Serum HMGB1 levels are independently associated with glucose clamp-derived measures of insulin resistance in women with PCOS

PURPOSE

PCOS is associated with low grade inflammation which could play a role in insulin resistance and ovarian dysfunction. Preliminary findings suggested that serum levels of HMGB1, a cytokine involved in inflammation, might be altered in women with PCOS. Primary aim of this study was to assess whether HMGB1 serum concentrations are associated with PCOS and with the state of insulin resistance of these women.

METHODS

Sixty women with PCOS, selected to have a similar proportion of subjects with altered or normal insulin sensitivity, and 29 healthy controls were studied. Serum HMGB1 levels were compared in subgroups of PCOS women and controls. In PCOS women, insulin sensitivity was assessed by the glucose clamp technique and HMGB1 was measured at baseline and after acute hyperinsulinemia.

RESULTS

HMGB1 levels were similar in women with PCOS and controls and no elements used for diagnosing PCOS were associated with serum HMGB1. However, HMGB1 concentrations were higher in insulin-resistant vs insulin-sensitive PCOS women (p = 0.017), and inversely associated with insulin-induced total and non-oxidative glucose metabolism. In both subgroups of PCOS women, serum HMBG1 levels significantly increased after acute hyperinsulinemia.

CONCLUSIONS

These data suggest that HMGB1 levels are not associated with PCOS per se, but with insulin resistance. Further research should establish the underlying nature of this relationship, and whether this protein might play a role in the metabolic complications of PCOS.

RAGE inhibition blunts insulin-induced oncogenic signals in breast cancer

The receptor for advanced glycation end products (RAGE) is implicated in diabetes and obesity complications, as well as in breast cancer (BC). Herein, we evaluated whether RAGE contributes to the oncogenic actions of Insulin, which plays a key role in BC progression particularly in obese and diabetic patients. Analysis of the publicly available METABRIC study, which collects gene expression and clinical data from a large cohort (n = 1904) of BC patients, revealed that RAGE and the Insulin Receptor (IR) are co-expressed and associated with negative prognostic parameters. In MCF-7, ZR75 and 4T1 BC cells, as well as in patient-derived Cancer-Associated Fibroblasts, the pharmacological inhibition of RAGE as well as its genetic depletion interfered with Insulin-induced activation of the oncogenic pathway IR/IRS1/AKT/CD1. Mechanistically, IR and RAGE directly interacted upon Insulin stimulation, as shown by in situ proximity ligation assays and coimmunoprecipitation studies. Of note, RAGE inhibition halted the activation of both IR and insulin like growth factor 1 receptor (IGF-1R), as demonstrated in MCF-7 cells KO for the IR and the IGF-1R gene via CRISPR-cas9 technology. An unbiased label-free proteomic analysis uncovered proteins and predicted pathways affected by RAGE inhibition in Insulin-stimulated BC cells. Biologically, RAGE inhibition reduced cell proliferation, migration, and patient-derived mammosphere formation triggered by Insulin. In vivo, the pharmacological inhibition of RAGE halted Insulin-induced tumor growth, without affecting blood glucose homeostasis. Together, our findings suggest that targeting RAGE may represent an appealing opportunity to blunt Insulin-induced oncogenic signaling in BC.

P-476 Why are they not coming back? A single-center follow-up study on oncological women oocyte's storing for fertility preservation

Study question

Which is the return rate and which factors are responsible for the non-return in cancer patients who underwent oocyte cryopreservation for fertility preservation?

Summary answer

Return rate was 11.7%. Young age at freezing, lack of a partner and type of cancer were the main factors responsible for the non-return.

What is known already

Improvements in oncological early diagnoses and therapies have significantly increased the survival rates of patients, allowing clinicians to focus on long-term quality-of-life issues, such as access to motherhood. An extensive literature on the importance of fertility preservation (FP) has been produced thanks to the growing number of patients undergoing FP cycles over the years. Nevertheless, the rates of patients returning to use their cryopreserved material have shown to be considerably low, ranging from 5 to 8%. Significant data regarding the reasons that might explain such low return rates are still scarce.

Study design, size, duration

This is a single-center follow-up retrospective study that includes all women who underwent oocyte cryopreservation cycles for oncological purposes at referral University affiliated center, from January 2001 to December 2017.

Participants/materials, setting, methods

The database consists of 171 patients, among those 110 (64%) were diagnosed with breast cancer, 45 (26%) hematological cancer, 5 (3%) gynecologic cancer and 11 (7%) other cancers. Data about returned patients were retrieved from internal registries. Non-returned patients were assessed by standardized phone survey on health and marital status, family projects, spontaneous conceptions, and reasons why they had not returned to use their gametes. A univariate analysis between returned and non-returned patients was performed.

Main results and the role of chance

Among the 171 women who underwent oocyte cryopreservation, 9 (5%) died and 17 (10%) were lost at follow up. In the remaining 145-patient group, the mean age at freezing was 32.2±6.1 and at follow-up 38.2±6.7 years. A total of 20 patients (11.7%) returned to use their frozen material and 125 did not. In the non-returned group, 37 (29.6%) did not have a partner, 10 (8%) had a previous spontaneous conception and 15 (12%) had recurrent malignancy at the time of follow-up. In the univariate analysis, younger age at freezing (31.8±6.2 vs 35.2±4.7; p 0.018), lack of a partner (p 0.002), type of cancer (other than breast cancer; p 0.024) were the significant factors in the non-returned group. As for the personal reason for not coming back, patients mainly answered as follows: lack of a partner (29, 23.2%), desire of spontaneous motherhood (24, 19.2%), previous spontaneous pregnancies after FP procedures (16, 12.8%), and still ongoing hormonal therapy for breast cancer (13, 10.4%). Nonetheless all of them confirmed their will to keep the storage of their oocytes.

