A Pharmacological Investigation of Eph-Ephrin Antagonism in Prostate Cancer: UniPR1331 Efficacy Evidence

The Eph kinases are the largest receptor tyrosine kinases (RTKs) family in humans. PC3 human prostate adenocarcinoma cells are a well-established model for studying Eph-ephrin pharmacology as they naturally express a high level of EphA2, a promising target for new cancer therapies. A pharmacological approach with agonists did not show significant efficacy on tumor growth in prostate orthotopic murine models, but reduced distal metastasis formation. In order to improve the comprehension of the pharmacological targeting of Eph receptors in prostate cancer, in the present work, we investigated the efficacy of Eph antagonism both in vitro and in vivo, using UniPR1331, a small orally bioavailable Eph-ephrin interaction inhibitor. UniPR1331 was able to inhibit PC3 cells' growth in vitro in a dose-dependent manner, affecting the cell cycle and inducing apoptosis. Moreover, UniPR1331 promoted the PC3 epithelial phenotype, downregulating epithelial mesenchymal transition (EMT) markers. As a consequence, UniPR1331 reduced in vitro PC3 migration, invasion, and vasculomimicry capabilities. The antitumor activity of UniPR1331 was confirmed in vivo when administered alone or in combination with cytotoxic drugs in PC3-xenograft mice. Our results demonstrated that Eph antagonism is a promising strategy for inhibiting prostate cancer growth, especially in combination with cytotoxic drugs.

The botanical drug PBI-05204, a supercritical CO2 extract of Nerium oleander, sensitizes alveolar and embryonal rhabdomyosarcoma to radiotherapy in vitro and in vivo

Treatment of rhabdomyosarcoma (RMS), the most common a soft tissue sarcoma in childhood, provides intensive multimodal therapy, with radiotherapy (RT) playing a critical role for local tumor control. However, since RMS efficiently activates mechanisms of resistance to therapies, despite improvements, the prognosis remains still largely unsatisfactory, mainly in RMS expressing chimeric oncoproteins PAX3/PAX7-FOXO1, and fusion-positive (FP)-RMS. Cardiac glycosides (CGs), plant-derived steroid-like compounds with a selective inhibitory activity of the Na+/K+-ATPase pump (NKA), have shown antitumor and radio-sensitizing properties. Herein, the therapeutic properties of PBI-05204, an extract from Nerium oleander containing the CG oleandrin already studied in phase I and II clinical trials for cancer patients, were investigated, in vitro and in vivo, against FN- and FP-RMS cancer models. PBI-05204 induced growth arrest in a concentration dependent manner, with FP-RMS being more sensitive than FN-RMS, by differently regulating cell cycle regulators and commonly upregulating cell cycle inhibitors p21Waf1/Cip1 and p27Cip1/Kip1. Furthermore, PBI-05204 concomitantly induced cell death on both RMS types and senescence in FN-RMS. Notably, PBI-05204 counteracted in vitro migration and invasion abilities and suppressed the formation of spheroids enriched in CD133+ cancer stem cells (CSCs). PBI-05204 sensitized both cell types to RT by improving the ability of RT to induce G2 growth arrest and counteracting the RT-induced activation of both Non‐Homologous End‐Joining and homologous recombination DSBs repair pathways. Finally, the antitumor and radio-sensitizing proprieties of PBI-05204 were confirmed in vivo. Notably, both in vitro and in vivo evidence confirmed the higher sensitivity to PBI-05204 of FP-RMS. Thus, PBI-05204 represents a valid radio-sensitizing agent for the treatment of RMS, including the intrinsically radio-resistant FP-RMS.

Anticancer effects of ABTL0812, a clinical stage drug inducer of autophagy-mediated cancer cell death, in glioblastoma models

BACKGROUND

Glioblastoma multiforme (GBM) is the most malignant adult brain tumor. Current standard of care treatments have very limited efficacy, being the patients´ overall survival 14 months and the 2-year survival rate less than 10%. Therefore, the treatment of GBM is an urgent unmet clinical need.

METHODS

The aim of this study was to investigate in vitro and in vivo the potential of ABTL0812, an oral anticancer compound currently in phase II clinical stage, as a novel therapy for GBM.

RESULTS

We showed that ABTL0812 inhibits cell proliferation in a wide panel of GBM cell lines and patient-derived glioblastoma stem cells (GSCs) with half maximal inhibitory concentrations (IC50s) ranging from 15.2 µM to 46.9 µM. Additionally, ABTL0812 decreased GSCs neurosphere formation. GBM cells aggressiveness is associated with a trans-differentiation process towards a less differentiated phenotype known as proneural to mesenchymal transition (PMT). ABTL0812 was shown to revert PMT and induce cell differentiation to a less malignant phenotype in GBM cell lines and GSCs, and consequently reduced cell invasion. As previously shown in other cancer types, we demonstrated that the molecular mechanism of action of ABTL0812 in glioblastoma involves the inhibition of Akt/mTORC1 axis by overexpression of TRIB3, and the activation of endoplasmic reticulum (ER) stress/unfolded protein response (UPR). Both actions converge to induce autophagy-mediated cell death. ABTL0812 anticancer efficacy was studied in vivo using subcutaneous and orthotopic intra-brain xenograft tumor models. We demonstrated that ABTL0812 impairs tumor growth and increases disease-free survival and overall survival of mice. Furthermore, the histological analysis of tumors indicated that ABTL0812 decreases angiogenesis. Finally, we investigated the combination of ABTL0812 with the standard of care treatments for GBM radiotherapy and temozolomide in an orthotopic model, detecting that ABTL0812 potentiates the efficacy of both treatments and that the strongest effect is obtained with the triple combination of ABTL0812+radiotherapy+temozolomide.

CONCLUSIONS

Overall, the present study demonstrated the anticancer efficacy of ABTL0812 as single agent and in combination with the GBM standard of care treatments in models of glioblastoma and supports the clinical investigation of ABTL0812 as a potential novel therapy for this aggressive brain tumor type.

An emerging role for DPP6: reciprocal regulation of INa-Ito and implications for arrhythmogenesis

Background

Since the association of a chromosomal risk haplotype harboring dipeptidyl peptidase-like protein-6 (DPP6) to familial idiopathic ventricular fibrillation (iVF), a growing number of DPP6 missense variants has been reported in patients with ventricular tachyarrhythmias. The mechanisms underlying DPP6 mediated-arrhythmogenesis are not yet fully elucidated. DPP6 is a subunit of the transient outward potassium (Ito) channel complex in Purkinje cells (PC) and ventricular myocytes (VM).

Purpose

Since other Ito-channel subunits (Navβ1, KChIP2, KCNE4 and DPP10) are also known to antagonize INa, we examined whether DPP6 could play a broader role in the inter-regulation of Kv4.3 and Nav1.5 channels. We identified two novel DPP6 variants (p.Arg274His and p.His213Tyr), each segregating in families with QT/QU prolongation. DPP6 p.Arg274His carriers suffered from iVF, ectopic beats from the conduction system, and mitral valve prolapse. Other DPP6 variants (p.Ala751Val identified in this study; p.Gln526His and DPP6-T p.His332Arg published) are associated with Brugada syndrome (BrS). We hypothesized that DPP6 has opposing effects on INa and Ito displaying a reciprocal regulation of these currents.

