Demonstrating Agreement between Radio and Fluorescence Measurements of the Depth of Maximum of Extensive Air Showers at the Pierre Auger Observatory

We show, for the first time, radio measurements of the depth of shower maximum (X_{max}) of air showers induced by cosmic rays that are compared to measurements of the established fluorescence method at the same location. Using measurements at the Pierre Auger Observatory we show full compatibility between our radio and the previously published fluorescence dataset, and between a subset of air showers observed simultaneously with both radio and fluorescence techniques, a measurement setup unique to the Pierre Auger Observatory. Furthermore, we show radio X_{max} resolution as a function of energy and demonstrate the ability to make competitive high-resolution X_{max} measurements with even a sparse radio array. With this, we show that the radio technique is capable of cosmic-ray mass composition studies, both at Auger and at other experiments.

Synergism of small molecules targeting VDAC with sorafenib, regorafenib or lenvatinib on hepatocarcinoma cell proliferation and survival

Voltage dependent anion channels (VDAC) in the outer mitochondrial membrane regulate the influx of metabolites that sustain mitochondrial metabolism and the efflux of ATP to the cytosol. Free tubulin and NADH close VDAC. The VDAC-binding small molecules X1 and SC18 modulate mitochondrial metabolism. X1 antagonizes the inhibitory effect of tubulin on VDAC. SC18 occupies an NADH-binding pocket in the inner wall of all VDAC isoforms. Here, we hypothesized that X1 and SC18 have a synergistic effect with sorafenib, regorafenib or lenvatinib to arrest proliferation and induce death in hepatocarcinoma cells. We used colony formation assays to determine cell proliferation, and a combination of calcein/propidium iodide, and trypan blue exclusion to assess cell death in the well differentiated Huh7 and the poorly differentiated SNU-449 cells. Synergism was assessed using the Chou-Talalay method. The inhibitory effect of X1, SC18, sorafenib, regorafenib and lenvatinib was concentration and time dependent. IC50s calculated from the inhibition of clonogenic capacity were lower than those determined from cell survival. At IC50s that inhibited cell proliferation, SC18 arrested cells in G0/G1. SC18 at 0.25-2 IC50s had a synergistic effect with sorafenib on clonogenic inhibition in Huh7 and SNU-449 cells, and with regorafenib or lenvatinib in SNU-449 cells. X1 or SC18 also had synergistic effects with sorafenib on promoting cell death at 0.5-2 IC50s for SC18 in Huh7 and SNU-449 cells. These results suggest that small molecules targeting VDAC represent a potential new class of drugs to treat liver cancer.

Predictive factors of selective transarterial embolization failure in acute renal bleeding: a single-center experience

PURPOSE

Transarterial embolization of renal artery branches (RTE) is a minimally invasive procedure commonly performed in life-threatening renal bleeding of different etiologies. Despite the widespread use of RTE, no consensus guidelines are currently available. Our aim was to investigate clinical and technical efficacy and to identify potential predictors for clinical failure of this procedure.

METHODS

All the RTE procedures performed in our Interventional Radiology unit in last 10 years were retrospectively collected and analyzed. All selected patients underwent both pre-procedural computed tomography angiography (CTA) and post-procedural CTA within 30 days. Clinical success was considered as primary endpoint. Demographic, laboratory, and diagnostic findings predictive of clinical failure of RTE were identified.

RESULTS

Over a total of 51 patients enrolled, 27 (53%) were females and 33 (64.7%) had a renal bleeding of iatrogenic origin. Technical and clinical success was 100% and 80.4%, respectively. Hematoma volumes > 258.5 cm3 measured at CTA, higher pre- and post-procedural serum creatinine (Scr) levels, an increase in Scr value > 0.135 mg/dl after the procedure, a worse post-procedural estimated glomerular filtration rate (eGFR), a post-procedural reduction of eGFR < 3.350 ml/min, and a post-procedural reduction of platelet count (PLT) > 46.50 × 103/mmc showed a significantly higher rate of clinical failure.

CONCLUSION

RTE is a safe and effective procedure in the management of acute renal bleeding of various origins. Hematoma volume, Scr, PLT, and eGFR values were found to be predictive factors of poor clinical outcome and should be closely monitored.

Limits to Gauge Coupling in the Dark Sector Set by the Nonobservation of Instanton-Induced Decay of Super-Heavy Dark Matter in the Pierre Auger Observatory Data

Instantons, which are nonperturbative solutions to Yang-Mills equations, provide a signal for the occurrence of quantum tunneling between distinct classes of vacua. They can give rise to decays of particles otherwise forbidden. Using data collected at the Pierre Auger Observatory, we search for signatures of such instanton-induced processes that would be suggestive of super-heavy particles decaying in the Galactic halo. These particles could have been produced during the post-inflationary epoch and match the relic abundance of dark matter inferred today. The nonobservation of the signatures searched for allows us to derive a bound on the reduced coupling constant of gauge interactions in the dark sector: α_{X}≲0.09, for 10^{9}≲M_{X}/GeV<10^{19}. Conversely, we obtain that, for instance, a reduced coupling constant α_{X}=0.09 excludes masses M_{X}≳3×10^{13}  GeV. In the context of dark matter production from gravitational interactions alone, we illustrate how these bounds are complementary to those obtained on the Hubble rate at the end of inflation from the nonobservation of tensor modes in the cosmological microwave background.

