Hypercholesterolemia and LDL apheresis

Several trials have assessed the link between low-density lipoprotein cholesterol (LDL) and the development of coronary heart disease (CHD). LDL apheresis provides an effective role in treating patients with familial hypercholesterolemia (FH) and in preventing the progression of coronary artery disease (CAD). Five different techniques of LDL apheresis are in current use: immunoadsorption (IMA), dextran sulphate-cellulose adsorption (DSA), heparin extracorporeal LDL precipitation system (HELP), double filtration plasmapheresis (DFPP) or lipidfiltration and direct adsorption of lipoprotein using hemoperfusion (DALI). All methods are efficient,but their cost restricts LDL apheresis to the treatment of FH. Indications could include other diseases, but controlled trials are still lacking.

Multicomponent collection as of 2005

Multicomponent apheresis (MCA) begun in Genoa in 1985 in autologous terms. Named "sequestration" it was the preoperative collection of autologous components (RBC-plasma-platelets) using the same apparatus and harness ready for intraoperative blood salvage. In 1986 the technique was applied to donor platelet apheresis with the goal of reducing the costs of platelet collection and concurrently reducing the risks of viral disease transmission to haematological patients who did receive, in the same transfusion event, the necessary blood components obtained from the same donor. The results of this application were maximized by the so called aggressive MCA by which in selected donors, it is possible to collect 2 units of platelets along with 1 or 2 units of PRBCs. These applications were made possible by the development of the concept of dry-platelet collection according to which platelets are collected in only 20-25 mL of plasma and subsequently resuspended in non-plasma solutions such as T-Sol. A last development of MCC is for RBC apheresis, with the collection of 1-2 units of RBC independently of platelet collection. This is going to be the first step of apheresis as the unique modality of collecting blood leaving the bags to history of blood transfusion. Interestingly it took 15 years to MCC to be rediscovered and appreciated worldwide both for its intrinsic cost saving capabilities offered along with an increasing safety for patients. In terms of donor acceptance it is our experience that, since 1989 no donor has refused MCC, consisting at least in the concurrent collection of plasma along with platelets, but also RBC and or a second unit of platelets.

Lupus vulgaris developing at the site of misdiagnosed scrofuloderma

Cutaneous tuberculosis is a rare form of extrapulmonary tuberculosis primarily occurring in developing countries. The recent increase in the incidence of tuberculosis, especially due to human immunodeficiency virus (HIV) infections, has led to a resurgence of extrapulmonary forms of this disease. We describe a case of lupus vulgaris in a 33-year-old woman who had a 5-year history of a slowly growing plaque on her neck. The lesion was located at the site of surgery repairing the scar resulting from the incision of a subcutaneous abscess during childhood. This lesion was misdiagnosed as bacterial abscess. Histopathologic examination of the plaque revealed non-caseating tuberculoid granulomas consisting of lymphocytes, epithelioid and giant cells. Staining for acid-fast bacilli and culture from biopsied tissue was negative. Polymerase chain reaction (PCR) for detection of Mycobacterium tuberculosis DNA, performed on a skin biopsy specimen, was positive. A diagnosis of lupus vulgaris developing at the site of a previous misdiagnosed scrofuloderma was made. Conventional antitubercular therapy with rifampicin, isoniazid and ethambutol was administered for 6 months, resulting in resolution of the lesion.

Biomechanics of anterior cruciate ligament reconstruction using twisted doubled hamstring tendons

We studied the biomechanical properties of a twisted doubled semitendinosus and gracilis graft. We applied an un-axial load in order to reproduce the kinematics of a reconstructed anterior cruciate ligament (ACL). A modified cryo-jaw clamp system was used to minimize soft tissue slippage. The lower grip, after fixation of the free ends of the tendons, was rotated 45 degrees, translated 1 cm, and bent 40 degrees, simulating a knee sprain. The graft was tested to failure using a servohydraulic machine. The specimen from one knee of seven unembalmed cadavers was assigned to the untwisted (parallel) bundles group, while its pair was assigned to the twisted group. For the parallel bundles group, the mean maximum load was 1,709.3+/-581.9 N, for the twisted group 2,428.3+/-475.4 N (P<0.05). The mean stiffness was respectively 213.6+/-72.4 N/mm and 310.3+/-97.3 N/mm (P=0.08). Although caution should be used in extrapolating the results to clinical estimates of the strength of hamstring grafts, the results of the present study could justify the use of twisted semitendinosus and gracilis bundles in ACL reconstruction.

