Comparative Analysis of Tumor Microbiome, Molecular Profile and Immune Cell Abundance by HPV Status in Head and Neck Cancers and Their Impact on Survival

PURPOSE/OBJECTIVE(S)

Traditional clinical and molecular prognostic factors offer valuable insight into the heterogeneous natural history and treatment response of head and neck squamous cell carcinoma (HNSCC) yet fail to explain the full spectrum of observed variability. The tumor microenvironment (TME), comprising microbiome and immune cells can impact treatment response and prognosis. We analyzed The Cancer Genome Atlas (TCGA) to evaluate the association of specific microbes and genes in TME with survival and their differential expression in HPV positive (+) and HPV negative (-) HNSCC.

MATERIALS/METHODS

HNSCC RNA sequencing (RNAseq) samples from TCGA were processed through the Exogenous sequencing in Tumors and Immune Cells (ExoTIC) pipeline to identify gene expression and microbial presence. HPV status was assessed by detection of papillomaviridae family of microbes. Clinical data from TCGA was extracted to compare overall survival (OS) and control for competing variables using Cox proportional hazards regression. Difference in immune cell abundance was evaluated by Kruskal-Wallis test. All statistical analysis was performed using R.

RESULTS

A total of 498 RNAseq samples from TCGA were analyzed. Oral cavity, oropharynx, hypopharynx, and larynx tumors comprised 21.6%, 15%, 1.8%, and 22.2% of specimens, respectively. HPV was detected in 111 patients (22%), most commonly Alpha papillomavirus 9 (90.1%). Of the 5838 enriched microbes, 330 were significantly associated with OS after controlling for tumor stage, smoking, and age. Specifically, the presence of Alpha papillomavirus 9 was associated with significantly improved OS [adjusted HR = 0.60 (95% CI 0.40 - 0.89, p = 0.01)]. Microbial species found in more abundance in HPV- tumors included Citrobacter farmeri, Thermoanaerobacter kivui and Yersinia pestis which are gram negative anaerobes. Genes related to cellular transport and DNA repair were enriched while genes related to proliferation (e.g., SAGE1) were depleted in HPV+ samples. HPV- tumors had a significantly higher number of M0 (p < 0.001) and M2 macrophages (p = 0.035) while HPV+ tumors had more T regulatory cells (p < 0.001) and CD8+ T-cells (p < 0.001).

CONCLUSION

Tumor microenvironment was significantly associated with survival for HNSCC patients, with particular microbes such as Alpha papillomavirus 9 correlating with improved OS. Greater abundance of certain anaerobic microbes was seen in HPV- tumors. These findings suggest TME can be used to predict patient outcomes and potentially guide personalized treatment approaches. We found an abundance of M0 and M2 macrophages in HPV- tumors, which are considered pro-tumorigenic, while anti-tumor M1 macrophages were similar in the two groups. This may help identify mechanism of resistance to immunotherapies and tailor novel immunotherapy combinations in specific patient subgroups. With further prospective research and external validation these findings have the potential to significantly impact the way we treat HNSCC in the future.

A Pilot Study of Head and Neck Cancer Patients Treated Daily with an Intraoral Photobiomodulation (PBM) Device while Undergoing IMRT Demonstrates Tolerability, Safety, and Preliminary Efficacy for Reducing the Impact of Oral Mucositis

PURPOSE/OBJECTIVE(S)

Radiotherapy (RT) when given for head and neck cancer (HNC) causes acute and chronic adverse events (AEs). Oral mucositis (OM) is a significant AE and can impact cancer treatment (interruptions and/or early termination), increase opioid usage, impact diet (dysgeusia, dysphagia, inadequate nutritional intake), and cause depression. Pharmacological options are limited; however supportive care treatment guidelines (MASCC, WALT) recommend photobiomodulation (PBM) therapy for the prevention/treatment of OM. PBM is the use of non-ionizing light in the visible and near-infrared light spectra to modulate biological systems, such as wound healing. Current PBM protocols for OM prevention involve laser-based treatments using spots that are technique sensitive and time consuming. The (Sponsor) Phototherapy System uses an LED-based intraoral mouthpiece to deliver a dosage of 6 J/cm2 to the entire oral cavity, soft palate, uvula, retromolar trigone, and portions of the oropharynx in a daily 10-minute treatment. Per sponsor protocol, this medical device is used daily in the radiation therapy clinic without proximate physician supervision.

MATERIALS/METHODS

A pilot study was performed at 7 centers (5 academic) to assess feasibility. HNC participants receiving chemotherapy and IMRT with a minimum of 30Gy to greater than one oral site received a 10-min PBM treatment prior to daily RT. Pain medications and mouthwashes were permitted. PBM treatment was delivered at the radiation clinic throughout the entire duration of IMRT. Device safety (daily) and OM (weekly) evaluations were completed, and participant status was reviewed for primary and secondary outcomes at week six. OM was graded according to the Oral Mucositis Index (OMI), NCI, and RTOG scales.