Antisenescence Effect of REAC Biomodulation to Counteract the Evolution of Myelodysplastic Syndrome

About 30 percent of patients diagnosed with myelodysplastic syndromes (MDS) progress to acute myeloid leukemia (AML). The senescence of bone marrow‐derived mesenchymal stem cells (BMSCs) seems to be one of the determining factors in inducing this drift. Research is continuously looking for new methodologies and technologies that can use bioelectric signals to act on senescence and cell differentiation towards the phenotype of interest. The Radio Electric Asymmetric Conveyer (REAC) technology, aimed at reorganizing the endogenous bioelectric activity, has already shown to be able to determine direct cell reprogramming effects and counteract the senescence mechanisms in stem cells. Aim of the present study was to prove if the anti-senescence results previously obtained in different kind of stem cells with the REAC Tissue optimization – regenerative (TO-RGN) treatment, could also be observed in BMSCs, evaluating cell viability, telomerase activity, p19ARF, P21, P53, and hTERT gene expression. The results show that the REAC TO-RGN treatment may be a useful tool to counteract the BMSCs senescence which can be the basis of AML drift. Nevertheless, further clinical studies on humans are needed to confirm this hypothesis.

P-101 Machine and Deep learning models to classify Comet assay tests for sperm DNA fragmentation evaluation

Study question

To evaluate the performance of Machine and Deep learning classification models for sperm DNA fragmentation testing.

Summary answer

Machine and Deep learning models achieved an accuracy over 90% for sperm DNA fragmentation testing.

What is known already

Artificial Intelligence (AI) is an up-to-date tool that could improve current diagnostics in reproductive medicine. Paternal genome integrity is essential after fertilization. Therefore, high levels of DNA damage have been associated with male infertility. Sperm DNA fragmentation (SDF) is a well-known male fertility biomarker. Among different diagnostic tests analysing SDF, the Comet assay offers high specificity and sensibility. Human expert-analysis has shown to be highly precise but can be influenced by external factors, samples’ variability or tiredness. Consequently, computer-assisted diagnostic based on AI models may be helpful to improve the Comet assay analysis.

Study design, size, duration

From February to June 2021, alkaline and neutral Comet assays tests were performed on semen samples from a heterogenous group of men. The CometAssay IVTM software was used to record quantitative data from spermatozoa: 500 normal and altered spermatozoa were assessed after the alkaline and neutral Comet assay. Images for each spermatozoon were also taken. The total size was 2000 analysed spermatozoa. Finally, a first validation step was performed using new data from 20000 spermatozoa.

Participants/materials, setting, methods

For each spermatozoon, ten quantitative parameters and a grayscale image were obtained. A Machine learning predictive model using the Random Forest (RF) algorithm was trained with the quantitative parameters. Moreover, a Deep learning Convolutional Neural Network (CNN) algorithm was trained with cell images. Both models were trained on 67% of data and tested using the remaining 33%.

Main results and the role of chance

Predictive models based on RF and CNN showed high performance for normal/altered cells automatic classification. The accuracy achieved by the RF models was 95.51% for the alkaline Comet assay and 92.64% for the neutral Comet assay. Regarding the CNN models, the accuracy was 96.71% for the alkaline Comet assay and 93.19% for the neutral Comet assay. CNN models showed better accuracy on both assays.

Regarding the quantitative parameters considered in the RF model, the most important parameters for classification are the following ones: Mean_Grey_Level and Total_Intensity in the alkaline Comet assay, and Tail_Migration and Tail_Length in the neutral Comet assay.

Finally, 20000 spermatozoa from 100 semen samples were analysed to compare the AI models result with the annotation from an expert human. The Kruskal-Wallis test did not show significant differences for the alkaline and the neutral Comet assays (p &gt; 0.05 for all cases). Paired comparisons using the Mann-Whitney U test did not show statistical differences (p &gt; 0.05 for all cases). According to these results, AI models may reproduce a human analysis.

To facilitate the use in the laboratory of the obtained models, a web application was developed to process new samples.

Limitations, reasons for caution

Diagnostic assays based on continuous variables include a threshold value to separate normal and altered populations. The final result of some samples could be mistaken when a high number of spermatozoa present a fragmentation index near the cut-off value.

Wider implications of the findings

Diagnostic of male infertility through the analysis of SDF can be achieved through AI predictive models. This technology might help in the standardization of SDF testing between laboratories.

Trial registration number

not applicable

Endocrine disruptor chlorpyrifos promotes migration, invasion, and stemness phenotype in 3D cultures of breast cancer cells and induces a wide range of pathways involved in cancer progression

Organophosphorus chlorpyrifos (CPF) is currently considered an endocrine disruptor (ED), as it can imitate hormone actions both in vitro and in vivo. We recently reported that CPF induces migration and invasion in 2D cultures and changes the expression of key molecular markers involved in epithelial mesenchymal transition in MCF-7 and MDA-MB-231 cell lines. In this study, we investigated whether CPF could behave as a predisposing factor for tumors to become more metastatic and aggressive using 3D culture models. In MCF-7 cells, 0.05 μM CPF induced an increase in the number and size of mammospheres via estrogen receptor alpha (ERα) and c-SRC. Furthermore, 0.05 μM CPF increased the area of spheroids generated from MCF-7 cells, induced invasion using both Matrigel® and type 1 collagen matrices, and increased cell migration capacity via ERα in this 3D model. In turn, 50 μM CPF increased cell migration capacity and invasion using type 1 collagen matrix. In monolayers, CPF increased the phosphorylation and membrane translocation of c-SRC at both concentrations assayed. CPF at 0.05 μM boosted p-AKT, p-GSK-3β and p-P38. While p-AKT rose in a ERα-dependent way, p-GSK-3β was dependent on ERα- and c-SRC, and p-P38 was only dependent on c-SRC. On the other hand, the increase in p-AKT and p-P38 induced by 50 μM CPF was dependent on the c-SRC pathway. We also observed that 0.05 μM CPF increased IGF-1R and IRS-1 expression and that 50 μM CPF induced IGF-1Rβ phosphorylation. In the MDA-MB-231 cell line, 0.05 and 50 μM CPF increased p-c-SRC. Finally, p-AKT and p-GSK-3β were also induced by CPF at 0.05 and 50 μM, and an increase in p-P38 was observed at 50 μM. Taken together, these data provide support for the notion that CPF may represent a risk factor for breast cancer development and progression.