Skin reactions due to anti-epileptic drugs: several case-reports with long-term follow-up

In this study, the clinical findings and management of allergic skin reactions induced by the most used antiepileptic drugs, Lamotrigine (LMT) and Carbamazepine (CBZ), were evaluated. Lamotrigine is an antiepileptic drug recently released in several countries; it is effective for a variety of seizure types in adults and children, both as an add-on agent and in monotherapy, and it is generally well tolerated. Clinical and epidemiologic evidence suggest serious cutaneous reactions to antiepileptic drugs are more likely to occur during the first 8 weeks and they appear to increase when drugs are administered with other anticonvulsants, such as Valproate (VPA). We selected 10 patients who presented an idiosyncratic skin rash when treated with carbamazepine (8 patients) and lamotrigine (2 patients) administered as monotherapy, and we followed up on these patients for several years. Seven reactions were mild/severe cutaneous eruptions; one Toxic Epidermal Necrolysis, a case of Stevens-Johnson and a case of Hypersensitivity Syndrome. All severe skin drug reactions were induced by Carbamazepine. In five patients the AEDs were ceased abruptly (sometimes with the administration of a different molecule), tapered in four and continued unchanged in one. We conclude that the discontinuation of the drug with substitution with another is the most effective treatment and that corticosteroids are helpful in mild cutaneous reactions, while in severe skin reactions, such as Toxic Epidermal Necrolysis, corticosteroids are only a complementary therapy since intravenous immunoglobulins are the first choice treatment.

Viscoelastic properties of the semitendinosus and gracilis tendons in reconstruction of the ACL: an in vivo evaluation

Tensioning of the tendons of the semitendinosus and the gracilis used to reconstruct the anterior cruciate ligament (ACL) of the knee is one of the main factors to take into consideration during surgery that aims at obtaining good postoperative joint stability. Some authors have shown in vitro that the viscoelastic nature of the patellar tendon is responsible for its gradual release (loss of tension). It is the purpose of this study to verify in vivo the biomechanical behavior of the semitendinosus and gracilis tendons. A total of 40 consecutive patients were submitted to reconstruction of the ACL with flexor tendons of the knee using a method that allows for the gradual tensioning of the doubled semitendinosus and gracilis tendons using the Swing Bridge method. Patients were divided into 2 groups: in the first 20 patients (group I), after adequate manual pretensioning and tibial and femoral stabilization, the tendons were twisted using a dynamometer to measure torsion forces until tensioning equal to 2.5 N was achieved. The control group (group II) was made up of the successive 20 patients in whom tensioning of the tendons at 2.5 N was carried out in many phases. Five minutes after initial tensioning at 2.5 N the decrease in tension was recorded that returned to initial values. A similar procedure was carried out after 5 more minutes. The patients in both groups were evaluated using a KT-1000 arthrometer one year after surgery. The patients in group II showed a decrease in torsion equal to 37.2% after the first 5 minutes, and a further 26.8% after 5 more minutes, and measurement by means of KT-1000 revealed mean values for S/S 30 lb. and S/S MM of 1.3 mm and 1.7 mm, respectively, that proved to have a statistically significant difference (p < 0.05) as compared to the patients in group I (S/S 30 lb.: 2.0 mm; S/S MM: 2.4 mm). Although these data do not provide indications on the amount and duration of pretensioning and definitive tensioning to be applied to the transplant, they do clearly show the viscoelastic properties of the tendons. These properties require a more in-depth study to better determine the exact tensioning of the neoligament.

Phosphorylation of seminal vesicle protein IV on Ser58 enhances its peroxidase-stimulating activity

In this study we show that SV-IV, a major immunomodulatory, anti-inflammatory, and sperm immunoprotective protein secreted from the rat seminal vesicle epithelium, acts in vitro as a substrate of protein kinase C (PKC) competing efficiently with H1 histone, a very well known PKC substrate. Electrospray mass spectrometry (ES-MS) analysis demonstrated that approximately 10% of the native SV-IV molecules were phosphorylated by PKC and that such a modification involved only a single serine residue (Ser58) out of the 22 occurring in the protein. Interestingly, this modification produced a substantial enhancement (approximately 50%) of the native SV-IV's ability to stimulate the activity of both horseradish peroxidase (POD) and selenium-dependent glutathione peroxidase (GPX), an enzyme that is known to protect the mammalian spermatozoa from oxidative stress and loss of motility in the female genital tract following ejaculation. In contrast, the phosphorylation of SV-IV on Ser58 did not produce any effect on the anti-inflammatory properties of SV-IV, as measured by its ability to inhibit the phospholipase A2.

