P165 CARDIOVASCULAR RISK FACTORS AND HYPOGONADISM INFLUENCE ON CARDIAC OUTCOMES IN AN AGING POPULATION OF BETA–THALASSEMIA PATIENTS: LOOKING AT THE HEART OF THE PROBLEM

Background

β–thalassemia major (β–TM) is a hereditary genetic disease hindered by many comorbidities due to transfusion–related iron. Despite iron chelation therapy increased the life expectancy up to 50 years today, Iron–related heart disease is still a leading complication, with an expected change in cardiac disease drivers with the ageing of these patients. This study aims to evaluate the distribution and prevalence of cardiovascular risk factors in a population of thalassemia major patients, and their relationship with observed cardiovascular events and potential modifying factors.

Methods and Results

One–hundred fifty–nine β–TM patients older than 18 years of age were included in this study. Mean age was 40.9 ± 8.4 years. Low serum lipid levels with low HDL levels were noted, with 28% having diabetes mellitus and 62% with hypogonadism; Splenectomy was reported in 70%. During the observed period, 3.8% of patients had at least one episode of heart failure, 35.9% showed early signs of heart failure, 22% received a diagnosis of diastolic dysfunction, 38% had a left ventricular ejection fraction <55%, and 21.4% showed supraventricular arrhythmias. Cardiovascular risk was then assessed using two algorithms (CUORE and Pooled Cohort Risk Equation – PCRE) and was generally low despite the high burden of cardiac–related events. Patients with hypogonadism (who showed lower cardiac T2* value than those without; p < 0.001) showed a statistically significant correlation with the occurrence of cardiovascular events.

Discussion

The β–TM population has a relatively low mean age, but shows a particular metabolic profile associated with numerous comorbidities: an increased prevalence of diabetes mellitus, low HDL values and frequent hypogonadism, which tends to be associated with increased iron deposition in the myocardium. The cardiovascular risk estimated by specific algorithms (CUORE and PCRE) was generally low, probably due to the young age of the cohort and derivation pitfalls when applied to this specific population, but the prevalence of cardiac events was not negligible.

Conclusions

The chronic accumulation of iron in the heart and the specific metabolic profile, mainly observed in patients with hypogonadism, allows us to define β–TM as a condition with high cardiovascular risk from many points of view (iron–related myopathy, atherosclerosis and arrhythmias), which requires better stratification tools and specific follow–up program.

External gap progression after cyclic fatigue of adhesive overlays and crowns made with high translucency zirconia or lithium silicate

OBJECTIVES

To evaluate three-dimensional external gap progression after chewing simulation of high translucency zirconia (HTZ) and zirconia-reinforced lithium silicate (ZLS) applied on endodontically treated teeth with different preparation designs.

MATERIALS AND METHOD

Endodontically treated molars were prepared with low-retentive (adhesive overlay) and high-retentive (full crown) designs above cementum-enamel junction and restored with HTZ and ZLS. Micro-computed tomography analysis was assessed before and after chewing simulation to evaluate three-dimensionally the external gap progression. Results were statistically analyzed with two-way ANOVA and post-hoc Tukey test.

RESULTS

High-retentive preparation design had a significantly inferior gap progression compared to the overlay preparation (p < 0.01); ZLS exhibited a significant inferior gap progression compared to HTZ (p < 0.01).

CONCLUSIONS

High-retentive preparations restored with ZLS seem to better perform in maintaining the sealing of the external margin after cyclic fatigue.

CLINICAL SIGNIFICANCE

The clinician should pay attention to the proper combination of preparation designs and ceramic material selection for an endodontically treated molar restoration. HTZ seems to perform worse than lithium silicate in terms of marginal sealing, still showing lacks in resistance to cyclic fatigue when adhesive preparations are performed.

Rehabilitation protocol after simultaneous anterior cruciate ligament reconstruction and high tibial osteotomy: introducing the concept of the individualized approach

Postoperative rehabilitation after simultaneous anterior cruciate ligament reconstruction and opening wedge high tibial osteotomy is a complex concept. Different osteotomy techniques, extremely selected patients, high expectations in returning to previous sport activities, and the different individual physical profile and performances make traditional chronological criteria impractical and unfeasible. This study presents a novel rehabilitation in which functional objective criteria are considered the key factors for standardizing a 4-step protocol. Each step is "individualized", based on the patient's response to the healing processes and to the different training phases, allowing for a safe return to sports competitions. This definitively implies a strict collaboration between patient, surgeon, physician and physiotherapists, as well as thorough and detailed patient education. Due to the high versatility of these new rehabilitation concepts, the application of the "individualized" steps described in this study may be broadened to include different sports medicine knee injuries that may benefit from a specific, detailed and carefully patient-centered rehabilitation project.