RESULTS

A total of 40 patients were enrolled, 3 withdrew consent and 3 did not complete 80% of PBM treatments. A total of 1227 of 1271 study treatments were completed in full and no device-related adverse events were reported. At week 6: Participants averaged of 8.74/60 on the OMI; NCI/RTOG grades ranged from 0-3. Grade distribution was 0 (1/1), 1 (5/5), 2 (9/8), 3 (19/20) respectively. A total of 52% of salivary flow was retained. Participants reported they could swallow solids for 24.3/30 treatments (avg). Thirteen of 34 patients retained the ability to swallow solids throughout.

CONCLUSION

PBM has been recommended to prevent/treat OM; however, current options are technique sensitive and time consuming for physicians. The (Sponsor) Phototherapy System shows encouraging results in a pilot cohort, is well tolerated for daily treatments in a clinic setting and is safe without apparent device-related adverse events. This device presents a promising alternative for PBM delivery and is currently being evaluated for safety and efficacy in a double-blind randomized clinical trial (NCT03972527).

Short-lived radioactive8Li and8He ions for hadrontherapy: a simulation study

Purpose.Although charged particle therapy (CPT) for cancer treatment has grown these past years, the use of protons and carbon ions for therapy remains debated compared to x-ray therapy. While a biological advantage of protons is not clearly demonstrated, therapy using carbon ions is often pointed out for its high cost. Furthermore, the nuclear interactions undergone by carbons inside the patient are responsible for an additional dose delivered after the Bragg peak, which deteriorates the ballistic advantage of CPT. Therefore, a renewed interest for lighter ions with higher biological efficiency than protons was recently observed. In this context, helium and lithium ions represent a good compromise between protons and carbons, as they exhibit a higher linear energy transfer (LET) than protons in the Bragg peak and can be accelerated by cyclotrons. The possibility of accelerating radioactive⁸Li, decaying in 2α-particles, and⁸He, decaying in⁸Li byβ^-decay, is particularly interesting.Methods. This work aims to assess the interest of the use of⁸Li and⁸He ions for therapy by Monte Carlo simulations carried out withGeant4.Results. It was calculated that the⁸Li and⁸He decay results in an increase of the LET of almost a factor 2 in the Bragg peak compared to stable⁷Li and⁴He. This results also in a higher dose deposited in the Bragg peak without an increase of the dose in the plateau region. It was also shown that both⁸He and⁸Li can have a potential interest for prompt-gamma monitoring techniques. Finally, the feasibility of accelerating facilities delivering⁸Li and⁸He was also discussed.Conclusion. In this study, we demonstrate that both⁸Li and⁸He have interesting properties for therapy. Indeed, simulations predict that⁸Li and⁸He are a good compromise between proton and¹²C, both in terms of LET and dose.

Évaluation de la prévalence des formes critiques de la COVID-19 parmi les patients hospitalisés porteurs d’une maladie respiratoire chronique

Introduction

Les infections virales respiratoires, dont l’infection à SARS-CoV-2, peuvent déclencher des symptômes respiratoires chez les patients souffrant de maladies respiratoires chroniques, entraînant des exacerbations et parfois des hospitalisations. Malgré le tropisme préférentiellement respiratoire du SARS-CoV-2, les études évaluant les maladies respiratoires chroniques comme facteurs de risque de forme critique de la COVID-19 sont controversées. L’objectif de cette étude était d’évaluer la prévalence de formes critiques de la COVID-19 chez les patients hospitalisés porteurs d’une maladie respiratoire chronique.

Méthodes

Cette étude rétrospective française bicentrique a inclus tous les patients hospitalisés du 15 mars au 30 juin 2020 pour motif respiratoire liée à la COVID-19, hors unités de soins intensifs et réanimation.

Résultats

Au total, 617 patients ont été inclus dont 125 présentant une maladie respiratoire chronique, principalement une bronchopneumopathie chronique obstructive (45 %) et un asthme (30 %) (Tableau 1). Le pourcentage de patients ayant obtenu un score de 6 ou plus sur l’échelle de progression clinique de l’Organisation mondiale de la santé 1 pendant leur hospitalisation était plus faible chez les patients atteints d’une maladie respiratoire chronique que dans la population générale (21,6 % contre 31,3 %, p = 0,03 %). Parmi les patients porteurs d’une maladie respiratoire chronique, une température supérieure à 38 °C à l’admission (OR 16,88 [IC 95 % 4,01–71,00]), une lymphopénie (OR 5,08 [1,25–20,72]), un traitement par pression positive continue (OR 4,46 [1,04–19,17]) et un âge élevé (OR 1,09 [1,02–1,16]) étaient associés à un risque accru d’atteindre un score de 6 ou plus.

Conclusion

Selon cette étude, les patients porteurs d’une maladie respiratoire chronique hospitalisés pour forme grave de la COVID-19 ont un risque plus faible de développer une forme critique de la maladie, en particulier les patients souffrant d’une broncho-pneumopathie chronique obstructive et d’un asthme. Des études prospectives pourraient permettre de confirmer nos résultats et d’éclaircir l’impact des traitements inhalés et notamment de la corticothérapie sur la sévérité des infections à SARS-CoV-2.

