A rare case of mesenteric heterotopic pancreas presenting as an inflammatory mass

Heterotopic pancreas (HP) is a rare condition, is commonly asymptomatic and found incidentally at autopsy or during abdominal surgery. HP is usually found in the upper gastrointestinal tract, particularly in the stomach, duodenum and jejunum. Mesenteric heterotopic pancreas (MHP) has been rarely described in the literature, and there has been no reported case under ten years of age. We report a unique case of a 7-year-old African boy who presented with clinical appendicitis and intraoperatively was found to have a necrotic nodular mass in the jejunal mesentery which required segmental small bowel resection. Histology revealed mesenteric heterotopic pancreas with normal pancreatic tissue. As pre-operative diagnosis of MHP is difficult; we encourage a heightened awareness of this condition as a differential diagnosis in children presenting with abdominal pain and an inflammatory mass, which will subsequently aid in the management of these patients.

Spontaneous evolution of a massive hematoma caused by type 1 neurofibromatosis: Case report

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Vascular complications are the second cause of death in type 1 Neurofibromatosis.

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Spontaneous fistulzation of the hematoma avoided the patient surgical morbidity.

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Venous system involvement is extremely rare in type 1 Neurofibromatosis and surgery should be considered on a case by case basis especially when the risk of iatrogenesis is high.

Introduction

Type1 Neurofibromatosis (NF1) is an autosomal dominant disorder with a great variety of clinical features. Vascular manifestations appear in less than 7%, and venous complications are extremely rare.

Case presentation

We report a case of an enormous cervical hematoma caused by bleeding from the internal jugular vein in a NF1 patient. As the patient refused surgery, natural evolution was marked by spontaneous fistulization and drainage of the mass.

Discussion

Several cases of fragility of both the vessel wall and the surrounding tissue are discussed and two jugular vein aneurysms were reported. Management of such cases remains unclear and some reports describe defective hemostatic control at surgery.

Conclusion

Surgery in NF1 vascular involvement should be considered on a case by case basis especially when the risk of iatrogenesis is high. Surgeons need to be aware of hemorrhagic risks, which could occur because of vessel friability.

Periocular basal cell carcinoma - clinical perspectives

Basal cell carcinoma (BCC) as a non-melanoma skin cancer type is the most common malignant tumor throughout the world. The incidence is higher in age over 60. The intense of exposure to ultraviolet radiation is one of the known risk factors. Over 50% of BCC of the periocular region initially occur on the lower lid and inner angle. Literature review of treatment options for basal cell carcinoma, which consist of surgery, or combined techniques plus vismodegib, radiotherapy and imiquimod. The first consideration for treatment of periocular BCC is radical surgical excision using Mohs micrographic technique. Functional and esthetic outcome in patients are important after clear excisions and reconstruction should be carefully considered. Radical exenteration is considered in the case of orbital invasion of high-risk aggressive BCC.

Periodontitis and oral cancer - current concepts of the etiopathogenesis

Gingival tissues are attacked by oral pathogens which can induce inflammatory reactions. The immune-inflammatory responses play essential roles in the patient susceptibility to periodontal diseases. There is a wealth of evidence indicating a link between chronic inflammation and risk of malignant transformation of the affected oral epithelium. Periodontitis is associated with an increased risk of developing chronic systemic conditions including autoimmune diseases and different types of cancers. Besides, some risk factors such as smoking, alcohol consumption and human papilloma virus have been found to be associated with both periodontitis and oral cancer. This review article aimed to study the current concepts in pathogenesis of chronic periodontitis and oral cancer by reviewing the related articles.

Improving the Mechanical Strength of Dental Applications and Lattice Structures SLM Processed

To manufacture custom medical parts or scaffolds with reduced defects and high mechanical characteristics, new research on optimizing the selective laser melting (SLM) parameters are needed. In this work, a biocompatible powder, 316L stainless steel, is characterized to understand the particle size, distribution, shape and flowability. Examination revealed that the 316L particles are smooth, nearly spherical, their mean diameter is 39.09 μm and just 10% of them hold a diameter less than 21.18 μm. SLM parameters under consideration include laser power up to 200 W, 250-1500 mm/s scanning speed, 80 μm hatch spacing, 35 μm layer thickness and a preheated platform. The effect of these on processability is evaluated. More than 100 samples are SLM-manufactured with different process parameters. The tensile results show that is possible to raise the ultimate tensile strength up to 840 MPa, adapting the SLM parameters for a stable processability, avoiding the technological defects caused by residual stress. Correlating with other recent studies on SLM technology, the tensile strength is 20% improved. To validate the SLM parameters and conditions established, complex bioengineering applications such as dental bridges and macro-porous grafts are SLM-processed, demonstrating the potential to manufacture medical products with increased mechanical resistance made of 316L.

Pericardial sarcoidosis presenting as PUO diagnosed on FDG PET CT scan

Pyrexia of unknown origin (PUO) is a common problem in day-to-day practice. FDG PET CT is an established investigation that aids in identifying the cause of PUO. Due to its high sensitivity PET detects an occult hypermetabolic focus in the body where CT helps in anatomical localization, vascularity, enhancement characteristics of the lesion detected on PET. It helps to differentiate benign versus malignant cause and target biopsy. Tuberculosis, lymphoma, pyelonephritis, thyroiditis appear hypermetabolic on FDG PET CT. Pericardial sarcoidosis is rare and not reported in literature as a cause of PUO. Presented here is a case of PUO secondary to pericardial granulomatosis diagnosed on PET CT. Cardiac MRI also helps in better tissue characterization and associated myocardial involvement of sarcoidosis. Histology confirmed the diagnosis of pericardial sarcoidosis in this case.

Medical disciplinary jurisprudence in alleged malpractice in radiology: 10-year Dutch experience

PURPOSE

To systematically investigate the frequency and types of allegations related to radiology practice handled by the Dutch Medical Disciplinary Court in the past 10 years.

METHODS

The Dutch Medical Disciplinary Court database was searched for verdicts concerning radiology practice between 2010 and 2019. The association between the number of verdicts and time (years) was assessed by Spearman's rho. Other data were summarized using descriptive statistics.

RESULTS

There were 48 verdicts (mean 4.8 per year). There was no significant association between the number of verdicts and time (Spearman's rho < 0.001, p = 0.99). Most allegations were in breast imaging and musculoskeletal radiology (each 18.8%), followed by interventional radiology, head and neck imaging, and abdominal imaging (each 12.5%), neuroradiology and vascular imaging (each 10.4%), and chest imaging (4.2%). There were 46 allegations against radiologists (95.8%) and 2 against residents (4.2%). The most common allegation (37.5%) was error in diagnosis. In 20.8% of verdicts, the allegation was judged (partially) founded; disciplinary measures were warnings (n = 8) and reprimands (n = 2). An appeal was submitted by the patient in 11 cases and by the radiologist in 3 cases. All appeals by patients were rejected, whereas 2 of the 3 appeals by radiologists were granted and previously imposed disciplinary measures were reversed.