When math meets surgery: how to improve femoral interference screw alignment in ACL reconstruction. A cadaveric study

Transtibial femoral tunnel drilling is still an alternative technique in ACL reconstruction. Femoral interference screw divergence is a potential pitfall associated with transtibial tunnel technique, as angles greater than 15° jeopardize graft fixation. Our mathematical model theorizes the proper degrees of knee flexion during femoral screw insertion and the correct screwdriver position to obtain a minimal divergence of the screw in the femoral tunnel. The cadaveric study confirms our method. Mathematical model: using rototranslation matrices, a correlation is demonstrated between the ACLtibial- guide angle, the knee flexion, and the screwdriver position. A theoretical minimal divergence between femoral interference screw and the femoral tunnel is obtainable following these assumptions: 1) knee hyperflexion during femoral screw insertion is obtained adding a flexion corresponding to the ACL-tibial-guide angle to the flexion while drilling the femoral tunnel; 2) screwdriver position (through the AM portal) is kept parallel to tibial plateau at a rotation of 15° medial to tibial sagittal plane. Cadaveric study: 24 cadaver knees were used. The transtibial tunnel was drilled with an 8 mm drill bit with the help of an ACL tibial guide set at 55°. To simulate femoral tunnel direction, a 2.4 mm K. wire was drilled through the femur with a transtibial 7 mm offset femoral drill guide. To simulate the femoral screw direction, a second 2.4 mm K. wire was drilled from the femoral entry point of the first wire through the femur, with a cannulated screwdriver. Screwdriver direction and knee flexion during the simulation were obtained following two different methods: GROUP A (mathematical model group, 12 knees), screwdriver direction and knee flexion were calculated following the mathematical model; in GROUP B (control group, 12 knees), knee hyperflexion and screwdriver medialization were manually obtained by a senior surgeon. The divergence between the femoral interference screw and the femoral tunnel was identified as the angle formed by the two wires, measured on the plane formed by the direction of the wires. Mean divergence angles between the K. wires were significantly different (p< 0.05) between the groups: GROUP 1 (mathematical rule): 7.25° (SD 2.2); GROUP 2 (free-hand technique): 17.3° (SD 2.9). Our study shows that a minimal divergence between the femoral tunnel and the screwdriver can be achieved simply by following a mathematical rule for correct intraoperative knee flexion and screwdriver position without the need for any specialized instrumentation. Namely, during femoral interference screw insertion through the anteromedial portal: 1) the correct knee flexion is the sum between the knee flexion angle while drilling the transtibial femoral tunnel AND the ACL tibial guide angle used during tibial tunnel drilling; 2) Correct screwdriver position is parallel to the tibial plateau, engaging the femoral tunnel with a position of 15° medial to tibial sagittal plane. This simple concept has clinical relevance in helping the surgeons in obtaining an optimal alignment between the femoral tunnel and the femoral interference screw during transtibial ACL reconstruction. Furthermore, following the assumptions of this study, a starting knee flexion angle around 70° during femoral tunnel drilling seems preferable for ACL reconstruction when the transtibial tunnel technique is used. Indeed, because ACL-tibial-guide angles range commonly from 50° to 60° and in vivo, the maximal intraoperative knee flexion attainable is 130°, a starting knee flexion around 70° is optimal to allows for adding flexion angles up to 60° before reaching the physiological limit value of 130°.

Comparing different approaches in robotic-assisted surgery for unicompartmental knee arthroplasty: outcomes at a short-term follow-up of MAKO versus NAVIO system

The popularity of unicompartmental knee arthroplasty (UKA) continues to grow among orthopaedic surgeons and robotic surgery may be helpful in obtaining a precise placement of the prosthetic components, thanks to the meticulous intra-operative computer study for simulating the prosthetic positioning. This may lead to longer implant survivorship as well as a reduction in intermediate and long-term prosthetic complications, despite the initial greater costs than those of manual UKA. In this preliminary study, from January 2017 and October 2017, 18 patients underwent UKA with MAKO robotic system assistance and 10 patients received UKA with NAVIO robotic system assistance. The two groups were homogeneous by age, BMI, degree of osteoarthritis involvement, and postoperative program. Patients were followed both clinically (Numeric Rating Scale NRS and Knee Injury Osteoarthritis Outcome Scores KOOS) and radiographically. At the end term follow up (2 years), no significant difference was observed for NRS and KOOS as well as for clinical parameters as an active range of motion. A significant discrepancy was detected regarding the duration of the surgery and time of using the robotic system, that appeared to be longer in the NAVIO group than that of MAKO group, likely due to the specific technical aspects that characterize these two different robotic systems. The main finding of this study is that favorable clinical and radiographical results may be obtained using a robotic approach (MAKO or NAVIO) for UKA positioning at a short follow up. Due to the lack of significant clinical differences observed between the two groups of patients at end term follow up, the "concept" of a robotic approach, more than a specific patented system, may be considered the key element for improving UKA technique and it is likely that in the near future the choice of a single specific robotic system will still be a "surgeon's preference". The results of the study add scientific evidence regarding the effective improvement of UKA results using different robotic approaches. They also show possible economic sustainability of this therapeutic strategy related to the optimal patients' performance obtained at short term follow up, suggesting that the robotic assistance may really become a key element for better long-term survivorship of unicompartmental knee arthroplasty.

