Impact of Sonic Hedgehog-dependent sphenoid bone defect on craniofacial growth

OBJECTIVES

The main objective of this study was to evaluate how an apparently minor anomaly of the sphenoid bone, observed in a haploinsufficient mouse model for Sonic Hedgehog (Shh), affects the growth of the adult craniofacial region. This study aims to provide valuable information to orthodontists when making decisions regarding individuals carrying SHH mutation.

MATERIALS AND METHODS

The skulls of embryonic, juvenile and adult mice of two genotypes (Shh heterozygous and wild type) were examined and measured using landmark-based linear dimensions. Additionally, we analysed the clinical characteristics of a group of patients and their relatives with SHH gene mutations.

RESULTS

In the viable Shh+/ - mouse model, bred on a C57BL/6J background, we noted the presence of a persistent foramen at the midline of the basisphenoid bone. This particular anomaly was attributed to the existence of an ectopic pituitary gland. We discovered that this anomaly led to premature closure of the intrasphenoidal synchondrosis and contributed to craniofacial deformities in adult mice, including a longitudinally shortened skull base. This developmental anomaly is reminiscent of that commonly observed in human holoprosencephaly, a disorder resulting from a deficiency in SHH activity. However, sphenoid morphogenesis is not currently monitored in individuals carrying SHH mutations.

CONCLUSION

Haploinsufficiency of Shh leads to isolated craniofacial skeletal hypoplasia in adult mouse. This finding highlights the importance of radiographic monitoring of the skull base in all individuals with SHH gene mutations.

O-218 Single-cell RNA sequencing reveals that Ashermańs syndrome is caused by chronic inflammation that induces differential molecular and cellular cartography in the human endometrium

Study question

What is the differential cellular, transcriptomic and immunological differences of the human endometrium in AS versus healthy patients at single cell resolution?

Summary answer

The epithelial fraction is decreased, the myeloid and lymphoid cell lineages increased with an altered inflammation, inhibition of angiogenesis and EM abnormal remodeling.

What is known already

Asherman’s Syndrome (AS) is an acquired pathological condition, defined by the presence of intrauterine adhesions (IUAs) causing the uterine walls to adhere to one another resulting in menstrual abnormalities, pelvic pain, infertility, recurrent miscarriage, and abnormal placentation. However, the underlaying cellular, transcriptomic and immunological mechanisms at the single-cell level that occur in AS have not been investigated. 

Study design, size, duration

Single cell RNA-seq (scRNA-seq) was performed on 41,854 cells corresponding to endometrial biopsies from a total of 7 individuals with severe AS (AFS classification 1998). These patients were involved in a phase I/II, prospective, non-randomized, uncontrolled, multicenter, interventional clinical trial authorized by the Spanish Medicines Agency (AEMPS)(2016-003973-23). Control healthy endometrium was represented by 68,026 cell transcriptomes from our previous work (Wang et al. 2020). 

Participants/materials, setting, methods

Seven patients were included. Ultrasound and hysteroscopies were performed in mid secretory phase. Endometrial specimens were digested with collagenase and filtered. Epithelial cells were digested with trypsin and red blood cells removed. After MACS live enrichment, cells were loaded onto ChromiumNext GEM (10xGenomics). Libraries were sequenced in a Novaseq, and reads processed with CellRanger. Quality filtering, normalization, clustering and differential expression analysis were applied from ‘Seurat’ package. Functional enrichment analysis was computed using ‘escape’ package.

Main results and the role of chance

In total 109,880 cell transcriptomes were compared and found changes in cell population ratios in two specific cell types. First, the epithelial fraction was decreased in AS compared to healthy condition (26.53% vs 45.7%, respectively) specifically the epithelium representing the opening of the window of implantation (WOI) (0.25% vs 2.01%respectively), and the ciliated epithelium (0.84% vs 6.12%, respectively). Second, the myeloid and lymphoid cell lineages, which are much more abundant in AS samples. Macrophages (1.97% vs 0.24%, respectively), CD8+ T cells (3.71% vs 1.34%, respectively), and CD8- T cells (2.28% vs 0.55%, respectively).

In addition, there was a different transcriptomic composition represented by three differential linked clusters related to AS condition. First, a unique stromal cluster labelled as stromal_ACTA2 that express genes related to contractile functions (ACTA2, MYH11, DES). Second, a specific AS epithelium cluster closely related to antigen processing and presentation of HLA class II family genes. Third, a KRT8 ACTA2 cluster composed by genes related to collagen (COL3A1 and COL1A1) and IGFBP5.

Enrichment analysis performed with ssGSEA revealed the functional impact of the AS condition identifying an increase in different GO terms related to tissue damage, pro-inflammatory processes, inhibition of angiogenesis.

Limitations, reasons for caution

Despite these promising results, this is an study in progress to be completed with 10 patients 

Wider implications of the findings

These findings describe for the first time the pathophysiology of AS at single cell level with the functional involvement of inflammation, fibrosis, and defective angiogenesis in this pathological condition. 