Methods and results

First, we determined the effect of the DPP6 variants on INa and Ito in transfected CHO cells. Ito density was significantly reduced only when PC subunits were co-expressed with the DPP6 p.Arg274His or p.His213Tyr variants. Indeed, DPP6 modulates Nav1.5 channels in CHO cells by reducing INa Peak and INa Late, whereas DPP6 mutants p.Arg274His or p.His213Tyr resulted in an increase of both components compared to WT. Co-immunoprecipitation experiments in human endocardium confirmed an interaction between DPP6 and Nav1.5 channels. Computing of mutant DPP6-driven Ito-INa changes in a published human PC model led to significant prolongation of the action potential duration, mainly caused by increased INa Late.

On the other hand, the DPP6 p.Gln526His and p.Ala751Val variants, linked to BrS, led to a decreased INa Peak compared to the WT, while there was a tendency towards increased Ito density in both PC and VM molecular setups.

DPP6 (p.Arg274His and p.Ala751Val) transfection experiments in hiPSC cardiomyocytes, expressing endogenous INa and Ito, confirmed the reciprocal results obtained in CHO cells.

Conclusions

DPP6 regulates INa and Ito in a reciprocal manner. The cardiac phenotype of DPP6 variants could encompass a spectrum between two opposite poles: 1) QT/QU prolongation by DPP6 variants causing loss of Ito and gain of INa, like p.Arg274His and p.His213Tyr versus 2) BrS by DPP6 variants leading to gain of Ito and loss of INa, like p.Gln526His and p.Ala751Val.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): ESC Personal research grant, obtained in 2019

It's not just a phase: Investigating text simplification in a second language from a process and product perspective

Text simplification involves making texts easier to understand, usually for lay readers. Simplifying texts is a complex task, especially when conducted in a second language. The readability of the produced texts and the way in which authors manage the different phases of the text simplification process are influenced by their writing expertise and by their language proficiency. Training on audience awareness can be beneficial for writers, but most research so far has devoted attention to first-language writers who simplify their own texts. Therefore, this study investigated the impact of text simplification training on second-language writers (university students) who simplify already existing texts. Specifically, after identifying a first and a second phase in the text simplification process (namely, two distinct series of writing dynamics), we analyzed the impact of our training on pausing and revision behavior across phases, as well as levels of readability achieved by the students. Additionally, we examined correlations between pausing behavior and readability by using keystroke logging data and automated text analysis. We found that phases of text simplification differ along multiple dimensions, even though our training did not seem to influence pausing and revision dynamics. Our training led to texts with fewer and shorter words, and with syntactically simpler sentences. The correlation analysis showed that longer and more frequent pauses at specific text locations were linked with increased readability in the same or adjacent text locations. We conclude the paper by discussing theoretical, methodological, and pedagogical implications, alongside limitations and areas for future research.

The Botanical Drug PBI-05204, a Supercritical CO2 Extract of Nerium Oleander, Is Synergistic With Radiotherapy in Models of Human Glioblastoma

Glioblastoma multiforme (GBM) is the most common as well as one of the most malignant types of brain cancer. Despite progress in development of novel therapies for the treatment of GBM, it remains largely incurable with a poor prognosis and a very low life expectancy. Recent studies have shown that oleandrin, a unique cardiac glycoside from Nerium oleander, as well as a defined extract (PBI-05204) that contains this molecule, inhibit growth of human glioblastoma, and modulate glioblastoma patient-derived stem cell-renewal properties. Here we demonstrate that PBI-05204 treatment leads to an increase in vitro in the sensitivity of GBM cells to radiation in which the main mechanisms are the transition from autophagy to apoptosis, enhanced DNA damage and reduced DNA repair after radiotherapy (RT) administration. The combination of PBI-05204 with RT was associated with reduced tumor progression evidenced by both subcutaneous as well as orthotopic implanted GBM tumors. Collectively, these results reveal that PBI-05204 enhances antitumor activity of RT in preclinical/murine models of human GBM. Given the fact that PBI-05204 has already been examined in Phase I and II clinical trials for cancer patients, its efficacy when combined with standard-of-care radiotherapy regimens in GBM should be explored.

ATX-101, a Peptide Targeting PCNA, Has Antitumor Efficacy Alone or in Combination with Radiotherapy in Murine Models of Human Glioblastoma

Cell proliferation requires the orchestrated actions of a myriad of proteins regulating DNA replication, DNA repair and damage tolerance, and cell cycle. Proliferating cell nuclear antigen (PCNA) is a master regulator which interacts with multiple proteins functioning in these processes, and this makes PCNA an attractive target in anticancer therapies. Here, we show that a cell-penetrating peptide containing the AlkB homolog 2 PCNA-interacting motif (APIM), ATX-101, has antitumor activity in a panel of human glioblastoma multiforme (GBM) cell lines and patient-derived glioma-initiating cells (GICs). Their sensitivity to ATX-101 was not related to cellular levels of PCNA, or p53, PTEN, or MGMT status. However, ATX-101 reduced Akt/mTOR and DNA-PKcs signaling, and a correlation between high Akt activation and sensitivity for ATX-101 was found. ATX-101 increased the levels of γH2AX, DNA fragmentation, and apoptosis when combined with radiotherapy (RT). In line with the in vitro results, ATX-101 strongly reduced tumor growth in two subcutaneous xenografts and two orthotopic GBM models, both as a single agent and in combination with RT. The ability of ATX-101 to sensitize cells to RT is promising for further development of this compound for use in GBM.

Multiple Antitumor Molecular Mechanisms Are Activated by a Fully Synthetic and Stabilized Pharmaceutical Product Delivering the Active Compound Sulforaphane (SFX-01) in Preclinical Model of Human Glioblastoma

