lt;0.001), and inversely with LV mass indexed for body surface area (LVMi) in both OMR (r = −0.50, P=0.005) and FMR (r = −0.48, P=0.042). While correlation with LVEF was better for FMR than OMR (Z − 1.95, P=0.026), correlation with LVMi was similar for OMR and FMR groups (Z − 0.082, P&gt;0.05).

Conclusions

In patients with OMR, GLS may be reduced, despite normal LVEF, in less than severe MR. Prevalence and degree of GLS impairment in OMR is less than in FMR. In OMR, as well as in FMR, GLS impairment is independent of entity of MR, but rather correlates with LVMi, maybe reflecting impact of myocardial fibrosis derived by increased LVMi on GLS.

Colchicine in ischemic heart disease: the good, the bad and the ugly

Inflammation is the main pathophysiological process involved in atherosclerotic plaque formation, progression, instability, and healing during the evolution of coronary artery disease (CAD). The use of colchicine, a drug used for decades in non-ischemic cardiovascular (CV) diseases and/or systemic inflammatory conditions, stimulated new perspectives on its potential application in patients with CAD. Previous mechanistic and preclinical studies revealed anti-inflammatory and immunomodulatory effects of colchicine exerted through its principal mechanism of microtubule polymerization inhibition, however, other pleiotropic effects beneficial to the CV system were observed such as inhibition of platelet aggregation and suppression of endothelial proliferation. In randomized double-blinded clinical trials informing our clinical practice, low doses of colchicine were associated with the significant reduction of cardiovascular events in patients with stable CAD and chronic coronary syndrome (CCS) while in patients with a recent acute coronary syndrome (ACS), early initiation of colchicine treatment significantly reduced major adverse CV events (MACE). On the other hand, the safety profile of colchicine and its potential causal relationship to the observed increase in non-CV deaths warrants further investigation. For these reasons, postulates of precision medicine and patient-tailored approach with regards to benefits and harms of colchicine treatment should be employed at all times due to potential toxicity of colchicine as well as the currently unresolved signal of harm concerning non-CV mortality. The main goal of this review is to provide a balanced, critical, and comprehensive evaluation of currently available evidence with respect to colchicine use in the setting of CAD.

Integrated OMICs unveil the bone-marrow microenvironment in human leukemia

The bone-marrow (BM) niche is the spatial environment composed by a network of multiple stromal components regulating adult hematopoiesis. We use multi-omics and computational tools to analyze multiple BM environmental compartments and decipher their mutual interactions in the context of acute myeloid leukemia (AML) xenografts. Under homeostatic conditions, we find a considerable overlap between niche populations identified using current markers. Our analysis defines eight functional clusters of genes informing on the cellular identity and function of the different subpopulations and pointing at specific stromal interrelationships. We describe how these transcriptomic profiles change during human AML development and, by using a proximity-based molecular approach, we identify early disease onset deregulated genes in the mesenchymal compartment. Finally, we analyze the BM proteomic secretome in the presence of AML and integrate it with the transcriptome to predict signaling nodes involved in niche alteration in AML.

Human Papilloma Virus vaccine and prevention of head and neck cancer, what is the current evidence?

OBJECTIVES

Human Papilloma Virus is associated with the development of cancers in the head and neck region. We have witnessed, in the last decades, an increase in number of cases directly related to HPV infection, in particular in the Western Countries. Recently the FDA expanded the indications for Gardasil-9® to include the prevention of head and neck cancer. Objective of this paper is to review the evidence supporting its use.

MATERIALS AND METHODS

Bibliographic review enquiring Medline, Web of Science and the Cochrane Library to assess the efficacy of vaccination against oncogenic HPV in the prevention of head and neck squamous cell carcinoma.

RESULTS

Two prospective and 4 retrospective studies have evaluated vaccination in prevention of head and neck cancer, using persistent oral infection as surrogate of efficacy. All studies showed lower prevalence of oral infection up to 4 years following vaccination. Vaccine efficacy was estimated between 88 and 93.3%. Because of low vaccine coverage the estimated population-level effect against oral HPV16/18/6/11 infections was only 17.0%.

CONCLUSIONS

Antibodies concentration in the oral fluid correlate with serum level, but the threshold to ensure protection is unknown. Duration of protection has not been established. HPV vaccination can provide protection from re-infection (at different mucosal sites) in previously exposed individuals, suggesting possible use of HPV vaccine later in life. Other studies should focus on confirming causal relationship between vaccination and prevention of persistent oral infection and investigate the duration of efficacy, which is crucial in its effectiveness against HNSCC.