A sphere fitting approach to determine the hip joint centre of the horse

Accurate identification of the hip joint centre (HJC) is crucial for the correct estimation of knee and hip joint loads and kinematics, which is particularly relevant in orthopaedic surgery and musculoskeletal modelling. Several methods have been described for calculation of the HJC in humans, however, no studies have used these methods in the horse despite a similar need for improved evaluation of hip joint biomechanics in rehabilitation and musculoskeletal modelling. This preliminary study uses the commonly used functional method (least-squares sphere fit) to determine the HJC in three equid cadavers. Bone pins with reflective markers attached were drilled into the tuber coxae (TC), tuber ischium (TI), tuber sacrale (TS), greater trochanter (GT), third trochanter (TT) and lateral femoral condyle (FC) of the uppermost limb of the cadavers positioned in lateral recumbency. Three repetitions of passive movements consisting of pro-and retraction, ab- and adduction and circumduction were performed. The HJC was calculated using a least-squares sphere fitting method and presented as a distance from the TC based on a percentage of the TC to TI vector magnitude. Mean (± standard deviation) of the HJC is located 52.4% (± 3.9) caudally, 0.2% (± 6.5) dorsally, and 19.8% (± 4.2) medially from the TC. This study is the first to quantify the HJC in horses ex vivo using a functional method. Further work (in vivo and imaging) is required to validate the findings of the present study.

Comparative need for spinal stabilisation between quadrupedal and bipedal locomotion

Sheep are commonly used as an animal model for the human lumbar spine, but similarities in trunk muscle activity of humans and sheep during functional tasks such as locomotion have not been investigated. Therefore, the aim of the study was to evaluate trunk and pelvic limb muscle activity during walk and run/trot gaits in man and sheep. Electromyography of the muscles erector spinae (ES), gluteus maximus (GM), rectus abdominis (RA), obliquus externus (OE) and obliquus internus (OI) were collected in 24 humans and 15 sheep during treadmill walk and run/trot. Kinematic data from the tarsus (human) or metatarsus (sheep) were obtained to define motion cycles and determine stride characteristics. Mean and range of normalised muscle activity were calculated. In phasic muscles, the occurrence of the maximum was reported. At walk, mean activity was greater in humans for all three abdominal muscles (all p<0.01). At the run/trot, mean activity of ES was significantly greater in sheep (p<0.05) and mean activity of right OI was greater in humans (p=0.016). At the walk, range of ES activity was significantly greater in humans compared to sheep (p<0.01), but significantly smaller in humans in RA and right OE (p<0.05). At the run/trot, range of activity was significantly greater in humans compared to sheep in all muscles (p<0.05), except right RA and OI. Compared to humans, occurrence of maximum activity was earlier in sheep for ES right during walk (p=0.005), and later for GM during walk and run/trot (p<0.001). The results suggest that numerous differences in trunk muscle activity exist between man and sheep during treadmill walk and run/trot, and that these differences are muscle-and gait-specific. Trunk muscle activity should therefore be regarded as species-specific which suggests differences in stabilization strategies. This should be taken into consideration when extrapolating animal model findings to the human spine.

Modulation of CD4+ T-cell activation by CD95 co-stimulation

CD95 is a dual-function receptor that exerts pro- or antiapoptotic effects depending on the cellular context, the state of activation, the signal threshold and the mode of ligation. In this study, we report that CD95 engagement modulates TCR/CD3-driven signaling pathways in resting T lymphocytes in a dose-dependent manner. While high doses of immobilized CD95 agonists silence T cells, lower concentrations augment activation and proliferation. We analyzed the co-stimulatory capacity of CD95 in detail in resting human CD4(+) T cells, and demonstrate that low-dose ligand-induced co-internalization of CD95 and TCR/CD3 complexes enables non-apoptotic caspase activation, the prolonged activation of MAP kinases, the upregulation of antiapoptotic proteins associated with apoptosis resistance, and the activation of transcription factors and cell-cycle regulators for the induction of proliferation and cytokine production. We propose that the levels of CD95L on antigen-presenting cells (APCs), neighboring T cells or epithelial cells regulate inhibitory or co-stimulatory CD95 signaling, which in turn is crucial for fine-tuning of primary T-cell activation.

Effect of fenofibrate on microcirculation and wound healing in healthy and diabetic mice

Objective

Disturbances in wound healing in patients with hyperglycaemic blood sugar values are a common clinical problem. Recent studies identified PPARα-ligands as potential skin therapeutic agents. The aim of this study was to investigate the effects of oral fenofibrate treatment on dermal wound healing and micro-circulatory parameters in diabetic mice.