Limitations, reasons for caution

The study population consists of a limited number of patients from a single Italian Fertility Center. Since the Italian law limits ART access to heterosexual couples, this setting may limit any possible adaptation of the study to other countries, with different legislations.

Wider implications of the findings

The impact of a cancer diagnosis on a woman’s maternal desire, sentimental status and life priorities should be studied more thoroughly. Moreover, it is important to encourage studies investigating so long hormonal therapy suppression in breast cancer patients seeking pregnancy in order to reduce their time to pregnancy.

Trial registration number

na

First trimester pregnancy outcomes in a large IVF center from the Lombardy County (Italy) during the peak COVID-19 pandemic

At the beginning of 2020, the Italian Lombardy region was hit by an "epidemic tsunami" which was, at that point in time, one of the worst pandemics ever. At that moment the effects of SARS-COV 2 were still unknown. To evaluate whether the pandemic has influenced ART (Assisted Reproduction Techniques) outcomes in an asymptomatic infertile population treated at one of the major COVID-19 epicentres during the weeks immediately preceding lockdown. All ART procedures performed during two time periods were compared: November 1st, 2018 to February 28th, 2019 (non-COVID-19 risk) and November 1st, 2019 to February 29th, 2020 (COVID-19 risk). In total 1749 fresh cycles (883 non-COVID-19 risk and 866 COVID-19 risk) and1166 embryos and 63 oocytes warming cycles (538 and 37 during non-COVID and 628 and 26 during COVID-19 risk, respectively) were analysed. Clinical pregnancies per cycle were not different: 370 (25.38%) in non-COVID versus 415 (27.30%) (p = 0.237) during COVID-19 risk. There were no differences in biochemical pregnancy rates 52 (3.57%) versus 38 (2.50%) (p = 0.089) nor in ectopic pregnancies 4 (1.08%) versus 3 (0.72%) (p = 0.594), spontaneous miscarriages 84 (22.70%) versus 103 (24.82%) p = 0.487, nor in intrauterine ongoing pregnancies 282 (76.22%) versus 309 (74.46%) p = 0.569. A multivariate analysis investigating differences in spontaneous miscarriage rate showed no differences between the two timeframes. Our results support no differences in asymptomatic infertile couples' ART outcomes between the pre COVID and COVID-19 periods in one of the earliest and most severe pandemic areas.

One step further: randomised single-centre trial comparing the direct and afterload techniques of embryo transfer

STUDY QUESTION

What are the differences in ease of use between two different embryo transfer (ET) techniques: the preload direct approach and the afterload approach.

SUMMARY ANSWER

The afterload technique seems to reduce the rate of difficult ETs.

WHAT IS KNOWN ALREADY

Numerous published trials now document that the ET procedure has an impact on pregnancy and delivery rates after IVF. Difficult transfers should be avoided, as they reduce implantation and pregnancy rates. Preload direct ETs with soft catheters under ultrasound guidance is currently considered the best procedure. However, when using soft catheters, it is not known which technique is preferable or which one should be implemented to reduce the operator factor.

STUDY DESIGN, SIZE, DURATION

This prospective randomised unblinded controlled clinical trial, included 352 ultrasound-guided ETs assigned to either direct ET or afterload ET, between September 2017 and March 2019. The sample size was calculated based on the historical rate of difficult ETs encountered between 2014 and 2015 with a direct ET procedure.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The inclusion criteria were women 18-38 years old, with BMI between 18 and 28, receiving a single-thawed blastocyst transfer. The exclusion criteria were use of testicular sperm and preimplantation genetic testing (PGT) cycles. The primary outcome was the rate of difficult or suboptimal transfers defined as: advancement of the outer sheath (specific for the direct transfer), multiple attempts, use of force, required manipulation, use of a stylet or tenaculum, dilatation, or use of a different catheter. The secondary outcome was clinical pregnancy rate.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 352 frozen ETs were randomised, with 176 patients in each group. The two arms were homogeneous for female and male age, female BMI, duration of infertility, secondary infertility, previous deliveries or miscarriages, myomas, previous surgery to the uterine cavity, cycle day at ovulation trigger, freeze all cycles, first transfers, indication for treatment, endometrial preparation protocol and duration, endometrial thickness, and blastocyst grade at vitrification. Across the entire population, 85 (24.1%) ETs were defined as difficult. The rate of difficult transfers was significantly higher in the direct ET group than in the afterload group: 68 (38.6%) versus 17 (9.7%), respectively (OR 0.17, 95% CI 0.09-0.30, P < 0.001). The mean percentage in the rate of difficult transfers per operator was 22.5% (SD ± 14.5%), of which 36.1% (SD ± 23.4%) were in the direct group compared with 8.6% (± 8.2%) in the afterload group (P < 0.001). The difficult transfer rate among operators varied from 0 to 43.8% (0-77.8% in the direct group and 0 to 25.0% in the afterload group). The clinical pregnancy rates (42.0% vs 48.3%, P = 0.239 in the direct and afterload groups, respectively) were not significantly different between the groups.

LIMITATIONS, REASONS FOR CAUTION

There were 18 experienced operators who participated in the trial. Conclusions about the pregnancy rate should not be generalised, since the sample analysis was not performed on this outcome and, although clinically relevant, the difference was not significantly different.

WIDER IMPLICATIONS OF THE FINDINGS

The rate of difficult transfers was significantly higher in the direct ET group compared with the afterload ET group, although a wide variation was observed among operators. Further studies regarding the association between transfer technique and ART outcomes are required.

STUDY FUNDING/COMPETING INTEREST(S)

No specific funding was sought and there are no competing interests.

TRIAL REGISTRATION NUMBER

NCT03161119.