Synthesis of novel anti-inflammatory peptides derived from the amino-acid sequence of the bioactive protein SV-IV

SV-IV is a basic, thermostable, secretory protein of low Mr (9758) that is synthesized by rat seminal vesicle (SV) epithelium under strict androgen transcriptional control. This protein is of obvious pharmacological interest because it has potent nonspecies-specific immunomodulatory, anti-inflammatory, and pro-coagulant activities. In evaluating the clinical relevance and the possible use in medicine of SV-IV, we became interested in the study of its structure-function relationships and aimed to identify in its polypeptide chain specific peptide fragments possessing the marked anti-inflammatory properties of the protein not associated with other biological activities (pro-coagulation and immunomodulation) typical of this molecule. By using two different experimental approaches (the fragmentation of the protein into peptide derivatives by chemical methods and the organic synthesis on solid phase of selected peptide fragments), data were obtained showing that in this protein: (a) the immunomodulatory activity is related to the structural integrity of the whole molecule; (b) the anti-inflammatory activity is located in the N-terminal region of the molecule, the 8-16 peptide fragment being the most active; (c) the identified anti-inflammatory peptide derivatives do not seem to possess pro-coagulant activity, even though this particular function has been located in the 1-70 segment of the molecule.

Combination of paclitaxel and etoposide in the treatment of advanced non-small cell lung cancer: a phase I-II study

Thirty-six patients (pts) with unpretreated advanced non-small cell lung cancer (NSCLC) stages IIIB and IV were enrolled in this two-stage phase I-II study aimed to establish the maximum tolerated dose (MTD) of paclitaxel and to evaluate the efficacy and safety of paclitaxel combined with etoposide every 3 weeks for a maximum of 6 courses, increasing the dose of paclitaxel according to a modified Fibonacci scheme. Nineteen pts were enrolled in the first stage and 17 pts in the second stage. The characteristics of the pts were as follows: median age 56 years (40-70), median Karnofsky's Performance Status 80% (70-80), 11 pts were stage IIIB and 25 pts stage IV. The doses of etoposide administered were 50 mg/m2 for 15 pts and 100 mg/m2 for 21 pts. MTD has not been reached and the study proceeded with the dose of paclitaxel 250 mg/m2. We obtained 9 (25%) partial remissions (PR) and 11 (31%) stable disease (SD) in 33 objectively evaluable pts. Median time to progression (TTP) was 4 months (0.3-21), median survival was 9.3 months (0.3-27). The main toxicity was neutropenia and neurotoxicity, while the gastrointestinal toxicity was mild. Two pts deceased after the first course. The causes of death were necrotizing enteritis in the first pt and congestive heart failure in the second pt. A total of 156 courses were administered at 7 dose levels, with a median of 4 courses per patient (1-6). The results seem to support the use of this combination in advanced non-small cell lung cancer.

Treatment of v-Ki-ras-transformed SVC1 cells with low retinoic acid induces malignancy reversion associated with ras p21 down-regulation

The effect of nontoxic, low concentrations (10(-8) M) of retinoic acid (RA) for a relatively long time (28 days) on a Kirsten ras-virus transformed cell line (Ki-SVC1), derived from the rat seminal vesicle epithelium, was investigated. In these experimental conditions, the cell treatment with RA induced a decrease of the proliferation rate, apoptosis and a marked reduction of both anchorage-independent growth and tumorigenicity. These biological responses were either preceded or associated with important changes in adenylate cyclase/protein kinase C signaling pathways, the activation of important apoptosis-linked genes and a marked decrease of the v-Ki-ras p21 protein. The significance of these findings is discussed.

Inhibition of antithrombin by protein SV-IV normalizes the coagulation of hemophilic blood

The aim of the study was to evaluate the effect of the protein Seminal Vesicle Protein No. 4 (SV-IV), a potent inhibitor of antithrombin III (antithrombin), on the coagulation of blood obtained from patients affected by hemophilia A. In the coagulating blood of these patients, the antithrombin/thrombin ratio was found to be markedly higher (about 44) than in normal individuals (about 4. 4). This high ratio was related to the low efficiency of thrombin-generating reactions induced by the factor VIII deficiency and to the high levels of free (not bound to serine proteases) antithrombin present in the hemophilic serum (antithrombin concentration was the same in normal and hemophilic plasma). The elevated concentration of free antithrombin in hemophiliacs was primarily a consequence of a reduced consumption caused by the scarce availability in the hemophilic serum of factors Xa and IIa, which are serine proteases possessing strong binding affinity for antithrombin. Addition of SV-IV to coagulating hemophilic blood reduced markedly the serum antithrombin and thrombin-antithrombin complexes, normalizing, as a consequence, the clotting time and other coagulation parameters. Similar results were obtained by using appropriate concentration of factor VIII.