Methods

Dermal wounds were created in CD-1 mice. Mice were randomized into four treatment groups: diabetic mice treated (dbf) or not-treated with fenofibrate (dbnf). As controls served non-diabetic mice treated (ndf) or not-treated with fenofibrate (ndnf). At various points in time microcirculation was analyzed by intravital fluorescent microscopy to determine wound surface area, vessel diameter, plasma leakage, functional capillary density, and leukocyte/endothelium interaction.

Results

The dbf-mice showed a significantly increased diameter of the venules and the arterioles up to 3 days after wound creation compared to dbnf-mice. However, wound healing was not improved in dbf-compared to dbnf-mice. Surprisingly, all microcirculatory parameter (vessel diameter, plasma leakage and functional capillary density) were not deteriorated in dbnf-compared to ndnf-mice.

Conclusion

We confirm that high blood sugar values lead to a delayed wound healing, but this could not traced back to altered microcirculatory patterns. Furthermore, in dbf-mice an improved vasodilatatory function of small vessels could be detected, but with no substantial effect on wound healing. Further studies are needed to clarify, if topical application of fenofibrate might be beneficial.

[Intra-thoracic fracture-dislocation of the humeral head: a case report and review of the literature]

A 50-year-old male traffic accident victim sustained high-energy trauma leading to intra-thoracic fracture-dislocation of the humeral head. Dislocation of the humeral head into the thoracic cavity is a very rare injury. Only twelve cases have been reported in the literature. Treatment modalities vary and no guidelines have been proposed. The mechanism of the injury and the treatment options are discussed together with a review of the literature.

Mélanome malin achromique : à propos de trois cas

The amelanotic melanoma is a rare type of malignant melanoma. The purpose of this report is to point out this aspect of melanoma, whose diagnostic delay is frequent. We describe one localisation on the penis, rare in this kind of melanoma and two cases of the extremities, more frequent localization of the amelanotic melanoma. The therapeutic issues and recommendation are similar to the classical pigmented malignant melanoma.

Methyltetrahydrofolate reductase polymorphism influences onset of Huntington's disease

Onset of Huntington's disease (HD) negatively correlates with CAG repeat length of the HD gene, which encodes the protein huntingtin. This protein interacts with the homocysteine metabolizing enzyme cystathionine betasynthase (CBS). Objective of this study was to analyze the impact of CAG repeats, polymorphisms of various homocysteine metabolizing enzymes, like CBS, Methyltetrahydrofolate Reductase (MTHTR), Methionine Synthase Reductase (MSR) and methionine synthase (MS) on HD onset in 171 patients. The significant impact of CAG repeats on HD onset (chi2= 25.54, FG = 4, p<0.0001) with a significant correlation between both (R= -0.521, p=0.01) was obvious. HD patients with the homozygous MTHFR-1298-CC significantly (p = 0.024) earlier experienced HD symptoms. There was no influence demonstrable of CBS, MSR and MS. Determination of MTHFR polymorphisms and CAG repeats enables screening for subjects with putative early HD onset in order to study neuroprotective compounds in their efficacy to delay HD symptoms.

Amniotic fluid embolism during caesarean section

Amniotic fluid embolism occurs rarely but is a leading cause of maternal mortality. A high index of clinical suspicion is necessary to make an early diagnosis to reduce morbidity and mortality. We report a non-fatal case of amniotic fluid embolism occurring during a caesarean section, with special emphasis on the mode of development and diagnosis. The initial presentation of this syndrome was a coagulopathy, followed by the usual complications of massive bleeding. Although non-specific, the diagnosis of amniotic fluid embolism was supported by the observation of amniotic fluid in the central venous blood as well as in the broncho-alveolar fluid.

Revised T3 uptake and T4-to-T3 conversion in brain and cerebellum of 10-day-old rats: a compartment analysis

The peripheral and cerebral metabolism of thyroid hormones in 10-day-old rats was evaluated by measuring the kinetics of thyroxine (T4) and 3,5,3'-triiodothyronine (T3) fluxes. Labeled iodo-compounds were measured in the plasma, cerebellum and brain (without cerebellum) for 24 hours after the intravenous injection of [125I]T4 plus [131I]T3. Data were interpreted by compartment analysis. T4 was produced at 8.93 pmol x h(-1) and T3 at 2.26 pmol x h(-1) for 22.7 g body weight. The T4 and T3 distribution volumes were 4.26 and 22.7 ml, whereas the extra-cellular fluid volume was 9.42 ml. T4 was therefore considered to be mostly extra-cellular and T3 mostly intracellular. This was confirmed in the brain and cerebellum, where the extra-cellular fluid (ECF) fraction was 0.021 ml/g organ and the tissue-to-plasma ratio of labeled and endogenous hormones was 0.54-6.54 ml plasma/g tissue for T3 and 0.048-0.136 ml plasma/g tissue for T4. The T3 in the brain and cerebellum was distributed in several pools. The first, representing 11% of the cerebellum and 8% of the brain (without cerebellum) T3, was quickly exchanged with circulating T3. The second pool, derived from the local T4 5'-deiodination, represented 48% of the cerebellum and 94% of the brain (without cerebellum) hormone; a possible third pool (41% of the hormonal content) in the cerebellum appeared to be unlabeled by radioactive T3, and motionless. The in vivo T4 to T3 conversion, as a function of weight, accounted for 21% of cerebellum needs and 43% of brain needs. The rest was provided by T3 uptake.