Measurement of the Fluctuations in the Number of Muons in Extensive Air Showers with the Pierre Auger Observatory

We present the first measurement of the fluctuations in the number of muons in extensive air showers produced by ultrahigh energy cosmic rays. We find that the measured fluctuations are in good agreement with predictions from air shower simulations. This observation provides new insights into the origin of the previously reported deficit of muons in air shower simulations and constrains models of hadronic interactions at ultrahigh energies. Our measurement is compatible with the muon deficit originating from small deviations in the predictions from hadronic interaction models of particle production that accumulate as the showers develop.

Chlorpyrifos subthreshold exposure induces epithelial-mesenchymal transition in breast cancer cells

Chlorpyrifos (CPF) is one of the most frequently used pesticide in extensive agriculture around the world and can be incorporated by humans and animals with possible consequences on health. The effects of this pesticide on carcinogenesis are not clear and there is no consensus concerning the risks of this compound. In previous work, we demonstrated that CPF induces proliferation of breast cancer cells both in vivo and in vitro. In this work we investigate whether CPF promotes the epithelial-mesenchymal transition (EMT) in breast cancer cells. Herein, we demonstrate that 50 μM CFP induces invasion in MCF-7 and MDA-MB-231 cells. In addition, 0.05 and 50 μM CPF increases migration in both cell lines. In MCF-7 cells, 0.05 and 50 μM CPF increase the metalloprotease MMP2 expression and decrease E-Cadherin and β-Catenin expression diminishing their membrane location. Furthermore, 50 μM CPF induces Vimentin expression and Slug nuclear translocation in MCF-7 cells. 0.05 and 50 μM CPF increase MMP2 gelatinolytic activity and expression, decrease β-Catenin expression and increase Vimentin expression in MDA-MB-231 cells. Inhibition of the oncoprotein c-Src reverses all the effects induced by CPF in MDA-MB-231 but not in MCF-7 indicating that c-Src is a kinase with a crucial role in the cells which grow in an estrogen-independent way. In MCF-7 cells both c-Src and estrogen receptor alpha must be blocked to completly inhibit the CPF-mediated effects. Our results show for the first time that the exposure to subthreshold concentrations of CPF promotes the modulation of EMT-molecular markers and pathways. These results, together with the ubiquitous distribution of the pesticide CPF, make it of utmost importance to take measures to minimize the risk of exposure to this compound.

Features of the Energy Spectrum of Cosmic Rays above 2.5×10^{18} eV Using the Pierre Auger Observatory

We report a measurement of the energy spectrum of cosmic rays above 2.5×10^{18}  eV based on 215 030 events. New results are presented: at about 1.3×10^{19}  eV, the spectral index changes from 2.51±0.03(stat)±0.05(syst) to 3.05±0.05(stat)±0.10(syst), evolving to 5.1±0.3(stat)±0.1(syst) beyond 5×10^{19}  eV, while no significant dependence of spectral features on the declination is seen in the accessible range. These features of the spectrum can be reproduced in models with energy-dependent mass composition. The energy density in cosmic rays above 5×10^{18}  eV is [5.66±0.03(stat)±1.40(syst)]×10^{53}  erg Mpc^{-3}.

Stem cells and physical energies: can we really drive stem cell fate?

Adult stem cells are undifferentiated elements able to self-renew or differentiate to maintain tissue integrity. Within this context, stem cells are able to divide in a symmetric fashion, feature characterising all the somatic cells, or in an asymmetric way, which leads daughter cells to different fates. It is worth highlighting that cell polarity have a critical role in regulating stem cell asymmetric division and the proper control of cell division depends on different proteins involved in cell development, differentiation and maintenance of tissue homeostasis. Moreover, the interaction between cells and the extracellular matrix are crucial in influencing cell behavior, included in terms of mechanical properties as cytoskeleton plasticity and remodelling, and membrane tension. Finally, the activation of specific transcriptional program and epigenetic modifications contributes to cell fate determination, through modulation of cellular signalling cascades. It is well known that physical and mechanical stimuli are able to influence biological systems, and in this context, the effects of electromagnetic fields (EMFs) have already shown a considerable role, even though there is a lack of knowledge and much remains to be done around this topic. In this review, we summarize the historical background of EMFs applications and the main molecular mechanism involved in cellular remodelling, with particular attention to cytoskeleton elasticity and cell polarity, required for driving stem cell behavior.

THU0477 SURAL NERVE SIZE IN FIBROMYALGIA SYNDROME

Background:

The pathophysiology of fibromyalgia syndrome (FM) still needs to be fully clarified. In addition to the central sensitization mechanisms, some evidence suggests an involvement of the peripheral nervous system, mainly intended as small fibers neuropathy. The sural nerve showed some alterations, in terms of increasead cross-sectional area (CSA), in the course of small fibers neuropathy.

Objectives:

To evaluate sural nerve CSA and factors associated with increased CSA in FM patients.