TRIAL REGISTRATION DATE

5 April 2017.

DATE OF FIRST PATIENT'S ENROLMENT

26 September 2017.

Diagnostic Approach to Acute Liver Failure in Children: A Position Paper by the SIGENP Liver Disease Working Group

Acute liver failure (ALF) is a clinical condition characterized by the abrupt onset of coagulopathy and biochemical evidence of hepatocellular injury, leading to rapid deterioration of liver cell function. In children, ALF has been characterized by raised transaminases, coagulopathy, and no known evidence of pre-existing chronic liver disease; unlike in adults, the presence of hepatic encephalopathy is not required to establish the diagnosis. Although rare, ALF has a high mortality rate without liver transplantation (LT). Etiology of ALF varies with age and geographical location, although it may remain indeterminate in a significant proportion of cases. However, identifying its etiology is crucial to undertake disease-specific management and evaluate indication to LT. In this position statement, the Liver Disease Working Group of the Italian Society of Gastroenterology, Hepatology and Nutrition (SIGENP) reviewed the most relevant studies on pediatric ALF to provide recommendations on etiology, clinical features and diagnostic work-up of neonates, infants and children presenting with ALF. Recommendations on medical management and transplant candidacy will be discussed in a following consensus conference.

The human factor: does the operator performing the embryo transfer significantly impact the cycle outcome?

STUDY QUESTION

Is Ongoing Pregnancy Rate (OPR) operator-dependent, and can experience improve embryo transfer efficiency?

SUMMARY ANSWER

OPR is influenced by the operators who perform the embryo transfer (ET), and experience does not assure proficiency for everyone.

WHAT IS KNOWN ALREADY

ET remains the critical step in assisted reproduction. Although many other factors such as embryo quality and uterine receptivity impact embryo implantation, the proper ET technique is clearly an operator-dependent variable and as such it should be objectively standardized.

STUDY DESIGN, SIZE, DURATION

Retrospective comparative analysis including all fresh ETs performed between January 1996 and December 2016 at the Humanitas Fertility Center after IVF—ICSI cycles.

PARTICIPANTS/MATERIALS, SETTING, METHODS

IVF/ICSI fresh ETs performed by 32 operators, 19 824 cycles in all, were analyzed. All transfers consisting of freehand insertion of a preloaded soft catheter into the uterine cavity under transabdominal ultrasound guidance were considered. Two different statistical analyses were performed. First, a logistic regression model with a random intercept for the operator was used to estimate the heterogeneity of the rate of success among operators, accounting for woman age, FSH, number of oocytes retrieved, fertilization rate, year of the procedure, number and stage of transferred embryos and operator’s experience. Second, the relationship between experience and pregnancy rate was estimated separately for each operator by logistic regression, and operator-specific results were combined and compared in a random-effects meta-analysis. In both analyses, the operator’s experience at time t was measured in terms of number of embryo transfers performed before t.

MAIN RESULTS AND THE ROLE OF CHANCE

The heterogeneity among operators was highly significant (P value <0.001) and explained 44.5% of the total variability. The odds ratio of success of the worst operator in respect to the mean was equal to 0.84. For the best operator, the odds ratio of success was equal to 1.13 in respect to the mean. Based on the meta-analysis of the relationship between operator’s experience and success rate, it resulted that, on average, the operators’ performance did not improve with additional transfers.

LIMITATIONS, REASONS FOR CAUTION

At our center, operators become independent for ET’s after performing between 30 and 50 transfers under supervision. It is also possible that other relevant factors, such as embryologists on duty for the ET, have not been included in the present analysis and this may represent a potential bias. Among these, it should be mentioned that the embryologists on duty for the ET were not taken into consideration.

WIDER IMPLICATIONS OF THE FINDINGS

Continued performance analysis and the use of a digital simulator could help operators to test their expertise over time and either correct poor performance or avoid doing transfers.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

NCT03561129.

Eculizumab treatment in patients with COVID-19: preliminary results from real life ASL Napoli 2 Nord experience

OBJECTIVE

SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2)-related pneumonia, referred to as COVID-19 (Coronavirus Disease 19), is a public health emergency as it carries high morbidity, mortality, and has no approved specific pharmacological treatments. In this case series, we aimed to report preliminary data obtained with anti-complement C5 therapy with eculizumab in COVID-19 patients admitted to intensive care unit (ICU) of ASL Napoli 2 Nord.

PATIENTS AND METHODS

This is a case series of patients with a confirmed diagnosis of SARS-CoV2 infection and severe pneumonia or ARDS who were treated with up to 4 infusions of eculizumab as an off-label agent. Patients were also treated with anticoagulant therapy with Enoxaparin 4000 IU/day via subcutaneous injection, antiviral therapy with Lopinavir 800 mg/day + Ritonavir 200 mg/day, hydroxychloroquine 400 mg/day, ceftriaxone 2 g/day IV, vitamine C 6 g/day for 4 days, and were on Non-Invasive Ventilation (NIV).

RESULTS

We treated four COVID-19 patients admitted to the intensive care unit because of severe pneumonia or ARDS. All patients successfully recovered after treatment with eculizumab. Eculizumab induced a drop in inflammatory markers. Mean C Reactive Protein levels dropped from 14.6 mg/dl to 3.5 mg/dl and the mean duration of the disease was 12.8 days.

CONCLUSIONS

Eculizumab has the potential to be a key player in treatment of severe cases of COVID-19. Our results support eculizumab use as an off-label treatment of COVID-19, pending confirmation from the ongoing SOLID-C19 trial.