5'-deiodinase activity in cultured glial and fibroblastic cells from the cerebella of newborn rats

The cerebellum of young rats contains significant 5'-deiodinase (5'-D) activity, but technical difficulties have made it impossible to identify the enzyme in cultured cerebellar astrocytes. We have developed a culture method which allows cerebellar astrocytes from 6-day-old rats to grow and develop 5'-D activity. Astrocytes cultured for 2 weeks in medium containing 3.25 microM reduced glutathione (GSH) and 0.21 microM vitamin E (VitE) as alpha-tocopherol had 5'-D activity which was stimulated by 1 mM dibutyryl cyclic adenosine monophosphate (dBcAMP) given 16 hours before measuring enzyme activity. Cells cultured without GSH and VitE showed little 5'-D activity, which was not stimulated by dBcAMP Primary cultures of cerebellar astrocytes were cultured for four weeks with or without GSH+VitE, and stimulated by dBcAMP had high 5'-D activity, but were also sometimes contaminated with fibroblasts. The effect of such contamination on the astrocyte 5'-D activity was assessed by preparing primary cultures of fibroblasts from the meninges surrounding 6-day-old rat cerebella. They were grown in the same media and under the same conditions as the astrocytes. The cultured fibroblasts had 5'-D activity independent of GSH+VitE or culture time. The 5'-D activity of both cell populations could be type II 5'-deiodinase (5'-DII) because it was not inhibited by 6-n-propylthiouracil (PTU). Thus, cerebellar astrocytes cultured for 2 weeks in medium containing GSH and VitE have 5'-DII activity. Prolonged cultures favor enzyme activity, but also enhance contamination with fibroblasts, which may also show 5'-DII activity.

Rat embryonic hippocampal neurons express a new class A calcium channel variant

The aim of this study was to investigate, using a RT-PCR strategy, rat voltage-gated class A calcium channel (alpha1A) splice variants during rat hippocampus development. Results demonstrate the presence of multiple alpha1A mRNAs with the hippocampus formation and revealed a new variant of the rat alpha1A subunit (alpha1A-EFe) that diverges from alpha1A-a in the EF-hand domain. alpha1A-EFe expression in hippocampal neurons is restricted to the embryonic period. This in vivo developmental program is recapitulated in dissociated cultures of E17 embryonic hippocampal neurons. These data demonstrate that rat hippocampus neurons express a unique alpha1A splice variant during the embryonic period and suggest that alternative RNA splicing may modulate neuronal calcium channel properties during development.

Calcium channel subtypes responsible for voltage-gated intracellular calcium elevations in embryonic rat motoneurons

The central role of electrical activity and Ca2+ influx in motoneuron development raises important questions about the regulation of Ca2+ signalling induced by voltage-dependent Ca2+ influx. In the purified embryonic rat motoneuron preparation, we recorded barium currents through voltage-activated Ca2+ channels using the whole-cell configuration of the patch-clamp technique. We found that motoneurons express at least four types of high-voltage-activated Ca2+ channels, based on their kinetics, voltage-dependences and pharmacological properties. Of the sustained Ca2+ current activated at 0 mV from a holding potential of -100 mV, approximately 45% was omega-conotoxin-GVIA (1 microM) sensitive, 25% was omega-agatoxin-IVA (30 nM) sensitive and 20% was nitrendipine (250 nM) sensitive. The residual current, after applying these three antagonists, was an inactivating current that differs from classical T-type Ca2+ currents. Based on this pharmacology, changes in intracellular free Ca2+ concentrations were then monitored by Fura 2 digital imaging microspectrofluorimetry. Upon K+ depolarization, the intracellular Ca2+ transient induced by the activation of each type of Ca2+ channel appeared to be quantitatively proportional to their Ca2+ influx. The existence of a calcium-induced calcium release mechanism through activation of caffeine-, ryanodine-sensitive intracellular stores was then investigated. High doses of caffeine and low doses of ryanodine failed to increase intracellular free calcium concentrations and low concentrations of caffeine and high concentrations of ryanodine did not affect K+-induced intracellular free calcium concentration transients indicating both the absence of Ca2+-gated Ca2+-release channels and of a Ca2+-induced Ca2+ release mechanism. Together, these data provide evidence that embryonic motoneurons express multiple Ca2+ channels that function as important regulators of intracellular Ca2+ signalling and may be involved in their development.