Methods:

A cross sectional evaluation was conducted in consecutive FM patients according to the 2016 American College of Rheumatology criteria. Demographic, clinimetric parameters (in particular the revised Fibromyalgia Impact Questionnaire [FIQR] to assess the severity of the disease and the PainDetect Questionnaire [PDQ] to evaluate neuropathic pain features) and the sural nerve dimensions measured by ultrasound were recorded for each patient. The size of the sural nerve was described in terms of the mean cross-sectional area (CSA) measured bilaterally. CSA was measured at the leg level, 14 cm from the apex of the lateral malleolus, where the sural nerve is detectable as a structure adjacent to the small saphenous vein in the distal portion of the leg. The ultrasound examination was performed with a MyLab Class C (Esaote S.p.A., Genoa, Italy) equipped with a 6-18 MHz multifrequency broad band probe. CSA was compared with demographic and clinimetric parameters through one-way analysis of variance (ANOVA). A multiple regression was also conducted using CSA as dependent variable, with age, body mass index (BMI), disease duration, FIQR and PDQ as independent variables.

Results:

The study involved 110 FM patients (105 women and five men), with a mean age of 50.7 (±11.1) years and a mean disease duration of 5.8 (±5.2) years. Sural nerve CSA showed a statistically significant increase in patients with higher PDQ scores (p=0.0096) and, even more significantly, in overweight or obese subjects (p <0.001). The multiple regression analysis, using CSA as dependent variable, confirmed that the PDQ score (p=0.0049) and the body mass index (p<0.0001) are the only two independent variables associated with CSA size (Table 1).

Table 1.

Multiple regression analysis of the independent variables related to the mean cross-sectional area (dependent variable) of sural nerve.

Indipendent variablesCoefficientStandard errortprpartialrsemipartialConstant-0.2551BMI0.075920.018474.1110.00010.37390.3462Disease duration-0.024920.02092-1.1910.2364-0.11600.1003Age0.0024550.0098330.2500.80330.024480.02103FIQR0.00013760.0068620.02010.98400.0019660.001689PDQ0.052720.019972.6390.00960.25060.2223

Abbreviations: BMI=Body Mass Index; FIQR=revised Fibromyalgia Impact Questionnaire; PDQ=PainDetect Questionnaire

Conclusion:

Increased sural nerve CSA is associated with neuropathic like pain features and BMI. Overweight and obesity appear to be associated with an FM phenotype with greater peripheral involvement than normal-weight subjects. Sural nerve ultrasound, an easy to perform examination, could be a useful tool to identify this kind of patients.

References:

[1]Ebadi H, Siddiqui H, Ebadi S, Ngo M, Breiner A, Bril V. Peripheral Nerve Ultrasound in Small Fiber Polyneuropathy. Ultrasound Med Biol. 2015;41(11):2820-6. doi: 10.1016/j.ultrasmedbio.2015.06.011

[2]Giannoccaro MP, Donadio V, Incensi A, Avoni P, Liguori R. Small nerve fiber involvement in patients referred for fibromyalgia. Muscle Nerve. 2014;49(5):757-9. doi: 10.1002/mus.24156

Disclosure of Interests: :

None declared

Effects of the pesticide chlorpyrifos on breast cancer disease. Implication of epigenetic mechanisms

Chlorpyrifos (CPF) is an organophosphorus pesticide used for agricultural pest control all over the world. We have previously demonstrated that environmental concentrations of this pesticide alter mammary gland histological structure and hormonal balance in rats chronically exposed. In this work, we analyzed the effects of CPF on mammary tumors development. Our results demonstrated that CPF increases tumor incidence and reduces latency of NMU-induced mammary tumors. Although no changes were observed in tumor growth rate, we found a reduced steroid hormone receptor expression in the tumors of animals exposed to the pesticide. Moreover, we analyzed the role of epigenetic mechanisms in CPF effects. Our results indicated that CPF alters HDAC1 mRNA expression in mammary gland, although no changes were observed in DNA methylation. In summary, we demonstrate that the exposure to CPF promotes mammary tumors development with a reduced steroid receptors expression. It has also been found that CPF affects HDAC1 mRNA levels in mammary tissue pointing that CPF may act as a breast cancer risk factor.

Abstract OT1-04-02: Mifepristone treatment for breast cancer patients expressing levels of progesterone receptor isoform A (PRA) higher than those of isoform B (PRB)

Seventy percent of breast cancers express estrogen (ER) and progesterone receptors (PR) and respond to antiestrogen therapies. Emerging evidence from experimental studies and human epidemiology, points to a relevant role for progestins in breast carcinogenesis and cancer growth. Others and we have proposed that there is a role for antiprogestins in the therapeutic armamentarium, but the challenge remains to identify which patients would benefit from targeting the PR in addition to ER. Preclinical data indicates that antiprogestins block cell proliferation and increase apoptosis only in ER+ breast cancers expressing levels of PRA higher than those of PRB. The aim of this study is to evaluate the therapeutic effects of Mifepristone (MFP) on breast cancer patients selected by their PRA/PRB isoform ratio, for 14 days in between core biopsy and surgery (MIPRA trial ClinicalTrials.gov Identifier: NCT02651844). Methods: This is an open label, interventional with single group assignment study. We perform core biopsies on menopausal patients with clinically palpable breast cancers larger than 1.5 cm to confirm diagnosis. We will assess the PRA/PRB ratio by western blotting in frozen samples and total PR in formalin-fixed samples by immunohistochemistry (IHC). Twenty eligible PR+ patients (PR &gt; 50 %) with PRA/PRB ≥1.5 who have signed consent forms, and meet the inclusion criteria will be recruited. Patients will be treated for 14 days with MFP p.o 200 mg. Surgery will be performed on day 15. Samples will be frozen for molecular studies or fixed for IHC. The primary outcome is the evaluation of Ki-67 staining pre- and post treatment. Secondary outcomes include comparatively expression of proliferation/apoptosis/PR signaling markers in core and surgical biopsy samples. Other pre-specified outcomes include molecular profiling, study of liquid biopsies, mammography, and ultrasound studies. Wilcoxon signed rank test will be used to evaluate differences in biomarker expression between core biopsy and surgical samples of each patient.

