Medicolegal approach to skin lesions in trafficking victims: A case report

Trafficking in human beings is an ancient phenomenon. The fight against trafficking in human beings is conceived as a priority by the European Union. Trafficked victims experience many types of abuse and neglect. Indeed, all human beings hold the right to have an identity and an estimated age as an assertion of their existence in the society, as expressly stated in the U.N. Convention on the Rights of the Child. Italy has been the scene of this phenomenon for many years. Since identification represents a fundamental human right and a prerequisite for any other measure of assistance and protection, the Italian procedure provides the execution of an interview and a forensic examination. This process takes time and requires willingness to listen and to create a trusting doctor-patient relationship. Although skin lesions in trafficking victims may be due to torture or other forms of mistreatment or abuse, they may also be related to ethnic practices. Here we demonstrate the importance of conducting a structured interview along with an accurate forensic examination to correctly discriminate the origin of skin lesions in trafficking victims.

GPR55 deficiency in B-cells promotes atherosclerosis and regulates plasma cell maturation

 

Atherosclerosis is a chronic and multifactorial disease accompanied by an imbalance between resolving and pro-inflammatory lipid mediators. Targeting lipid signaling might offer new therapeutical targets for improving the clinical outcome in cardiovascular disease patients. We considered lysophosphatidylinositol (LPI) and its receptor G protein-coupled receptor (GPR)55 as a potential modulator of atherosclerosis. Its role in regulating atherosclerosis and B cell function is unknown.

We hypothesize that GPR55 signaling affects atherosclerosis by regulating B cell function.

Atherosclerotic plaques were compared between apolipoprotein-E-deficient (ApoE−/−) and ApoE−/−Gpr55−/− mice after 4 to 16 weeks Western Diet (WD; 0.15% cholesterol; n=12–15 per group). To test the role of B cell GPR55, we generated mixed chimeras by irradiating low density lipoprotein receptor deficient (Ldlr−/−) mice and reconstituting with a mixture of μMT and wildtype or μMT and Gpr55−/− bone marrow cells. Circulating B cells were sorted and bulk RNA sequencing analysis was performed. We performed atheroma plaque characterization, qPCR and ELISA of tissue lysates and measure plasma immunoglobulins. Circulating and tissue leukocyte counts were determined.

We confirmed Gpr55 expression on circulating B cells, which was higher compared to T and myeloid cells. ApoE−/−Gpr55−/− mice had significantly larger plaques after 4 & 16 weeks WD compared to ApoE−/−, with increased body weight & cholesterol levels. In addition, global Gpr55 deficiency resulted in enhanced aortic pro-inflammatory cytokine mRNA expression, a massively upregulated IgG levels and increased counts of splenic germinal center and plasma cells. ApoE−/−Gpr55−/− B-cell RNA-seq analysis showed 460 differential expressed genes compared to ApoE−/−. The main pathways affected were calcium ion transport, immunoglobulin production, T & B cell activation, and cellular response to stress. B cell specific Gpr55 deficiency blunted the metabolic effects but still translated in larger atherosclerotic plaques and elevated plasma IgG levels.

Both global and B cell-restricted Gpr55 deficiency promotes atherosclerosis and is associated with a pro-inflammatory phenotype.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The authors received funds from the Deutsche Forschungsgemeinschaft (STE1053/6-1, STE1053/8-1 to S.S. and SFB1123 to S.S., C.W. and L.M.), the German Ministry of Research and Education (DZHK FKZ 81Z0600205 to S.S.) and the LMU Medical Faculty FöFoLe program (1061 to R.G.P.). I.H. is supported by the DFG (HI1573/2 and CRC1425 #422681845).

The pro-thrombotic transcriptomic signature of reticulated platelets in patients with chronic coronary syndrome

Introduction

Reticulated or immature platelets (RPs) are hyper-reactive young platelets that are larger and contain significantly more RNA compared to mature platelets (MPs). High levels of RPs in peripheral blood are predictors of an insufficient response to dual antiplatelet therapy and of adverse cardiovascular events in cardiovascular patients. Recently, we reported for the first time an enrichment of prothrombotic transcripts in RPs transcriptome of healthy donors. However, the biology of RPs in patients with coronary artery disease has not been investigated yet.

Purpose

We aimed to compare for the first time the transcriptomic profiles of RPs and MPs in patients with chronic coronary syndrome (CCS).