CONCLUSION

Allegations against radiologists at the Dutch Medical Disciplinary Court are relatively few, their number has remained stable over the past 10 years, and a minority were judged to be (partially) founded. We can learn from the cases presented in this article, which may improve patient care.

KEY POINTS

• The frequency of allegations against radiologists at the Dutch Medical Disciplinary Court is relatively low and has not exhibited any temporal change over the past 10 years. • These allegations reflect patient dissatisfaction, but this infrequently equals malpractice. • Knowledge of the circumstances under which these allegations have arisen may improve patient care.

Biomechanical changes of degenerated adjacent segment and intact lumbar spine after lumbosacral topping-off surgery: a three-dimensional finite element analysis

Background

Previous studies have revealed positive effect of Topping-off technique on upper adjacent segment after fusion surgery, while for the cases with fusion surgery on L5-S1 segment, owning maximal range of motion, and preexisting degenerated upper adjacent disc, it is necessary to clarify the superiority of Topping-ff technique and the effect exerted on the lumbar spine.

Methods

A young healthy male volunteer was selected for thin-slice CT scanning. Then the image information was imported into the computer to establish the whole lumbar spine model as the health model. The medium degeneration model of intervertebral disc was established by changing the material properties of L4-S1 disc on the basis of the health model, and the fusion model and Topping-off model were respectively established on the basis of the degenerated model. The variation trend of ROM of L2-L5 and the stress changes of L4-L5 intervertebral disc, nucleus pulposus and facet joints were calculated respectively.

Results

The L4-L5 ROM of fusion model increased significantly but the ROM of L2-L3 and L3-L4 segments did not change significantly. Compared with the degenerated model, L4-L5 activity of the Topping-off model decreased, and ROM of the L2-L3 and L3-L4 increased to some extent in the flexion and extension positions. The stress on the disc, nucleus pulposus and facet joint of the fusion model L4-L5 increased in four positions of flexion, extension, rotation and bending compared with the degenerated model, while the fiber stress on the Topping-off model decreased significantly in all four positions.

Conclusion

Topping-off technology can decrease the stress and ROM of the adjacent upper degenerated segment, and increase the ROM of other upper segments, thereby protecting the degenerated upper adjacent segments and compensating the lumbar spine mobility.

Plasma Lysyl-tRNA Synthetase 1 (KARS1) as a Novel Diagnostic and Monitoring Biomarker for Colorectal Cancer

Colorectal cancer (CRC) is one of the leading causes of world cancer deaths. To improve the survival rate of CRC, diagnosis and post-operative monitoring is necessary. Currently, biomarkers are used for CRC diagnosis and prognosis. However, these biomarkers have limitations of specificity and sensitivity. Levels of plasma lysyl-tRNA synthetase (KARS1), which was reported to be secreted from colon cancer cells by stimuli, along with other secreted aminoacyl-tRNA synthetases (ARSs), were analyzed in CRC and compared with the currently used biomarkers. The KARS1 levels of CRC patients (n = 164) plasma were shown to be higher than those of healthy volunteers (n = 32). The diagnostic values of plasma KARS1 were also evaluated by receiving operating characteristic (ROC) curve. Compared with other biomarkers and ARSs, KARS1 showed the best diagnostic value for CRC. The cancer specificity and burden correlation of plasma KARS1 level were validated using azoxymethane (AOM)/dextran sodium sulfate (DSS) model, and paired pre- and post-surgery CRC patient plasma. In the AOM/DSS model, the plasma level of KARS1 showed high correlation with number of polyps, but not for inflammation. Using paired pre- and post-surgery CRC plasma samples (n = 60), the plasma level of KARS1 was significantly decreased in post-surgery samples. Based on these evidence, KARS1, a surrogate biomarker reflecting CRC burden, can be used as a novel diagnostic and post-operative monitoring biomarker for CRC.

De novo discovery of metabolic heterogeneity with immunophenotype-guided imaging mass spectrometry

Imaging mass spectrometry enables in situ label-free detection of thousands of metabolites from intact tissue samples. However, automated steps for multi-omics analyses and interpretation of histological images have not yet been implemented in mass spectrometry data analysis workflows. The characterization of molecular properties within cellular and histological features is done via time-consuming, non-objective, and irreproducible definitions of regions of interest, which are often accompanied by a loss of spatial resolution due to mass spectra averaging.

Methods: We developed a new imaging pipeline called Spatial Correlation Image Analysis (SPACiAL), which is a computational multimodal workflow designed to combine molecular imaging data with multiplex immunohistochemistry (IHC). SPACiAL allows comprehensive and spatially resolved in situ correlation analyses on a cellular resolution. To demonstrate the method, matrix-assisted laser desorption-ionization (MALDI) Fourier-transform ion cyclotron resonance (FTICR) imaging mass spectrometry of metabolites and multiplex IHC staining were performed on the very same tissue section of mouse pancreatic islets and on human gastric cancer tissue specimens. The SPACiAL pipeline was used to perform an automatic, semantic-based, functional tissue annotation of histological and cellular features to identify metabolic profiles. Spatial correlation networks were generated to analyze metabolic heterogeneity associated with cellular features.

Results: To demonstrate the new method, the SPACiAL pipeline was used to identify metabolic signatures of alpha and beta cells within islets of Langerhans, which are cell types that are not distinguishable via morphology alone. The semantic-based, functional tissue annotation allows an unprecedented analysis of metabolic heterogeneity via the generation of spatial correlation networks. Additionally, we demonstrated intra- and intertumoral metabolic heterogeneity within HER2/neu-positive and -negative gastric tumor cells.

Conclusions: We developed the SPACiAL workflow to provide IHC-guided in situ metabolomics on intact tissue sections. Diminishing the workload by automated recognition of histological and functional features, the pipeline allows comprehensive analyses of metabolic heterogeneity. The multimodality of immunohistochemical staining and extensive molecular information from imaging mass spectrometry has the advantage of increasing both the efficiency and precision for spatially resolved analyses of specific cell types. The SPACiAL method is a stepping stone for the objective analysis of high-throughput, multi-omics data from clinical research and practice that is required for diagnostics, biomarker discovery, or therapy response prediction.

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Novel method enables phenotype-guided in situ metabolomics on intact tissue sections.

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Metabolic heterogeneity can be objectified under (patho-)physiological conditions.

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Innovative approach for tissue-based, preclinical, and clinical research.

The Complex Interplay Between Inflammatory Bowel Disease and Malignancy

PURPOSE OF REVIEW

Both the chronic inflammation in inflammatory bowel disease (IBD), and its treatment, can increase the risk of malignancy. There is also an increasing number of patients with current and prior cancer who require IBD treatment. Thus, there is a complex interplay between immunosuppressive treatment and monitoring for new and recurrent cancer.