Frequent relapses and therapeutic resistance make the management of glioblastoma (GBM, grade IV glioma), extremely difficult. Therefore, it is necessary to develop new pharmacological compounds to be used as a single treatment or in combination with current therapies in order to improve their effectiveness and reduce cytotoxicity for non-tumor cells. SFX-01 is a fully synthetic and stabilized pharmaceutical product containing the α-cyclodextrin that delivers the active compound 1-isothiocyanato-4-methyl-sulfinylbutane (SFN) and maintains biological activities of SFN. In this study, we verified whether SFX-01 was active in GBM preclinical models. Our data demonstrate that SFX-01 reduced cell proliferation and increased cell death in GBM cell lines and patient-derived glioma initiating cells (GICs) with a stem cell phenotype. The antiproliferative effects of SFX-01 were associated with a reduction in the stemness of GICs and reversion of neural-to-mesenchymal trans-differentiation (PMT) closely related to epithelial-to-mesenchymal trans-differentiation (EMT) of epithelial tumors. Commonly, PMT reversion decreases the invasive capacity of tumor cells and increases the sensitivity to pharmacological and instrumental therapies. SFX-01 induced caspase-dependent apoptosis, through both mitochondrion-mediated intrinsic and death-receptor-associated extrinsic pathways. Here, we demonstrate the involvement of reactive oxygen species (ROS) through mediating the reduction in the activity of essential molecular pathways, such as PI3K/Akt/mTOR, ERK, and STAT-3. SFX-01 also reduced the in vivo tumor growth of subcutaneous xenografts and increased the disease-free survival (DFS) and overall survival (OS), when tested in orthotopic intracranial GBM models. These effects were associated with reduced expression of HIF1α which, in turn, down-regulates neo-angiogenesis. So, SFX-01 may have potent anti-glioma effects, regulating important aspects of the biology of this neoplasia, such as hypoxia, stemness, and EMT reversion, which are commonly activated in this neoplasia and are responsible for therapeutic resistance and glioma recurrence. SFX-01 deserves to be considered as an emerging anticancer agent for the treatment of GBM. The possible radio- and chemo sensitization potential of SFX-01 should also be evaluated in further preclinical and clinical studies.

Romidepsin (FK228) fails in counteracting the transformed phenotype of rhabdomyosarcoma cells but efficiently radiosensitizes, in vitro and in vivo, the alveolar phenotype subtype

PURPOSE

Herein we describe the in vitro and in vivo activity of FK228 (Romidepsin), an inhibitor of class I HDACs, in counteracting and radiosensitizing embryonal (ERMS, fusion-negative) and alveolar (ARMS, fusion-positive) rhabdomyosarcoma (RMS).

METHODS

RH30 (ARMS, fusion-positive) and RD (ERMS, fusion-negative) cell lines and human multipotent mesenchymal stromal cells (HMSC) were used. Flow cytometry analysis, RT-qPCR, western blotting and enzymatic assays were performed. Irradiation was delivered by using an x-6 MV photon linear accelerator. FK228 (1.2 mg/kg) in vivo activity, combined or not with radiation therapy (2 Gy), was assessed in murine xenografts.

RESULTS

Compared to HMSC, RMS expressed low levels of class I HDACs. In vitro, FK228, as single agents, reversibly downregulated class I HDACs expression and activity and induced oxidative stress, DNA damage and a concomitant growth arrest associated with PARP-1-mediated transient non-apoptotic cell death. Surviving cells upregulated the expression of cyclin A, B, D1, p27, Myc and activated PI3K/Akt/mTOR and MAPK signaling, known to be differently involved in cancer chemoresistance. Interestingly, while no radiosensitizing effects were detected, in vitro or in vivo, on RD cells, FK228 markedly radiosensitized RH30 cells by impairing antioxidant and DSBs repair pathways in vitro. Further, FK228 when combined with RT in vivo significantly reduced tumor mass in mouse RH30 xenografts.

CONCLUSION

FK228 did not show antitumor activity as a single agent whilst its combination with RT resulted in radiosensitization of fusion-positive RMS cells, thus representing a possible strategy for the treatment of the most aggressive RMS subtype.

The Botanical Drug PBI-05204, a Supercritical CO2 Extract of Nerium Oleander, Inhibits Growth of Human Glioblastoma, Reduces Akt/mTOR Activities, and Modulates GSC Cell-Renewal Properties

Glioblastoma multiform (GBM) is the most common primary glial tumor resulting in very low patient survival despite current extensive therapeutic efforts. Emerging evidence suggests that more effective treatments are required to overcome tumor heterogeneity, drug resistance and a complex tumor-supporting microenvironment. PBI-05204 is a specifically formulated botanical drug consisting of a modified supercritical C0₂ extract of Nerium oleander that has undergone both phase I and phase II clinical trials in the United States for treatment of patients with a variety of advanced cancers. The present study was designed to investigate the antitumor efficacy of this botanical drug against glioblastoma using both in vitro and in vivo cancer models as well as exploring efficacy against glioblastoma stem cells. All three human GBM cell lines, U87MG, U251, and T98G, were inhibited by PBI-05204 in a concentration dependent manner that was characterized by induction of apoptosis as evidenced by increased ANNEXIN V staining and caspase activities. The expression of proteins associated with both Akt and mTOR pathway was suppressed by PBI-05240 in all treated human GBM cell lines. PBI-05204 significantly suppressed U87 spheroid formation and the expression of important stem cell markers such as SOX2, CD44, and CXCR4. Oral administration of PBI-05204 resulted in a dose-dependent inhibition of U87MG, U251, and T98G xenograft growth. Additionally, PBI-05204–treated mice carrying U87-Luc cells as an orthotropic model exhibited significantly delayed onset of tumor proliferation and significantly increased overall survival. Immunohistochemical staining of xenograft derived tumor sections revealed dose-dependent declines in expression of Ki67 and CD31 positive stained cells but increased TUNEL staining. PBI-05204 represents a novel therapeutic botanical drug approach for treatment of glioblastoma as demonstrated by significant responses with in vivo tumor models. Both in vitro cell culture and immunohistochemical studies of tumor tissue suggest drug induction of tumor cell apoptosis and inhibition of PI3k/mTOR pathways as well as cancer stemness. Given the fact that PBI-05204 has already been examined in phase I and II clinical trials for cancer patients, its efficacy when combined with standard of care chemotherapy and radiotherapy should be explored in future clinical trials of this difficult to treat brain cancer.

Clinically relevant radioresistant rhabdomyosarcoma cell lines: functional, molecular and immune-related characterization

BACKGROUND

The probability of local tumor control after radiotherapy (RT) remains still miserably poor in pediatric rhabdomyosarcoma (RMS). Thus, understanding the molecular mechanisms responsible of tumor relapse is essential to identify personalized RT-based strategies. Contrary to what has been done so far, a correct characterization of cellular radioresistance should be performed comparing radioresistant and radiosensitive cells with the same isogenic background.

METHODS

Clinically relevant radioresistant (RR) embryonal (RD) and alveolar (RH30) RMS cell lines have been developed by irradiating them with clinical-like hypo-fractionated schedule. RMS-RR cells were compared to parental isogenic counterpart (RMS-PR) and studied following the radiobiological concept of the "6Rs", which stand for repair, redistribution, repopulation, reoxygenation, intrinsic radioresistance and radio-immuno-biology.

RESULTS

RMS-RR cell lines, characterized by a more aggressive and in vitro pro-metastatic phenotype, showed a higher ability to i) detoxify from reactive oxygen species; ii) repair DNA damage by differently activating non-homologous end joining and homologous recombination pathways; iii) counteract RT-induced G2/M cell cycle arrest by re-starting growth and repopulating after irradiation; iv) express cancer stem-like profile. Bioinformatic analyses, performed to assess the role of 41 cytokines after RT exposure and their network interactions, suggested TGF-β, MIF, CCL2, CXCL5, CXCL8 and CXCL12 as master regulators of cancer immune escape in RMS tumors.

CONCLUSIONS

These results suggest that RMS could sustain intrinsic and acquire radioresistance by different mechanisms and indicate potential targets for future combined radiosensitizing strategies.