Methods

RPs and MPs from peripheral blood of CCS patients were isolated using fluorescent activated cell sorting (FACS) based on their RNA-content. After sorting, RNA was extracted and quality, concentration and integrity were assessed with the Tapestation 4200 platform (Agilent). Total-RNA libraries were prepared, multiplexed and sequenced on a NextSeq 500 Illumina platform obtaining 80 to 100 million paired-end reads per sample. RNA-sequencing analysis was performed with R and DESeq2.

Results

Total-RNA-sequencing detected 538 genes differentially expressed (300 downregulated, 238 upregulated) in RPs compared to MPs in CCS patients (Figure 1A). In particular, transcripts for the collagen receptor GP6 (FC 1.89, p=4.7x10–23), thrombin receptor PAR4 (F2RL3, FC 1.97, p=3.5x10–11), the ATP receptor P2RX1 (FC 1.94, p=3.1x10–15) and the ADP receptor P2RY1 (FC 1.82, p=3.15x10–10) were significantly enriched in RPs, whereas RNA regulators as the RISC-component TNRC6A (FC 0.5, p=7.98x10–13) and the splicing factor LUC7L3 (log2FC 0.55, p=1.76x10–11) were downregulated in RPs. Gene ontology analysis revealed an enrichment of relevant biological categories in RPs including “platelet activation” (fold enrichment = 10.5, p=1.8x10–8) and “blood coagulation” (fold enrichment = 4.4, p=2.4x10–3). Splicing analysis detected several differential splicing events. Of note, we detected an alternative splicing on GP6 transcript present only in RPs and absent in MPs (p=0.03, Figure 1B) At last, backsplicing analysis detected an enrichment of circular-RNAs in MPs.

Conclusions

This study represents the first deep transcriptomic profiling of RPs and MPs in patients with CCS and reports for the first time a differential enrichment of transcripts involved in platelet activation. Moreover, we could detect for the first time alternative splicing events in RPs and an enrichment of circular-RNAs in MPs. The clear upregulation of prothrombotic signaling in RPs (schematic overview Figure 1C) could explain, at least in part, their hyper-activity and their correlation with cardiovascular events in different pathological settings at it may offer a new therapeutic niche in patients with CCS.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): German society of cardiology (DGK)

5224Endothelial autophagy triggers nuclear enrichment of miR-126-5p via a Mex3a-dependent pathway to confers endothelial protection and prevent atherosclerosis

Background

MicroRNAs are versatile regulators of gene expression with profound implications for cardiovascular diseases and atherosclerosis. Among the most expressed in endothelial cells (ECs), the miR-126 duplex is crucial for angiogenesis and vascular protection, featuring different functional roles and homeostasis of the two strands. In line with separate activities, miR-126-3p and -5p undergo differential regulation in response to shear-stress in a KLF2-dependent manner. As both strands derive from a common precursor, the mechanism for strand specificity is unrelated to miRNA transcription and remains largely elusive as well as unknown is its relevance for vascular biology.

Methods and results

In human ECs (HUVECs) overexpression of KLF2 produced an up-regulation of the miR-126 precursor and miR-126-5p, but not miR-126-3p. Analysis of ECs overexpressing KLF2 or exposed to high-shear stress at transcriptional and protein level revealed the activation of the autophagic flux. Moreover, stimulation of autophagy by rapamycin replicated strand-specific regulation of miR-126. In particular, rapamycin promoted miR-126-3p degradation, while miR-126-5p was preserved and translocated to a nuclear reservoir complexed with the protein argonaute-2 (Ago2). Mutational scanning of fluorescently-labelled miR-126-5p revealed that nuclear shuttling required motifs distinct from the seed sequence. Size exclusion chromatography and Ago2-immunoprecipitation in autophagic ECs, as well as surface plasmon resonance (SPR) and electrophoretic mobility shift assays in vitro showed the formation of a ternary complex with the RNA-binding protein Mex3a. Preferential binding of miR-126-5p to Mex3a was confirmed by SPR, isothermal calorimetry, and nuclear magnetic resonance spectroscopy. Super-resolution microscopy by stimulated emission depletion (STED) visualized the Mex3a/Ago2 interaction on autophagosomal surfaces and silencing of Mex3a dampened rapamycin-induced nuclear miR-126-5p enrichment. Gain- and loss-of-function studies for miR-126-5p and Mex3a showed that Mex3a-guided nuclear miR-126-5p affect apoptosis mediators (e.g. caspase-3) at RNA and protein level, thus reducing the apoptotic rate. High-shear flow at non-predilection sites for atherosclerosis induced endothelial autophagy to promote nuclear enrichment of Ago2 and miR-126-5p in vivo in mice. Consistently, fewer nuclear Ago2 and miR-126-5p were observed in the endothelium of atheromatous area at bifurcations of human carotid arteries. These effects were abrogated in vivo by endothelial-specific deficiency in autophagy, thereby exacerbating atherosclerosis, and by Mex3a knock-out favouring apoptosis.