Tissue factor pathway inhibitor: regulation of its inhibitory activity by phospholipid surfaces

The basic C-terminus of Tissue Factor Pathway Inhibitor (TFPI) appears to be essential for its anticoagulant activity when tested in a diluted thromboplastin prothrombin time assay. Although the data reported so far have increased our knowledge about the C-terminus as a major binding site for heparin, lipoproteins and phospholipids, it is still unclear how this region of TFPI plays a role in its anticoagulant mode of action. We earlier reported that in the presence of phospholipid the rate of association of factor Xa with full length TFPI (FL-TFPI) is about 10-fold faster than with C-terminus truncated TFPI. This in turn makes that, in vitro, full length TFPI is a more potent inhibitor of tissue factor-factor VIIa catalyzed factor X activation than truncated TFPI. Binding studies, utilizing an ellipsometer, revealed that in contrast to the complex of C-terminus truncated TFPI (TFPI1-161) and factor Xa, the FL-TFPI.factor Xa complex has a high affinity for negatively charged phospholipids. However, when examined in a tubular flow reactor containing tissue factor embedded in a phospholipid bilayer composed of 25 mol% phosphatidyl-serine/75 mol% phosphatidylcholine, no differences in the potency of FL-TFPI and TFPI1-161 to inhibit factor X activation were found. The two variants of TFPI did show an interesting difference though. We found that the quaternary complex of TF.factor VIIa.FL-TFPI.factor Xa was much more stable than the complex containing TFPI1-161. This difference could not be attributed to their different phospholipid-binding properties since the same difference in stability was found on membranes that contained only DOPC.

Factor Xa enhances the binding of tissue factor pathway inhibitor to acidic phospholipids

In the present study, the interaction between tissue factor pathway inhibitor (TFPI) and phospholipids has been characterized using a microtitre plate assay. TFPI was shown to bind calcium-independently to an acidic phospholipid surface composed of phosphatidylserine, but not a surface composed of the neutral phosphatidylcholine. The interaction was demonstrated to be dependent on the presence of the TFPI C-terminus. The presence of heparin (1 U/ml, unfractionated) was able to significantly reduce the binding of TFPI to phospholipid. The interaction of TFPI with phosphatidylserine was significantly decreased in the presence of calcium, but this was counteracted, and even enhanced, following complex formation of TFPI with factor Xa prior to incubation with the phospholipid surface. Moreover, a TFPI variant, not containing the third Kunitz domain and the C-terminus, was unable to bind to phospholipid. However, following the formation of a TFPI/factor Xa-complex this TFPI variant was capable of interacting with the phospholipid surface. This indicates that the role of factor Xa as a TFPI cofactor, at least in part, is to mediate the binding of TFPI to the phospholipid surface.

Inhibition of factor X activation at extracellular matrix of fibroblasts during flow conditions: a comparison between tissue factor pathway inhibitor and inactive factor VIIa

Tissue factor pathway inhibitor (TFPI) is a naturally occurring factor Xa-dependent inhibitor of factor VIIa/tissue factor activity. In the present study, we examined the importance of the TFPI C-terminus and 3rd Kunitz-like domain for the inhibitory capacity of TFPI towards factor VIIa/tissue factor-catalyzed factor X activation and compared the inhibition with that of inactivated factor VIIa (factor VIIai). The extra-cellular matrix of fibroblasts, mounted in a parallel-plate flow chamber, were perfused with reaction mixtures that contained factors X, VIIa, and varying amounts of TFPI or factor VIIai. Inhibition was evaluated from the time course of factor Xa production at the outlet of the flow chamber. The factor VIIa/tissue factor-catalyzed factor Xa production was inhibited by factor VIIai and compatible with a direct competition between factor VIIai for tissue factor. In contrast, TFPI showed a progressive inhibition of factor Xa production; the initial rate of factor X activation, however, was not inhibited by TFPI. Inhibition of factor Xa generation already in progress was seen for TFPI but not factor VIIai. In both cases we found that the truncated TFPI variants were as potent as full length TFPI. As to the stability of the enzyme-inhibitor complexes, TFPI-/Xa/VIIa/tissue factor and factor VIIai/tissue factor, marked differences were observed. About 60% of the factor VIIa/tissue factor activity was recovered from the truncated TFPI/Xa/VIIa/tissue factor complex after 150 min of perfusion with reaction mixtures that contained factors X and VIIa. In contrast, full length TFPI did not dissociate from the complex, nor could factor VIIai be displaced by a large excess of factor VIIa.

Surgical workshop on liver surgery using isolated perfused livers in moulded casts of the upper abdomen

The basic training in liver surgery on isolated perfused livers used at the workshop in the First Surgical Course of the Alps--Adriatic Hepatobiliary School is presented. The methods for the excision, preservation, perfusion and preparation of the liver are described, as is the manner of manufacturing the upper abdomen moulded casts, into which an isolated perfused liver is placed for training. The methods proved to be sufficiently successful, enabling participants to perform basic liver surgery like an intraoperative ultrasound investigation, as well as liver dissection techniques, liver suturing, segmental resection and even hepatectomy. Some technical improvements are proposed for future surgical workshops, such as washing out the blood from the liver, and a triple perfusion.