A Multicellular Network Mechanism for Temperature-Robust Food Sensing

Responsiveness to external cues is a hallmark of biological systems. In complex environments, it is crucial for organisms to remain responsive to specific inputs even as other internal or external factors fluctuate. Here, we show how the nematode Caenorhabditis elegans can discriminate between different food levels to modulate its lifespan despite temperature perturbations. This end-to-end robustness from environment to physiology is mediated by food-sensing neurons that communicate via transforming growth factor β (TGF-β) and serotonin signals to form a multicellular gene network. Specific regulations in this network change sign with temperature to maintain similar food responsiveness in the lifespan output. In contrast to robustness of stereotyped outputs, our findings uncover a more complex robustness process involving the higher order function of discrimination in food responsiveness. This process involves rewiring a multicellular network to compensate for temperature and provides a basis for understanding gene-environment interactions. Together, our findings unveil sensory computations that integrate environmental cues to govern physiology.

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C. elegans’ ability to modulate lifespan in response to food is robust to temperature

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Robustness requires TGF-β and serotonin signaling in a neuronal network

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Specific regulations in the neuronal network change sign with temperature

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Temperature-dependent regulations compensate for temperature

Cadherins regulate nuclear topography and function of developing ocular motor circuitry

In the vertebrate central nervous system, groups of functionally related neurons, including cranial motor neurons of the brainstem, are frequently organised as nuclei. The molecular mechanisms governing the emergence of nuclear topography and circuit function are poorly understood. Here we investigate the role of cadherin-mediated adhesion in the development of zebrafish ocular motor (sub)nuclei. We find that developing ocular motor (sub)nuclei differentially express classical cadherins. Perturbing cadherin function in these neurons results in distinct defects in neuronal positioning, including scattering of dorsal cells and defective contralateral migration of ventral subnuclei. In addition, we show that cadherin-mediated interactions between adjacent subnuclei are critical for subnucleus position. We also find that disrupting cadherin adhesivity in dorsal oculomotor neurons impairs the larval optokinetic reflex, suggesting that neuronal clustering is important for co-ordinating circuit function. Our findings reveal that cadherins regulate distinct aspects of cranial motor neuron positioning and establish subnuclear topography and motor function.

Learning steers the ontogeny of an efficient hunting sequence in zebrafish larvae

Goal-directed behaviors may be poorly coordinated in young animals but, with age and experience, behavior progressively adapts to efficiently exploit the animal’s ecological niche. How experience impinges on the developing neural circuits of behavior is an open question. We have conducted a detailed study of the effects of experience on the ontogeny of hunting behavior in larval zebrafish. We report that larvae with prior experience of live prey consume considerably more prey than naive larvae. This is mainly due to increased capture success and a modest increase in hunt rate. We demonstrate that the initial turn to prey and the final capture manoeuvre of the hunting sequence were jointly modified by experience and that modification of these components predicted capture success. Our findings establish an ethologically relevant paradigm in zebrafish for studying how the brain is shaped by experience to drive the ontogeny of efficient behavior.

A stochastic framework of neurogenesis underlies the assembly of neocortical cytoarchitecture

The cerebral cortex contains multiple areas with distinctive cytoarchitectonic patterns, but the cellular mechanisms underlying the emergence of this diversity remain unclear. Here, we have investigated the neuronal output of individual progenitor cells in the developing mouse neocortex using a combination of methods that together circumvent the biases and limitations of individual approaches. Our experimental results indicate that progenitor cells generate pyramidal cell lineages with a wide range of sizes and laminar configurations. Mathematical modeling indicates that these outcomes are compatible with a stochastic model of cortical neurogenesis in which progenitor cells undergo a series of probabilistic decisions that lead to the specification of very heterogeneous progenies. Our findings support a mechanism for cortical neurogenesis whose flexibility would make it capable to generate the diverse cytoarchitectures that characterize distinct neocortical areas.