Trial registration number

Eudra CT 2016-003975-23

Yeast interaction on Chardonnay wine composition: Impact of strain and inoculation time

It is of great importance to understand the molecular characteristics and substantial chemical transformations due to yeast-yeast interaction. Non-targeted metabolomics was used to unravel must in fermentation composition, inoculated with non-Saccharomyces (NS) yeasts and Saccharomyces cerevisiae (S) for sequential fermentation. ultrahigh-resolution mass spectrometry was able to distinguish thousands of metabolites and provides deep insights into grape must composition allowing better understanding of the yeast-yeast interactome. The dominance of S, characterized by a metabolic richness not found with NS, is dependent on inoculation time and on the yeast species present. Co-inoculation leads to the formation of new compounds, reflecting a reshuffling of yeast metabolism linked to interaction mechanisms. Among the modifications observed, metabolomic unravels deep changes in nitrogen metabolism due to yeast-yeast interactions and suggests that the redistribution pattern affects two different routes, the pentose phosphate and the amino acid synthesis pathways.

Effects of diclofenac on sentinel species and aquatic communities in semi-natural conditions

Due to the potential hazard of diclofenac on aquatic organisms and the lack of higher-tier ecotoxicological studies, a long-term freshwater mesocosm experiment was set up to study the effects of this substance on primary producers and consumers at environmentally realistic nominal concentrations 0.1, 1 and 10 µg/L (average effective concentrations 0.041, 0.44 and 3.82 µg/L). During the six-month exposure period, the biovolume of two macrophyte species (Nasturtium officinale and Callitriche platycarpa) significantly decreased at the highest treatment level. Subsequently, a decrease in dissolved oxygen levels was observed. High mortality rates, effects on immunity, and high genotoxicity were found for encaged zebra mussels (Dreissena polymorpha) in all treatments. In the highest treatment level, one month after the beginning of the exposure, mortality of adult fish (Gasterosteus aculeatus) caused effects on the final population structure. Total abundance of fish and the percentage of juveniles decreased whereas the percentage of adults increased. This led to an overall shift in the length frequency distribution of the F₁ generation compared to the control. Consequently, indirect effects on the community structure of zooplankton and macroinvertebrates were observed in the highest treatment level. The No Observed Effect Concentration (NOEC) value at the individual level was < 0.1 µg/L and 1 µg/L at the population and community levels. Our study showed that in more natural conditions, diclofenac could cause more severe effects compared to those observed in laboratory conditions. The use of our results for regulatory matters is also discussed.

Synonymous variants in holoprosencephaly alter codon usage and impact the Sonic Hedgehog protein

Synonymous single nucleotide variants (sSNVs) have been implicated in various genetic disorders through alterations of pre-mRNA splicing, mRNA structure and miRNA regulation. However, their impact on synonymous codon usage and protein translation remains to be elucidated in clinical context. Here, we explore the functional impact of sSNVs in the Sonic Hedgehog (SHH) gene, identified in patients affected by holoprosencephaly, a congenital brain defect resulting from incomplete forebrain cleavage. We identified eight sSNVs in SHH, selectively enriched in holoprosencephaly patients as compared to healthy individuals, and systematically assessed their effect at both transcriptional and translational levels using a series of in silico and in vitro approaches. Although no evidence of impact of these sSNVs on splicing, mRNA structure or miRNA regulation was found, five sSNVs introduced significant changes in codon usage and were predicted to impact protein translation. Cell assays demonstrated that these five sSNVs are associated with a significantly reduced amount of the resulting protein, ranging from 5% to 23%. Inhibition of the proteasome rescued the protein levels for four out of five sSNVs, confirming their impact on protein stability and folding. Remarkably, we found a significant correlation between experimental values of protein reduction and computational measures of codon usage, indicating the relevance of in silico models in predicting the impact of sSNVs on translation. Considering the critical role of SHH in brain development, our findings highlight the clinical relevance of sSNVs in holoprosencephaly and underline the importance of investigating their impact on translation in human pathologies.

PharmFrag: An Easy and Fast Multiplex Pharmacogenetics Assay to Simultaneously Analyze 9 Genetic Polymorphisms Involved in Response Variability of Anticancer Drugs

Regarding several cytotoxic agents, it was evidenced that genetic polymorphisms in genes encoding enzymes involved in their metabolism are associated with higher risk of toxicity. Genotyping these genes before treatment is a valuable strategy to prevent side effects and to predict individual response to drug therapy. This pharmacogenetic approach is recommended for chemotherapies such as thiopurines (azathioprine, 6-mercaptopurine, thioguanine), irinotecan, and fluoropyrimidines (capecitabine and 5-fluorouracil). In this study, we aimed at developing and validating a fast, cost-effective, and easily implementable multiplex genotyping method suitable for analyzing a panel of nine variants involved in the pharmacogenetics of widely prescribed anticancer drugs. We designed a multiplex-specific PCR assay where fragments were labeled by two different fluorescent dye markers (HEX/FAM) identifiable by fragment analysis. These two labels were used to discriminate bi-allelic variants, while the size of the fragment allowed the identification of a particular polymorphism location. Variants of interest were TPMT (rs1800462, rs1142345, rs1800460), NUDT15 (rs116855232), DPYD (rs55886062, rs3918290, rs67376798, rs75017182), and UGT1A1 (rs8175347). The assay was repeatable, and genotypes could be determined when DNA sample amounts ranged from 25 to 100 ng. Primers and dye remained stable in a ready-to-use mixture solution after five freeze–thaw cycles. Accuracy was evidenced by the consistency of 187 genotyping results obtained with our multiplex assay and a reference method. The developed method is fast and cost-effective in simultaneously identifying nine variants involved in the pharmacological response of anticancer drugs. This assay can be easily implemented in laboratories for widespread access to pharmacogenetics in clinical practice.