Conclusion

The autophagy-activated Mex3a-driven nuclear translocation represents a non-canonical mechanism by which miR-126-5p confer endothelial protection. Modulation of this pathway may open new opportunities for prevention and treatment of atherosclerosis.

2181The prothrombotic transcriptome of reticulated platelets

Introduction

Reticulated platelets (RPs) are young, hyper-reactive platelets that are larger and contain significantly more RNA compared to older mature platelets. High levels of RPs in peripheral blood are predictors of an insufficient response to dual antiplatelet therapy in cardiovascular patients and of adverse cardiovascular events also in non-cardiac patients. However, the mechanisms underlying these correlations remains widely unknown and the biology of RPs has not been investigated yet.

Purpose

We aimed to compare for the first time the transcriptomic profiles of RPs and mature platelets (MPs).

Methods

RPs and MPs from peripheral blood of healthy donors were identified and isolated using FACS/Sorting based on their RNA-content. Immediately after sorting, RNA was extracted and quality, concentration and integrity was assessed with the Tapestation 4200 platform (Agilent). Total- and small-RNA libraries were prepared, multiplexed and sequenced on a NextSeq 500 Illumina platform

Results

Total-RNA-sequencing revealed 1744 differentially expressed genes (670 downregulated 1074 upregulated) in RPs compared to MPs (Figure 1A, B). In particular, transcripts for the collagen receptor GP6, thromboxane receptor A2 (TBXA2R), thrombin receptor PAR4 (F2RL3) and ATP receptor P2RX1 were significantly enriched in RPs, whereas several RNA regulators as the ribonuclease PARN, the RISC-component TNRC6A and the splicing factor LUC7L3 were downregulated in RPs. Gene ontology analysis revealed an enrichment of relevant biological categories in RPs including platelet activation and blood coagulation (Figure 1C). Gene Set Enrichment Analysis showed an enrichment of several activation pathways like thrombin, thromboxane and GPIIb/IIIa signaling in RPs. Small-RNA-sequencing reported 9 miRNAs significantly downregulated in RPs with targets involved in platelet reactivity.

Figure 1

Conclusions

This study represents the first comparative transcriptome analysis of RPs and MPs and reports for the first time a differential enrichment of transcripts involved in platelet activation. The clear upregulation of prothrombotic signaling in RPs could explain, at least in part, their hyper-activity and their correlation with cardiovascular events in different pathological settings (trancripts enriched in RPs: Figure 1D).

Acknowledgement/Funding

German Society of Cardiology (DGK Nr.102018) ESC First conctact initiative grant 2018

Identification of microRNAs 758 and 33b as potential modulators of ABCA1 expression in human atherosclerotic plaques

BACKGROUND AND AIM

Adenosine triphosphate (ATP)-binding cassette (ABC) transporters A1 and G1 are the main transporters involved in macrophage cholesterol efflux. The understanding of the molecular mechanism(s) of their regulation in atherosclerosis is crucial for potential therapeutic approaches. Preclinical studies support a role for microRNAs in the posttranscriptional regulation of these transporters; however, no evidence is still available on human atherosclerosis. Thus, the aim of this study was to investigate the modulation of the ABCA1 and ABCG1 pathway in human atherosclerotic plaques and microRNA involvement in its modulation.

METHODS AND RESULTS

Thirty-one human atherosclerotic plaques were obtained from patients undergoing carotid endarterectomy for high-grade (>70%) vessel stenosis, and divided into normocholesterolemic (n = 15) and hypercholesterolemic groups (n = 16) according to the presence/absence of hypercholesterolemia. Both ABCA1 and ABCG1 messenger RNAs (mRNAs) were significantly upregulated in carotid plaques from hypercholesterolemic patients as assessed by real-time polymerase chain reaction (RT-PCR). Despite this result, no difference was found at the protein levels analyzed by Western blot, thus suggesting a strong posttranscriptional modulation. MicroRNA microarray and subsequent validation by RT-PCR showed a significant upregulation of ABCA1-linked miR-758 and miR-33b in plaques from hypercholesterolemic patients.