Bayesian inference of neuronal assemblies

In many areas of the brain, both spontaneous and stimulus-evoked activity can manifest as synchronous activation of neuronal assemblies. The characterization of assembly structure and dynamics provides important insights into how brain computations are distributed across neural networks. The proliferation of experimental techniques for recording the activity of neuronal assemblies calls for a comprehensive statistical method to describe, analyze and characterize these high dimensional datasets. The performance of existing methods for defining assemblies is sensitive to noise and stochasticity in neuronal firing patterns and assembly heterogeneity. To address these problems, we introduce a generative hierarchical model of synchronous activity to describe the organization of neurons into assemblies. Unlike existing methods, our analysis provides a simultaneous estimation of assembly composition, dynamics and within-assembly statistical features, such as the levels of activity, noise and assembly synchrony. We have used our method to characterize population activity throughout the tectum of larval zebrafish, allowing us to make statistical inference on the spatiotemporal organization of tectal assemblies, their composition and the logic of their interactions. We have also applied our method to functional imaging and neuropixels recordings from the mouse, allowing us to relate the activity of identified assemblies to specific behaviours such as running or changes in pupil diameter.

Increased Vascular Permeability in the Bone Marrow Microenvironment Contributes to Disease Progression and Drug Response in Acute Myeloid Leukemia

The biological and clinical behaviors of hematological malignancies can be influenced by the active crosstalk with an altered bone marrow (BM) microenvironment. In the present study, we provide a detailed picture of the BM vasculature in acute myeloid leukemia using intravital two-photon microscopy. We found several abnormalities in the vascular architecture and function in patient-derived xenografts (PDX), such as vascular leakiness and increased hypoxia. Transcriptomic analysis in endothelial cells identified nitric oxide (NO) as major mediator of this phenotype in PDX and in patient-derived biopsies. Moreover, induction chemotherapy failing to restore normal vasculature was associated with a poor prognosis. Inhibition of NO production reduced vascular permeability, preserved normal hematopoietic stem cell function, and improved treatment response in PDX.

Minimally Invasive Versus Open Surgery For Acute Achilles Tendon Ruptures A Systematic Review And Meta-Analysis

The minimally invasive surgery (MIS) approach has been popularised as an alternative to the standard open approach in acute Achilles tendon repair. Advocates of MIS suggest earlier functional recovery, due to reduced trauma to adjacent soft tissues. Critics, however, argue that due to inadequate surgical exposure, complications of such surgery are higher compared to an open technique. A systematic review and meta-analysis of randomised, prospective studies weas conducted to compare MIS and open surgery in acute Achilles tendon ruptures. Thirteen studies were included in the meta-analysis with a total of 854 patients. Although re-rupture rates were not significantly different between the groups (P = 0.43), there were significantly more complications in the open surgery group (P = <.00001). MIS in acute Achilles tendon ruptures result in similar re-rupture rates, sural nerve injury rates and return to sport time in comparison with open surgical method, but with significantly less post-operative complications.

Quantification of Information Encoded by Gene Expression Levels During Lifespan Modulation Under Broad-range Dietary Restriction in C. elegans

Sensory systems allow animals to detect, process, and respond to their environment. Food abundance is an environmental cue that has profound effects on animal physiology and behavior. Recently, we showed that modulation of longevity in the nematode Caenorhabditis elegans by food abundance is more complex than previously recognized. The responsiveness of the lifespan to changes in food level is determined by specific genes that act by controlling information processing within a neural circuit. Our framework combines genetic analysis, high-throughput quantitative imaging and information theory. Here, we describe how these techniques can be used to characterize any gene that has a physiological relevance to broad-range dietary restriction. Specifically, this workflow is designed to reveal how a gene of interest regulates lifespan under broad-range dietary restriction; then to establish how the expression of the gene varies with food level; and finally, to provide an unbiased quantification of the amount of information conveyed by gene expression about food abundance in the environment. When several genes are examined simultaneously under the context of a neural circuit, this workflow can uncover the coding strategy employed by the circuit.

Genetic control of encoding strategy in a food-sensing neural circuit

Neuroendocrine circuits encode environmental information via changes in gene expression and other biochemical activities to regulate physiological responses. Previously, we showed that daf-7 TGFβ and tph-1 tryptophan hydroxylase expression in specific neurons encode food abundance to modulate lifespan in Caenorhabditis elegans, and uncovered cross- and self-regulation among these genes (Entchev et al., 2015). Here, we now extend these findings by showing that these interactions between daf-7 and tph-1 regulate redundancy and synergy among neurons in food encoding through coordinated control of circuit-level signal and noise properties. Our analysis further shows that daf-7 and tph-1 contribute to most of the food-responsiveness in the modulation of lifespan. We applied a computational model to capture the general coding features of this system. This model agrees with our previous genetic analysis and highlights the consequences of redundancy and synergy during information transmission, suggesting a rationale for the regulation of these information processing features.