RECENT FINDINGS

Vedolizumab and ustekinumab have not been shown to increase the risk of malignancy. Transplant data shows a potential risk with tofacitinib although rheumatoid arthritis data does not. IBD patients have been shown to tolerate chemotherapy, specifically with cytotoxic compared with hormonal chemotherapy. Patients with prior cancer are at increased risk of new or recurrent cancers; however, immunosuppression appears to be safe. Emerging treatments for IBD have demonstrated acceptable safety profiles for malignancy risk, and immunosuppression appears to be safe for use in patients with current and prior malignancy. More data is still needed to assess long-term risk of malignancy in these patients, especially with newer treatments.

Quorum sensing system: Target to control the spread of bacterial infections

Quorum Sensing (QS) systems regulate the gene expression of different types of virulence factors in accordance with the cell population density. A literature search was performed, including electronic databases such as MEDLINE/PubMed, SciELO, and LILACS, as well as other databases not indexed, such as Google Scholar. The search was conducted between July 2018 and April 2019, through online research. Antimicrobial resistance is one of the biggest threats to global health and the dissemination of resistant microbes in the environment is a major public health problem. Therefore, it is important to develop new therapies to control the spread of resistant bacteria to humans. Thus, interference in the chemical signal (autoinducers) of the QS system has been postulated as a good alternative, technically known as "Quorum Quenching" or QS inhibitors. Inhibition of QS signaling is not intended to kill the microorganism, but to block the expression of the target genes, making the cells less virulent and more vulnerable to host immune response. Anti-virulence therapy by agents that interfere with this system in pathogenic bacteria is a well-studied strategy, including medicinal plants and their bioactive constituents, and presents good prospects. This review aims to provide an overview of the QS system in bacteria and describe the main inhibitors of the system.

Expanding the clinical and EEG spectrum of CNKSR2-related encephalopathy with status epilepticus during slow sleep (ESES)

OBJECTIVE

To investigate the clinical and EEG features of Encephalopathy with Status Epilepticus during slow Sleep (ESES) related to CNKSR2 pathogenic variants.

METHODS

Detailed clinical history, repeated wakefulness/overnight sleep EEGs, brain MRI were collected in five patients, including one female, with CNKSR2-related ESES.

RESULTS

Neurodevelopment in infancy was normal in two patients, delayed in three. Epilepsy onset (age range: 2-6 years) was associated with appearance or aggravation of cognitive impairment, language regression and/or behavioral disorders. Worsening of epilepsy and of cognitive/behavioral disturbances paralleled by enhancement of non-rapid eye movement (NREM) sleep-related, frontally predominant, EEG epileptic discharges [spike-wave-index (SWI): range 60-96%] was consistent with ESES. In three patients, episodes of absence status epilepticus or aggravation of atypical absences occurred, in this latter case associated with striking increment of awake SWI. Speech/oro-motor dyspraxia was diagnosed in four patients. In two patients, long-term follow-up showed epilepsy remission and persistence of mild/moderate cognitive disorders and behavioral disturbances into adulthood.

CONCLUSIONS

Novel findings of our study are occurrence also in females, normal neurodevelopment before epilepsy onset, epilepsy aggravation associated with enhanced awake SWI, mild/moderate evolution in adulthood and language disorder due to speech/oro-motor dyspraxia.

SIGNIFICANCE

Our findings expand the phenotypic spectrum of CNKSR2-related ESES.

Quo Vadis PCA? A Review on Current Concepts, Economic Considerations, Patient-Related Aspects, and Future Development with respect to Patient-Controlled Analgesia

This review assesses four interrelating aspects of patient-controlled analgesia (PCA), a long-standing and still widely used concept for postoperative pain management. Over the years, anaesthesiologists and patients have appreciated the benefits of PCA alike. The market has seen new technologies leveraging noninvasive routes of administration and, thus, further increasing patient and staff satisfaction as well as promoting safety aspects. Pharmaceutical research focuses on the reduction or avoidance of opioids, side effects, and adverse events although influence of these aspects appears to be minor. The importance of education is still eminent, and new educational formats are tested to train healthcare professionals and patients likewise. New PCA technology can support the implementation of efficient processes to reduce workload and human errors; however, these new products come with a cost, which is not necessarily reflected through beneficial budget impact or significant improvements in patient outcome. Although first steps have been taken to better recognize the importance of postoperative pain management through the introduction of value-based reimbursement, in most western countries, PCA is not specifically compensated. PCA is still an effective and valued technique for postoperative pain management. Although there is identifiable potential for future developments in various aspects, this potential has not materialized in new products.

Insulin-Producing Cell Transplantation Platform for Veterinary Practice

Diabetes mellitus (DM) remains a global concern in both human and veterinary medicine. Type I DM requires prolonged and consistent exogenous insulin administration to address hyperglycemia, which can increase the risk of diabetes complications such as retinopathy, nephropathy, neuropathy, and heart disorders. Cell-based therapies have been successful in human medicine using the Edmonton protocol. These therapies help maintain the production of endogenous insulin and stabilize blood glucose levels and may possibly be adapted to veterinary clinical practice. The limited number of cadaveric pancreas donors and the long-term use of immunosuppressive agents are the main obstacles for this protocol. Over the past decade, the development of potential therapies for DM has mainly focused on the generation of effective insulin-producing cells (IPCs) from various sources of stem cells that can be transplanted into the body. Another successful application of stem cells in type I DM therapies is transplanting generated IPCs. Encapsulation can be an alternative strategy to protect IPCs from rejection by the body due to their immunoisolation properties. This review summarizes current concepts of IPCs and encapsulation technology for veterinary clinical application and proposes a potential stem-cell-based platform for veterinary diabetic regenerative therapy.

Herpes Zoster, Hepatitis C, and Tuberculosis Risk with Apremilast Compared to Biologics, DMARDs and Corticosteroids to Treat Psoriasis and Psoriatic Arthritis

Purpose

Psoriasis and psoriatic arthritis (PsA) are associated with an increased infection risk. In this cohort study of patients with treated psoriasis or PsA, we used MarketScan (2014–2018) to estimate rates of herpes zoster, hepatitis C (HepC) and tuberculosis (TB) with apremilast compared to other systemic treatments.

Materials and Methods

Patients were exposed from first apremilast [APR], DMARD, TNF-inhibitor [TNF], IL-inhibitor [IL], or corticosteroids [CS] prescription after March 21, 2014. Study exposures were APR, DMARDs only, TNF-only, IL-only, CS-only, DMARDs+CS, TNF+DMARDs and/or CS, IL+DMARDs and/or CS. Cases had treated herpes zoster, HepC, or TB event. We calculated incidence rates (IRs) [95% confidence intervals] per 1000 patient-years.

Results

The study population included 131,604 patients. For herpes zoster (N=2271), IRs were highest for users of DMARDs+CS (12.5 [9.8–15.7]), CS-only (12.5 [10.4–14.1]), and TNF+DMARDs and/or CS (11.9 [10.6–13.4]), compared with DMARDs only (9.9 [8.7–11.2]). IRs were lowest for users of IL-only (6.7 [5.8–7.8]) and APR (7.0 [5.8–8.4]). IRs of HepC (N=150) and TB (N=81) were low and between-treatment differences were not significant.