Synthesis and chemical characterization of several perfluorinated sialic acid glycals and evaluation of their in vitro antiviral activity against Newcastle disease virus

Newcastle Disease Virus (NDV), belonging to the Paramyxoviridae family, causes a serious infectious disease in birds, resulting in severe losses in the poultry industry every year. Haemagglutinin neuraminidase glycoprotein (HN) has been recognized as a key protein in the viral infection mechanism, and its inhibition represents an attractive target for the development of new drugs based on sialic acid glycals, with the 2-deoxy-2,3-didehydro-d-N-acetylneuraminic acid (Neu5Ac2en) as their backbone. Herein we report the synthesis of several Neu5Ac2en glycals and of their perfluorinated C-5 modified derivatives, including their respective stereoisomers at C-4, together with evaluation of their in vitro antiviral activity. While all synthesized compounds were found to be active HN inhibitors in the micromolar range, we found that their potency was influenced by the chain-length of the C-5 perfluorinated acetamido functionality. Thus, the binding modes of the inhibitors were also investigated by performing a docking study. Moreover, the perfluorinated glycals were found to be more active than the corresponding normal C-5 acylic derivatives. Finally, cell-cell fusion assays on NDV infected cells revealed that the addition of a newly synthesized C-4α heptafluorobutyryl derivative almost completely inhibited NDV-induced syncytium formation.

SIRT1 is involved in oncogenic signaling mediated by GPER in breast cancer

A number of tumors exhibit an altered expression of sirtuins, including NAD⁺-dependent histone deacetylase silent information regulator 1 (SIRT1) that may act as a tumor suppressor or tumor promoter mainly depending on the tumor types. For instance, in breast cancer cells SIRT1 was shown to exert an essential role toward the oncogenic signaling mediated by the estrogen receptor-α (ERα). In accordance with these findings, the suppression of SIRT1 led to the inhibition of the transduction pathway triggered by ERα. As the regulation of SIRT1 has not been investigated in cancer cells lacking ER, in the present study we ascertained the expression and function of SIRT1 by estrogens in ER-negative breast cancer cells and cancer-associated fibroblasts obtained from breast cancer patients. Our results show that 17β-estradiol (E2) and the selective ligand of GPER, namely G-1, induce the expression of SIRT1 through GPER and the subsequent activation of the EGFR/ERK/c-fos/AP-1 transduction pathway. Moreover, we demonstrate that SIRT1 is involved in the pro-survival effects elicited by E2 through GPER, like the prevention of cell cycle arrest and cell death induced by the DNA damaging agent etoposide. Interestingly, the aforementioned actions of estrogens were abolished silencing GPER or SIRT1, as well as using the SIRT1 inhibitor Sirtinol. In addition, we provide evidence regarding the involvement of SIRT1 in tumor growth stimulated by GPER ligands in breast cancer cells and xenograft models. Altogether, our data suggest that SIRT1 may be included in the transduction network activated by estrogens through GPER toward the breast cancer progression.

Neuroendocrine tumors and their association with rare tumors: observation of 4 cases

PURPOSE

Neuroendocrine tumors are rare neoplasms, with an incidence of about 1/100,000/year. The association between digestive neuroendocrine tumors and epithelial tumors is known, accounting for about 10% of cases, whilst in a very small number of other cases an association with other low incidence tumors has been observed.

METHODS

During the past 19 years the Rare Hormonal Tumors Group of the Istituti Ospitalieri in Cremona, Italy has observed 300 patients affected by neuroendocrine tumors. We report here on four cases in which there was an unusual association with other rare neoplasms.

RESULTS

Overall, four of the 300 observed cases (1.3%) showed an unusual association with rare nonepithelial neoplasms: (1) gastric carcinoid and glioblastoma multiforme; (2) Merkel cell tumor and squamous cell carcinoma of the skin; (3) medullary thyroid carcinoma, yolk sac tumor of the testis and gastrointestinal stromal tumor (GIST); (4) gastric carcinoid and gastrointestinal stromal tumor (GIST).

DISCUSSION

There cases are of interest not only from an epidemiological point of view, but also offer insight into possible geno-phenotypical implications. The c-kit expression, typical of GISTs but observed also in other epithelial and neuroendocrine tumors, not only broadens the possibility to gain insight into the carcinogenesis of these neoplasms, but also opens the field to possible new therapeutic opportunities using multitargeted molecules. The contemporaneous presence of other lesions, such as the Merkel cell tumor and the squamous cell carcinoma of the skin can be interpreted as an answer by the cell to the same mutagenic stimulus. In other cases, where a possible link is not yet found which could explain the synchronism or metachronism of low incidence neoplasms, it remains possible that the associations are entirely coincidental. We await for new instruments which could help us demonstrate the possible relationships between low incidence neoplasms.

Changes in insulin levels following 6-month treatment with recombinant human growth hormone in growth hormone-deficient adults

INTRODUCTION

Eighty-six adult patients with GH deficiency (GHD) of adult or childhood onset were treated for 6 months, with recombinant human growth hormone (rhGH) at a low (LD) or conventional dose (CD). The treatment effect on insulin levels was investigated.

METHODS

This manuscript refers to the Italian addendum to an International Study (B9R-EW-GDED) in which patients with GHD were randomized to receive r-hGH replacement therapy at a dose of either 3 microg/kg/day or 6 microg/kg/day for the 3 months. The dose was then doubled for the next 3 months.

RESULTS

After 6 months of r-hGH treatment, insulin levels increased with both GH dosages, with a greater increase achieved in the low-dose subgroup. Insulin levels also increased significantly in the childhood-onset, while even decreased in the adult-onset subgroup. On the whole, in more than 50% of patients, insulin values rose by >13%. Moreover, mean levels of IGF-I increased 2-3 fold (p<0.001 vs baseline) in both the LD and CD groups. Significant and similar increases in IGF binding protein-3 levels were seen in both the LD and CD groups over the treatment period, regardless the time of onset of GHD.