The potential role of rho GTPases in Alzheimer's disease pathogenesis

Alzheimer's disease (AD) is characterized by a wide loss of synapses and dendritic spines. Despite extensive efforts, the molecular mechanisms driving this detrimental alteration have not yet been determined. Among the factors potentially mediating this loss of neuronal connectivity, the contribution of Rho GTPases is of particular interest. This family of proteins is classically considered a key regulator of actin cytoskeleton remodeling and dendritic spine maintenance, but new insights into the complex dynamics of its regulation have recently determined how its signaling cascade is still largely unknown, both in physiological and pathological conditions. Here, we review the growing evidence supporting the potential involvement of Rho GTPases in spine loss, which is a unanimously recognized hallmark of early AD pathogenesis. We also discuss some new insights into Rho GTPase signaling framework that might explain several controversial results that have been published. The study of the connection between AD and Rho GTPases represents a quite unchartered avenue that holds therapeutic potential.

Rho GTPase-dependent plasticity of dendritic spines in the adult brain

Brain activity is associated with structural changes in the neural connections. However, in vivo imaging of the outer cortical layers has shown that dendritic spines, on which most excitatory synapses insist, are predominantly stable in adulthood. Changes in dendritic spines are governed by small GTPases of the Rho family through modulation of the actin cytoskeleton. Yet, while there are abundant data about this functional effect of Rho GTPases in vitro, there is limited evidence that Rho GTPase signaling in the brain is associated with changes in neuronal morphology. In the present work, both chronic in vivo two-photon imaging and Golgi staining reveal that the activation of Rho GTPases in the adult mouse brain is associated with little change of dendritic spines in the apical dendrites of primary visual cortex pyramidal neurons. On the contrary, considerable increase in spine density is observed (i) in the basal dendrites of the same neurons (ii) in both basal and apical dendrites of the hippocampal CA1 pyramidal cells. While confirming that Rho GTPase-dependent increase in spine density can be substantial, the study indicates region and dendrite selectivity with relative stability of superficial cortical circuits.

Finite-time erasing of information stored in fermionic bits

We address the issue of minimizing the heat generated when erasing the information stored in an array of quantum dots in finite time. We identify the fundamental limitations and trade-offs involved in this process and analyze how a feedback operation can help improve it.

Four-jet production at the Large Hadron Collider at next-to-leading order in QCD

We present the cross sections for production of up to four jets at the Large Hadron Collider, at next-to-leading order in the QCD coupling. We use the BLACKHAT library in conjunction with SHERPA and a recently developed algorithm for assembling primitive amplitudes into color-dressed amplitudes. We adopt the cuts used by ATLAS in their study of multijet events in pp collisions at √s=7 TeV. We include estimates of nonperturbative corrections and compare to ATLAS data. We store intermediate results in a framework that allows the inexpensive computation of additional results for different choices of scale or parton distributions.

Long-lasting efficacy of the cognitive enhancer cytotoxic necrotizing factor 1

Rho GTPases are key regulators of the activity-dependent changes of neural circuits. Besides being involved in nervous system development and repair, this neural structural plasticity is believed to constitute the cellular basis of learning and memory. Here we report that concurrent modulation of cerebral Rho GTPases, including Rac, Rho and Cdc42 subfamilies, by Cytotoxic Necrotizing Factor 1 (CNF1, 10 fmol/kg intracerebroventricularly) improves object recognition in both C57BL/6J and CD1 mice. The improvement is long lasting, as it is still observed 90 days post treatment. At this time, the treatment is associated with enhancement of neurotransmission and long-term potentiation. The effects depend on changes in Rho GTPase status, since the recombinant molecule CNF1 C866S, in which the enzymatic activity was abolished through substitution of serine to cysteine at position 866, is ineffective. The study confirms the role of Rho GTPases in learning and suggests that a single administration of CNF1 is effective for a long time after administration. In general, the long-lasting cognition enhancing effect of CNF1 might be beneficial for the treatment of CNS disorders. This article is part of a Special Issue entitled 'Cognitive Enhancers'.

The Rho GTPase activating CNF1 improves associative working memory for object-in-place

Cerebral Rho GTPases are crucially involved in cognitive abilities. This activity is thought to be related to the regulation of actin polymerization and, thereby, of the shape of the dendritic tree. Here we report that Cytotoxic Necrotizing Factor 1 (CNF1, 1fmol/kgicv), a bacterial protein endowed with Rho GTPase activating properties, enhances working memory for object location/discrimination in C57BL/6 mice. CNF1 selectively increased the exploration of a specific familiar object moved to a position that had been previously occupied by another familiar object. Conversely, the treatment left unaffected (i) exploration of a familiar object moved to a location that was previously unoccupied and (ii) exploration of a novel object. The effects were associated with changes in Rho GTPase status, since CNF1 C866S, a recombinant CNF1 in which the enzymatic activity was abolished through substitution of serine to cysteine at position 866, was ineffective in all the experiments. The study suggests that working memory for specific object-location associations critically depends on neural connectivity. It also confirms the therapeutic potential of the manipulation of Rho GTPase signaling in the modulation of memory processes.