Conclusion

Rates of herpes zoster varied by treatment: highest among those who received polytherapy, lowest in users of apremilast only. IRs for HepC and TB were low for all exposures.

The Effects of Leukocyte-Platelet Rich Fibrin (L-PRF) on Suppression of the Expressions of the Pro-Inflammatory Cytokines, and Proliferation of Schwann Cell, and Neurotrophic Factors

This study evaluates the use of L-PRF as an autologous scaffold in nerve regeneration, and Schwann cells (SCs) proliferation and secretion of neurotrophic factors and its anti-inflammatory effect on SC Porphyromonas Gingivalis-Lipopolysaccharide (PG-LPS)-induced inflammatory responses in vitro. SEM was done to investigate various features of L-PRF. L-PRF-extracts was used to investigate the release of growth factors and treatment of SCs line. ELISA was applied to examine the release of IGF-1. The proliferative effect of L-PRF on SCs was assessed with CCK-8 assay. The effect of L-PRF on the mRNA and protein expression of SC neurotrophic factors were analyzed by RT-qPCR and ELISA. CCK-8 assay and RT-qPCR were used to determine the required concentration and the action time of PG-LPS before the anti-inflammatory effect of L-PRF was determined by measuring the changes in IL-1β, IL-6, and TNF-a with RT-qPCR and ELISA. There are different features in L-PRF. Fourteen days was sufficient to release adequate GF. The mRNA expressions of the pro-inflammatory cytokines were notably raised by PG-LPS in 3-hours treatment. L-PRF can increase SC proliferation, neurotrophic factors secretion, and suppress SC PG-LPS-induced inflammatory responses in vitro. L-PRF has the potential as an autologous biological additive for peripheral nerve regeneration in the event of nerve inflammation and injuries.

Covalent conjugation of bioactive peptides to graphene oxide for biomedical applications

Graphene is a valuable material in biomedical implant applications due to its mechanical integrity, long-range order, and conductivity; but graphene must be chemically modified to increase biocompatibility and maximize functionality in the body. Here, we developed a foundational synthetic method for covalently functionalizing a reduced GO with bioactive molecules, focusing on synthetic peptides that have shown osteogenic or neurogenic capability as a prototypical example. X-ray photoelectron spectroscopy provides evidence that the peptide is covalently linked to the graphenic backbone. These peptide-graphene (Pep-G) conjugate materials can be processed into mechanically robust, three-dimensional constructs. Differences in their electrostatic charges allow the Pep-G conjugates to form self-assembled, layer-by-layer coatings. Further, the Pep-G conjugates are cytocompatible and electrically conductive, leading us to investigate their potential as regenerative scaffolds, as conductive surfaces can stimulate bone and nerve regeneration. Notably, PC12 cells grown on an electrically stimulated Pep-G scaffold demonstrated enhanced adhesion and neurite outgrowth compared to the control. The functionalization strategy developed here can be used to conjugate a wide variety of bioactive molecules to graphene oxide to create cell-instructive surfaces for biomedical scaffold materials.

Deletion of Von Hippel-Lindau Interferes with Hyper Osmolality Induced Gene Expression and Induces an Unfavorable Gene Expression Pattern

Loss of von Hippel–Lindau (VHL) protein function can be found in more than 90% of patients with clear cell renal carcinoma (ccRCC). Mice lacking Vhl function in the kidneys have urine concentration defects due to postulated reduction of the hyperosmotic gradient. Hyperosmolality is a kidney-specific microenvironment and induces a unique gene expression pattern. This gene expression pattern is inversely regulated in patients with ccRCC with consequences for cancer-specific survival. Within this study, we tested the hypothesis if Vhl function influences the hyperosmolality induced changes in gene expression. We made use of the Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR)/Cas9 technology to inhibit functional Vhl expression in murine collecting duct cell line. Loss of Vhl function induced morphological changes within the cells similar to epithelial to mesenchymal transition like phenotype. Vhl-deficient cells migrated faster and proliferated slower compared to control cells. Gene expression profiling showed significant changes in gene expression patterns in Vhl-deficient cells compared to control cells. Several genes with unfavorable outcomes showed induced and genes with favorable outcomes for patients with renal cancer reduced gene expression level. Under hyperosmotic condition, the expression of several hyperosmolality induced genes, with favorable prognostic value, was downregulated in cells that do not express functional Vhl. Taken together, this study shows that Vhl interferes with hyperosmotic signaling pathway and hyperosmolality affected pathways might represent new promising targets.

Tick-Borne Encephalitis Virus Vaccines Contain Non-Structural Protein 1 Antigen and may Elicit NS1-Specific Antibody Responses in Vaccinated Individuals

Vaccination against tick-borne encephalitis (TBE) is based on the use of formalin-inactivated, culture-derived whole-virus vaccines. Immune response following vaccination is primarily directed to the viral envelope (E) protein, the major viral surface antigen. In Europe, two TBE vaccines are available in adult and pediatric formulations, namely FSME-IMMUN^® (Pfizer) and Encepur^® (GlaxoSmithKline). Herein, we analyzed the content of these vaccines using mass spectrometry (MS). The MS analysis revealed that the Encepur vaccine contains not only proteins of the whole virus particle, but also viral non-structural protein 1 (NS1). MS analysis of the FSME-IMMUN vaccine failed due to the high content of human serum albumin used as a stabilizer in the vaccine. However, the presence of NS1 in FSME-IMMUN was confirmed by immunization of mice with six doses of this vaccine, which led to a robust anti-NS1 antibody response. NS1-specific Western blot analysis also detected anti-NS1 antibodies in sera of humans who received multiple doses of either of these two vaccines; however, most vaccinees who received ≤3 doses were negative for NS1-specific antibodies. The contribution of NS1-specific antibodies to protection against TBE was demonstrated by immunization of mice with purified NS1 antigen, which led to a significant (p < 0.01) prolongation of the mean survival time after lethal virus challenge. This indicates that stimulation of anti-NS1 immunity by the TBE vaccines may increase their protective effect.