Eosinophilic cytoplasmic inclusions in type 2 papillary renal cell carcinoma

A case of a patient with type 2 papillary renal cell carcinoma with eosinophilic cytoplasmatic inclusions is presented. About 50% of tumor cells were characterized by a well-circumscribed intra-cytoplasmatic round-to-oval or irregular inclusion/globule. Inclusions were 7-30 micron in diameter. They were glassy and pale to slightly eosinophilic in color in hematoxylin and eosin, were stained red by trichrome and were negative for periodic acid-Schiff reaction. Immunohistochemically, globules were negative for PAX8, epithelial membrane antigen, Carbonic Anhydrase IX, pan-cytokeratin (AE1/AE3), CD10, S100 protein, α-smooth-muscle actin, cytokeratin 7 and cytokeratin 34βE12. Glassy hyaline globules were not detected in any adjacent normal kidney cells. The presence of eosinophilic cytoplasmic inclusions in renal cell carcinoma, especially in papillary renal cell carcinoma, has been rarely emphasized in the literature. In this article, we review similar cases in the literature and discuss the nature of eosinophilic globules.

Validation of large-volume batch solar reactors for the treatment of rainwater in field trials in sub-Saharan Africa

The efficiency of two large-volume batch solar reactors [Prototype I (140 L) and II (88 L)] in treating rainwater on-site in a local informal settlement and farming community was assessed. Untreated [Tank 1 and Tank 2-(First-flush)] and treated (Prototype I and II) tank water samples were routinely collected from each site and all the measured physico-chemical parameters (e.g. pH and turbidity, amongst others), anions (e.g. sulphate and chloride, amongst others) and cations (e.g. iron and lead, amongst others) were within national and international drinking water guidelines limits. Culture-based analysis indicated that Escherichia coli, total and faecal coliforms, enterococci and heterotrophic bacteria counts exceeded drinking water guideline limits in 61%, 100%, 45%, 24% and 100% of the untreated tank water samples collected from both sites. However, an 8 hour solar exposure treatment for both solar reactors was sufficient to reduce these indicator organisms to within national and international drinking water standards, with the exception of the heterotrophic bacteria which exceeded the drinking water standard limit in 43% of the samples treated with the Prototype I reactor (1 log reduction). Molecular viability analysis subsequently indicated that mean overall reductions of 75% and 74% were obtained for the analysed indicator organisms (E. coli and enterococci spp.) and opportunistic pathogens (Klebsiella spp., Legionella spp., Pseudomonas spp., Salmonella spp. and Cryptosporidium spp. oocysts) in the Prototype I and II solar reactors, respectively. The large-volume batch solar reactor prototypes could thus effectively provide four (88 L Prototype II) to seven (144 L Prototype I) people on a daily basis with the basic water requirement for human activities (20 L). Additionally, a generic Water Safety Plan was developed to aid practitioners in identifying risks and implement remedial actions in this type of installation in order to ensure the safety of the treated water.

Six-year experience with antegrade intramedullary nail for the treatment of proximal and diaphyseal humeral fractures

BACKGROUND

Proximal and shaft humeral fractures are very common worldwide; surgical treatment can be a viable option to reduce limb immobilization and to allow the patient an earlier return to daily activities. The aim of our study was to evaluate the outcomes of patients treated with intramedullary nail in our Institute from January 2010 to December 2016.

MATERIALS AND METHODS

This is an observational cohort study. Inclusion criteria were: traumatic proximal and diaphyseal humeral fractures treated with antegrade nail; a minimum follow-up of 6 months. We evaluated the fracture healing time, the functional recovery (using the Constant score) and postoperative complications (need of blood transfusion, infections and need of re-intervention). The t test was used for statistical analysis.

RESULTS

Ninety-five patients were included (20 proximal and 75 diaphyseal fractures). Bone callus formation was evident a mean of 57 days after surgery. In all patients, there was an improvement in the functional recovery over time, but those younger than 65 years had better outcomes. The type of fracture and patients' gender did not affect these results at one and 6 months of follow-up. In 18 cases, blood transfusions were needed; infections never occurred; finally, revision surgery was performed in 10 cases (two reverse total shoulder arthroplasties, one open reduction and internal fixation with plate and screws and seven nail removals for intolerance).

CONCLUSION

In our study, intramedullary nail proved to be a minimally invasive technique with a rapid improvement in range of motion, an earlier rehabilitation and acceptable pain.