Citation Format: Liguori M, Lanari C, Gass H, Rojas P, Elia A, Martinez Vazquez P, Burruchaga J, Gonzalez P, Caillet Bois I, Ventura C, San Martin G, Castets A, Lovisi S, Acosta Haab G, Lamb C, Fabris V, Novaro V, Molinolo A. Mifepristone treatment for breast cancer patients expressing levels of progesterone receptor isoform A (PRA) higher than those of isoform B (PRB) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT1-04-02.

How health service delivery guides the allocation of major trauma patients in the intensive care units of the inclusive (hub and spoke) trauma system of the Emilia Romagna Region (Italy). A cross-sectional study

OBJECTIVE

To evaluate cross-sectional patient distribution and standardised 30-day mortality in the intensive care units (ICU) of an inclusive hub and spoke trauma system.

SETTING

ICUs of the Integrated System for Trauma Patient Care (SIAT) of Emilia-Romagna, an Italian region with a population of approximately 4.5 million.

PARTICIPANTS

5300 patients with an Injury Severity Score (ISS) >15 were admitted to the regional ICUs and recorded in the Regional Severe Trauma Registry between 2007 and 2012. Patients were classified by the Abbreviated Injury Score as follows: (1) traumatic brain injury (2) multiple injuriesand (3) extracranial lesions. The SIATs were divided into those with at least one neurosurgical level II trauma centre (TC) and those with a neurosurgical unit in the level I TC only.

RESULTS

A higher proportion of patients (out of all SIAT patients) were admitted to the level I TC at the head of the SIAT with no additional neurosurgical facilities (1083/1472, 73.6%) compared with the level I TCs heading SIATs with neurosurgical level II TCs (1905/3815; 49.9%). A similar percentage of patients were admitted to level I TCs (1905/3815; 49.9%) and neurosurgical level II TCs (1702/3815, 44.6%) in the SIATs with neurosurgical level II TCs. Observed versus expected mortality (OE) was not statistically different among the three types of centre with a neurosurgical unit; however, the best mean OE values were observed in the level I TC in the SIAT with no neurosurgical unit.

CONCLUSION

The Hub and Spoke concept was fully applied in the SIAT in which neurosurgical facilities were available in the level I TC only. The performance of this system suggests that competition among level I and level II TCs in the same Trauma System reduces performance in both. The density of neurosurgical centres must be considered by public health system governors before implementing trauma systems.

Impact of multidisciplinary hip fracture program on timing of surgery in elderly patients

The effect of patient characteristics and organizational and system factors on time to surgery were studied using Emilia Romagna Region database and hospital survey. The results showed that the implementation of a Hip Fracture Program significantly increased the probability of early surgery while single intervention had only slight effect

INTRODUCTION

The purpose of this study is to evaluate the effect of formal Hip Fracture Program (HFP) on timing of surgery in hip fracture older patients.

METHODS

This is a retrospective cohort study based on Emilia Romagna administrative databases. Data on organizational and system factor were also obtained through a hospital survey. A multilevel logistic regression analysis was carried out to assess the effect of covariates on early surgery, taking into account patient level, hospital level, and trust level variability.

RESULTS

From 1 January to 31 December 2011, 5,520 subjects over 65 years old underwent surgical repair for hip fracture in Emilia Romagna. The mean waiting time to surgery was 3.4 ± 12.3 days, and the overall percentage of patients operated within 2 days was 52.2%. In the adjusted multilevel logistic model, significant risk factors affecting the timing of surgical intervention at patient level were age, comorbidity, day of admission, and antiplatelet or warfarin therapy while no significant single variables were found at hospital level including dedicated operation theater, hospital volume, dedicated orthogeriatric beds, and geriatrician involvement. The most significant variable was the implementation of HFP at trust level that increased three times the probability of early surgery after adjusting for confounding variables (OR 3.216, 95% CI 0.582-6.539).

CONCLUSIONS

Several modifiable organizational factors may affect the proportion of patients with hip fracture undergoing early surgery. This study suggests that the development and the implementation of an evidence-based HFP at trust level are a key point of the strategy of quality of care.

Stem cell senescence. Effects of REAC technology on telomerase-independent and telomerase-dependent pathways

Decline in the gene expression of senescence repressor Bmi1, and telomerase, together with telomere shortening, underlay senescence of stem cells cultured for multiple passages. Here, we investigated whether the impairment of senescence preventing mechanisms can be efficiently counteracted by exposure of human adipose-derived stem cells to radio electric asymmetrically conveyed fields by an innovative technology, named Radio Electric Asymmetric Conveyer (REAC). Due to REAC exposure, the number of stem cells positively stained for senescence associated β-galactosidase was significantly reduced along multiple culturing passages. After a 90-day culture, REAC-treated cells exhibited significantly higher transcription of Bmi1 and enhanced expression of other stem cell pluripotency genes and related proteins, compared to unexposed cells. Transcription of the catalytic telomerase subunit (TERT) was also increased in REAC-treated cells at all passages. Moreover, while telomere shortening occurred at early passages in both REAC-treated and untreated cells, a significant rescue of telomere length could be observed at late passages only in REAC-exposed cells. Thus, REAC-asymmetrically conveyed radio electric fields acted on a gene and protein expression program of both telomerase-independent and telomerase-dependent patterning to optimize stem cell ability to cope with senescence progression.

Evaluation of the survival benefit of Trauma-Centre care in the Italian setting

BACKGROUND

Trauma Centres (TC) are expected to have a lower mortality - after controlling for injury-severity - than non-designated hospitals in order to justify their funding. This benefit has been demonstrated in the USA not long ago, while the evidence from other settings is still limited. We evaluated the mortality benefit of TC care in an Italian setting, where the first Trauma System with designated TCs was instituted six years ago.