Sophisticated polycaprolactone/gelatin nanofibrous nerve guided conduit containing platelet-rich plasma and citicoline for peripheral nerve regeneration: In vitro and in vivo study

Peripheral nerve injury (PNI) is a devastating condition that may result in loss of sensory function, motor function, or both. In the present study, we construct an electrospun nerve guide conduit (NGC) based on polycaprolactone (PCL) and gelatin filled with citicoline bearing platelet-rich plasma (PRP) gel as a treatment for PNI. The NGCs fabricated from PCL/Gel polymeric blend using the electrospinning technique. The characterizations demonstrated that the fabricated nanofibers were straight with the diameter of 708 ± 476 nm, the water contact angle of 78.30 ± 2.52°, the weight loss of 41.60 ± 6.94% during 60 days, the tensile strength of 5.31 ± 0.97 MPa, and the young's modulus of 3.47 ± 0.10 GPa. The in vitro studies revealed that the PCL/Gel/PRP/Citi NGC was biocompatible and hemocompatible. The in vivo studies conducted on sciatic nerve injury in rats showed that the implantation of PCL/Gel/PRP/Citi NGC induced regeneration of nerve tissue, demonstrated with histopathological assessments. Moreover, the sciatic function index (SFI) value of -30.3 ± 3.5 and hot plate latency time of 6.10 ± 1.10 s revealed that the PCL/Gel/PRP/Citi NGCs recovered motor and sensory functions. Our findings implied that the fabricated NGC exhibited promising physicochemical and biological activates favorable for PNI treatment.

An Engineered Microvirin Variant with Identical Structural Domains Potently Inhibits Human Immunodeficiency Virus and Hepatitis C Virus Cellular Entry

Microvirin (MVN) is one of the human immunodeficiency virus (HIV-1) entry inhibitor lectins, which consists of two structural domains sharing 35% sequence identity and contrary to many other antiviral lectins, it exists as a monomer. In this study, we engineered an MVN variant, LUMS1, consisting of two domains with 100% sequence identity, thereby reducing the chemical heterogeneity, which is a major factor in eliciting immunogenicity. We determined carbohydrate binding of LUMS1 through NMR chemical shift perturbation and tested its anti-HIV activity in single-round infectivity assay and its anti-hepatitis C virus (HCV) activity in three different assays including HCVcc, HCVpp, and replicon assays. We further investigated the effect of LUMS1 on the activation of T helper (T_h) and B cells through flow cytometry. LUMS1 showed binding to α(1-2)mannobiose, the minimum glycan epitope of MVN, potently inhibited HIV-1 and HCV with EC₅₀ of 37.2 and 45.3 nM, respectively, and showed negligible cytotoxicity with CC₅₀ > 10 µM against PBMCs, Huh-7.5 and HepG2 cells, and 4.9 µM against TZM-bl cells. LUMS1 did not activate T_h cells, and its stimulatory effect on B cells was markedly less as compared to MVN. Together, with these effects, LUMS1 represents a potential candidate for the development of antiviral therapies.

Identification of pmrB mutations as putative mechanism for colistin resistance in A. baumannii strains isolated after in vivo colistin exposure

Colistin resistance among extensively-resistant Acinetobacter baumannii isolates is a serious health-care problem. Alterations in PmrA-PmrB two-component system have been associated with resistance to colistin. We investigated three pairs of colistin-susceptible and colistin-resistant A. baumannii, sequentially isolated from three patients before and after colistin treatment, respectively. The pmrA and pmrB genes were sequenced by Sanger method. Amino acidic positions and their effect on protein were predicted by InterPro and PROVEAN tools. Expression of pmrA, pmrB and pmrC genes was assessed by semi-quantitative reverse transcription-PCR (qRT-PCR). We found three different nonsynonymous substitutions P233T, E301G and L168K in pmrB coding region, each one in a different colistin resistance strain. The E301G and L168K substitutions represent novel mutations in pmrB, not previously described. Relative expression of pmrA, pmrB and pmrC mRNA increased in all colistin resistant strains. In our study, pmrB substitutions were associated with pmrC over-expression and colistin resistance. Further studies are necessary to understand their impact on modification of lipid A components.

Emerging Targeted Therapies for HER2 Positive Gastric Cancer That Can Overcome Trastuzumab Resistance

Trastuzumab, a monoclonal antibody to human epidermal growth factor receptor 2 (HER2), has improved survival in patients with HER2-positive advanced gastric or gastroesophageal junction cancer (AGC). The inevitable development of resistance to trastuzumab remains a problem, however, with several treatment strategies that have proven effective in breast cancer having failed to show clinical benefit in AGC. In this review, we summarize the mechanisms underlying resistance to HER2-targeted therapy and outline past and current challenges in the treatment of HER2-positive AGC refractory to trastuzumab. We further describe novel agents such as HER2 antibody-drug conjugates that are under development and have shown promising antitumor activity in early studies.

Case of primary hepatic leiomyosarcoma successfully treated with laparoscopic right hepatectomy

We describe the case of a 77-year-old woman, presenting with non-specific epigastric pain. Physical examination and subsequent imaging revealed the presence of a large mass in the right liver lobe. This was shown to be a leiomyosarcoma on biopsy histology. Further investigation confirmed this to be a primary hepatic leiomyosarcoma with no evidence of metastases. The patient underwent successful surgical resection. She is currently under imaging follow-up, with no evidence of disease recurrence.

Processed Food Additive Microbial Transglutaminase and Its Cross-Linked Gliadin Complexes Are Potential Public Health Concerns in Celiac Disease

Microbial transglutaminase (mTG) is a survival factor for microbes, but yeasts, fungi, and plants also produce transglutaminase. mTG is a cross-linker that is heavily consumed as a protein glue in multiple processed food industries. According to the manufacturers’ claims, microbial transglutaminase and its cross-linked products are safe, i.e., nonallergenic, nonimmunogenic, and nonpathogenic. The regulatory authorities declare it as “generally recognized as safe” for public users. However, scientific observations are accumulating concerning its undesirable effects on human health. Functionally, mTG imitates its family member, tissue transglutaminase, which is the autoantigen of celiac disease. Both these transglutaminases mediate cross-linked complexes, which are immunogenic in celiac patients. The enzyme enhances intestinal permeability, suppresses mechanical (mucus) and immunological (anti phagocytic) enteric protective barriers, stimulates luminal bacterial growth, and augments the uptake of gliadin peptide. mTG and gliadin molecules are cotranscytosed through the enterocytes and deposited subepithelially. Moreover, mucosal dendritic cell surface transglutaminase induces gliadin endocytosis, and the enzyme-treated wheat products are immunoreactive in CD patients. The present review summarizes and updates the potentially detrimental effects of mTG, aiming to stimulate scientific and regulatory debates on its safety, to protect the public from the enzyme’s unwanted effects.

Clinical Features and Outcomes of Patients with Chemotherapy-induced Takotsubo Syndrome

Chemotherapy treatment of malignancy accounts for 1–2% of takotsubo syndrome (TS) triggers. Women comprise 60–70% of patients with chemotherapy-associated TS, a distinctly lower prevalence than the 90% female prevalence in TS overall. Fluorouracil is the most commonly reported TS-triggering chemotherapeutic agent, although this must be interpreted in the context of the frequency of worldwide use of this agent. The onset of TS relative to chemotherapy initiation is quite variable, ranging from the initial administration to subsequent chemotherapy cycles several weeks beyond initiation. Limited information suggests chemotherapy can be safely reinitiated once the patient has recovered from the initial TS event. Having a TS event in the setting of chemotherapy treatment for malignancy is associated with substantial mortality.