Abstract P6-08-12: DSCAM-AS1, a breast cancer specific and Estrogen receptor α-dependent long noncoding RNA, is a key component of the pathway controlling cell growth and migration

We previously reported that the long noncoding RNA (lncRNA) DSCAM-AS1 is one of the most interesting functional molecules in the Estrogen Receptor alpha (ERα) pathway in breast cancer cells, among a set of lncRNAs showing dependency on ERα in MCF7 cells (Miano et al., Oncotarget Jan 19, 2016. DOI: 10.18632/oncotarget.6420). Importantly, these lncRNAs were identified as dependent on ERα expression in absence of hormones, and DSCAM-AS1 was the most representative of them, presenting a clear ERα ChIP-Seq signal on the DSCAM-AS1 promoter and responding sharply to ERα silencing, but not to estradiol treatment. This behavior was shared with some other, but not all, ERα-dependent lncRNAs. We showed also that DSCAM-AS1 expression was strongly related to the luminal B &gt; A tumor subtype and strongly related to ER+, in all datasets examined. Together with other lncRNAs we identified, they constituted a sharp luminal-specific gene signature. All this was confirmed more recently by another group (Niknafs et al., Nat. Comm. Sept 26, 2016. DOI: 10.1038/ncomms12791), also showing that DSCAM-AS1 may be related to endocrine resistance in breast cancer.

We report here that DSCAM-AS1 silencing in MCF7 cells evokes a response very similar to what we observed by knocking down ERα (Caizzi et al., PNAS 2009. DOI: 10.1073/pnas.1315445111), i.e. growth arrest, morphological changes and cell death. Noteworthy, ERα expression was not altered by DSCAM-AS1 silencing, thus indicating that DSCAM-AS1 is downstream ERα. Thus, we were interested in evaluating the overall transcriptional response to DSCAM-AS1 silencing. LNA-mediated DSCAM-AS1 down-regulation led to changes in the expression level of 436 protein-coding genes, as determined by RNA-seq and the following sample validation by qRT-PCR. Data analysis by means of IPA and EnrichR indicated that DSCAM-AS1 silencing regulated genes of cell growth and proliferation, cell signaling, cell death and survival and cellular movement. On the other side, there was also a clear stress response with involvement of the interferon signaling pathway. As in the case of ERα silencing, the overall picture is that DSCAM-AS1 may have a function in the maintenance of the luminal epithelial phenotype in breast cancer cells. Interestingly, genes related to cell movement were actually activated by DSCAM-AS1 knock-down and, in this respect, our result may be somehow contrasting with those shown by Niknafs et al. (above) who reported that stable DCAM-AS1 silencing by shRNA led to decreased migration and invasiveness. Differences in RNA-mediated long-term downregulation versus shorter term, LNA-mediated downregulation may account for discrepancies, but the matter clearly deserves more investigation.

Finally, we present further data on the association of DSCAM-AS1 with ERα in breast tumors and clinical data. We suggest that its high level of expression, tissue-of-origin specificity and breast tumor phenotype specificity make DSCAM-AS1 an extremely interesting novel biomarker of luminal breast cancer.We previously reported that the long noncoding RNA (lncRNA) DSCAM-AS1 is one of the most interesting functional molecules in the Estrogen Receptor alpha (ERα) pathway in breast cancer cells, among a set of lncRNAs showing dependency on ERα in MCF7 cells (Miano et al., Oncotarget Jan 19, 2016. DOI: 10.18632/oncotarget.6420). Importantly, these lncRNAs were identified as dependent on ERα expression in absence of hormones, and DSCAM-AS1 was the most representative of them, presenting a clear ERα ChIP-Seq signal on the DSCAM-AS1 promoter and responding sharply to ERα silencing, but not to estradiol treatment. This behavior was shared with some other, but not all, ERα-dependent lncRNAs. We showed also that DSCAM-AS1 expression was strongly related to the luminal B &gt; A tumor subtype and strongly related to ER+, in all datasets examined. Together with other lncRNAs we identified, they constituted a sharp luminal-specific gene signature. All this was confirmed more recently by another group (Niknafs et al., Nat. Comm. Sept 26, 2016. DOI: 10.1038/ncomms12791), also showing that DSCAM-AS1 may be related to endocrine resistance in breast cancer.

We report here that DSCAM-AS1 silencing in MCF7 cells evokes a response very similar to what we observed by knocking down ERα (Caizzi et al., PNAS 2009. DOI: 10.1073/pnas.1315445111), i.e. growth arrest, morphological changes and cell death. Noteworthy, ERα expression was not altered by DSCAM-AS1 silencing, thus indicating that DSCAM-AS1 is downstream ERα. Thus, we were interested in evaluating the overall transcriptional response to DSCAM-AS1 silencing. LNA-mediated DSCAM-AS1 down-regulation led to changes in the expression level of 436 protein-coding genes, as determined by RNA-seq and the following sample validation by qRT-PCR. Data analysis by means of IPA and EnrichR indicated that DSCAM-AS1 silencing regulated genes of cell growth and proliferation, cell signaling, cell death and survival and cellular movement. On the other side, there was also a clear stress response with involvement of the interferon signaling pathway. As in the case of ERα silencing, the overall picture is that DSCAM-AS1 may have a function in the maintenance of the luminal epithelial phenotype in breast cancer cells. Interestingly, genes related to cell movement were actually activated by DSCAM-AS1 knock-down and, in this respect, our result may be somehow contrasting with those shown by Niknafs et al. (above) who reported that stable DCAM-AS1 silencing by shRNA led to decreased migration and invasiveness. Differences in RNA-mediated long-term downregulation versus shorter term, LNA-mediated downregulation may account for discrepancies, but the matter clearly deserves more investigation.