[Hemoperitoneum from rupture of liver subcapsular hematoma after laparoscopic cholecystectomy attributed to ketorolac. Report of a case]

Ketorolac is one of the most common nonsteroidal anti-inflammatory drugs used to control postoperative pain. However, peri- and postoperative administration of ketorolac is associated with an increased risk of gastrointestinal bleeding as described in the literature. Notwithstanding this event is not frequent, it can expose the patient to serious complications that should be quickly recognised and effectively treated. We present a report about a female patient with cholelithiasis who underwent a laparoscopic cholecystectomy. After the operation, the patient had a haemorrhage that we attributed to surgery in a first time and then to administration of ketorolac.

Anastomotic leaks after anterior resection for mid and low rectal cancer: survey of the Italian Society of Colorectal Surgery

BACKGROUND

The aim of the survey was to assess the incidence of anastomotic leaks (AL) and to identify risk factors predicting incidence and gravity of AL after low anterior resection (LAR) for rectal cancer performed by colorectal surgeons of the Italian Society of Colorectal Surgery (SICCR).

METHODS

Information about patients with rectal cancers less than 12 cm from the anal verge who underwent LAR during 2005 was collected retrospectively. AL was classified as grade I to IV according to gravity. Fifteen clinical variables were examined by univariate and multivariate analyses. Further analysis was conducted on patients with AL to identify factors correlated with gravity.

RESULTS

There were 520 patients representing 64% of LAR for rectal cancer performed by SICCR members. The overall rate of AL was 15.2%. Mortality was 2.7% including 0.6% from AL. The incidence of AL was correlated with higher age (p<0.05), lower (<20 per year) centre case volume (p<0.05), obesity (p<0.05), malnutrition (p<0.01) and intraoperative contamination (p<0.05), and was lower in patients with a colonic J-pouch reservoir (p<0.05). In the multivariate analysis age, malnutrition and intraoperative contamination were independent predictors. The only predictor of severe (grade III/IV) AL was alcohol/smoking habits (p<0.05) while the absence of a diverting stoma was borderline significant (p<0.07).

CONCLUSION

Our retrospective survey identified several risk factors for AL. This survey was a necessary step to construct prospective interventional studies and to establish benchmark standards for outcome studies.

Enhancement of learning and memory after activation of cerebral Rho GTPases

The mechanism whereby the morphology and connectivity of the dendritic tree is regulated depends on an actin dynamics that, in turn, is controlled by Rho GTPases, a family of small GTP-binding proteins encompassing Rho, Rac, and Cdc42 subfamilies. Cytotoxic necrotizing factor 1 (CNF1), a protein toxin from Escherichia coli, constitutively activates Rho GTPases, thus leading to remodeling of the actin cytoskeleton in intact cells. Here, we show that the modulation of cerebral RhoA and Rac1 activity induced by CNF1 in mice leads to (i) rearrangement of cerebral actin cytoskeleton, (ii) enhanced neurotransmission and synaptic plasticity, and (iii) improved learning and memory in various behavioral tasks. The effects persist for weeks and are not observed in mice treated with a recombinant CNF1, in which the enzymatic activity was abolished by substituting serine to cysteine at position 866. The results suggest that learning ability can be improved through pharmacological manipulation of neural connectivity.

Differential effects of three species ofHypericum in an open field test

The effects of three species of Hypericum (H.) on mice motor activity were compared in an automated open field test. Methanol extracts of H. perforatum L., H. hircinum L. and H. perfoliatum L. were tested at doses ranging from 2.5 to 200 mg i.p. H. hircinum decreased locomotion at most dose levels. Moreover, a dose of 200 mg/kg of all three herbal species sharply decreased motor activity. Ten mg/kg of H. perforatum, a dose that is comparable to that endowed with antidepressant effects in humans, tended to increase exploration and stereotypic activity and to decrease immobility. The study suggests that there are differences in the neuropharmacological actions of the three plant extracts. However, common constituents might explain the reduced motor activity observed at high dose levels.