Uncovering Tumour Heterogeneity through PKR and nc886 Analysis in Metastatic Colon Cancer Patients Treated with 5-FU-Based Chemotherapy

Colorectal cancer treatment has advanced over the past decade. The drug 5-fluorouracil is still used with a wide percentage of patients who do not respond. Therefore, a challenge is the identification of predictive biomarkers. The protein kinase R (PKR also called EIF2AK2) and its regulator, the non-coding pre-mir-nc886, have multiple effects on cells in response to numerous types of stress, including chemotherapy. In this work, we performed an ambispective study with 197 metastatic colon cancer patients with unresectable metastases to determine the relative expression levels of both nc886 and PKR by qPCR, as well as the location of PKR by immunohistochemistry in tumour samples and healthy tissues (plasma and colon epithelium). As primary end point, the expression levels were related to the objective response to first-line chemotherapy following the response evaluation criteria in solid tumours (RECIST) and, as the second end point, with survival at 18 and 36 months. Hierarchical agglomerative clustering was performed to accommodate the heterogeneity and complexity of oncological patients’ data. High expression levels of nc886 were related to the response to treatment and allowed to identify clusters of patients. Although the PKR mRNA expression was not associated with chemotherapy response, the absence of PKR location in the nucleolus was correlated with first-line chemotherapy response. Moreover, a relationship between survival and the expression of both PKR and nc886 in healthy tissues was found. Therefore, this work evaluated the best way to analyse the potential biomarkers PKR and nc886 in order to establish clusters of patients depending on the cancer outcomes using algorithms for complex and heterogeneous data.

Novel germline STK11 variants and breast cancer phenotype identified in an Indian cohort of Peutz-Jeghers syndrome

Peutz-Jeghers syndrome (PJS) caused by germline STK11 variants is a rare autosomal dominant cancer predisposition syndrome characterized by multiple gastrointestinal (GI) hamartomatous polyps, mucocutaneous pigmentation and a high inherited risk of developing GI, breast and other cancers. Despite GI and breast being the two most common PJS-associated cancer sites, the immunohistochemical (IHC) and molecular features of these tumors in carriers of STK11 variant is not known. Detailed phenotyping including tumor IHC and its correlation with comprehensive STK11 genotyping by full gene sequencing followed by large genomic rearrangement analysis was performed in an Indian PJS cohort. A total of 4 distinct STK11 pathogenic or likely pathogenic variants were identified in 10 PJS cases from 7 of the 19 families tested-in 4/5 classical PJS families and 3/14 suspected PJS families. The pathogenic STK11 variant identified was novel in 3/7 families. In addition, four distinct, likely benign variants identified in seven families were also novel. All of the four breast cancer cases in families with STK11 pathogenic variant were estrogen receptor (ER)-positive and Her2-negative. Several novel STK11 variants identified in this Indian PJS cohort highlight the need to study PJS in different populations across the world. This is the first report showing ER positivity in breast cancer in carriers of STK11 variants and needs confirmation in a larger pooled cohort of PJS associated breast cancers. This could help establish the role of chemoprevention or prophylactic oophorectomy in female carriers of STK11 pathogenic variants.

Preoperative Bilirubin-Adjusted Carbohydrate Antigen 19-9 as a Prognostic Factor for Extrahepatic Cholangiocarcinoma Patients at a Single Center

Purpose

The aims of our study were to investigate the prognostic impact of the rate of preoperative serum carbohydrate antigen 19-9/bilirubin (CA19-9/BR) on patients with extrahepatic bile duct cancer.

Patients and Methods

We collected clinical data from 89 patients who underwent surgery for extrahepatic cholangiocarcinoma (ECC) at Peking Union Medical College Hospital between January 2012 and December 2017. The Kaplan–Meier analysis for univariate analysis and the Cox proportional hazards models for multivariate analysis were used to determine possible independent prognostic factors.

Results

CA19-9/BR was classified as elevated compared with normal based on the upper serum normal values of CA19-9 (37 U/mL) and bilirubin (1.5 mg/dL), which gives a cut-off at 25 U/mL/mg/dL. Univariate analysis showed that the overall survival of patients with a high CA19-9/BR ratio was significantly worse compared with patients with a low CA19-9/BR ratio (Hazard Ratio [HR] 2.149; 95% Confidence Interval [95% CI] 1.027–4.495; P=0.042). Multivariate analysis revealed that a high CA19-9/BR ratio (HR 3.250; 95% CI 1.165–9.067; P=0.024), low differentiation (HR 3.551; 95% CI 1.231–10.244; P=0.019), and positive margin (HR 2.555; 95% CI 1.111–5.875; P=0.027) remained independent prognostic factors after adjusting for age at diagnosis, maximal diameters, and other possible factors.

Conclusion

The preoperative CA19-9/BR ratio is a good prognostic factor in predicting survival in ECC patients and closer follow-up is recommended in patients with a higher CA19-9/BR ratio before surgery.

Gliosarcomas: magnetic resonance imaging findings

BACKGROUND

Central nervous system (CNS) gliosarcoma (GSM) is a rare primary neoplasm characterized by the presence of glial and sarcomatous components.

OBJECTIVE

In this report, we describe the clinical and neuroimaging aspects of three cases of GSM and correlate these aspects with pathological findings. We also provide a brief review of relevant literature.

METHODS

Three patients were evaluated with magnetic resonance imaging (MRI), and biopsies confirmed the diagnosis of primary GSM, without previous radiotherapy.

RESULTS

The analysis of conventional sequences (T1, T1 after contrast injection, T2, Fluid attenuation inversion recovery, SWI and DWI/ADC map) and advanced (proton 1H MR spectroscopy and perfusion) revealed an irregular, necrotic aspect of the lesion, peritumoral edema/infiltration and isointensity of the solid component on a T2-weighted image. These features were associated with irregular and peripheral contrast enhancement, lipid and lactate peaks, increased choline and creatine levels in proton spectroscopy, increased relative cerebral blood volume (rCBV) in perfusion, multifocality and drop metastasis in one of the cases.

CONCLUSION

These findings are discussed in relation to the general characteristics of GSM reported in the literature.

Computed Tomography Findings of Emergency Cases Resulting From Fish Bone Ingestion

Fish bones are some of the most commonly ingested foreign bodies. In most cases, fish bone ingestion is asymptomatic, and the bones are expelled from the body spontaneously. Otherwise, patients with fish bone ingestion can present to the emergency department with nonspecific symptoms. Fish bones can become impacted in various part of the body. Even in cases that are initially asymptomatic after ingestion, serious complications may develop at a later stage. Computed tomography (CT) plays an important role in the diagnosis of fish bone ingestion because it is the most sensitive modality for detecting these foreign bodies. It is important to be familiar with CT findings to detect ingested fish bones and the related complications and to direct further management of the condition.