Characterization of the binding between tissue factor pathway inhibitor and glycosaminoglycans

Tissue Factor Pathway Inhibitor (TFPI) is a heparin binding protein and injection of heparin causes a release of TFPI to plasma. In order to understand the binding between TFPI and heparin in more detail we have in this study looked into some of the heparin characteristics and their importance for the TFPI-heparin interaction. We have developed an assay based on the use of heparin-Sepharose micro columns in order to compare small quantities of heparin fractions as well as different glycosaminoglycans on a weight basis for their TFPI binding. In this assay a glycosaminoglycan in solution compete with heparin-Sepharose for TFPI binding. Size fractionated heparin was analyzed for binding to TFPI, and a clear dependency on the molecular weight was observed. The highest TFPI binding capacity was found for fractions with a molecular weight above 10,000 Da, while no binding was measured below 2,000 Da. No difference in TFPI binding appeared after fractionation of heparin according to its affinity towards antithrombin, thus indicating that TFPI binding does not require the specific antithrombin binding site. A heparin fraction of 10,000 Da was fractionated on a mono Q column, resulting in four fractions with different charge densities. The charge density turned out to be a very important parameter for the binding of TFPI. A number of different glycosaminoglycans were tested and the following order of TFPI affinity was found: heparin >> dermatan sulphate > heparan sulphate > chondroitin sulphate C. No binding was observed for chondroitin sulphate A or hyaluronic acid.

Evidence that the C-terminus of tissue factor pathway inhibitor (TFPI) is essential for its in vitro and in vivo interaction with lipoproteins

We have previously shown that the C-terminus of TFPI is essential for its anticoagulant activity. In the present study we have assessed the role of this region in the binding of TFPI to lipoproteins. We found that full length TFPI, but not C-terminal degraded TFPI, was capable of coeluting with the plasma lipoprotein fraction on a Superose-6 column. The importance of the TFPI C-terminus in lipoprotein interactions was also assessed using a microtitre plate binding assay. We found that full-length TFPI was capable of binding to VLDL or LDL coated microtitre plates. C-terminal degraded TFPI also bound to VLDL, but with a ten-fold lower affinity than full length TFPI. Interestingly, removal of the C-terminus along with the third Kunitz-type domain resulted in a TFPI form incapable of lipoprotein binding. Since heparin shows strong binding to the C-terminus of TFPI, we also tested its effect on the binding of full length TFPI to VLDL. We found that co-incubation of TFPI with heparin inhibited this binding in a dose-dependent manner. Heparin was also capable of releasing TFPI from a preformed TFPI:VLDL complex, although this reaction required unphysiological amounts of heparin. To assess the physiological function of heparin on FL-TFPI:lipoprotein interactions we also performed gel filtration chromatography of rabbit plasma immediately following i.v. administration of FL-TFPI with and without heparin. Previous experiments indicated that heparin has a protective effect on exogenously added FL-TFPI, increasing its recovery by ten-fold.(ABSTRACT TRUNCATED AT 250 WORDS)

The significance of TFPI in clotting assays--comparison and combination with other anticoagulants

The anticoagulant activities of Tissue Factor Pathway Inhibitor (TFPI), heparin and hirudin were compared in intrinsic (APTT) and extrinsic (PT) activated clotting assays. In contrast to the thrombin inhibitor hirudin, heparin was 10 fold more potent in the APTT assay than in the PT assay, indicating that inhibition of intrinsic activation is important for the anticoagulant activity of heparin as measured in an APTT assay. TFPI was most potent in the PT assay and the effect of TFPI was most pronounced in the presence of other anticoagulants (heparin and hirudin). The activities of the two natural anticoagulants antithrombin III (ATIII) and TFPI were compared in a PT assay with very dilute tissue factor. In this assay system TFPI in normal plasma affected the clotting time more than ATIII in the plasma. However, when heparin was added ATIII was the major anticoagulant, but profound prolongation of the clotting time was only seen when TFPI was also added. In an ATIII deficient plasma heparin did not augment the effect of TFPI, showing that the increased effect of TFPI in the presence of heparin is dependent on the anticoagulant activity of ATIII/heparin. The effect of TFPI at prolonged clotting times was also illustrated by the significant effect of blocking TFPI in the plasma from warfarin-treated patients. Thus TFPI is a major anticoagulant in normal plasma and the effect of TFPI is especially seen at prolonged clotting times.

Is tissue factor pathway inhibitor involved in the antithrombotic effect of heparins? Biochemical considerations

Tissue factor pathway inhibitor (TFPI) is released into the circulation after intravenous or subcutaneous injection of heparin or low-molecular-weight heparin (Logiparin) in humans. The plasma concentration of TFPI is increased 2- to 4-fold by a prophylactic dose of Logiparin, and this excess TFPI remains in the circulation only in the presence of the heparin. TFPI and heparin show strong synergism in clotting assays at concentrations obtained after heparin injection in humans. Animal studies have demonstrated that TFPI by itself has antithrombotic properties. It is concluded that the release of TFPI may contribute significantly to the antithrombotic effect of heparin.