MATERIALS AND METHODS

We compared 30-day mortality among 4059 severely injured patients treated in the three TCs and in 12 other hospitals of the region Emilia-Romagna, Italy between 2007 and 2011. We used propensity-score weighting to adjust for differences in potential confounders.

RESULTS

In the overall population there was no difference in the adjusted mortality - OR (95% CI) 1.02 (0.81-1.29). However, an interaction existed between TC care and injury severity. Subgroup analyses showed that the benefit of TC care was significant for the patients with a TMPM-ICD9 severity score>0.12 - OR (95% CI) 0.70 (0.52-0.97). These patients comprised about one-third of the study population. Further subgroup investigations showed that this effect was concentrated in the patients with less than 45 years.

CONCLUSIONS

The risk of death for patients with particularly severe injuries is significantly lower when they are treated in TCs as compared to Non-Trauma Centres, especially if they are younger than 45 years. TC care should be provided to a larger number of patients than currently done.

High sensitive thyroglobulin assay on thyroxine therapy: can it avoid stimulation test in low and high risk differentiated thyroid carcinoma patients?

Thyroglobulin (Tg) is a key marker in the follow-up of differentiated thyroid cancer (DTC). Diagnostic accuracy of serum Tg is higher after TSH stimulation than during thyroxine treatment. However, some studies suggest that TSH stimulation could be not necessary in a large part of patients, if Tg is measured by high sensitive assay under replacement therapy. The aim of this study was to evaluate the need of Tg stimulation test in DTC followed-up by sensitive Tg assay. In a prospective multicenter explorative study, 68 low or high risk patients underwent Tg measurement on thyroxine (ON-LT4-Tg) and after LT4 withdrawal (OFF-LT4-Tg). Undetectable ON-LT4-Tg and OFF-LT4-Tg values (i. e.,<0.15 ng/ml) were found in 56/68 patients, all with negative imaging workup. Twelve subjects had skewed OFF-LT4-Tg: 8 cases had increased ON-LT4-Tg and local recurrence (n=6), distant metastasis (n=1), or benign thyroglossal duct (n=1); the remaining 4 patients had undetectable ON-T4-Tg but detectable OFF-LT4-Tg and neck metastasis was recorded in one of these. By ROC analysis, the most accurate cutoff for ON-LT4-Tg and OFF-LT4-Tg were set at 0.23 ng/ml and 0.70 ng/ml, respectively. A positive ON-LT4-Tg value accurately predicts a positive stimulation test and confers an Odds Ratio of 464 (95% CI from 26.3 to 8 173.2, p<0.0001) to have persistent/recurrent disease. This study shows that DTC patients with ON-LT4-Tg below 0.23 ng/ml by our high sensitive assay should be considered disease free and they can avoid Tg stimulation test. High sensitive Tg assays should be used to better manage DTC patients.

A population based study on the night-time effect in trauma care

BACKGROUND

The so-called off hour effect-that is, increased mortality for patients admitted outside normal working hours-has never been demonstrated in trauma care. However, most of the studies excluded transferred cases. Because these patients are a special challenge for trauma systems, we hypothesised that their processes of care could be more sensitive to the off hour effect.

METHODS

The study design was retrospective, cohort and population based. We compared the mortality of all patients by daytime and night-time admittance to hospitals in an Italian region, with 4.5 million inhabitants, following a major injury in 2011. Logistic regression was used, adjusted for demographics and severity of injury (TMPM-ICD9), and stratified by transfer status.

RESULTS

1940 major trauma cases were included; 105 were acutely transferred. Night-time admission had a significant pejorative effect on mortality in the adjusted analysis (OR=1.49; 95% CI 1.05 to 2.11). This effect was most evident in transferred cases (OR=3.71; 95% CI 1.11 to 12.43).

CONCLUSIONS

The night-time effect in trauma care was demonstrated for the first time and was maximal in transferred cases. This may explain why it was not found in previous studies where these patients were mostly excluded. Also, the use of population based data-whereby patients not accessing trauma centre care and presumably receiving poorer care were included-may have contributed to the findings.

A new approach for the extraction of pollutants from wastewaters handled by the graphic industry

It is widely recognized that the Graphic Industry handles toxic products and produces, in its various operations, toxic wastes. These wastes can cause serious environmental damages and can lead to severe health problems. In this work we report an efficient, simple and cheap to run method for the removal of some of the most common pollutants involved in the various stages of the Graphic Industry production, using a Solid-Phase Extraction (SPE) methodology. We have determined equilibrium constants, K(eq), and adsorption (k(up)) and desorption (k(off)) rate constants for the extraction of benzene, xylene, toluene and ethylbenzene (BXTE) from water, using C18 disks. The removal of these compounds was monitored by UV-vis spectroscopy, at room temperature. Average extraction efficiencies were of 60% in a mixture of BXTEs and close to 80% when pollutants were assessed separately. Since the retention mechanism in the C18 disk is essentially governed by hydrophobic interactions between the compounds and the alkyl chains of the disk, we have also shown that these pollutants' lipophilicity plays an important role in the rationalization of their behavior during the extraction process.

Clinical governance network for clinical audit to improve quality in epithelial ovarian cancer management

BACKGROUND

Epithelial ovarian cancer (EOC) is the most lethal gynecological cancer. Several hospitals throughout the region provide primary treatment for these patients and it is well know that treatment quality is correlated to the hospital that delivers. The aim of this study was to investigate the management and treatment of EOC in a Region of the North Italy (Emilia-Romagna, Italy).