Recommandations Formalisées d’Experts SRLF/SFMU : Prise en charge des états de mal épileptiques en préhospitalier, en structure d’urgence et en réanimation dans les 48 premières heures (A l’exclusion du nouveau-né et du nourrisson)

La Société de réanimation de langue française et la Société française de médecine d’urgence ont décidé d’élaborer de nouvelles recommandations sur la prise en charge de l’état mal épileptique (EME) avec l’ambition de répondre le plus possible aux nombreuses questions pratiques que soulèvent les EME : diagnostic, enquête étiologique, traitement non spécifique et spécifique. Vingt-cinq experts ont analysé la littérature scientifique et formulé des recommandations selon la méthodologie GRADE. Les experts se sont accordés sur 96 recommandations. Les recommandations avec le niveau de preuve le plus fort ne concernent que l’EME tonico-clonique généralisé (EMTCG) : l’usage des benzodiazépines en première ligne (clonazépam en intraveineux direct ou midazolam en intramusculaire) est recommandé, répété 5 min après la première injection (à l’exception du midazolam) en cas de persistance clinique. En cas de persistance 5 min après cette seconde injection, il est proposé d’administrer la seconde ligne thérapeutique : valproate de sodium, (fos-)phénytoïne, phénobarbital ou lévétiracétam. La persistance avérée de convulsions 30 min après le début de l’administration du traitement de deuxième ligne signe l’EMETCG réfractaire. Il est alors proposé de recourir à un coma thérapeutique au moyen d’un agent anesthésique intraveineux de type midazolam ou propofol. Des recommandations spécifiques à l’enfant et aux autres EME sont aussi énoncées.

P933Novel missense variant in DPP6 in familial ventricular fibrillation

Funding Acknowledgements

This work was supported by an ESC Research Grant to A.R., and by The Netherlands CardioVascular Research Initiative (CVON PREDICT2), Den Haag, The N

Background

The DPP6 gene, encoding dipeptidyl aminopeptidase-like protein-6, has been associated with familial ventricular fibrillation (VF) and early repolarization. The DPP6 protein is part of the macromolecular Ito-channel complex and functionally expressed in ventricular myocytes (VM) and Purkinje cells (PC). Here we report a novel missense variant in DPP6 identified in a family with sudden cardiac death/arrest due to VF.

Purpose

To examine the consequences of the novel DPP6 variant c.821G > A, p.(R274H) for cardiac Ito and their potential contribution to a VF substrate.

Methods: Clinical

Co-segregation of DPP6-R274H with major adverse cardiac events in the family members was investigated. Ambulatory ECGs, echocardiograms, exercise tests and ICD recordings were systematically analyzed.

Cellular

Chinese hamster ovary cells were transiently transfected with Ito α and β subunits in order to mimic the VM (Kv4.3 + KChIP2) or the PC phenotype (Kv4.3 + NCS1). Additionally, DPP6 wild type (WT) or variant was transfected. Ito was assessed by patch clamping.

Results: Clinical

DPP6-R274H, affecting a conserved region in the extracellular protein domain segregated with an autosomal dominant pattern of inheritance. The female index patient experienced first VF at 17 years, and subsequent ICD therapy, after her brother had died suddenly at 13 years. Both carriers were also known with mitral-valve prolapse (MVP), but otherwise without structural heart disease. A third sibling without arrhythmia, but with mild MVP, did not carry the DPP6 variant. No other pathogenic mutations were found by next generation sequencing in the index patient. ECGs of the index patient revealed dynamic early repolarization, U waves with varying amplitudes and pause-dependent prominence, and >8000/24 h superimposed premature ventricular complexes (PVCs) and (non)sustained VT. PVCs (QRS duration 120 ms) displayed both a left posterior (80%) and anterior (20%) fascicular origin. PVC burden was higher during daytime and exercise, with pause-dependent occurrence.

Cellular

In the PC model DPP6-R274H markedly decreased Ito density (at +30 mV: 291 pA/pF vs 995 pA/pF in WT; p < 0.001), whereas it did not in the VM model. In VM, but not in PC, Ito inactivation was slowed by the variant (Tau at 0 mV: 91 ms vs 49 ms in WT; p < 0.001).

Conclusions

The novel DPP6 variant R274H has differential effects on Ito in cellular models of VM versus PC. Our main finding of a loss-of-function in the PC model combined with a slowed Ito inactivation in the VM phenotype may exaggerate electrical heterogeneity, especially at the PC-VM junction. Ito loss in PC would prolong action-potential duration and promote early afterdepolarizations, consistent with the dynamic patterns of T-U-dispersion and (fascicular) ectopy in the index case. Mechano-electric influences by the MVP further promote arrhythmogenesis.

Diagnosis and First-Line Treatment of Patients with Lung Cancer in Italian General Hospitals

The quality of diagnostic and therapeutic care was examined in a series of 380 consecutive newly diagnosed cases of primary lung cancer seen in 20 Italian general hospitals between January and June 1987. At diagnosis most patients (78%) had one or more symptoms related to the tumor, and in an additional 9 % symptoms were related to the presence of distant metastases. The median diagnostic time lag between first symptoms and final diagnosis was 50 days with a significantly longer delay in patients first seen by their general practitioner compared with those who sought first care in hospital outpatient departments. The diagnostic process was satisfactorily carried out in fewer than two-thirds of the patients leading to complete ascertainment of disease stage and histology in 58% cases with significantly better performance in more specialized institutions. Analysis of the first-line treatment profile indicated a rather aggressive therapeutic attitude In the case of patients with non-small cell lung cancer – 28% of them had chemotherapy despite the lack of any proof of efficacy in controlled clinical trials – and a failure to identify among the patients with small cell disease those amenable to more aggressive treatment. The lack of progress in the treatment of lung cancer over the last decades seems to have resulted in widely varying practice patterns where a mixture of aggressive and laissez-faire attitudes does not take into account that in the absence of effective therapies a more conservative attitude would at least have some advantage in terms of quality of remaining life for many patients.

Fibroblast proliferation over dialysis membrane: an experimental model for “tissue” biocompatibility evaluation

The present study reports on a biological model based on fibroblast proliferation applied to 3 different types of flat-plate dialysis membrane, in order to ascertain whether the artificial materials currently used in hemodialysis cause in vitro cellular proliferation. The study plan we followed involved plate membrane isolation from non-used dialyzers and used dialyzers, observed through scanning electron microscopy (SEM) both before and after testing with human fibroblasts by means of cell culture. Fibroblast growth was assessed by phase contrast light microscopy examination and cytometric DNA content evaluation. Our investigations proved that the artificial materials we considered interact with fibroblast cultures. Noticeable proliferative response was observed both after contact with unused material and on mediation by the protein layer absorbed on the membrane surface at the end of dialysis sessions. In this last case fibroblast proliferative activity appeared higher than that observed with unused membranes, showing that the soluble molecules entrapped in the protein layer appeared able to exert a biological activity even in in vitro tests

Prognostic Factors for Enteroatmospheric Fistula in Open Abdomen Treated with Negative Pressure Wound Therapy: a Multicentre Experience

BACKGROUND

Reductions in mortality were reported with negative pressure wound therapy for laparostomy. However, some authors have voiced concern over an increased risk of enteroatmospheric fistulae. In this retrospective study, we hypothesized that surgical and metabolic derangements could increase the incidence of enteroatmospheric fistulae. We aimed to assess our experience and report long-term outcomes.