Sodium butyrate/retinoic acid costimulation induces apoptosis-independent growth arrest and cell differentiation in normal and ras-transformed seminal vesicle epithelial cells unresponsive to retinoic acid

Retinoic acid (RA) and sodium butyrate (NaB) are regulators of cell growth and differentiation. We studied their effect on normal (SVC1) or v-Ki-ras-transformed (Ki-SVC1) rat seminal vesicle (SV) epithelial cell lines. The treatment of these cells with 10(-((7( M RA did not produce significant changes in the morphological and biochemical parameters analyzed. When RA was used in combination with 2 mM NaB, the treatment induced substantial morphological changes, apoptosis-independent growth arrest, up-regulation of tissue transglutaminase (tTGase), and down-regulation of beta and gamma RA receptor (RAR) mRNA expression. The same cells did not express RAR alpha either before or after NaB/RA treatment. A similar treatment did not change the amount of mRNA coding for the protein SV-IV (a typical differentiation marker of the SV epithelium) in normal or ras-transformed cells nor the level of v-Ki-ras mRNA in Ki-SVC1 cells. These findings suggest that a defective RA/RARs signaling pathway is probably the biochemical condition that underlies the unresponsiveness to RA of our in vitro culture system, and indirectly points to the possibility that the NaB/RA-induced effects were brought about by a cooperation at the transcription level between the histone deacetylase inhibitory activity of NaB and the ability of RA/RAR to modulate the expression of various genes involved in the control of cell growth and differentiation.

Multiplex semi-quantitative reverse transcriptase-polymerase chain reaction of low abundance neuronal mRNAs

The sequential use of reverse transcriptase and the polymerase chain reaction (RT-PCR) has provided molecular biology research with an exquisitely sensitive and fast technique for studying gene expression. This method is particularly useful to study transcripts in the nervous system, which are on average present at low levels and the amount of tissue or cells to be analyzed is often limited. Here, we describe a RT-PCR assay which allows the simultaneous detection and semi-quantitation of several transcripts (multiplex). Multiple PCR primer pairs are used to detect different target transcripts in a single reaction, together with a pair of primers able to amplify the hypoxantine-phosphoribosyl-transferase (HPRT), a gene constitutively expressed at low levels throughout the nervous system. HPRT levels remain constant also during neurogenesis and it is thus apt to be used in developmental neurobiology. This internal standard is the mRNA of reference to evaluate sample variation in RT and PCR reactions and to monitor the degradation and recovery of RNAs. Normalization with respect to HPRT cDNA allows to estimate the relative abundance of each target mRNA.

Autoapheresis and intraoperative blood salvage in oncologic surgery

Transfusion of predeposit or salvaged autologous blood has continued to grow since the 1980s. Issues such as the indications for use and cost effectiveness as well as the safety of autologous blood salvaged during cancer surgery have emerged and should be addressed. The concern for possible contamination of autologous RBC with cancer cells responsible for metastasis has limited the use of autologous salvaged blood in cancer patients. Nevertheless, clinical experience has been gained on the use of salvaged blood in patients with colorectal, gastric, renal, hepatic, breast, bladder and lung cancer. No evidence has been reported showing an increase in metastasis or a decrease in patient survival, in spite of the obvious demonstration that salvaged blood is contaminated with viable tumor cells which are not washed out of the RBC layer during intraoperative blood salvage (IOBS). However, a number of limitations have hampered the widespread use of IOBS in these patients and the technique is not well established. Increasing knowledge of the deleterious effects of allogeneic blood transfusion both in terms of the increased number of viral or bacterial infections and the down-regulation of the patient's immune system have recalled attention to IOBS and to the techniques such as filtration, which might reduce the risk of reinfusion of cancer cells, or totally eliminate the risks such as irradiation has been proposed by Hansen's group. This paper reviews the topic with some emphasis on our personal experience with gamma and X-ray irradiation of salvaged blood in a large reference hospital, where IOBS and filtration of salvaged blood were established for use in cancer patients in 1993 and 1996.