Deferasirox protects against hydrogen peroxide-induced cell apoptosis by inhibiting ubiquitination and degradation of p21WAF1/CIP1

Deferasirox (DFX) is an iron chelator approved for the treatment of iron overload diseases. However, the role of DFX in oxidative stress-induced cell apoptosis and the exact molecular mechanisms underlying these processes remain poorly understood and require further investigation. In this study, we found that DFX rendered resistant to H₂O₂-induced apoptosis in HEK293T cells, reduced the intracellular levels of the labile iron pool (LIP) and oxidative stress induced by H₂O₂. Furthermore, DFX inhibited the ubiquitination and degradation of the cyclin-dependent kinase inhibitor p21^WAF1/CIP1 (p21) via modulation of the interaction of p21 with SCF-Skp2. DFX also showed the inhibition effect on the activation of c-Jun N-terminal kinase (JNK), pro-caspase-3 and related mitochondrial apoptosis pathway induced by H₂O₂. These results provide novel insights into the molecular mechanism underpinning iron-mediated oxidative stress and apoptosis, and they may represent a promising target for therapeutic interventions in related pathological conditions.

Internal Medicine Residents and the Practice of Defensive Medicine: A Pilot Study Across Three Internal Medicine Residency Programs

Background

Defensive medicine is becoming increasingly prevalent in the United States and is estimated to cost billions of dollars in excess healthcare spending. There is evidence that the practice of defensive medicine starts early in the medical career. Defensive medicine has been investigated among residents in high medico-legal risk specialties, but there is a paucity of information on its prevalence among internal medicine residents.

Objective 

To examine the prevalence and patterns of defensive medical practices among internal medicine residents.

Methods

We conducted an online survey among the residents of three internal medicine residency programs in the 2018-2019 academic cycle. We invited all internal medicine residents within the selected programs to participate through email and asked them to complete an electronic survey assessing defensive medical practices.

Results

A total of 49 out of 143 residents participated in the study (response rate: 34.3%); 55% (n = 27) of the residents who participated considered the risk of being sued during residency to be low, compared to 40.8% (n = 20) who considered it to be moderate and 4.1% (n = 2) who considered it to be high. Defensive medical practices were found to be widely prevalent (40.0-91.3%) among internal medicine residents across all three clinical training stages. Assurance defensive practices were more common than avoidance practices.

Conclusion

Defensive medical practices, especially of the assurance type, were widely prevalent among our sample of internal medicine residents.

Outcomes of intrathecal analgesia in multiparous women undergoing normal vaginal delivery: A randomised controlled trial

Background and Aims

Although intrathecal analgesia is an effective option during labour, there is a need to establish sustainable and assured analgesia during the entire labour process. We aimed to assess the effect of adding dexmedetomidine, fentanyl or morphine to low-dose bupivacaine-dexamethasone for intrathecal labour analgesia in multiparous women.

Methods

This was a triple-blind, randomised controlled trial that included 140 multiparous women. Eligible women were randomly allocated to have intrathecal bupivacaine-dexamethasone with dexmedetomidine (group D), fentanyl (group F), morphine (group M) or saline (placebo) (group C). The duration of analgesia, intrathecal block characteristics and maternal and foetal outcomes were assessed and analysed.

Results

The longest analgesia duration and S1 regression time was recorded in group D followed by groups M, F and C, respectively, with statistical significance between all of them (P < 0.001). The shortest analgesia onset time and the highest sensory levels were recorded in group D followed by group F then group M with statistical significance between all of them (P < 0.001 and 0.003, respectively). Visual analogue scale values were comparable among groups M, F and D (P > 0.05) at most of the measurement time points and at the peak of the last uterine contraction before delivery while being significantly lower than those in group C (P < 0.001). However, there were similar motor block characteristics and normal neonatal outcomes in all groups.

Conclusion

In comparison to morphine and fentanyl, dexmedetomidine addition to intrathecal bupivacaine-dexamethasone significantly prolonged the duration and accelerated the onset of labour analgesia, with a good maternal and neonatal outcome.

Novel MicroRNA Biomarkers for Colorectal Cancer Early Diagnosis and 5-Fluorouracil Chemotherapy Resistance but Not Prognosis: A Study from Databases to AI-Assisted Verifications

Colorectal cancer (CRC) is one of the major causes of cancer death worldwide. In general, early diagnosis for CRC and individual therapy have led to better survival for the cancer patients. Accumulating studies concerning biomarkers have provided positive evidence to improve cancer early diagnosis and better therapy. It is, however, still necessary to further investigate the precise biomarkers for cancer early diagnosis and precision therapy and predicting prognosis. In this study, AI-assisted systems with bioinformatics algorithm integrated with microarray and RNA sequencing (RNA-seq) gene expression (GE) data has been approached to predict microRNA (miRNA) biomarkers for early diagnosis of CRC based on the miRNA-messenger RNA (mRNA) interaction network. The relationships between the predicted miRNA biomarkers and other biological components were further analyzed on biological networks. Bayesian meta-analysis of diagnostic test was utilized to verify the diagnostic value of the miRNA candidate biomarkers and the combined multiple biomarkers. Biological function analysis was performed to detect the relationship of candidate miRNA biomarkers and identified biomarkers in pathways. Text mining was used to analyze the relationships of predicted miRNAs and their target genes with 5-fluorouracil (5-FU). Survival analyses were conducted to evaluate the prognostic values of these miRNAs in CRC. According to the number of miRNAs single regulated mRNAs (NSR) and the number of their regulated transcription factor gene percentage (TFP) on the miRNA-mRNA network, there were 12 promising miRNA biomarkers were selected. There were five potential candidate miRNAs (miRNA-186-5p, miRNA-10b-5, miRNA-30e-5p, miRNA-21 and miRNA-30e) were confirmed as CRC diagnostic biomarkers, and two of them (miRNA-21 and miRNA-30e) were previously reported. Furthermore, the combinations of the five candidate miRNAs biomarkers showed better prediction accuracy for CRC early diagnosis than the single miRNA biomarkers. miRNA-10b-5p and miRNA-30e-5p were associated with the 5-FU therapy resistance by targeting the related genes. These miRNAs biomarkers were not statistically associated with CRC prognosis.

Noninvasive assessment of oral lesions using elastic light single-scattering spectroscopy: a pilot study

PURPOSE

In the present study, we investigated the potential application of elastic light single-scattering spectroscopy (ELSSS) as a noninvasive, adjunctive tool to differentiate between malignant and benign oral lesions in vivo.

METHODS

ELSSS spectra were acquired from 52 oral lesions of 47 patients prior to surgical biopsy using a single optical fiber probe. The sign of the spectral slope was used as a diagnostic parameter and was compared to the histopathology findings to obtain sensitivity and specificity of the ELSSS system in differentiating between benign and malignant tissues.