CONCLUSION

Insulin increased with both GH dosages and more than half of patients presented an important increase in insulin plasma levels. It would be of interest to assess if there is a correlation between the changes in insulin levels and other cardiovascular risk factors such as hemostatic parameters.

Histochemical study of glycoconjugates in the toadfish Halobatrachus didactylus oesophagus epithelium

The carbohydrate expression in the epithelium lining the oesophagus of the toadfish Halobatrachus didactylus was studied by means of conventional and lectin histochemistry. The stratified epithelium was constituted by basal cells, polymorphous cells in the intermediate layer, pyramidal and flattened cells in the outer layer and contained two types of large secretory cells: goblet cells and sacciform cells. PAS, Alcian blue pH 2.5 and pH 1.0 stained very strongly the goblet cells, weakly the surface of the other epithelial cells but did not stain the sacciform cells. The goblet cells cytoplasm contained oligosaccharides with terminal Galbeta1,3GalNAc, alpha/betaGalNAc, Galbeta1,4GlcNAc, alphaL-Fuc and internal betaGlcNAc residues (PNA, SBA, RCA120, UEA I, LTA and KOH-sialidase-WGA affinity). Galbeta1,4GlcNAc, alphaL-Fuc and internal betaGlcNAc were also found in the glycocalyx. The sacciform cells expressed sialyloligosaccharides terminating with Neu5Acalpha2,3Galbeta1,4GlcNac, Neu5Acbeta2,6Gal/GalNAc, Neu5AcForssman pentasaccharide (MAL II, SNA, KOH-sialidase-DBA staining) as well as asialo-glycoconjugates with terminal/internal alphaMan (Con A affinity) and with terminal Galbeta1,3GalNAc, Forssman pentasaccharide, Galbeta1,4GlcNAc, GalNAc (HPA and SBA reactivity), alphaGal (GSA I-B4 reactivity), D-GlcNAc (GSA II labelling), alphaL-Fuc. The basal cells cytoplasm exhibited terminal/internal alphaMan and terminal Neu5Acalpha2,6Gal/GalNAc, Galbeta1,4GlcNAc, alpha/betaGalNAc, alphaGal, GlcNAc, alphaL-Fuc. Intermediate cells showed oligosaccharides with terminal/internal alphaMan and/or terminating with Neu5Acalpha2,6Gal/GalNAc, Galbeta1,4GlcNAc in the cytoplasm and with Neu5Acalpha2,3Galbeta1,4GlcNac, alpha/betaGalNAc, alphaGal, GlcNAc, alphaL-Fuc in the glycocalyx. The pyramidal cells expressed terminal/internal alphaMan and terminal Neu5Acalpha2,6Gal/GalNAc, alpha/betaGalbeta1,4NAc, alphaGal, alphaL-Fuc in the entire cytoplasm, terminal Neu5Acalpha2,3Galbeta1,4GlcNac and Forssman pentasaccharide in the apical extension, internal betaGlcNAc and/or terminal alphaL-Fuc in the luminal surface, Neu5Acalpha2,3Galbeta1,4GlcNac, Neu5Acalpha2,6Gal/GalNAc, Galbeta1,4GlcNAc, alphaGal in the basolateral surface. The flattened cells displayed glycans with terminal/internal alphaMan and terminal Neu5Acalpha2,6Gal/GalNAc, alpha/betaGalNAc, alphaGal, D-GlcNAc in the entire cytoplasm, glycans terminating with Galbeta1,3GalNAc and/or internal betaGlcNAc in the sub-nuclear cytoplasm.

Immunohistochemical localization of CYP1A, vitellogenin and Zona radiata proteins in the liver of swordfish (Xiphias gladius L.) taken from the Mediterranean Sea, South Atlantic, South Western Indian and Central North Pacific Oceans

Cytochrome P4501A (CYP1A) monoxygenase, vitellogenin (Vtg) and Zona radiata proteins (Zrp) are frequently used as biomarkers of fish exposure to organic contaminants. In this work, swordfish liver sections obtained from the Mediterranean Sea, the South African coasts (South Atlantic and South Western Indian Oceans) and the Central North Pacific Ocean were immunostained with antisera against CYP1A, Zrp, and Vtg. CYP1A induction was found in hepatocytes, epithelium of the biliary ductus and the endothelium of large blood vessels of fish from the Mediterranean Sea and South African waters, but not from the Pacific Ocean. Zrp and Vtg were immunolocalized in hepatocytes of male swordfish from the Mediterranean Sea and from South African waters. Plasma Dot-Blot analysis, performed in Mediterranean and Pacific specimens, revealed the presence of Zrp and Vtg in males from Mediterranean but not from Pacific. These results confirm previous findings about the potential exposure of Mediterranean swordfish to endocrine, disrupting chemicals and raise questions concerning the possible presence of xenobiotic contaminants off the Southern coasts of South Africa in both the South Atlantic and South Western Indian Oceans.

Evidence of a high percentage of intersex in the Mediterranean swordfish (Xiphias gladius L.)

The first evidence of the presence of intersexuality in a wild population of Mediterranean swordfish (Xiphias gladius L.) is reported. Forty of 162 specimens (25%) macroscopically classified as males, showed the presence of female germ cells within the testes. In two specimens grouped previtellogenic oocytes were present; all the other specimens possessed single scattered previtellogenic oocytes. The presence of vitellogenin was demonstrated immunohistochemically in the liver of both intersex and normal males. These findings could be due to the exposure to oestrogen-mimicking substances.

Plasma levels of atrial and brain natriuretic peptides as indicators of recovery of left ventricular systolic function after coronary artery bypass

OBJECTIVE

The purpose of this study was to investigate the effectiveness of atrial and brain natriuretic peptides (ANP and BNP, respectively) as indicators of recovery of left ventricular (LV) function after coronary surgery.