METHODS

A multicentre review of all patients with a laparostomy managed with negative pressure wound therapy between 2005 and 2015 was undertaken. Features associated with enteroatmospheric fistulae were included in multivariate logistic regression.

RESULTS

Fifty-seven patients were treated according to uniform protocol. Fourteen per cent (8/57) presented enteroatmospheric fistulae. Mesenteric ischaemia and preoperative arterial serum lactate >3.5 mmol/L were associated with a significantly increased risk of enteroatmospheric fistulae. Preoperative arterial serum lactate >3.5 mmol/L was an independent predictor of enteroatmospheric fistulae with an odds ratio of 12.41 (95% CI 1.54-99.99). All mesenteric ischaemia patients with anastomosis (5/15) presented enteroatmospheric fistulae. In-hospital mortality was 26.3% (15/57). One-year mortality was 33.3% (19/57). Incisional hernia rate was 5.2% (2/38) after 14.2 (2.4-56.3) months of follow-up.

DISCUSSION

Mesenteric ischaemia increases the risk of enteroatmospheric fistulae. Anastomosis should only be created in revascularized patients. When mesenteric vascularization is not restored, diversion is advised.

Diagnosis and treatment of lymph node metastases of a rectal carcinoid tumor using In111-octreotide-scintigraphy and intraoperative gamma probe detection

Carcinoids represent 1-2% of the rectal cancer. We report the case of a woman with a rectal carcinoid and a hypogastric node metastasis. We propose a less invasive treatment of the metastase using In11-octreotide-scintigraphy and intraoperative gamma-probe detector.

Aminoterminal B-type natriuretic peptide (NT-proBNP) in the therapy of patent ductus arteriosus

BACKGROUND

NT-proBNP is a reliable index in case of cardiac diseases.

OBJECTIVE

To evaluate the diagnostic usefulness of NT-proBNP as index of the closure of patent ductus arteriosus (PDA) in ELBW.

METHODS

Considered 73 ELBW (mGA 26+3 weeks; mBW 789 g) with echocardiographical diagnosis of PDA. The closure of the duct was spontaneous in 22%, pharmacological in 49.3% and by surgical ligation in 28.7%. Plasma NT-proBNP levels were measured on day 3 in 35 preterm infants; in 20 of them concentrations of the peptide were assayed on day 3 and on closure of the duct.

RESULTS

On day 3 the median of NT-proBNP levels was 13718 pg/ml (range 1918-70000). Peptide concentrations did not differ between pharmacological treatment and surgical ligation (respectively 13718 and 12342 pg/ml; p = 0.33). Concentrations of NT-proBNP were significantly lower on the closure of the duct (p < 0.0001) compared to concentrations on day 3 (median 12666 at day 3 versus 2443.5 pg/ml at closure), with a decrease of 80.71%.

CONCLUSIONS

ELBW showed high variability of NT-proBNP concentrations both on day 3 and on closure of PDA. Although NT-proBNP high levels were indicative of the presence of hsPDA, due to the extreme heterogeneity of the values it was not possible to determine an absolute cut-off concentration of NT-proBNP below which closure of the duct occurred, while a decrease of NT-proBNP > or =80% was a reliable index of PDA closure.

Outbreak of Bacterial Blossom Blight Caused by Pseudomonas viridiflava on Actinidia chinensis Kiwifruit Plants in Italy

During the springs from 2006 to 2008, a new disease was observed on 4- to 5-year-old Actinidia chinensis (cv. Jin Tao) trees in different commercial kiwifruit-production areas in northern Italy (Lombardy). Initially, disease occurrence was sporadic but later became widespread. Symptoms on flowers appeared as a dark brown rot of anthers, filaments, sepals, and whole buds. Blossoms abscised prematurely from buds. Symptoms appeared as confluent brown spots often present on rolled margins. Bacteria were isolated from symptomatic tissue on nutrient agar medium supplemented with 5% sucrose. The isolated bacteria were aerobic; produced a diffusible fluorescent pigment on King's B medium; levan, oxidase, and arginine dihydrydrolase negative, and catalase positive; rotted potato tuber tissue; caused a hypersensitive response on tobacco; and failed to reduce nitrate or utilize sucrose and were ice nuclease-positive at -5°C, suggesting the organism was P. viridiflava (1,3). Inoculation of 2-year-old A. chinensis cv. Jin Tao plants were carried out in the greenhouse under controlled environmental conditions (15 to 27°C, night/day; relative humidity up to 70%) by spraying five plants in bloom with a suspension (1 × 10⁸ CFU/ml) of isolated bacteria with a hand-held sprayer that produced large spray droplets. Symptoms, similar to those in nature, were observed on flowers and buds 3 to 5 days after inoculation and on leaves after 7 to 10 days. Using the same tests described above with the original strains, the strains that were isolated from symptomatic tissue were identified as Pseudomonas viridiflava. Seven bacterial strains (PV508-PV1108) were identified by sequencing 1,481 bp of their 16S rDNA region (2) and using BlastN (4) for the most similar sequences in the INSD (GenBank, EMBL, and DDBJ). Our sequences shared 99.53% (1,474 of 1,481 bp) to 99.9% (1480 of 1,481 bp) identity with the analogous sequences of P. viridiflava available in the database. To our knowledge, this is the first report of an outbreak of blossom blight caused by P. viridiflava on A. chinensis cv. Jin Tao kiwifruit plants in Italy. Previously, it was reported on A. deliciosa cv. Hayward (3). Because of the risk of bacterial contamination among the different cultivars of kiwifruit, further investigation and development of control measures are in progress. References: (1) R. A. Lelliott and D. E. Stead. Methods for the Diagnosis of Bacterial Diseases of Plants. Blackwell Scientific, Oxford, UK, 1987. (2) E. R. B. Moore et al. Syst. Appl. Microbiol. 19:478, 1996. (3) L. Varvaro et al. Inf. Fitopatol. 6:49, 1990. (4) Z. Zhang et al. J. Comput. Biol. 7(1-2):203, 2000.