Disrupted Hypothalamo-Pituitary Axis in Association With Reduced SHH Underlies the Pathogenesis of NOTCH-Deficiency

CONTEXT

In human, Sonic hedgehog (SHH) haploinsufficiency is the predominant cause of holoprosencephaly, a structural malformation of the forebrain midline characterized by phenotypic heterogeneity and incomplete penetrance. The NOTCH signaling pathway has recently been associated with holoprosencephaly in humans, but the precise mechanism involving NOTCH signaling during early brain development remains unknown.

OBJECTIVE

The aim of this study was to evaluate the relationship between SHH and NOTCH signaling to determine the mechanism by which NOTCH dysfunction could cause midline malformations of the forebrain.

DESIGN

In this study, we have used a chemical inhibition approach in the chick model and a genetic approach in the mouse model. We also reported results obtained from the clinical diagnosis of a cohort composed of 141 holoprosencephaly patients.

RESULTS

We demonstrated that inhibition of NOTCH signaling in chick embryos as well as in mouse embryos induced a specific downregulation of SHH in the anterior hypothalamus. Our data in the mouse also revealed that the pituitary gland was the most sensitive tissue to Shh insufficiency and that haploinsufficiency of the SHH and NOTCH signaling pathways synergized to produce a malformed pituitary gland. Analysis of a large holoprosencephaly cohort revealed that some patients possessed multiple heterozygous mutations in several regulators of both pathways.

CONCLUSIONS

These results provided new insights into molecular mechanisms underlying the extreme phenotypic variability observed in human holoprosencephaly. They showed how haploinsufficiency of the SHH and NOTCH activity could contribute to specific congenital hypopituitarism that was associated with a sella turcica defect.

One year prospective survey of azole resistance in Aspergillus fumigatus at a French cystic fibrosis reference centre: prevalence and mechanisms of resistance

BACKGROUND

Studies on Aspergillus fumigatus azole resistance in cystic fibrosis patients are scarce despite the fact that it is the most frequently isolated fungus from respiratory samples from these individuals.

OBJECTIVES

To evaluate resistance prevalence, investigate mechanisms of resistance and explore the relationship between resistant isolates by genotyping.

METHODS

We conducted a prospective 1 year study (from 1 January to 31 December 2015), based on the investigation of up to five colonies per sample from cystic fibrosis patients.

RESULTS

Twenty-three (6.5%) isolates among the 355 tested were resistant to at least one triazole drug, using the EUCAST reference method, leading to a prevalence of 6.8% (6/88 patients). Analysis of resistance mechanisms highlighted TR34/L98H (n = 10), TR46/Y121F/T289A (n = 1), WT cyp51A (n = 11) and F46Y/M172V/N248T/D255E/E427K (n = 1). No genotype was shared between patients.

CONCLUSIONS

This study showed a relatively stable resistance prevalence in comparison with the previous study conducted in 2010-11 (8%), although resistance mechanisms varied between the two studies.

GREB1L variants in familial and sporadic hereditary urogenital adysplasia and Mayer-Rokitansky-Kuster-Hauser syndrome

Congenital uterine anomalies (CUA) may have major impacts on the health and social well-being of affected individuals. Their expressivity is variable, with the most severe end of the spectrum being the absence of any fully or unilaterally developed uterus (aplastic uterus), which is a major feature in Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH). So far, etiologies of CUA remain largely unknown. As reports of familial occurrences argue for strong genetic contributors in some cases, we performed whole exome sequencing in nine multiplex families with recurrence of uterine and kidney malformations, a condition called hereditary urogenital adysplasia. Heterozygous likely causative variants in the gene GREB1L were identified in four of these families, confirming GREB1L as an important gene for proper uterine and kidney development. The apparent mode of inheritance was autosomal dominant with incomplete penetrance. The four families included fetuses with uterovaginal aplasia and bilateral renal agenesis, highlighting the importance to investigate GREB1L in such phenotypes. Subsequent sequencing of the gene in a cohort of 68 individuals with MRKH syndrome or uterine malformation (mostly sporadic cases) identified six additional variants of unknown significance. We therefore conclude that heterozygous GREB1L variants contribute to MRKH syndrome and this probably requires additional genetic or environmental factors for full penetrance.

Conceptualization of an ICU Infrastructure for Simulation Based Education in Medical Engineering & eHealth

The use of simulation-based training is gaining importance in medical as well as engineering related education. The complex environment of an intensive care unit is characterized by a high need of interaction between clinical as well as technical components and views. These diverse interactions and the connected requirements are the focus for the presented simulation infrastructure, enabling research, education and training. The presented concept of a modular and flexible intensive care environment provides a high degree of interoperability and flexibility for individual research questions and full support of connectivity for typical clinical workflows. The presented simulation and testing bed will allow both, education for engineering and medical students using patient simulation and simultaneous data transfer as well as research on medical workflows, infrastructural demands and connectivity conformance questions.