CONCLUSION

We provide evidence of a strong posttranscriptional regulation of ABCA1 and ABCG1 expression in human atherosclerotic plaques from hypercholesterolemic patients. This effect is potentially due to the concomitant increase of miR-33b and miR-758, two well-established regulators of ABCA1 and ABCG1 expression. The identification of miR-33b and miR-758 as putative key regulators of ABCA1 protein expression within human atherosclerotic plaques provides further data for the realization of new anti-atherosclerotic drugs with specific targets based on anti-miRNA technologies.

MicroRNAs and atherosclerosis: new actors for an old movie

To date, cardiovascular diseases (CVDs) are the leading causes of morbidity and mortality worldwide. MicroRNAs (miRNAs) are endogenous, short, non-coding RNA sequences able to regulate gene expression principally at the post-transcriptional level. Initially, they were thought to be involved only in developmental timing of worms. Their involvement in human biology was recently discovered and many studies have been performed to demonstrate the role of miRNA in human cancer. Since the first observation in 2005 of their implication in cardiac biology, many studies have demonstrated their role in the genetic modulation of cardiovascular development and in cardiovascular diseases such as cardial remodeling and heart failure, cardiac arrhythmias, cardiac ischaemia, cardiac fibrosis, atherosclerosis and stroke. Thus, the aim of this review is to describe the role of miRNA in atherosclerosis development and evolution and to individuate their role as potential therapeutic target.

Symptomatic carotid stenosis. Diagnosis and treatment guidelines. Juridical and medico-legal approach

An increasing body of health care regulations and the growing concern of physicians and patients about health care services have sharpened the debate surrounding the concept of quality in medicine. Once unknown terms such as audit, peer review, accreditation, ISO 9000, quality assurance (QA), continuous quality improvement (CQI) and risk management have become more familiar but also less clear. Following recent reports, medical error has been cited as a result of a health care system that has not yet fully embraced the tenets of quality management. A clearer explanation of definitions, knowledge and procedures is therefore needed. In Italy, the general debate on surgical risk led to a proposal to implement control systems that would monitor the work of each team member in the operating room, from the patient's arrival to transfer to the floor. But to understand the dynamics of doubtful cases, we need to start from new concepts that release the surgeon from the role of ''high priest in the surgery temple.'' Such concepts would underpin a process analysis of how much is effectively done and by whom. This means, on one hand, developing a greater awareness of one's role and competences, and on the other, delineating the stages within which each health care professional is expected to operate. Entering into the debate are the guidelines scientific societies have drawn up to rationalise and improve health care delivery through recommendations directed at optimizing the efficacy and efficiency of surgical intervention as the result of scientific evaluation and clinical observation. However, the critics in question do not always allow the surgeon to work under a medico-legal ''guarantee'' that covers his medical conduct. Further-more, they can be a double-edged sword in court if not adequately considered and critically evaluated with regard to a specific case, the object of censure and charge. In fact, they can be ''exploited'' as an instrument of accusation or defence in an arena where the mass media rush to blame the surgeon but later forget to duly report the acquittal of charges held against the surgeon. The present article examines the light and dark sides of guidelines, taking as an example those profiled by the Italian Society of Vascular and Endovascular Surgery and based on international guidelines for the treatment of symptomatic carotid stenosis.

Vascular surgeon and endovascular practice: legal possibility or absolute prohibition?

In Italy the diagnostic and therapeutic radiology practice is regulated by special laws, which are changed acting in accordance with EURATOM directive so that other specialists can use radiological instrument, such as orthopedic surgeons and cardilogists do. Medical and technological progress enables vascular surgeons to choose other treatments alternative to conventional surgery in the treatment of some vascular diseases by the use of radiological instruments. In our country there are special laws for the practice of radiology, so we verify if vascular surgeons can legally perform endovascular procedures using radiological techniques.

[The surgeons civil responsibility insurance]

After a short research in the field national insurances, the author analyses the professional physician insurance policy; the ambiguity and difficulty of contracts concerning the professional health activity of surgeon, whether as state employee or as independent professional are pointed put. With the introduction of the ministerial decree dated January 29,1992, the new labour agreement, the privacy law, the evolution of ''informed consent'', the esthetic injury concept, the safety regulations law and the administrative liability, surgeons must pay attention to draw up an insurance policy suitable to their profession.