Porin from Pseudomonas aeruginosa induces apoptosis in an epithelial cell line derived from rat seminal vesicles

Micromolar concentrations of porin, purified from the outer membranes of Pseudomonas aeruginosa, induced in vitro the classic morphological and biochemical signs of apoptosis in an epithelial cell line (SVC1) derived from the rat seminal vesicle secretory epithelium. The programmed cell death (PCD) was p53 independent and associated with significant decrease of bcl-2 expression, a marked increase of c-myc transcriptional activity, and an absence of the mRNA coding for tissue transglutaminase. The Ca(2+) influx, caused by the porin treatment of SVC1 cells, appears to play an important role in the triggering of apoptosis in our biological model. The possibility that the porin property of inducing PCD plays a role in the infertility of individuals chronically infected by gram-negative bacteria is discussed.

Multicomponent collection (MCC) with the latest hemapheresis apparatuses

BACKGROUND

Collection of multiple products including plasma, packed red blood cells (PBRC) and double units of platelets, is increasingly improving donor utilisation and decreasing blood transfusion costs. Total apheresis is the new trend in blood banking and both industry and physicians are progressively expanding their involvement in this field. During 1998, at our hemapheresis unit, we used three new apparatuses for multicomponent collection (MCC). These apparatuses vary in terms of principle, operation and specific capabilities, and thus knowledge of them is essential to match their characteristics with plateletapheresis needs.

STUDY DESIGN

We reviewed all MCCs carried out in 1998 with MCS+, Trima and Excel-Pro cell separators. These apparatuses were evaluated in terms of platelet yield, white blood cell (WBC) contamination, efficiency per minute, platelet activation, and PBRC product quality.

RESULTS

The three machines are compared in the following table [table in text].

CONCLUSIONS

MCC with the new apparatuses is well accepted by donors and personnel. There are no risks for the donors and, excluding ACD reactions and/or vaso/vagal attacks at the beginning of procedures, no severe reaction was seen. The quality and quantity of platelet products are good. When PRBC or a second platelets unit are collected, the cost of the kit is covered by this double product.

[Case series of mesotheliomas from hospital archives as contribution to preventive intervention]

The clinical charts of 18 patients in the departments of radiotherapy and oncology of the hospital "Casa Sollievo della Sofferenza" (San Giovanni Rotondo, Italy) from 1993 to August 1998, were reviewed. Each case was assigned to first (fine needle aspiration, cytologic exam), second (multiple biopsies during thoracoscopy or laparoscopy) or third (operation) diagnostic level and asbestos exposure was analysed. The age-group was between 21 and 76 years (median 57 years). Three patients were less than 30 years old. The ratio M:F was 17:1. Malignant mesotheliomas were histologically confirmed in 16 cases: 1 patient was classified as malignant pleural tumor (cytology and CT scan), 1 patient as suspicious malignant pleural tumor (only radiological diagnosis) and both were excluded for analysis. We observed 1 case in 1993, 2 in 1994, 3 in 1995, 3 in 1996, 5 in 1997, 2 up to August 1998. Second level diagnosis was assigned to 9 patients and third level to 7 patients. In 9 out 16 cases (56%) the exposure was occupational: 5 ascertained, 2 probable, 2 possible.

[High dose chemotherapy in metastatic carcinoma of the breast]

PURPOSE

To verify tolerance and clinical efficacy of high-dose chemotherapy (HDCT) in metastatic breast cancer (MBC).

PATIENTS AND METHODS

We submitted to HDCT with autologous peripheral blood cells transplant 66 patients, with MBC responding to induction chemotherapy. The condizioning regimen was ICE: iphosphamide 3.3 g/m2 dd. -8/-6, carboplatin 450 mg/m2 plus etoposide 400 mg/m2 dd. -5/-3 (21 patients = 78%); CTM: cyclophosphamide 100 mg/kg dd. -4/-3, tyothepa 500 mg:m2 d.-5, mytoxantrone 40 mg/m2 d. -6 (6 patients, 22%).

RESULTS

Median number of aphereses was 2 (range 1-5), median amount of CD34+ cells/kg bw of 10 x 10E6 (range 3.5-38.2). Median recovery time was 10th day for PMN (range 8-37) while for platelets it was 9th day (range 8-37): total hospital stay was of 24 days (range 22-48). After induction therapy we had PR in 13/27 metastatic patients (48%) and CR in 14/27 (52%). After conditioning treatment we had PR in 12/27 (44%) and CR in 15/27 (56%). Median time to progression was 19 months (range 7-38) and median survival 52 months (range 7-59+), with 30% surviving beyond 4 years.

CONCLUSIONS

Feasibility of HDCT in advanced breast cancer seems verified. The promising results need to be confirmed.