Finally, we present further data on the association of DSCAM-AS1 with ERα in breast tumors and clinical data. We suggest that its high level of expression, tissue-of-origin specificity and breast tumor phenotype specificity make DSCAM-AS1 an extremely interesting novel biomarker of luminal breast cancer.

Citation Format: De Bortoli M, Miano V, Ferrero G, Annaratone L, Coscujuela L, Castellano I, Cordero F, Sapino A. DSCAM-AS1, a breast cancer specific and Estrogen receptor α-dependent long noncoding RNA, is a key component of the pathway controlling cell growth and migration [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-08-12.

Patellofemoral Joint Arthroplasty: Our Experience in Isolated Patellofemoral and Bicompartmental Arthritic Knees

INTRODUCTION

Isolated patellofemoral (PF) arthritis is rare, and there is no complete agreement about the best surgical treatment. The operative treatments are total knee arthroplasty and patellofemoral replacement (PFR). The incidence of many early complications of PF arthroplasty has decreased with the introduction of newer designs. Nowadays, the main cause of revision surgery is the progression of tibiofemoral osteoarthritis. In the past, PF arthroplasty was contraindicated in patients with evidence of osteoarthritis or pain in medial or lateral tibiofemoral compartments. The improvement in implant designs and surgical techniques has allowed the addition of a monocompartmental arthroplasty for the medial or lateral tibiofemoral compartment. In this work, we evaluate our first experience with PF arthroplasty and its combination with unicompartmental knee arthroplasty.

MATERIALS AND METHODS

From May 2014 to March 2016, we treated 14 patients. An isolated PF arthroplasty was performed in six knees (five patients), and a combined PF and unicompartmental knee arthroplasty was performed in nine cases. We observed a significant improvement in the clinical and functional Knee Society Scores (KSSs) after surgery in our patients.

RESULTS

We obtained good results in our cases both for clinical and functional KSSs. Patellar clunk was recorded in one case.

DISCUSSION AND CONCLUSION

We are going toward a new attitude in which partial osteoarthritic changes could be treated with partial resurfacing prosthetic solutions such as unicompartmental, bi–unicompartmental or PFR alone, or unicompartmental combined, which respects the cruciates and achieves maximal bone preservation, which is vital, particularly, for young patients.

Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with T2 to T4, N0 and N1 breast cancer

BACKGROUND

Histological status of axillary lymph nodes is an important prognostic factor in patients receiving surgery for breast cancer (BC). Sentinel lymph node (SLN) biopsy (B) has rapidly replaced axillary lymph node dissection (ALND), and is now the standard of care for axillary staging in patients with clinically node-negative (N0) operable BC. The aim of this study is to compare pretreatment lymphoscintigraphy with a post primary systemic treatment (PST) scan in order to reduce the false-negative rates for SLNB.

METHODS

In this single-institution study we considered 170 consecutive T2-4 N0-1 M0 BC patients treated with anthracycline-based PST. At the time of incisional biopsy, we performed sentinel lymphatic mapping. After PST, all patients repeated lymphoscintigraphy with the same methodology. During definitive surgery we performed further sentinel lymphatic mapping, SLNB and ALND.

RESULTS

The SLN was removed in 158/170 patients giving an identification rate of 92.9% (95% confidence interval (CI) = 88.0-96.3%) and a false-negative rate of 14.0% (95% CI = 6.3-25.8%). SLNB revealed a sensitivity of 86.0% (95% CI = 74.2-93.7%), an accuracy of 94.9% (95% CI = 90.3-97.8%) and a negative predictive value of 92.7% (95% CI = 86.1-96.8%).

CONCLUSION

Identification rate, sensitivity and accuracy are in accordance with other studies on SLNB after PST, even after clinically negative node conversion following PST. This study confirms that diagnostic biopsy and neoadjuvant chemotherapy maintain breast lymphatic drainage unaltered.

Risk factors for shoulder pain in patients with spinal cord injury: a multicenter study

INTRODUCTION

Shoulder pain in spinal cord injury (SCI) is common due to the repetition of the wheelchair propulsion and the increased intra-articular pressure during transfers. Known risk factors for the onset of shoulder pain are age and level of SCI. Aims of this study were to assess how body mass index affects the onset of shoulder pain and to evaluate the relationship between the age at the moment of SCI and the number of years between SCI and the onset of shoulder pain.