Pharmacogenetic-Whole blood and intracellular pharmacokinetic-Pharmacodynamic (PG-PK2-PD) relationship of tacrolimus in liver transplant recipients

Tacrolimus (TAC) is the cornerstone of immunosuppressive therapy in liver transplantation. This study aimed at elucidating the interplay between pharmacogenetic determinants of TAC whole blood and intracellular exposures as well as the pharmacokinetic-pharmacodynamic relationship of TAC in both compartments. Complete pharmacokinetic profiles (Predose, and 20 min, 40 min, 1h, 2h, 3h, 4h, 6h, 8h, 12h post drug intake) of twice daily TAC in whole blood and peripheral blood mononuclear cells (PBMC) were collected in 32 liver transplanted patients in the first ten days post transplantation. A non-parametric population pharmacokinetic model was applied to explore TAC pharmacokinetics in blood and PBMC. Concurrently, calcineurin activity was measured in PBMC. Influence of donor and recipient genetic polymorphisms of ABCB1, CYP3A4 and CYP3A5 on TAC exposure was assessed. Recipient ABCB1 polymorphisms 1199G>A could influence TAC whole blood and intracellular exposure (p<0.05). No association was found between CYP3A4 or CYP3A5 genotypes and TAC whole blood or intracellular concentrations. Finally, intra-PBMC calcineurin activity appeared incompletely inhibited by TAC and less than 50% of patients were expected to achieve intracellular IC₅₀ concentration (100 pg/millions of cells) at therapeutic whole blood concentration (i.e.: 4–10 ng/mL). Together, these data suggest that personalized medicine regarding TAC therapy might be optimized by ABCB1 pharmacogenetic biomarkers and by monitoring intracellular concentration whereas the relationship between intracellular TAC exposure and pharmacodynamics biomarkers more specific than calcineurin activity should be further investigated.

Integrated clinical and omics approach to rare diseases: novel genes and oligogenic inheritance in holoprosencephaly

Holoprosencephaly is a pathology of forebrain development characterized by high phenotypic heterogeneity. The disease presents with various clinical manifestations at the cerebral or facial levels. Several genes have been implicated in holoprosencephaly but its genetic basis remains unclear: different transmission patterns have been described including autosomal dominant, recessive and digenic inheritance. Conventional molecular testing approaches result in a very low diagnostic yield and most cases remain unsolved. In our study, we address the possibility that genetically unsolved cases of holoprosencephaly present an oligogenic origin and result from combined inherited mutations in several genes. Twenty-six unrelated families, for whom no genetic cause of holoprosencephaly could be identified in clinical settings [whole exome sequencing and comparative genomic hybridization (CGH)-array analyses], were reanalysed under the hypothesis of oligogenic inheritance. Standard variant analysis was improved with a gene prioritization strategy based on clinical ontologies and gene co-expression networks. Clinical phenotyping and exploration of cross-species similarities were further performed on a family-by-family basis. Statistical validation was performed on 248 ancestrally similar control trios provided by the Genome of the Netherlands project and on 574 ancestrally matched controls provided by the French Exome Project. Variants of clinical interest were identified in 180 genes significantly associated with key pathways of forebrain development including sonic hedgehog (SHH) and primary cilia. Oligogenic events were observed in 10 families and involved both known and novel holoprosencephaly genes including recurrently mutated FAT1, NDST1, COL2A1 and SCUBE2. The incidence of oligogenic combinations was significantly higher in holoprosencephaly patients compared to two control populations (P < 10-9). We also show that depending on the affected genes, patients present with particular clinical features. This study reports novel disease genes and supports oligogenicity as clinically relevant model in holoprosencephaly. It also highlights key roles of SHH signalling and primary cilia in forebrain development. We hypothesize that distinction between different clinical manifestations of holoprosencephaly lies in the degree of overall functional impact on SHH signalling. Finally, we underline that integrating clinical phenotyping in genetic studies is a powerful tool to specify the clinical relevance of certain mutations.

[Quality criteria for the transition to adult care in French CF centers - results from the SAFETIM APP study?]

INTRODUCTION

SAFETIM-APP compiled an inventory of professional practice in the 45 French cystic fibrosis reference centres (CFRC), between February 2015 and December 2016, related to the transition of adolescents with cystic fibrosis to adult centres.

METHOD

This multicentre cross-sectional study addressed the modalities of the transition in CFRCs and proposed a list of items that could be used to establish quality criteria. Quantitative analysis of the criteria and a qualitative analysis of the transition procedure were carried out.

RESULTS

A total of 77% of the CFRCs that were contacted took part. Transition lasted 3 to 5 years and began at around 15 years of age. Nine criteria were described as fundamental, including: collaboration between teams, taking adolescence into account, having a time for adolescents to speak with the physician alone, defining a program including therapeutic education, involving the family, accompanying the parents. Seven additional criteria were noted to be important, including: re-announcing the diagnosis, identifying a common thread (caregiver) accompanying the family, scheduling adult follow-up from paediatrics onwards, visiting the adult department, organizing a formal departure/reception time, initiating the process early enough, identifying indicators to evaluate practices.

CONCLUSION

The transition processes in place in CFRCs can be improved by implementing the use of these quality criteria systematically.

Variable expressivity of HJV related hemochromatosis: "Juvenile" hemochromatosis?