METHODS

We measured the concentrations of these peptides in 31 patients with poor LV function (ejection fraction, EF<35%) undergoing coronary artery bypass, and evaluated their correlation with the echocardiographic indexes of LV function.

RESULTS

Pre-operatively, the plasma levels of both ANP and BNP were markedly higher in coronary patients than in normal control subjects, and strongly correlated with both EF (BNP: r=-0.8, P<0.001; ANP: r=-0.6, P<0.001) and wall motion score index (WMSI). At post-operative follow up, plasma levels of both natriuretic peptides were markedly reduced compared with pre-operative values in 21 patients. In addition, the post-operative-pre-operative differences of BNP (Delta(BNP)) and ANP (Delta(ANP)) plasma levels strongly correlated with the differences of both EF (r=-0.7, P<0.0001 vs. Delta(BNP); r=-0.6, P=0.0003 vs. Delta(ANP)) and WMSI (r=0.6, P=0.002 vs. Delta(BNP); r=0.6, P=0.04 vs. Delta(ANP)). Finally, by logistic regression analysis, BNP appeared a significant predictor of LVEF recovery after surgery.

CONCLUSION

Plasma levels of ANP and BNP might be used in routine clinical practice as a support to echocardiography in detecting recovery of the LV function after coronary surgery.

Associated vascular lesions in patients undergoing coronary artery bypass grafting

Atherosclerotic involvement of extracoronary arteries in patients undergoing myocardial revascularization can cause severe postoperative complications and increase postoperative mortality. Between January and November 1998, routine preoperative echo-Doppler study of carotid vessels, abdominal aorta and iliac-femoral arteries was performed in all patients undergoing coronary artery bypass grafting (CABG) at our institution, in order to assess the prevalence and the degree of associated vascular lesions. Correlations between echo-Doppler findings, angiographic patterns of coronary lesions and atherosclerotic risk factors were analyzed in all cases. Among 302 patients undergoing CABG, 186 (61.6%) had carotid disease, with a haemodynamically significant stenosis (>70%) of internal carotid in 31 (10.2%). Twenty-three patients had asymptomatic severe carotid disease. A significant correlation between severity of coronary disease and prevalence of severe carotid disease was found (p = 0.02). An abdominal aortic dilatation (diameter > 25 mm) was found in 20 cases (6.6%), with a diameter >35 mm in 7 patients (2.3%), 6 with triple-vessel coronary disease, and 1 with double-vessel disease. Atherosclerotic lesions of iliac-femoro-popliteal axis were found in 165 (54.6%) patients, with a strong correlation to the severity of coronary disease (p = 0.02); lesions were haemodynamically significant (> 70%) in 48 (15.8%) cases. Symptoms of carotid and peripheral vascular disease are no reliable predictors of perioperative risk in patients undergoing CABG. Non-invasive complete arterial investigation should be routinely performed in these patients, in order to plan the most suitable operative approach and to prevent perioperative vascular complications.

[Prevalence of vascular disease in candidates for myocardial revascularization with aortocoronary bypass: review of the literature and practical implications]

BACKGROUND

Cardiovascular disease remains the main cause of death and morbidity in the industrialized world. Atherosclerosis is a slowly progressive disease; coronary artery disease may be the first presentation of a systemic pathology. The association between coronary artery disease and peripheral vascular disease has often been confirmed by multicenter trials; nevertheless it still remains a subject of debate.

METHODS

In order to assess the incidence of coronary artery disease and the degree of associated vascular lesions, between January 1997 and September 1999, in the Department of Cardiothoracic Surgery of the Second University of Naples (Italy), all candidates to coronary artery bypass grafting (CABG) were submitted to routine preoperative echo color Doppler study of the carotid vessels, abdominal aorta and iliac-femoral arteries. The correlation between the echo color Doppler findings, the angiographic patterns of coronary lesions and atherosclerotic risk factors was analyzed in all cases.

RESULTS

Among 540 patients undergoing CABG, 418 (77.4%) had carotid disease, with a stenosis > 70% in 62 (11.3%). Forty-nine (79%) patients had asymptomatic severe carotid disease. A significant correlation between the severity of coronary disease and the incidence of severe carotid disease was found (p = 0.02). An abdominal aortic dilation was found in 37 cases (6.7%). Its diameter exceeded 35 mm in 14 patients (2.5%) and in 8 it was associated with triple vessel coronary disease. Atherosclerotic lesions of the iliac-femoro-popliteal axis were found in 394 (72.9%) patients and strongly correlated with the severity of coronary artery disease (p = 0.02); lesions were hemodynamically significant in 91 (16.8%) cases.

CONCLUSIONS

Our study emphasizes the association between coronary artery disease and vascular disease. Non-invasive complete arterial investigation should be routinely performed in patients undergoing CABG.

Duromedics original prosthesis: what do we really know about diagnosis and mechanism of leaflet escape?