METHODS

A retrospective study was performed including subjects with SCI between C5 and S3. Excluding criteria were spina bifida and subjects not using manual wheelchair or presenting with shoulder pain before SCI. Patients in the two spinal cord units were reviewed with a self-made questionnaire, and patients were also enrolled during sport events. Age at the moment of SCI, current age and number of years between SCI and the onset of shoulder pain were recorded.

RESULTS

Ninety-six patients were enrolled: 77 men and 19 women; 46.4 % reported shoulder pain. Overweight patients who do more than 12 transfers per day showed an increased incidence of shoulder pain (p = 0.0434). A linear regression showed a significant relationship between the age of the subject at the moment of SCI and the number of years between the SCI and the onset of pain.

CONCLUSION

Our study confirms that age and level of SCI are risk factors for shoulder pain, but we demonstrated also that overweight patients who do more than 12 transfers per day have higher chances of having shoulder pain.

Prospective neoadjuvant analysis of PET imaging and mechanisms of resistance to Trastuzumab shows role of HIF1 and autophagy

Background:

Although Trastuzumab has improved survival of HER2+ breast cancer patients, resistance to the agent pre-exists or develops through the course of therapy. Here we show that a specific metabolism and autophagy-related cancer cell phenotype relates to resistance of HER2+ breast cancer to Trastuzumab and chemotherapy.

Methods:

Twenty-eight patients with locally advanced primary breast cancer were prospectively scheduled to received one cycle of Trastuzumab followed by a new biopsy on day 21, followed by taxol/Trastuzumab chemotherapy for four cycles before surgery. FDG PET/CT scan was used to monitor tumour response. Tissue samples were immunohistochemically analysed for metabolism and autophagy markers.

Results:

In pre-Trastuzumab biopsies, the LC3A+/HER2+ cell population was correlated with HIF1α expression (P=0.01), while GLUT1 and LC3B expression were correlated with Ki67 proliferation index (P=0.01 and P=0.01, respectively). FDG PET tumour dimensions before therapy were correlated with LC3B expression (P=0.005). Administration of Trastuzumab significantly reduced clinical and PET-detected tumour dimensions (P<0.01). An inverse association of tumour response with the percentage of cells expressing HIF1α at baseline was documented (P=0.01). Administration of Trastuzumab resulted in a decrease of the proliferation index (P=0.004), GLUT1 (P=0.04) and HER2 (P=0.01) expression. In contrast, the percentage of LC3A+/HER2+ cells was increased (P=0.01). High baseline HIF1α expression was the only parameter associated with poorer pathological response to preoperative chemotherapy (P=0.001).

Conclusions:

As the HER2+/LC3A+ phenotype, which often overexpresses HIF1α, is a major subpopulation increasing after therapy with Trastuzumab, LC3A- and HIF1α-targeting therapies should be investigated for the augmentation of anti-HER2 therapy efficacy.

Assessment of energy-saving strategies and operational costs in full-scale membrane bioreactors

The energy-saving strategies and operational costs of stand-alone, hybrid, and dual stream full-scale membrane bioreactors (MBRs) with capacities ranging from 1100 to 35,000 m(3) day(-1) have been assessed for seven municipal facilities located in Northeast Spain. Although hydraulic load was found to be the main determinant factor for the energy consumption rates, several optimisation strategies have shown to be effective in terms of energy reduction as well as fouling phenomenon minimization or preservation. Specifically, modifications of the biological process (installation of control systems for biological aeration) and of the filtration process (reduction of the flux or mixed liquor suspended solids concentration and installation of control systems for membrane air scouring) were applied in two stand-alone MBRs. After implementing these strategies, the yearly specific energy demand (SED) in flat-sheet (FS) and hollow-fibre (HF) stand-alone MBRs was reduced from 1.12 to 0.71 and from 1.54 to 1.12 kW h(-1) m(-3), respectively, regardless of their similar yearly averaged hydraulic loads. The strategies applied in the hybrid MBR, namely, buffering the influent flow and optimisation of both biological aeration and membrane air-scouring, reduced the SED values by 14%. These results illustrate that it is possible to apply energy-saving strategies to significantly reduce MBR operational costs, highlighting the need to optimise MBR facilities to reconsider them as an energy-competitive option.

High-resolution ultrasound of the extrinsic carpal ligaments

Thanks to its intrinsic high spatial resolution, ultrasound is an ideal imaging modality for examining very thin, superficial structures, and this makes it very helpful in the evaluation of extrinsic carpal ligaments. These structures, which arise from the radius and ulna and insert on the carpal bones, are extremely important for wrist stability. Previous studies have assessed the use of ultrasound to study the extrinsic carpal ligaments in cadavers, healthy asymptomatic subjects, and patients with rheumatoid arthritis. In the present report, we review the normal anatomy, biomechanics, and ultrasound appearance of these ligaments.

Preliminary ultrasound evaluation of the rotator cable in asymptomatic volunteers()

PURPOSE

To characterize the rotator cable high-resolution ultrasound appearance in asymptomatic shoulders of volunteers of different age.