METHODS

A multidisciplinary group made up of 11 physicians and 3 biostatisticians was formed in 2009 to perform clinical audits in order to identify quality indicators and to develop Region-wide workup in accordance with the principles of evidence-based medicine (EBM). The rationale was that, by setting up an oncogynecology network so as to achieve the best clinical practice, critical points would decrease or even be eliminated. Analysis of cases was based on the review of the medical records.

RESULTS

614 EOC patients treated between 2007 and 2008 were identified. We found only 2 high-volume hospitals (≥ 21 patients/year), 3 medium-volume hospitals (11-20 operated patients/year), and 7 low-volume hospitals (≤ 10 operated patients /year). Only 222 patients (76.3%) had a histological diagnosis, FIGO surgical staging was reported only in 206 patients (70.9%) but not all standard surgical procedures were always performed, residual disease were not reported in all patients. No standard number of neoadjuvant chemotherapy cycles was observed.

CONCLUSIONS

The differences in terms of treatments provided led the multidisciplinary group to identify reference centers, to promote centralization, to ensure uniform and adequate treatment to patients treated in regional centers and to promote a new audit involving all regional hospitals to a complete review of the all the EOC patients.

Is the TMPM-ICD9 revolution in trauma risk-adjustment compatible with imperfect administrative coding?

BACKGROUND

TMPM-ICD9 is the latest injury-severity measure based on empirical estimation from ICD-9-CM codes. It is candidate to replace expert-based AIS measures worldwide because of easier accessibility and better predictive performances. In Italy and other countries administrative ICD coding is generally less complete than dedicated AIS coding. We attempted to ascertain how this affects TMPM performances.

METHODS

Discrimination (c statistics) and calibration (calibration curves, Akaike's criterion) of hierarchical logistic regression models for hospital mortality comprising TMPM or ISS were compared using trauma-registry data on 3570 patients of years 2007-2009. The completeness of AIS vs. ICD-9-CM coding was also investigated through the ratio of the respective numbers of codes per patient. Model discrimination was further analyzed after stratification according to the above ratio (>1 and ≤ 1).

RESULTS

The models with TMPM showed worse performances. The differences, concerned calibration (graphical evidence) in univariate models and discrimination (-1.2% of area under the ROC curve, p<0.05) in models completed with age, gender, mechanism of injury, motor GCS and systolic pressure. In parallel, ICD coding was less complete than AIS, as expected: 68% of patients had a ratio >1. The discrimination of TMPM vs. ISS models improved when the ratio changed from >1 to ≤ 1.

CONCLUSIONS

The predictive performances of TMPM-ICD9 vs. ISS were lower than in the previous studies; the sub-optimal quality of ICD coding was a main cause. Imperfect administrative coding may hence hamper the TMPM-ICD9 revolution, although in our setting the negligible differences and the ready availability of administrative data may still give reason for adopting TMPM-ICD9.

The counterintuitive effect of multiple injuries in severity scoring: a simple variable improves the predictive ability of NISS

Background

Injury scoring is important to formulate prognoses for trauma patients. Although scores based on empirical estimation allow for better prediction, those based on expert consensus, e.g. the New Injury Severity Score (NISS) are widely used. We describe how the addition of a variable quantifying the number of injuries improves the ability of NISS to predict mortality.

Methods

We analyzed 2488 injury cases included into the trauma registry of the Italian region Emilia-Romagna in 2006-2008 and assessed the ability of NISS alone, NISS plus number of injuries, and the maximum Abbreviated Injury Scale (AIS) to predict in-hospital mortality. Hierarchical logistic regression was used. We measured discrimination through the C statistics, and calibration through Hosmer-Lemeshow statistics, Akaike's information criterion (AIC) and calibration curves.

Results

The best discrimination and calibration resulted from the model with NISS plus number of injuries, followed by NISS alone and then by the maximum AIS (C statistics 0.775, 0.755, and 0.729, respectively; AIC 1602, 1635, and 1712, respectively). The predictive ability of all the models improved after inclusion of age, gender, mechanism of injury, and the motor component of Glasgow Coma Scale (C statistics 0.889, 0.898, and 0.901; AIC 1234, 1174, and 1167). The model with NISS plus number of injuries still showed the best performances, this time with borderline statistical significance.

Conclusions

In NISS, the same weight is assigned to the three worst injuries, although the contribution of the second and third to the probability of death is smaller than that of the worst one. An improvement of the predictive ability of NISS can be obtained adjusting for the number of injuries.

Does normal thyroid gland by ultrasonography match with normal serum thyroid hormones and negative thyroid antibodies?

Few papers have shown that a hypoechoic appearance of the thyroid gland at ultrasonography (US) is related to a hypofunction and serum positivity of thyroid antibodies (T-Ab). However, it is not ascertained if normal thyroid appearance at US correspond to normal thyroid laboratory tests. The aim of this study was to assess the value of normal thyroid at US in predicting normal thyroid hormones and negative T-Ab in a cohort of 48 adult patients. All patients (37 females and 11 males) were referred to our hospital to undergo their first thyroid US examination, followed by a thyroid function evaluation. All subjects had normal thyroid gland at US. As a control group 65 patients with hypoechoic and inhomogeneous thyroid gland were enrolled. All 48 patients had normal free-T (3) and free-T (4) levels. While 41 patients (85.4%) showed normal TSH, in 7 subjects (14.6%) TSH was elevated and a significant (p < 0.001) difference was recorded between the two groups in mean TSH value. Positive T-Ab value was found in 5 patients (10.4%) and the remaining 43 patients (89.6%) had negative T-Ab. TSH was not significantly correlated with age, thyroid volume or BMI. The multivariate model showed that only BMI was significantly correlated to thyroid volume (p < 0.01, r(2)=0.31). These results showed that normal thyroid recorded by US matches with normal thyroid laboratory assessment to a large degree. These preliminary data need to be confirmed in a prospective study and in a larger series and should suggest the evaluation of thyrotropin and thyroid antibodies in subjects with normal thyroid gland as assessed by US.