The Edwards-Duromedics (ED) is a bileaflet pyrolitic carbon mechanical valve introduced by Hemex Scientific Inc in 1982, subsequently acquired by Baxter Healthcare Corp, withdrawn from the market in 1988, and modified and reintroduced in 1990. From 1982 to date, 46 cases of leaflet escape have been registered by the manufacturer of an estimated total of 20,000 valves implanted. Disc embolization 12 years after an ED mitral prosthesis implantation is reported in a 45-year-old man operated on when he was in cardiogenic shock because a preliminary transthoracic Doppler echocardiography did not show malfunction of the valve. A correct diagnosis was made four days after the onset of the symptoms by transesophageal echocardiography. During the operation, the posterior leaflet of the ED valve was not found, a 29 mm St Jude Medical bileaflet mechanical prosthesis was implanted and the patient died in the intensive care unit because of low cardiac output syndrome. Cavitation damage is generally considered the most frequent mechanism in cases of such fracture. Thus, any patient with a mechanical valve presenting with acute pulmonary edema must be immediately transferred to a surgical unit; cinefluoroscopy or transesophageal echocardiography may be performed rapidly to achieve successful management of patients with leaflet embolization.

p53 but not bcl-2 immunostaining is predictive of poor clinical complete response to primary chemotherapy in breast cancer patients

Preoperative chemotherapy administered to breast cancer (BC) patients is a model for studying in vivo the interaction between cytotoxic treatment and clinical and biological parameters. Apoptosis induced by anticancer agents is a mechanism of treatment activity; therefore, overexpression of genes inhibiting the apoptotic pathway could produce drug resistant tumors. In the present study, the two most studied inhibitors of apoptosis, the bcl-2 gene and the mutant p53, have been evaluated to assess whether they may play a role in modulating response of BC to primary chemotherapy. From August 1990 to January 1997, 143 patients bearing T(2-4)N(0-1)M0 primary BC were submitted to two different chemotherapeutic regimens before surgery. The first 64 received the cyclophosphamide, methotrexate, 5-fluorouracil (CMF) regimen (on days 1 and 8 and every 28 days thereafter) associated with tamoxifen (30 mg daily) in case of estrogen receptor (ER)-positive BC, and the remaining 79 were submitted to single agent epirubicin (120 mg/m2 every 21 days). The expression of p53, bcl-2, Ki67, ER, progesterone receptor, c-erbB2, and the multidrug resistance P-glycoprotein (gp-170) was evaluated in BC specimens obtained at diagnosis by incision biopsy and at postchemotherapy surgery. At the end of chemotherapy administration (median, 3 cycles; range, 2-6), the clinical complete response (cCR) rate was superimposable in the patient subgroups with bcl-2-positive or -negative primary tumors; conversely, p53 expression, at a cutoff of 10% positive cells, was significantly associated with a lower cCR rate (9.4 versus 27.0%; P < 0.04). p53 was a significant predictor for poor cCR in the subset submitted to epirubicin (3.6 versus 25.5%; P < 0.02; in patients with p53+ and p53- BC, respectively); by contrast, only a trend toward lower cCR has been observed in patients with p53+ tumors receiving CMF +/- tamoxifen with respect to p53- ones. The distribution of cCR according to the gp-170-positive or -negative tumors was 8 versus 22% in patients submitted to epirubicin and 29 versus 30% in those receiving CMF +/- tamoxifen, respectively. In a multivariate regression analysis, after adjusting for treatment administered (epirubicin versus CMF +/- tamoxifen), menopausal status, tumor and node status, histology grade, ER, progesterone receptor, c-erbB2, Ki67, bcl-2, and gp-170 expression, the p53 status maintained an independent predictive role for cCR. Most of the tumors undergoing change in percentage of p53 expression after both treatments originally harbored mutant protein, and only four BC specimens that were p53 negative before chemotherapy became positive afterward. These data confirm in vivo the concept that the responsiveness of tumors to chemotherapy in part derives from the capability of BC cells to undergo apoptosis. The role of mutated p53 in preventing response is more evident in patients submitted to epirubicin, and this may be caused by the up-regulation of multidrug resistance gene expression by p53 inactivation. p53 is a stable phenotype and is not inducible by at least three or four chemotherapy cycles.

[Radioguided surgery in the treatment of gastro-entero-pancreatic neuroendocrine tumors]

Neuroendocrine tumors are rare neoplasms. In most cases conventional imaging techniques (US,CT,RMN) are not able to identify primitive tumors. This fact conditions the approach to the treatment of these tumors. 111In-Pentetreotide scintigraphy (Octreoscan) permits to visualize occult primary tumor by somatostatin receptors, changing the clinical history of patients. This method can be used in guided surgery with a hand-held gamma probe allowing to improve the detection of occult tumor (inverse square law), giving to the patient further possibilities of survival. Intraoperative gamma probe was still utilized with success in the management of other tumors, as relapsed colorectal cancer, while reports about gamma probe in neuroendocrine tumors are poor because of the rarity of disease. In two cases we have utilized a gamma probe (ORIS model 2) in neuroendocrine tumors: in a case we have observed liver recurring localizations originating from pancreas, with high proliferative index (Ki-67 = 2033 x 10 HPF), and in a case liver metastatic carcinoid of lung. The difference between tumor and background counts was significant exceeds 2 standard deviation count rate. Gamma probe permits a radical cure in many cases and completes intraoperative ultrasound in order to provide the surgeon with other information on the intraoperative staging of the patient.

Persistent impairment of platelet aggregation following cessation of a short-course dietary supplementation of moderate amounts of N-3 fatty acid ethyl esters

The duration of the effect of a short-course (1-mo twice-daily) supplementation of moderate amounts (2.28 g) of n-3 fatty acid ethyl esters (FA) on platelet lipid composition and aggregation was compared with that of olive oil (3 g/d) supplementation in 14 healthy volunteers. The FA preparation employed contained eicosapentaenoic acid (EPA) and docosahexaenoic acids (DHA) in a ratio of 1:1.4. A marked rise (p <0.05) in the plasma and platelet content of EPA and DHA, and minimal changes in the content of arachidonic acid (AA) were documented at withdrawal of the n-3 FA supplementation. EPA/AA and DHA/AA ratios in platelet phospholipids showed that the FA accumulation persisted 8-12 wks after stopping the supplementation (p <0.05). The aggregation of platelets in response to collagen or ADP, and thromboxane B2 (TXB2) formation were impaired at withdrawal. The impaired aggregation lasted 8-12 weeks (p always <0.05), whereas TXB2 formation returned to basal values 4 weeks after stopping the n-3 supplementation. No correlation was found between impaired aggregation and TXB2 formation. In contrast, the impaired sensitivity to ADP (p = 0.036) and, to a lesser extent, to collagen (p = 0.068) were related to changes in the intracellular pH (pHi) of the Na+/H+ reverse transport. No changes in platelet composition or function were observed either during or following olive oil supplementation. These results document a long-lasting impairment of platelet sensitivity to ADP and collagen; changes in the pHi values of the Na+/H+ reverse transport, and a simultaneous persistent accumulation of EPA and DHA in platelet phospholipids, after stopping a short-course dietary supplementation of moderate amounts of n-3 fatty acid ethyl esters.