Susceptibility trends of Bacteroides fragilis group isolates from Buenos Aires, Argentina

The aim of this study was to analyze the susceptibility trends to seven antibiotics of Bacteroides fragilis group isolates based on three survey studies performed by the Committee of Anaerobic Bacteria between 1989 and 2002. Fifty three, 82 and 65 B. fragilis group isolates were collected during each period. The antimicrobial agents included were: ampicillin, ampicillin-sulbactam (2:1), cefoxitin, piperacillin, imipenem, clindamycin, and metronidazole. Minimal inhibitory concentrations (MICs) were determined according to the reference agar dilution method described by the Clinical and Laboratory Standards Institute (CLSI, formerly NCCLS). The most active antibiotics for B. fragilis and non-B. fragilis species throughout the three periods were: imipenem with 99.1 and 100% of activity, respectively, and metronidazole with 100% of activity. The susceptibility to ampicillin-sulbactam showed a decrease, from 100% to 90.3% and to 82.4 % in the last period, for both B. fragilis and non-B. fragilis species, respectively. The overall susceptibility rates for cefoxitin, piperacillin, and clindamycin were significantly different between B. fragilis and non-B. fragilis species (84.2% vs. 56.5%; 85.9% vs. 66.7% and 88.8% vs. 64.7%, respectively, p < 0.05). Cefoxitin was the antibiotic that showed more variations as regards periods and species. The susceptibility rates for clindamycin were low, about 60%, for non-B. fragilis species during the last two periods. The variations observed in the susceptibility patterns of the B. fragilis group isolates emphasize the need to continue monitoring the emergence of resistance in order to guide the election of the most appropriate antibiotic therapy scheme for anaerobic infections.

Pregnancy in immigrant women

OBJECTIVE

We wanted to study how foreign women face pregnancy and childbirth in a society quite different from their own.

METHODS

In 2004 we studied 328 pregnant women at the Department of Gynaecology at the "General Hospital Umberto I" in Rome. Information on patients' personal lives and experiences was collected.

RESULTS

Women were classified into six (6) groups based on nationality, race, religion and culture.

CONCLUSIONS

Arabian women had the most natural childbirths. African women had a longer duration of gestation. Women from Eastern Europe underwent frequent tests and examinations, but had the highest chance of having preterm births. Chinese women did not usually undergo many examinations and were able to tolerate pain during childbirth quite well.

["In vitro" activity of ten antimicrobial agents against anaerobic bacteria. A collaborative study, 1999-2002]

The antimicrobial activity of ampicillin, ampicillin-sulbactam, cefoxitin, ceftriaxone, imipenem, piperacillin, piperacillin-tazobactam, clindamycin, metronidazole, and azitromycin was assesed against 166 strains of anaerobic bacteria recovered from eight hospitals in Buenos Aires. The strains studied were Bacteroides fragilis group (65), Fusobacterium spp. (26), Prevotella spp. (21), Porphyromonas spp. (10), Clostridium difficile (10), other clostridia (12), and gram-positive cocci (22). The MICs were determined by the agar dilution method according to NCCLS document M11-A5. Metronidazole and piperacillin-tazobactam were the most active antimicrobial agents tested and exhibited MIC90 values of < or = 2 microg/ml and < or = 4 microg/ml against gram-negative organisms, and < or = 2 microg/ml, and < or = 8 microg/ml against gram-positive organisms, respectively. Among beta-lactams the activity against gram-negative rods was in the following order: imipenem > piperacillin > cefoxitin > ceftriaxone > ampicillin. Among the gram-positive bacteria the decreased activity was: piperacillin > imipenem > cefoxitin > ceftriaxone > ampicillin. The majority of the species studied showed different degrees of resistance to clindamycin and azitromycin. Nevertheless, 90% of Fusobacterium nucleatum and Porphyromonas spp. isolates were inhibited by 0.125 mg/ml of clindamycin and azitromycin, respectively.

Assessment of inhaled BDP-dose dependency of exhaled nitric oxide and local and serum eosinophilic markers in steroids-naive nonatopic asthmatics

The aim of the present study was to assess the dose-dependency from inhaled steroids of changes of airways inflammation [eosinophils count and eosinophil cationic protein (ECP)] measures in induced sputum and in serum, as well as that of exhaled nitric oxide. Twenty steroid-naive patients with nonatopic asthma of mild to moderate degree [forced expiratory volume in 1 s (FEV1) = 70% of predicted] and with negative response to the standard tests for allergy were selected; after a 1-week run-in period they were randomized to receive a 12-week treatment period of inhaled beclomethasone dipropionate dry powder given with the Pulvinal inhaler (Clenil P, Chiesi Farmaceutici S.p.A., Parma, Italy) in two different dose regimens, 400 microg bid (high dose) or 200 microg bid (low dose), over a double blind, parallel groups design. The following outcome measures were assessed in baseline and after 1, 6 and 12 weeks of treatment: FEV1 (l), eosinophils count in sputum (%), is ECP (microg/l), serum eosinophils count (%), serum ECP (microg/l) and exhaled NO (ppb). The results showed that all the considered parameters improved in both groups: the increase over baseline of FEV1 and the decrease of NO were significant at any time in the high-dose group and only at week 12 in the low-dose group (NS between groups), whereas the markers of eosinophilic activity showed more consistent reductions in the high-dose than in the low-dose group when measured in induced sputum (P < 0.05 between groups after 6 and 12 weeks for eosinophils count and after 12 weeks for ECP). Decreases over baseline of markers measured in serum were more rapid in the high-dose group, without differences between groups. A marked trend towards a negative correlation was found between FEV1 and ECP, (r = -0.72, P < 0.05), between FEV1 and eosinophils in sputum (r = -0.31, NS) and between FEV1 and exhaled NO (r = -0.38, NS), all of them only in the high-dose group. The results of the study demonstrate that changes of levels of eosinophilic activity in the airways are dependent from the daily dose of inhaled steroids when measured in induced sputum and that the local assessment can therefore represent a practical and noninvasive method to monitor the extent of airways inflammation.

Effects on lung function, symptoms, and bronchial hyperreactivity of low-dose inhaled beclomethasone dipropionate given with HFA-134a or CFC propellant

The aim of this study was to compare the efficacy of BDP 200 microg bid via metered dose inhaler, using HFA-134a (Chiesi Farmaceutici S.p.A., Parma, Italy) versus CFC (Becotide, Allen & Hanburys, U.K.) as a propellant. 172 adult patients (86 in each group) with stable mild persistent asthma who completed a 7-day run-in period were randomized to receive a 6-week treatment in a double-blind, double dummy, parallel-group design; 164 patients completed the study. Morning and evening PEFR, use of rescue salbutamol, number of day-time and night-time asthma attacks, number of night-time awakenings and clinical symptoms were recorded daily on a diary card. Pulmonary function tests (FEV(1), FVC, PEFR, and MEF(50)) were measured at the clinic before and after the 1-week run-in period, and after 3 and 6 weeks of treatment. A challenge test with inhaled methacholine was completed at baseline and at the end of the treatment period to assess potential bronchial hyper-reactivity in a subgroup of subjects (n = 65; 34 HFA, 31 CFC). In accordance with asthma of mild severity (FEV(1) predicted over 90% in both groups), a small improvement in lung function compared to baseline was seen for both treatments, significantly for FEV(1) in BDP HFA and MEF(50) in both groups. The two formulations of BDP had similar efficacy for the primary outcome variable morning PEFR (ITT population mean difference 5.8 L/min; C.I. -4.9 to +16.5) as well as for the secondary outcomes of evening PEFR and clinic FEV(1). There were small improvements in methacholine PD(20) and PC20 in both groups, with no significant difference between treatments. A total of 22 and 19 drug-related adverse events were reported in the BDP HFA and CFC groups, respectively; most events were of seasonal nature or were local effects due to the use of inhaled corticosteroids. It can be concluded that the newly developed formulation of BDP given via HFA-134a seems to provide similar asthma control, compared with the same low daily dose of the active drug delivered via CFC. Further studies are needed using higher doses in moderate to severe asthma to confirm these preliminary findings.