[Expression of metanephric differentiation markers in human mesenchymal stem cells]

Stem cells are a potential source for the regeneration of many tissues, including damaged kidneys. The present study describes the adoption of hyaluronic- butyric acid monoesters (HB) to induce expression of nephrogenic genes by mesenchymal cells isolated from human placental membranes. HB at a concentration of 1 mg/mL induces chromatin opening and increases the expression of the observed markers (cadherin 11, CD24, RAR-alpha, stearoyl-CoA desaturase 2, 14-3-3 0, Ewing sarcoma homolog.). These results open new routes toward cell regeneration after kidney injury.

Autocrine and intracrine signaling for cardiogenesis in embryonic stem cells: a clue for the development of novel differentiating agents

Cardiogenesis, one of the earliest and most complex morphogenetic events in the embryo, is not fully understood at the molecular level and is typically a low-yield process. Affording a high throughput of cardiogenesis from a suitable population of pluripotent cells is therefore a major assignment in the perspective of a stem cell therapy for heart failure. Analysis of cardiac lineage commitment in mouse embryonic stem cells and in vivo models of cardiac differentiation revealed that a number of crucial growth factors are released from precursor cells, acting in an autocrine fashion on specific plasma membrane receptors to prime a cardiogenic decision. Nevertheless, it is increasingly becoming evident that cell nuclei harbor the potential for intrinsic signal transduction pathways. The term "intracrine" has been proposed for growth regulatory peptides that have been shown to act within their cell of synthesis at the level of the nuclear envelope, chromatin, or other subnuclear components. Considerable evidence links known intracrines with transcriptional responses and self-sustaining loops that behave as long-lived signals and impart features characteristic of differentiation, growth regulation and cell memory. This review focuses on a number of autocrine and intracrine systems within the context of cardiac differentiation and emphasizes the identification of cardiogenic mechanisms as a clue for the development of unprecedented differentiating strategies. In this regard, recently synthesized mixed esters of hyaluronan with butyric and retinoic acid primed the expression of cardiogenic genes and elicited a remarkable increase in cardiomyocyte yield in mouse embryonic stem cells. This demonstrates the potential for chemically modifying the gene program of cardiac differentiation without the aid of gene transfer technologies and sets the basis for the design of a novel generation of chemicals suited for the organization of targeted lineage patterning in stem cells.

NAMI-A inhibits the PMA-induced ODC gene expression in ECV304 cells: involvement of PKC/Raf/Mek/ERK signalling pathway

Imidazolium trans-imidazole dimethyl sulfoxide tetrachlororuthenate (NAMI-A) is a new compound active against lung metastasis of solid metastasizing tumours. While its in vivo effect has been studied, the molecular insights that underlie its action are largely unknown. Among the possible pathways responsible for malignant transformation, PKC arose as one of the most promising targets for new antineoplastic drugs. We demonstrated the capability of NAMI-A of inhibiting PMA induced-PKC activity in ECV304 in a dose-dependent fashion. Furthermore, NAMI-A through modulation of PKC activity has been proved capable of reducing the phorbol ester induced expression of ornithine decarboxilase (ODC) gene and to abrogate the activation of the Raf/MEK/ERK pathway. Taken together these results suggest that many of the in vivo outcomes of NAMI-A treatment may be the result of a direct action on PKC.

Female haemophiliac homozygous for the factor VIII intron 22 inversion mutation, with transcriptional inactivation of one of the factor VIII alleles

Phenotypic expression of X-linked recessive disorders, including haemophilia A, is rare in females. This report describes a female with sporadic severe haemophilia A. The female patient and her family members were evaluated by coagulation assays. Visible detectable disturbance of X chromosome structure or number, as well as 2N von Willebrand disease, were excluded as possible explanations of the haemophilia A phenotype. Molecular studies, factor VIII (FVIII) intron 22 inversion mutation analysis showed that the severe haemophilia A phenotype is the result of a maternally inherited, distal, FVIII gene inversion and a paternally inherited de novo, also distal, FVIII gene inversion. Furthermore, comparative single-stranded conformation polymorphism analysis revealed the absence of detectable maternally inherited abnormal FVIII gene transcript in the patient's peripheral blood lymphocytes. X chromosome methylation analysis indicates that this could be explained by preferential inactivation of the maternally inherited X chromosome carrying the distal FVIII gene inversion.

Small dose of recombinant factor VIIa (rFVIIa) to perform percutaneous liver biopsies in cirrhotic patients

Low levels of vitamin K-dependent coagulation factors, synthesized in the liver, play a key role in the hypocoagulable state of end-stage liver disease patients. Recombinant factor VII (rFVIIa) has been developed for, and currently is used in the treatment of patients with hemophilia A and B with inhibitors. Some experience was gained with rFVIIa in liver diseases since 1995. We used a low dose of rFVIIa to perform percutaneous liver biopsy in three patients, all of them with abnormal coagulation, impeditive of the percutaneous liver biopsy. The first one was a 29 years old man with alcoholic cirrhosis and a liver nodule; the second was a 32 years old man with post hepatitis C cirrhosis and excessive alcohol intake; the third was a 53 years old man with chronic hepatitis C and a congenital deficit of factor VII. A single dose of 5 micrograms/Kg of rFVII administered before liver biopsies raised levels of factor VII to acceptable values during more than 5 hours in the first two patients. We conclude that a small dose of rFVIIa can be enough to correct the abnormal coagulation of cirrhotic patients, permits percutaneous liver biopsy, and is cost-effective, compared to transjugular access.