MATERIALS AND METHODS

IRB approval and volunteers' written consent was obtained. Excluding subjects with known shoulder affections, we screened 24 asymptomatic volunteers. Supraspinatus and infraspinatus tendons high-resolution ultrasound evaluation was performed according to standard scan protocols, further excluding shoulders with partial/full-thickness cuff tears. Thus, we studied 24 shoulders in 12 young volunteers (age range 21-39 years, mean age 33 ± 8 years) and 21 shoulders in 11 elderly volunteers (age range 62-83 years, mean age 75 ± 45 years). For each shoulder, we noted rotator cable visibility and its thickness and width. Fisher's and U Mann-Whitney statistics were used.

RESULTS

Rotator cable was less frequently detected in young than in elderly volunteers (5/24 vs. 11/21 shoulders; P = 0.034). When detected, rotator cable was significantly thicker in young (range 1.2-1.5 mm, mean thickness 1.3 ± 0.1 mm) than in elderly (range 0.9-1.4 mm, mean thickness 1.2 ± 0.1 mm) volunteers (P = 0.025), while its width was not significantly different in young (range 4.5-7.1 mm, mean 5.6 ± 1.1 mm) compared to elderly (range 2.5-7.1 mm, mean 4.2 ± 1.4 mm) volunteers (P = 0.074) although a tendency can be highlighted.

CONCLUSIONS

Ultrasound demonstrated the different consistency of rotator cable in young and elderly asymptomatic patients, with high interobserver reproducibility.

Imaging studies of crystalline arthritides

Gout, calcium pyrophosphate dihydrate (CPPD) deposition disease, and calcium hydroxyapatite deposition disease (HADD) are the three most common crystal-induced arthropathies. Multimodality imaging may help in their diagnosis, and is useful for a precise and comprehensive assessment and grading of the related osteoarticular damage. Plain film radiography, due to its low cost and wide availability, is the first imaging technique to be used in crystal deposition diseases, providing well-known and specific findings for CPPD deposition disease and HADD, while it may undergrade the early osteoarticular lesions in gouty patients. Ultrasonography (US) is a radiation-free approach that accurately depicts crystal deposits in cartilage, peri- and intra-articular soft tissues, but it does not give a panoramic view of the affected joints. Cross-sectional imaging techniques can examine crystal deposits in the spine and axial joints. CT has the potential to distinguish monosodium urate (MSU) crystals from calcium containing crystals, due to their different attenuation values. MRI may demonstrate synovitis, erosions and bone marrow edema in gouty patients and it may differentiate tophi from other soft tissue nodules due to its high contrast resolution and power of tissue characterization.

Imaging of tophi with an extremity-dedicated MRI system

OBJECTIVES

To describe the MRI features of gout tophi in the soft-tissues or joints of the limbs by low-field extremity-dedicated MRI.

METHODS

Nine consecutive patients, 8M/1W, affected by chronic tophaceous gout were studied. Mean patients' age was 71.3±11.5 years, mean disease duration 98.1±44.9 months, and mean serum uric acid concentration 9.2±2.8 mg/L. Diagnosis was based on the ACR classification criteria for gout, and by identification of MSU crystals in the tophi and synovial fluid. Conventional radiograms and MRI with an extremity-dedicated system were obtained of the joint areas involved by tophi.

RESULTS

At T1 weighted MRI images, all tophi showed a homogeneous intermediate signal intensity, similar to that of muscle. Conversely, in T2 weighted images, a wide spectrum of signal intensity patterns was observed. The pattern of contrast enhancement was variable from intense homogeneous to peripheral and heterogeneous. Capsulo-ligamentous structures were often thickened and degenerated and, on occasion, could be recognised as inhomogeneous, hypointense ribbon-shaped elements in the context of the tophus. In only two cases, tendons were infiltrated by tophaceous matter. Bone marrow oedema (BME) and erosions were seen in 8 out of 10 bones adjacent to tophi.

CONCLUSIONS

The MRI appearance of gout tophi using an extremity-dedicated machine is similar to that described in the literature using whole body machines. BME adjacent to the tophus was a frequent finding. This technique may occasionally help in the differential diagnosis of nodules and in the follow-up of the disease. It also represents a useful tool to investigate the pathogenesis of gout and to better understand its clinical progression.

A knowledge-based control system for air-scour optimisation in membrane bioreactors

Although membrane bioreactors (MBRs) technology is still a growing sector, its progressive implementation all over the world, together with great technical achievements, has allowed it to reach a mature degree, just comparable to other more conventional wastewater treatment technologies. With current energy requirements around 0.6-1.1 kWh/m3 of treated wastewater and investment costs similar to conventional treatment plants, main market niche for MBRs can be areas with very high restrictive discharge limits, where treatment plants have to be compact or where water reuse is necessary. Operational costs are higher than for conventional treatments; consequently there is still a need and possibilities for energy saving and optimisation. This paper presents the development of a knowledge-based decision support system (DSS) for the integrated operation and remote control of the biological and physical (filtration and backwashing or relaxation) processes in MBRs. The core of the DSS is a knowledge-based control module for air-scour consumption automation and energy consumption minimisation.