Juvenile hemochromatosis is a rare autosomal recessive disease due to variants in the Hemojuvelin (HJV) gene. Although biological features mimic HFE hemochromatosis, clinical presentation is worst with massive iron overload diagnosed during childhood. Our study describes clinical features and results of genetic testing for a group of patients initially referred for a hepcidino-deficiency syndrome and for whom HJV hemochromatosis was finally diagnosed. 662 patients with iron overload and high serum transferrin saturation were tested, and five genes (HFE, HJV, HAMP, TFR2, SLC40A1) were sequenced. Among our cohort, ten unrelated patients were diagnosed with HJV hemochromatosis. Genetic testing revealed five previously published and five undescribed variants: p.Arg41Pro, p.His180Arg, p.Lys299Glu, p.Cys361Arg and p.Ala384Val. Surprisingly, this study revealed a late age of onset in some patients, contrasting with the commonly accepted definition of "juvenile" hemochromatosis. Five of our patients were 30 years old or older, including two very late discoveries. Biological features and severity of iron overload were similar in younger and older patients. Our study brings new insight on HJV hemochromatosis showing that mild phenotype and late onset are possible. Genetic testing for HJV variants should thus be performed for all patients displaying a non-p.Cys282Tyr homozygous HFE hemochromatosis with hepcidin deficiency phenotype.

A de novo variant in ADGRL2 suggests a novel mechanism underlying the previously undescribed association of extreme microcephaly with severely reduced sulcation and rhombencephalosynapsis

Extreme microcephaly and rhombencephalosynapsis represent unusual pathological conditions, each of which occurs in isolation or in association with various other cerebral and or extracerebral anomalies. Unlike microcephaly for which several disease-causing genes have been identified with different modes of inheritance, the molecular bases of rhombencephalosynapsis remain unknown and rhombencephalosynapsis presents mainly as a sporadic condition consistent with de novo dominant variations. We report for the first time the association of extreme microcephaly with almost no sulcation and rhombencephalosynapsis in a fœtus for which comparative patient-parent exome sequencing strategy revealed a heterozygous de novo missense variant in the ADGRL2 gene. ADGRL2 encodes latrophilin 2, an adhesion G-protein-coupled receptor whose exogenous ligand is α-latrotoxin. Adgrl2 immunohistochemistry and in situ hybridization revealed expression in the telencephalon, mesencephalon and rhombencephalon of mouse and chicken embryos. In human brain embryos and fœtuses, Adgrl2 immunoreactivity was observed in the hemispheric and cerebellar germinal zones, the cortical plate, basal ganglia, pons and cerebellar cortex. Microfluorimetry experiments evaluating intracellular calcium release in response to α-latrotoxin binding showed significantly reduced cytosolic calcium release in the fœtus amniocytes vs amniocytes from age-matched control fœtuses and in HeLa cells transfected with mutant ADGRL2 cDNA vs wild-type construct. Embryonic lethality was also observed in constitutive Adgrl2^−/− mice. In Adgrl2^+/− mice, MRI studies revealed microcephaly and vermis hypoplasia. Cell adhesion and wound healing assays demonstrated that the variation increased cell adhesion properties and reduced cell motility. Furthermore, HeLa cells overexpressing mutant ADGRL2 displayed a highly developed cytoplasmic F-actin network related to cytoskeletal dynamic modulation. ADGRL2 is the first gene identified as being responsible for extreme microcephaly with rhombencephalosynapsis. Increased cell adhesion, reduced cell motility and cytoskeletal dynamic alterations induced by the variant therefore represent a new mechanism responsible for microcephaly.

Recent advances in understanding inheritance of holoprosencephaly

Holoprosencephaly (HPE) is a complex genetic disorder of the developing forebrain characterized by high phenotypic and genetic heterogeneity. HPE was initially defined as an autosomal dominant disease, but recent research has shown that its mode of transmission is more complex. The past decade has witnessed rapid development of novel genetic technologies and significant progresses in clinical studies of HPE. In this review, we recapitulate genetic epidemiological studies of the largest European HPE cohort and summarize the novel genetic discoveries of HPE based on recently developed diagnostic methods. Our main purpose is to present different inheritance patterns that exist for HPE with a particular emphasis on oligogenic inheritance and its implications in genetic counseling.

Clinical Use of an Imaging Probe in Breast Cancer Surgery

Aim

Portable cameras allow easy transfer of the detector, and thus of radioisotope imaging, to the operating room. In this paper we describe our preliminary experience in radionuclide imaging of breast cancer with a 22.8 × 22.8 mm2 field-of-view minicamera called “Imaging Probe” (IP).

Methods

Breast cancer detection by IP was performed to guide biopsy, in particular open biopsy, or help fine-needle or core-needle positioning when the main guidance method was ultrasonography or digital radiography. 99mTc Sestamibi (MIBI) was injected 1 h before imaging and biopsy to 14 patients with suspected or known breast cancer. Scintigraphic images were acquired before and after biopsy in each patient. The surgeon was allowed to take into account scintigraphic images as well as previously performed mammograms and ultrasonography.

Results

High-resolution IP images were able to guide biopsy toward cancer or toward washout zones of cancer, which are thought to be chemoresistant, in seven patients out of 10. Four patients in whom IP and MIBI were unable to guide biopsy were found not to have cancer.

Conclusions

Our study confirms the ability of IP to guide breast biopsy even when our minicamera has to be handled manually by trained physicians during surgery.