The C-terminus of tissue factor pathway inhibitor is essential to its anticoagulant activity

Tissue factor pathway inhibitor (TFPI) from different cell lines shows up to 15-fold differences in the ratio of anticoagulant to chromogenic activity. The anticoagulant activity was dependent on the purification procedure used and it was possible to isolate two fractions of recombinant TFPI. Only one of these fractions showed anticoagulant activity comparable with TFPI from normal human plasma, and Western blotting showed that the low-activity fraction did not react with an antibody raised against a peptide of TFPI located near the C-terminal. Analysis by mass spectroscopy of peptides from V8 protease digests showed that C-terminal amino acids could only be identified from the high-activity form, while heterologous fragmentation had taken place in the form with low anticoagulant activity. Previously published studies on TFPI have been performed using material of low anticoagulant activity compared with plasma TFPI, and we suggest that these studies have been performed with material degraded in the C-terminus.

Simultaneous presence of tissue factor pathway inhibitor (TFPI) and low molecular weight heparin has a synergistic effect in different coagulation assays

Injection of heparin releases tissue factor pathway inhibitor (TFPI) to the blood and, after heparin neutralization, it has been recently demonstrated that the released TFPI has an anticoagulant activity. Using recombinant TFPI (rTFPI) we have investigated how the simultaneous presence of TFPI and low molecular weight heparin (LMW heparin) affects different coagulation assays. Coagulation was measured using the activated partial thromboplastin time, the prothrombin time and a dilute tissue factor assay. The anticoagulant activity of partly purified plasma TFPI (pTFPI) was much higher than that of TFPI. However, this high anticoagulant activity was unstable, so in order to investigate the effect of pTFPI and LMW heparin we used an inhibitory antibody towards TFPI and looked at the effect of removing TFPI from plasma. When both rTFPI and LMW heparin was added to plasma a synergistic effect was observed in all assays. In the tissue factor dependent coagulation assays, the effect of adding rTFPI or removing pTFPI was more pronounced in the presence of heparin. TFPI plays a significant role in assays where the coagulation time is prolonged for some reason. This may be caused by dilution of tissue factor, by the presence of heparin or by a defect in the coagulation cascade such as that seen in haemophilia.

Inhibition of extrinsic pathway inhibitor shortens the coagulation time of normal plasma and of hemophilia plasma

An increasing amount of evidence suggests that coagulation factors VIII and IX play a role not only in the intrinsic but also in the extrinsic pathway of coagulation. In this context the influence of the Extrinsic Pathway Inhibitor (EPI) on the coagulation time of hemophilia plasma lacking FVIII or FIX has been investigated. The coagulation time was measured in a dilute thromboplastin assay. Addition of recombinant EPI (rEPI) prolonged the coagulation time of normal plasma while the addition of an inhibitory antibody against EPI shortened the coagulation time. At low concentrations of thromboplastin the coagulation time of hemophilia plasma was prolonged and at all dilutions of thromboplastin, addition of anti-EPI IgG normalized the coagulation time of a hemophilia plasma. Analysis of 10 individual donor plasma samples and 8 individual hemophilia samples showed that addition of anti-EPI IgG shortened the coagulation time more in hemophilia plasma than in normal plasma. This illustrates the importance of a powerful extrinsic FVII dependent pathway to achieve hemostasis in the case of FVIII or FIX deficiency (hemophilia A and B).

Prevention of recurrent variceal bleeding in alcoholic cirrhotic patients: prospective controlled trial of propranolol and sclerotherapy

We conducted a prospective randomized controlled study to evaluate the effectiveness of propranolol and sclerotherapy, compared to a control group, in the prevention of variceal rebleeding in alcoholic cirrhotic patients. Among the 79 patients included, the distribution of patients according to Child-Pugh classification was: A, 22%; B, 40%; and C, 38%. Propranolol was given twice daily with a mean final dose of 54 +/- 16 mg/day, this resulted in a mean reduction in resting heart rate of 26 +/- 7%. Sclerotherapy was performed weekly using 1% polidocanol. End points were rebleeding or death. During the mean follow up of 19 +/- 16 months, 43 patients bled and 22 patients died. The cumulative percentages of patients free of rebleeding at 1 year were: propranolol, 81% (95% confidence interval (CI): 63-92); sclerotherapy, 64% (95% CI: 45-82); control, 54% (95% CI: 36-71); these differences did not reach statistical significance. The cumulative percentages of patients alive at 1 year were: propranolol, 92% (95% CI: 76-98); sclerotherapy, 79% (95% CI: 58-91); control, 81% (95% CI: 60-93); these differences were not statistically significant. Alcohol withdrawal, which occurred in 66% of patients, was an independent predictive factor associated with a decreased risk of rebleeding or death. In conclusion, a life table analysis of patients free of rebleeding, as well as of patients surviving, revealed a tendency in favour of propranolol. The lack of a statistical support for these two favorable effects could be due to poor statistical power.(ABSTRACT TRUNCATED AT 250 WORDS)