Equivalent efficacy and safety of a new HFA-134a formulation of BDP compared with the conventional CFC in adult asthmatics

The present study demonstrates the equivalent efficacy for BDP 500 microg bid given via MDI with the new HFA-134a propellant (Chiesi Farmaceutici S.p.A., Parma) compared to a conventional CFC propellant (Becotide, Allen & Hanburys, UK). One hundred and sixteen adult patients with stable mild to moderate asthma (FEV1 > or = 60% of predicted normal) entered a 2-week run-in period where they maintained their own inhaled corticosteroids and were then assigned to a 12-week treatment with the test drug in a randomized, multicentre, double-blind, double-dummy, parallel-group design. Ninety-one patients completed the study period. Morning and evening peak expiratory flow rate (PEFR), use of rescue salbutamol, number of daytime and nighttime asthma attacks, number of nighttime awakenings, and clinical symptoms were recorded daily by patients on a diary card. Pulmonary function tests (FEV1, FVC, PEFR, MEF50 and FEF25) were completed at study entry, at the start of treatment and every 2 weeks thereafter. Morning (08.00-10.00 AM) serum cortisol was measured at the start and at the end of treatment. Adverse events were collected for the total study period. Equivalence between groups was demonstrated for the primary end-point morning PEFR, as well as for evening PEFR and FEV1 (the 95% CI of the treatments' difference was within the 5% of the LSM of BDP CFC). The other secondary pulmonary function tests measured at the clinic visit showed a satisfactory asthma control, albeit without statistically significant differences between groups. Decreases in the use of rescue salbutamol and in clinical symptoms were also reported in both groups, with no differences between them. Adverse events were reported in 81.4% of patients in the BDP HFA group and in 82.5% in the CFC group. There were 73 and 59 adverse drug reactions in the two groups, respectively; the difference was mainly due to differences in taste. No drug-related serious adverse events were reported in either group. No difference was seen for morning serum cortisol between baseline and end of treatment, or between groups. In conclusion, the BDP-HFA 134a formulation proved to be statistically equivalent to the standard BDP CFC product over 12 weeks in adult patients with mild to moderate asthma.

Comparison of once- versus twice-daily use of beclomethasone dipropionate aqueous nasal spray in the treatment of allergic and non-allergic chronic rhinosinusitis

The aim of the study was to assess the efficacy and safety of nasal aqueous beclomethasone dipropionate (BDP), 400 micro g/day, given via a metered pump in a once-daily or twice-daily regimen following a double-blind, parallel group design over a 12-week period. Adult patients (n=112) with allergic or non-allergic chronic rhinosinusitis recorded their nasal and ocular symptoms for the 7-day run-in period and for the first 4 weeks of treatment. At baseline and after 4 weeks the airways' resistance via active anterior rhinomanometry and the volume and area section via acoustic rhinometry were measured. Morning serum cortisol was measured at baseline and at week 12. Adverse events were to be reported at each visit. Of the 112 randomised patients, three did not enter the ITT analysis and another 13 in total discontinued the treatment. Significant improvements over the baseline were reported in both groups for the primary variable sum of nasal scores (-53.7% in the once-daily group and -59.7 in the twice-daily group), as well as for each nasal and ocular symptoms, without differences between the groups. Because of a wider variability than expected, the 95% confidence interval (C.I.) for the difference between the least square means exceeded the pre-defined limit of +/-10% of the reference mean. Similar improvements in both groups were also reported for the nasal airway patency's parameters. The total number of drug-related adverse events was 26 in the once-daily group and 32 in the twice-daily group, with most of the events consisting of local effects at the site of application. No signs of adrenal suppression were observed, and serum morning cortisol values did not significantly change. The once-daily BDP dosing (400 micro g/day) therefore has a similar efficacy and safety profile as the same daily dose given in a twice-daily regimen.

The reversed ipsilateral acoustic reflex: clinical features and kinetic analysis

OBJECTIVE

The reversed ipsilateral acoustic reflex (RIAR) has been the subject of few studies in the past literature and the nature of this "reflex" response is not yet completely understood. It can be observed in different diseases, all of which result from inactivity of the stapedial reflex (SR). We aimed to investigate the occurrence of the RIAR in different diseases.

MATERIAL AND METHODS

An extensive clinical investigation of the RIAR was carried out.

RESULTS

The RIAR was found to be present in 100% of ears lacking an effective SR arc. Its amplitude is modulated by the air pressure level in the external ear canal whilst its sign is constantly positive and never reverses.

CONCLUSION

Kinetic analysis of the RIAR suggests the existence of a single underlying phenomenon while the interaction of the RIAR with the SR may explain the complex morphology frequently observed in the normal ipsilateral acoustic reflex.

A new HFA-134a propellant in the administration of inhaled BDP via the Jet spacer: controlled clinical trial vs the conventional CFC

This study was carried out with the aim of demonstrating the efficacy and tolerability of beclomethasone dipropionate (BDP) aerosol spray 500 microg b.i.d. via a spacer device (Jet, Chiesi Farmaceutici S.p.A.) using a new HFA-134a formulation or chlorofluorocarbon (CFC) propellant. After having completed a 2-week run-in period, 154 adult patients (77 in each group) with mild-to-moderate persistent asthma were randomised into two groups to receive the study treatment for a duration of 12 weeks in a double-blind, multinational, multicentre, parallel-group design. Morning and evening peak expiratory flow rate (PEFR), use of rescue salbutamol, number of day- and night-time asthma attacks, number of night-time awakenings due to asthma and clinical symptoms were recorded daily by patients on diary cards. Pulmonary function tests (FEV1, FVC, PEFR, FEF25-75%, MEF50 and FEF25) and vital signs were measured at the clinic at study entry, at the start of treatment and every 2 weeks thereafter. Morning serum cortisol (8.00-10.00 a.m.) was measured at the start and at the end of the treatment period. Adverse events were recorded throughout the total study period. Significant improvements over baseline were reported in both groups in terms of lung function, symptoms and use of rescue inhaled salbutamol. Equivalence between groups was demonstrated for the primary end-point morning PEFR, as well as for evening PEFR and FEV1. No statistically significant differences in the comparisons between groups, except for FEF25 (P=0.044), were observed in any of the other efficacy variables. Adverse events were reported in 31% of patients in the BDP-HFA group and in 32% in the CFC group. Adverse drug reactions were 4 and 2 in the two groups, respectively. No drug-related serious adverse events were reported in either of the groups. No signs of relevant adrenal suppression were observed in both groups: 2 patients in each group had final values below the normal range. In conclusion, the BDP-HFA-134a formulation proved to be equivalent in efficacy and comparable in safety to the standard BDP-CFC product over 12 weeks in adult patients with mild-to-moderate persistent asthma.