New Localization Technique for Breast Cancer Biopsy: Mammotome Guidance with Imaging Probe

Aims and Background

The “Imaging probe” (IP) is a small, portable, high-resolution gamma camera to be used in radioguided surgery. The present work discusses a special prototype designed for guiding biopsies. The IP was mounted to a Fischer digital X-ray stereotactic core biopsy system in such a way that biopsy could be guided simultaneously by X-ray stereotaxis and 99mTc-Sestamibi (MIBI) images from IP.

Methods

The IP field of view was 22.8 × 22.8 mm2, with a spatial resolution of approx. 2.5 mm. We used off-line software for image fusion on a dedicated Pentium III portable PC. It was matched with a Fischer digital X-ray stereotactic biopsy system dedicated to direct the mammotome towards breast opacities. The operator was allowed to slightly correct the direction of the mammotome needle taking into account stereotactic X-ray, scintigraphic and fused images. Biopsy samples were counted by IP before they were sent to the pathologist.

Results

High-resolution IP scintigraphy showed substantial, though not exact, matching between MIBI hot spots and X-ray opacities. More than one hot spot was detected even in the smallest (0.6 cm) lesion. Post-biopsy scintigraphy showed absence of significant hot spots in two patients, whereas in the third patient one of the three hot spots was still partially present. All lesions showed cancer on histological examination.

Conclusions

Measurement of radioactivity in biopsy specimens confirmed the heterogeneous distribution of radioactivity within cancers that IP had detected before biopsy.

Sentinel Node Detection with Imaging Probe

A one-square-inch-field-of-view mini gamma camera, whose first prototype was built by us in 1998 and given the name imaging probe (IP), was initially employed in sentinel lymph node (SLN) detection. This is probably the best way of learning how to use it. In the present work IP was used for SLN localization by a medical team that, after having been trained by the group of nuclear physicians of “La Sapienza” University who designed and first used the detector, used IP at their own hospital to 1) acquire experience for future use during surgery (a cooperative project on IP-radioguided orthopedic surgery is ongoing) and 2) start multicenter trials with IP. The SLN was identified and localized with IP and a non-imaging probe, Neoprobe 2000, in six patients with breast cancer who underwent lymphoscintigraphy for SLN biopsy. The operators who used Neoprobe and IP were blinded to each other's findings and to the results obtained with the large-field-of-view Anger camera that was used for lymphoscintigraphy. The Anger camera, IP and Neoprobe detected seven SLNs in six patients. The mean detection time was 2 mins 6 s (standard deviation (SD) 26 s) with IP, and 2 mins 18 s (SD 47 s) with Neoprobe 2000. The SLN that was most difficult to find was detected in 2 mins 56 s with IP and 3 mins 45 s with Neoprobe. The operators' subjective impression of having detected the SLN was “absolutely sure” for 7/7 nodes with IP and “absolutely sure” for 5/7 nodes with Neoprobe.

Detection of Sentinel Node in Breast Cancer: Pilot Study with the Imaging Probe

The commonly used gamma probes are easy to use but also give rough information when employed in radioisotope-guided surgery. When images are required for exact localization, a gamma camera as well as a probe have to be used. Position-sensitive photomultipliers have contemporaneously allowed high-resolution scintigraphy and miniaturization of gamma cameras. We have assembled a miniature gamma camera with a 1-square-inch field of view and an intrinsic resolution of about 1 mm. When the minicamera is collimated with a large-holed, highly sensitive collimator, it acquires a spatial resolution of 3 mm. This prototype has been tested in the detection of difficult-to-image breast cancer sentinel nodes. Five nodes that had not been found with the usual technique of an Anger camera plus conventional probe were checked with the miniature camera that we named imaging probe: it actually is small enough to be used as a probe and large enough to give an image. One of the five nodes was found and imaged. It was small, disease-free, close to the tumor and probably hidden by the Compton halo around the peritumoral injection site. Our pilot study shows that the imaging probe, although still a prototype, has certain advantages over conventional methods when lymph node localization is required during surgery.

Evaluating wearable multimodal sensor insoles for motion-pattern measurements in stroke rehabilitation - A pilot study

The majority of stroke patients experience deficits in motoric functions, especially in gait and mobility. They need rehabilitation to regain walking independence, which is a major goal of rehabilitation after stroke. To document and assess the rehabilitation progress, instrumented motion analysis and clinical assessments are commonly used. In a clinical pilot study the applicability of an instrumented insole system in stroke rehabilitation is evaluated. Motion parameter of 35 stroke patients were gathered with the system while completing 90 s level walking and Timed Up & Go test at the beginning and end of four weeks inpatient rehabilitation. For level walking the motion parameter were gathered with the clinical reference system simultaneously. The mean stride time for level walking decreased from 1.20 s to 1.16 s (clinical system), or from 1.19 s to 1.12 s (insole system), respectively. Focusing on individual comparison of each patient's progress, 9 gait parameters are extracted for level walking, 6 sub-phases of Timed Up & Go test are detected and analyzed, as well as progress of Center of Pressure in the sub-phases is examined. Although the overall data show wide distribution, the system proofed to be applicable in clinical stroke rehabilitation routine. As the system is location-independent, and has the advantage of assessing additional parameters of the Timed Up & Go test, it is additionally suitable for integration in a tele-or home rehabilitation system.