Inhibition by dipyridamole of neutrophil adhesion to vascular endothelium during coronary bypass surgery

BACKGROUND

Release of reactive oxygen radicals by activated neutrophils and neutrophil adhesion to endothelial cells have been observed after cardiopulmonary bypass. The aim of the present study was to evaluate the effects of preoperative dipyridamole treatment on neutrophil superoxide anion generation and endothelial cell-neutrophil interactions.

METHODS

Two groups of patients scheduled for elective coronary artery bypass grafting were randomized to receive oral dipyridamole or a placebo. Nitro blue tetrazolium scores of circulating neutrophils, neutrophil CD11b/CD18 expression, and their adhesion to human umbilical vein endothelial cells were assayed before anesthesia, 30 minutes after the beginning of cardiopulmonary bypass, at the end of bypass, and 60 minutes postoperatively.

RESULTS

In both groups, cardiopulmonary bypass resulted in a significant increase in nitro blue tetrazolium scores in circulating neutrophils as well as a significant increase in both neutrophil CD11b/CD18 expression and neutrophil adhesion to endothelial cells. The extent of neutrophil superoxide anion generation was higher in the control group; a significant (p < 0.01) reduction in neutrophil adhesion to endothelial cells was observed 1 hour postoperatively in the dipyridamole group. In 5 patients treated with dipyridamole, the incubation of activated polymorphonuclear leukocytes with adenosine deaminase significantly increased their adhesion to endothelial cells (p < 0.05).

CONCLUSIONS

Our study demonstrated that preoperative treatment with oral dipyridamole significantly reduces both neutrophil superoxide anion generation and extent of neutrophil adhesion to endothelial cells after coronary bypass grafting procedures with cardiopulmonary bypass. The mechanism is probably mediated by endogenous adenosine.

[Octreotide in the treatment of advanced pancreatic tumor. Preliminary study]

BACKGROUND

Data from experimental studies suggest that octreotide, the long acting somatostatin analogue, improves survival of animals with pancreatic cancer. To assess the antitumour effect of octreotide, a randomized trial was performed comparing octreotide with supportive care in advanced pancreatic cancer patients. All patients, aged 59-75 years, were not liable to radical surgical treatment and were not submitted to other treatments (chemo and/or radiotherapy).

METHODS

Six patients were enrolled, 4 of these treated with octreotide (500 micrograms two times a day subcutaneous for six months) and the other 2 were inserted a control group.

RESULTS

The patients treated with octreotide showed a significant advantage in quality of life (restored appetite, improvement of digestion and intestine function, remission of abdominal pain and preservation of baseline body weight) with a mean > 80 of karnofsky performance score. Monitoring of tumour size changes (US-TC) over the 6 months study period, showed slackened neoplastic growth in all treated patients, whereas neoplasm grew according to an almost exponential trend in untreated patients. Also survival was better in treated patients: in particular, 2 patients out of 4 who completed the study underwent follow-up until they died 12 and 16 months after beginning of treatment, respectively. Karnofsky performance score was particularly high in both patients. This supports the view that octreotide is endowed with antiproliferative activity.

CONCLUSION

In conclusion octreotide therapy seems to confer a survival benefit and a better quality of life in advanced pancreatic tumour. Additional studies are needed to confirm these results and to clarify other questions about dose and somatostatin receptors in this kind of tumour.

Neutrophil-endothelial cells modulation in diabetic patients undergoing coronary artery bypass grafting

OBJECTIVE

Diabetes mellitus is a well-known risk factor in patients undergoing coronary artery bypass grafting. Myocardial and pulmonary injury often occurs after cardiopulmonary bypass (CPB), mediated in part by neutrophil activation and adhesion to endothelial cells. The objectives of the present study are to compare the degree of neutrophil activation and neutrophil-endothelial cells adhesive interactions in diabetic patients after CPB.

METHODS

Nitro-blu tetrazolium scores, CD 11b expression and neutrophil-endothelial cells adhesion were assessed in blood samples from 15 diabetic and 15 control patients who had undergone elective coronary bypass grafting. Blood samples were obtained at baseline, 30 min after beginning CPB, at the end of CPB and 60 min postoperatively. At the same sampling points as above, blood glucose levels were also checked in all patients.

RESULTS

Diabetes was associated with a significant basal increase in neutrophil CD1 lb expression and adhesion to endothelial cells as well as with an increased superoxide anion production. The increased adhesion of diabetic neutrophils persisted by the end of the CPB to 60 min postoperatively independently of the blood glucose levels. Antibodies directed against CD1 lb and CD18 significantly reduced the degree of neutrophil adhesion observed 60 min postoperatively.

CONCLUSIONS

These results indicate that diabetes mellitus is associated with an increased neutrophil-endothelial cell adhesion probably mediated by the CD1 1b/CD18 molecule; this, in turn, might be responsible for the increased risk of postoperative complications observed in diabetic patients undergoing coronary artery bypass grafting.