RESULTS

The sign of the spectral slope was positive for the benign tissues and negative for the malignant tissues. Nine malignant lesions and one high-grade dysplasia were correctly classified as cancerous. Six out of the ten low-grade dysplasia were correctly classified as cancerous, and four of them were misclassified as benign. Thirty benign lesions were correctly classified as benign, and two were misclassified as malignant. Our results indicate that the sign of the spectral slope enables the differentiation between malignant and benign oral lesions with a sensitivity of 80% and specificity of 94%.

CONCLUSIONS

ELSSS has the potential to be developed as an adjunctive screening tool in the noninvasive evaluation of oral lesions in vivo. This new diagnostic system may reduce the number of unnecessary biopsies.

Clinical Uses of Platelet-Rich Fibrin in Oral and Maxillofacial Surgery

Platelet-rich fibrin (PRF) is an autogenous material that is derived from a person's own platelets and is used to enhance wound healing and tissue regeneration. Platelet concentrates have been applied in dermatology, pain management, sports medicine, plastic surgery, cardiac surgery, urology, and also dentistry. PRF has garnered significant interest in the dental community because of its proposed regenerative properties and its ability to aid in wound healing. PRF is proposed to have a direct effect on enhancing a patient's wound healing by suprasaturating the wound with growth factors that promote tissue healing. Clinically, PRF is easily produced chairside from the patient's own blood. The autologous nature of PRF makes it preferred over a variety of allografts used in dentistry today. Therefore, PRF has significant potential in being applicable to all areas of dentistry, including oral and maxillofacial surgeries.

Elizabethkingia miricola bacteraemia in a haemodialysis patient

We report a case of catheter-associated Elizabethkingia miricola bacteraemia in a haemodialysis patient. The patient was a 73-year-old home haemodialysis patient who presented with a history of recurrent falls and fevers. Blood cultures grew Gram-negative bacilli identified by MALDI-TOF MS (matrix-assisted laser desorption/ionization time-of-flight mass spectrometry 6903 MSP Library) and 16S rRNA gene sequencing as E. miricola. E. miricola is an emerging human pathogen and is multidrug-resistant, making the choice of antimicrobial therapy challenging. There are only a small number of case reports of human infection worldwide and this is the second reported case of catheter-related bacteraemia. It has also been found in the hospital environment in South Korea and is pathogenic in black-spotted frogs.

Role of locoregional therapies in the wake of systemic therapy

Multiple systemic agents have recently been approved in the first- and second-line setting for hepatocellular carcinoma (HCC), increasing the therapeutic options for patients and treating physicians. The randomised controlled trials that led to these approvals were predominantly conducted in a population comprised of patients with advanced HCC. However, these trials also included a subset of patients who had progressed after locoregional therapies (LRTs), mostly transarterial chemoembolisation. With a greater number of systemic agents available, the role of LRTs has become a topic of debate, specifically regarding when to transition to systemic therapy in unresectable HCC and the potential opportunities for combining locoregional and systemic therapies. Trials of immuno-oncology agents (notably T cell checkpoint inhibitors) are ongoing in the advanced disease setting and these agents also present opportunities for combination therapies, both with other systemic agents and with LRTs in earlier stage disease. This article will review strategies to guide patient selection for LRT as well as the development of locoregional-systemic combinations based on scientific rationale and the challenges of clinical trial design in this setting.

Scientific Opinion on the update of the list of QPS-recommended biological agents intentionally added to food or feed as notified to EFSA (2017-2019)

The qualified presumption of safety (QPS) was developed to provide a safety pre-assessment within EFSA for microorganisms. Strains belonging to QPS taxonomic units (TUs) still require an assessment based on a specific data package, but QPS status facilitates fast track evaluation. QPS TUs are unambiguously defined biological agents assessed for the body of knowledge, their safety and their end use. Safety concerns are, where possible, to be confirmed at strain or product level, and reflected as 'qualifications'. Qualifications need to be evaluated at strain level by the respective EFSA units. The lowest QPS TU is the species level for bacteria, yeasts and protists/algae, and the family for viruses. The QPS concept is also applicable to genetically modified microorganisms used for production purposes if the recipient strain qualifies for the QPS status, and if the genetic modification does not indicate a concern. Based on the actual body of knowledge and/or an ambiguous taxonomic position, the following TUs were excluded from the QPS assessment: filamentous fungi, oomycetes, streptomycetes, Enterococcus faecium, Escherichia coli and bacteriophages. The list of QPS-recommended biological agents was reviewed and updated in the current opinion and therefore now becomes the valid list. For this update, reports on the safety of previously assessed microorganisms, including bacteria, yeasts and viruses (the latter only when used for plant protection purposes) were reviewed, following an Extensive Literature Search strategy. All TUs previously recommended for 2016 QPS list had their status reconfirmed as well as their qualifications. The TUs related to the new notifications received since the 2016 QPS opinion was periodically evaluated for QPS status in the Statements of the BIOHAZ Panel, and the QPS list was also periodically updated. In total, 14 new TUs received a QPS status between 2017 and 2019: three yeasts, eight bacteria and three algae/protists.

Cocoa diet modulates gut microbiota composition and improves intestinal health in Zucker diabetic rats

Cocoa supplementation improves glucose metabolism in Zucker diabetic fatty (ZDF) rats via multiple mechanisms. Furthermore, cocoa rich-diets modify the intestinal microbiota composition both in humans and rats in healthy conditions. Accordingly, we hypothesized that cocoa could interact with the gut microbiota (GM) in ZDF rats, contributing to their antidiabetic effects. Therefore, here we investigate the effect of cocoa intake on gut health and GM in ZDF diabetic rats. Male ZDF rats were fed with standard (ZDF-C) or 10% cocoa-rich diet (ZDF-Co) during 10 weeks. Zucker Lean animals (ZL) received the standard diet. Colon tissues were obtained to determine the barrier integrity and the inflammatory status of the intestine and faeces were analysed for microbial composition, short-chain fatty acids (SCFA) and lactate levels. We found that cocoa supplementation up-regulated the levels of the tight junction protein Zonula occludens-1 (ZO-1) and the mucin glycoprotein and reduced the expression of pro-inflammatory cytokines such as tumour necrosis factor-α (TNF-α), interleukin-6 (IL-6) and monocyte chemoattractant protein 1 (MCP-1) in the colon of ZDF diabetic animals. Additionally, cocoa modulated the microbial composition of the ZDF rats to values similar to those of the lean group. Importantly, cocoa treatment increased the relative abundance of acetate-producing bacteria such as Blautia and prevented the increase in the relative amount of lactate-producing bacteria (mainly Enterococcus and Lactobacillus genera) in ZDF diabetic animals. Accordingly, the total levels of SCFA (mainly acetate) increased significantly in the faeces of ZDF-Co diabetic rats. Finally, modified GM was closely associated with improved biochemical parameters related to glucose homeostasis and intestinal integrity and inflammation. These findings demonstrate for the first time that cocoa intake modifies intestinal bacteria composition towards a healthier microbial profile in diabetic animals and suggest that these changes could be associated with the improved glucose homeostasis and gut health induced by cocoa in ZDF diabetic rats.