Efficacy and safety of a new coverlet device on skin microclimate management: a pilot study in critical care patients

OBJECTIVE

To test the effect of a new coverlet device, allowing air circulation at the body/underlying surface interface, on skin microclimate management.

METHOD

This prospective observational pilot study took place in a 15-bed university-affiliated intensive care unit. Overall, 34 mechanically ventilated patients were included. Skin humidity and temperature were monitored before and after the implementation of the tested device at the occiput, scapulas, buttocks and sacrum. Humidity and temperature were evaluated through surface skin impedance and an infra-red thermometer, respectively. Health professionals were asked to evaluate the device.

RESULTS

After implementation of the coverlet device, there was a rapid, sustained and significant decrease in skin humidity at all sites ranging from 6 % to 15 %, excluding the occiput. Skin temperature also significantly decreased from 1 % at both scapulas, but not at the other studied body sites. No side effects were observed. Health professionals reported that the device was easy and quick to install. Although they did not report a subjective improvement in skin moisture or temperature, they considered the device to be efficient.

CONCLUSION

Although limited by its design, this pilot study suggests a good efficacy of the studied device on skin microclimate management. Further data are warranted to test the clinical implications of our findings.

[Comparison of diagnostic quality in hysterosalpingography between iodinated non-ionic contrast media with low and high osmolarity]

PURPOSE

Comparison of diagnostic quality in hysterosalpingography between low and high-osmolality contrast media.

MATERIALS AND METHODS

We performed a retrospective evaluation of two cohorts of patients who underwent HSG using contrast media with different osmolarity: the first group ,47 patients, underwent hysterosalpingography in the period September 2011-December 2012 using Iopromide 370 mg/ml; the second group, 50 patients, underwent HSG from January 2013 to October 2013 using Iomeprol 400 mg/ml. Three radiologists, in consensus reading,, reviewed the radiographs by assessing the following four parameters: opacification of the uterine cavity, uterine profiles definition, Fallopian tubes visualization, contrast media spillage into peritoneum. A score-scale from 0 to 3 was assigned for each of the mentioned parameter (0 = minimum non-diagnostic exam, 1 = sufficient examination; 2 = good quality examination; maximum 3 = high quality images).

RESULTS

We documented a statistically significant higher quality in displaying Fallopian tubes among patients studied through high osmolarity contrast medium (Iopromide 370 mg/ml) than what obtained through lower osmolarity contrast medium (Iomeprol 400 mg/ml).

CONCLUSIONS

The use of high osmolarity contrast medium enabled better visualization of the tubes and a greater number of diagnoses of chronic aspecific salpigintis due to the increased osmolality and viscosity of Iomeprol 400 mg/ml. There were no significant differences between the two contrast agents in the evaluation of intra-uterine pathology and in the evaluation of the tubal patency.

[Necrotizing Fasciitis: A comprehensive review]

Even though necrotizing fasciitis is considered a rare disease, the spreading of the predisposing factors such as diabetes and chronic diseases, contribute to increase the incidence of this infection. Thus, how to diagnose and treat this clinical pathology, which represents an emerging need. This infection could be fatal for patients if not early diagnosed and treated and it represents a challenge both for the clinicians both for the surgeons. From this consideration was born the idea to write this review article in order to furnish to the readers a helpful tool in the management of this disease starting from its clinical and epidemiological features leading to the diagnosis, both clinical and radiological, and concluding with the treatment both medical both surgical .This article reviews literature on PubMed/MEDLINE with key words "necrotizing", "fasciitis" and "necrotizing fasciitis" from 1967 to 2014, considering all the aspects of the disease. The authors attempt to draw comparisons to their own experience managing this condition to give an Italian perspective to the condition.

Regulation of downstream neuronal genes by proneural transcription factors during initial neurogenesis in the vertebrate brain

BACKGROUND

Neurons arise in very specific regions of the neural tube, controlled by components of the Notch signalling pathway, proneural genes, and other bHLH transcription factors. How these specific neuronal areas in the brain are generated during development is just beginning to be elucidated. Notably, the critical role of proneural genes during differentiation of the neuronal populations that give rise to the early axon scaffold in the developing brain is not understood. The regulation of their downstream effectors remains poorly defined.

RESULTS

This study provides the first overview of the spatiotemporal expression of proneural genes in the neuronal populations of the early axon scaffold in both chick and mouse. Overexpression studies and mutant mice have identified a number of specific neuronal genes that are targets of proneural transcription factors in these neuronal populations.

CONCLUSION

Together, these results improve our understanding of the molecular mechanisms involved in differentiation of the first neuronal populations in the brain.