Differences in gene expression in muscle-invasive bladder cancer: a comparison of Italian and American patients

OBJECTIVE

To seek differences in gene expression in the primary muscle-invasive bladder cancers of two cohorts of patients having different survival rates. An Italian group treated by transurethral resection of the bladder tumor (TURBT) and neo-adjuvant chemotherapy using methotrexate, vinblastine, adriamycin and cisplatin (M-VAC) followed by TURBT, partial cystectomy or radical cystectomy (75% 3-year survival) was compared to an American cohort treated by radical cystectomy (51% 3-year survival).

METHODS

Immunohistochemistry was used to examine the protein expression levels of three genes that act at the G1/S cell cycle checkpoint, p53, p21/waf-1/cip1 (a downstream effector gene in the p53 pathway) and Rb, plus a major inhibitor of apoptosis, Bcl-2.

RESULTS

For the bladder cancers of the Italian patient cohort, there was a significantly higher rate of p53 immunopositivity (93 vs. 63%, p = 0.002) and a significantly lower rate of Rb loss (25 vs. 54%, p = 0.009). In bivariate analysis, 72% of Italian tumors were immunopositive for both p53 and p21 (p53+/p21+) vs. 49% for the American tumors. The subset of Italian patients with p53+/p21+ tumors were more frequently disease-free (stage pT0) following chemotherapy and were less likely to fail therapy than those with p53+/p21- tumors (p = 0.0357). Loss of Rb staining was associated with a decreased 5-year survival in the Italian, but not in the American patients.

CONCLUSIONS

(1) Significant differences in the expression of the p53, p21 and Rb genes were found between the 2 groups of patients. (2) Italian patients with p53+/p21+ tumors had significantly lower recurrence rates after TURBT and chemotherapy than those having p53+/p21- tumors. (3) Absence of p21 immunopositivity in the Italian tumors may identify alterations in the p53 pathway that predict poor outcome.

Long-term results of laparoscopic myomectomy: recurrence rate in comparison with abdominal myomectomy

Laparoscopic myomectomy is still a debated procedure and there are conflicting opinions regarding the recurrence rate. Laparoscopic myomectomy may present a higher risk of recurrence compared with abdominal myomectomy. The aim of this investigation was to analyse the recurrence rate of myomas after surgery. From January 1991 to June 1998, 165 myomectomies were performed for symptomatic myomas measuring at least 3 cm in diameter and numbering seven or less per patient. During the first 3 years of this survey, 81 patients were randomized for abdominal or laparoscopic myomectomy. Transvaginal ultrasound examination was performed within 15-30 days of surgery and every 6 months for a post-operative period of 40 months. The two groups had similar pre-operative clinical features and the number and volume of myomas did not differ between the two groups. At the end of the study the group of abdominal myomectomies showed nine recurrences (23%) against 11 (27%) of the laparoscopic group. In order to evaluate the recurrence rate in relation to several risk factors, laparoscopic myomectomies were performed from 1991 in 84 patients who agreed to follow-up (and were not in the randomized group). Of these, 78 patients were evaluated with transvaginal ultrasound for a mean interval of 26 months and 17 (21.78%) recurrences were found. Most recurrences (75%) were seen at ultrasound between 10 and 30 months after surgery. The patient's age, pre- and post-operative gravidity and parity had no influence on recurrence. Neither the number of myomas removed nor the depth of penetration or size were positively associated with the risk of recurrence. However, an associated risk factor was pre-operative gonadotrophin-releasing hormone agonist treatment (P < 0.02). None of the women with recurrence required additional surgery. We conclude that laparoscopic myomectomy is a reliable procedure. The recurrence rate is similar to that seen after abdominal myomectomy.

Fertility outcome: long-term results after laparoscopic myomectomy

From 1991 to 1998, 29 patients desiring a pregnancy underwent laparoscopic myomectomy for symptomatic myomas measuring 5.4 +/- 3.6 cm (mean +/- SD) (median 5; range 1-9). The overall rate of intrauterine pregnancy was 65.5% (19 pregnancies; two patients had two pregnancies each). Results were analyzed in relation to different preoperative clinical conditions. Out of nine patients with other infertility factors associated with uterine myomas, three (33.3%) became pregnant; out of 10 infertile patients with no other associated infertility factors, seven (70%) became pregnant; out of 10 patients to whom myomectomy was performed for the rapid growth of the tumor or for myoma encroaching on the cavity, nine (90%) had a pregnancy. Nine patients (73.4%) had a Cesarean section (one twice), four (26.6%) had spontaneous vaginal delivery, one patient had a serious placental failure at the 28th week, and four patients (19%) miscarried. Two pregnancies are still in progress (one in a patient with previous miscarriage). Out of 21 pregnancies, the viable term delivery rate was 57.14%. No uterine ruptures were observed. The pregnancy rate after laparoscopic myomectomy was similar to that reported in other studies after laparotomic myomectomy. It is concluded that laparoscopic myomectomy is a reliable procedure even in the presence of multiple or enlarged myomas. Moreover, our pregnancy rate and pregnancy outcome seem to indicate that both desire for pregnancy and infertility prior to surgery should not be exclusion criteria for the laparoscopic approach.

Improvement of hysterosalpingographic accuracy in the diagnosis of peritubal adhesions

OBJECTIVE

Our purpose was to compare hysterosalpingography with laparoscopy in the diagnosis of peritubal adhesions and to verify whether a combination of radiographic signs improves hysterosalpingographic accuracy.

SUBJECTS AND METHODS

Thirty candidates for laparoscopy underwent hysterosalpingography before surgery. Two radiologists evaluated the presence or absence and types of radiographic signs of peritubal adhesions (convoluted tubes, vertical tubes, loculation of contrast medium in peritoneum, halo effect, and fixed laterodeviation of the uterus) using two different criteria for normality or abnormality: no sign means a normal result, one or more signs mean an abnormal result (first criterion); no sign or one sign means a normal result, two or more signs mean an abnormal result (second criterion). Interpretation discrepancies were resolved by consensus. Peritubal and periovarian adhesions were evaluated by a single operating surgeon during laparoscopy (recorded on S-VHS videotape) and by a different surgeon reviewing the videotape. The radiographic results obtained using the two criteria in radiologically patent as well as in distally nonpatent tubes were compared with corresponding laparoscopic results by 2 x 2 tables and were statistically analyzed (kappa statistics).

RESULTS

The first criterion displayed poor diagnostic accuracy. The correlation with laparoscopy was not statistically significant in either radiologically patent or distally nonpatent tubes. The second criterion greatly improved the agreement with laparoscopy, but only in patent tubes (kappa = 0.7789; p<0.001).

CONCLUSION

Hysterosalpingographic accuracy in peritubal adhesion diagnosis can be improved in patent tubes by taking into account more than one of the reported radiographic signs.