Targeted resequencing identifies PTCH1 as a major contributor to ocular developmental anomalies and extends the SOX2 regulatory network

Ocular developmental anomalies (ODA) such as anophthalmia/microphthalmia (AM) or anterior segment dysgenesis (ASD) have an estimated combined prevalence of 3.7 in 10,000 births. Mutations in SOX2 are the most frequent contributors to severe ODA, yet account for a minority of the genetic drivers. To identify novel ODA loci, we conducted targeted high-throughput sequencing of 407 candidate genes in an initial cohort of 22 sporadic ODA patients. Patched 1 (PTCH1), an inhibitor of sonic hedgehog (SHH) signaling, harbored an enrichment of rare heterozygous variants in comparison to either controls, or to the other candidate genes (four missense and one frameshift); targeted resequencing of PTCH1 in a second cohort of 48 ODA patients identified two additional rare nonsynonymous changes. Using multiple transient models and a CRISPR/Cas9-generated mutant, we show physiologically relevant phenotypes altering SHH signaling and eye development upon abrogation of ptch1 in zebrafish for which in vivo complementation assays using these models showed that all six patient missense mutations affect SHH signaling. Finally, through transcriptomic and ChIP analyses, we show that SOX2 binds to an intronic domain of the PTCH1 locus to regulate PTCH1 expression, findings that were validated both in vitro and in vivo. Together, these results demonstrate that PTCH1 mutations contribute to as much as 10% of ODA, identify the SHH signaling pathway as a novel effector of SOX2 activity during human ocular development, and indicate that ODA is likely the result of overactive SHH signaling in humans harboring mutations in either PTCH1 or SOX2.

A Framework for (Tele-) Monitoring of the Rehabilitation Progress in Stroke Patients: eHealth 2015 Special Issue

BACKGROUND

Preservation of mobility in conjunction with an independent life style is one of the major goals of rehabilitation after stroke.

OBJECTIVES

The Rehab@Home framework shall support the continuation of rehabilitation at home.

METHODS

The framework consists of instrumented insoles, connected wirelessly to a 3G ready tablet PC, a server, and a web-interface for medical experts. The rehabilitation progress is estimated via automated analysis of movement data from standardized assessment tests which are designed according to the needs of stroke patients and executed via the tablet PC application.

RESULTS

The Rehab@Home framework's implementation is finished and ready for the field trial (at five patients' homes). Initial testing of the automated evaluation of the standardized mobility tests shows reproducible results.

CONCLUSIONS

Therefore it is assumed that the Rehab@Home framework is applicable as monitoring tool for the gait rehabilitation progress in stroke patients.

Homozygous STIL mutation causes holoprosencephaly and microcephaly in two siblings

Holoprosencephaly (HPE) is a frequent congenital malformation of the brain characterized by impaired forebrain cleavage and midline facial anomalies. Heterozygous mutations in 14 genes have been identified in HPE patients that account for only 30% of HPE cases, suggesting the existence of other HPE genes. Data from homozygosity mapping and whole-exome sequencing in a consanguineous Turkish family were combined to identify a homozygous missense mutation (c.2150G>A; p.Gly717Glu) in STIL, common to the two affected children. STIL has a role in centriole formation and has previously been described in rare cases of microcephaly. Rescue experiments in U2OS cells showed that the STIL p.Gly717Glu mutation was not able to fully restore the centriole duplication failure following depletion of endogenous STIL protein indicating the deleterious role of the mutation. In situ hybridization experiments using chick embryos demonstrated that expression of Stil was in accordance with a function during early patterning of the forebrain. It is only the second time that a STIL homozygous mutation causing a recessive form of HPE was reported. This result also supports the genetic heterogeneity of HPE and increases the panel of genes to be tested for HPE diagnosis.

Dynamic expression of Notch-dependent neurogenic markers in the chick embryonic nervous system

The establishment of a functional nervous system requires a highly orchestrated process of neural proliferation and differentiation. The evolutionary conserved Notch signaling pathway is a key regulator of this process, regulating basic helix-loop-helix (bHLH) transcriptional repressors and proneural genes. However, little is known about downstream Notch targets and subsequently genes required for neuronal specification. In this report, the expression pattern of Transgelin 3 (Tagln3), Chromogranin A (Chga) and Contactin 2 (Cntn2) was described in detail during early chick embryogenesis. Expression of these genes was largely restricted to the nervous system including the early axon scaffold populations, cranial ganglia and spinal motor neurons. Their temporal and spatial expression were compared with the neuronal markers Nescient Helix-Loop-Helix 1 (Nhlh1), Stathmin 2 (Stmn2) and HuC/D. We show that Tagln3 is an early marker for post-mitotic neurons whereas Chga and Cntn2 are expressed in mature neurons. We demonstrate that inhibition of Notch signaling during spinal cord neurogenesis enhances expression of these markers. This data demonstrates that Tagln3, Chga and Cntn2 represent strong new candidates to contribute to the sequential progression of vertebrate neurogenesis.

[Perceptions of cystic fibrosis patients, patient relatives and physicians: barriers or motivations to lung transplantation]

INTRODUCTION

The aims of this study are to describe qualitatively the perceptions of three groups involved in the cystic fibrosis transplant decision, looking for similarities and differences between groups, and to identify those that act as motivations or barriers to transplantation.

METHODS

Thirty patients, 26 patient relatives and 27 physicians were interviewed, and concept maps were constructed from those interviews. Their degree of transplant acceptance at the time of the interview was measured.

RESULTS

There were motivations and barriers in the pre-, peri- and post-transplant period. Analysis revealed similar perceptions regarding the risks and benefits of transplantation, but also different perceptions in the specific concerns of each group. Patients and patient relatives expressed many questions and fears in their concept maps, and physicians expressed difficulties.

CONCLUSIONS

This study highlights the value of better understanding the perceptions of patients, relatives and physicians, in order to remove some of the barriers to transplantation. It also demonstrates the benefits of education and support activities for patients and patient relatives prior to transplantation, and continuing education and supervision for physicians.