Knowledge-based system for automatic MBR control

MBR technology is currently challenging traditional wastewater treatment systems and is increasingly selected for WWTP upgrading. MBR systems typically are constructed on a smaller footprint, and provide superior treated water quality. However, the main drawback of MBR technology is that the permeability of membranes declines during filtration due to membrane fouling, which for a large part causes the high aeration requirements of an MBR to counteract this fouling phenomenon. Due to the complex and still unknown mechanisms of membrane fouling it is neither possible to describe clearly its development by means of a deterministic model, nor to control it with a purely mathematical law. Consequently the majority of MBR applications are controlled in an "open-loop" way i.e. with predefined and fixed air scour and filtration/relaxation or backwashing cycles, and scheduled inline or offline chemical cleaning as a preventive measure, without taking into account the real needs of membrane cleaning based on its filtration performance. However, existing theoretical and empirical knowledge about potential cause-effect relations between a number of factors (influent characteristics, biomass characteristics and operational conditions) and MBR operation can be used to build a knowledge-based decision support system (KB-DSS) for the automatic control of MBRs. This KB-DSS contains a knowledge-based control module, which, based on real time comparison of the current permeability trend with "reference trends", aims at optimizing the operation and energy costs and decreasing fouling rates. In practice the automatic control system proposed regulates the set points of the key operational variables controlled in MBR systems (permeate flux, relaxation and backwash times, backwash flows and times, aeration flow rates, chemical cleaning frequency, waste sludge flow rate and recycle flow rates) and identifies its optimal value. This paper describes the concepts and the 3-level architecture of the knowledge-based DSS and details the knowledge-based control module. Preliminary results of the application of the control module to regulate the air flow rate of an MBR working with variable flux demonstrates the usefulness of this approach.

Four years trial in elderly people of appraisal and comparison by geriatric assessment instruments: Use of high potency opioids for cancer pain control and quality of life

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Background: Pain is probably under-recognized and under-treated in the Elderly with advanced cancer disease but the effect of a therapy with high potency opioids is not studied so much in geriatric age people. To evaluate efficacy and tollerability of escalating doses of Transdermal Fentanyl (TTS-F) or equipollent doses of oral morphine long acting with Immediate Release Oral Morphine (IROM) as rescue medication for treatment of moderate-severe cancer pain, we have started a Multicentric Observational Analysis in four cancer centres of north-western Italy. Studies of oncological palliation using valid measures of quality of life show that patients may be willing to accept some side effects of treatment as long as they gain relief from tumor-related symptoms Methods: -TIQ (Therapy Impact Questionnaire) -VAS (Visual Analogic Scale): 0 to 10 -Toxicity (WHO criteria) -Geriatric Assessment for pts aged >70 yrs (only at time 0): CIRS (Comorbility Index) IADL/ADL (Instrumental Activities Daily Living/Activities Daily Living). Patients characteristics -159 pts -Total Median Age: 66 yrs (range 38–86) -Median ECOG PS: 1 (range 0–2) -Elderly (>70 yrs): 75. Pain Starting situation -Median starting VAS: 5.5 (range 3–9) -TIQ: depression 70 pts, cachexia 55 pts, dispnoea 40 pts -CIRS (Comorbidity index): comorbidity were present among 66 pts. TTS-Fentanyl starting dose: 25 mcg/h every 72 h (range 25–50 mcg) or oral morphine long acting 60–90 mg plus IROM 10 mg every 4–6 hours for breakthrough pain present in 38 pts Results: -Quickly pain VAS downloading during first two weeks of treatment (median VAS 1) -Analgesic doses were not significantly increased after two months and not exceeded WHO grade 2 -IROM rescue was similar to that observed for the overall population -TIQ, ADL and IADL were not influenced by therapy. Conclusions: High potency opioids (TTS-F or long acting morphine equipollent doses, plus Rescue-IROM) offers durable long term maintenance pain relief wild acceptable toxicity also in elderly people, is particularly useful for cancer pts with compliance problems and may be considered as first-line treatment for moderate/severe cancer pain.

No significant financial relationships to disclose.

Vascular endothelial growth factor and microvessel density around healthy and failing dental implants

Inflammatory infiltrate may be important in the evolution of inflammatory processes involving peri-implant tissues. Angiogenesis is an important feature of inflammation and healing, but its role in the development and progression or in the healing of periodontal lesions has not been elucidated. Vascular endothelial growth factor (VEGF) is a potent inducer of endothelial cell proliferation. The aim of the present study was to conduct a comparative immunohistochemical evaluation of VEGF and microvessel density (MVD) in normal keratinized gingiva and in peri-implant soft tissues surrounding failing implants. Fifteen patients participated in this study. Ten biopsies were taken from healthy keratinized gingiva, and 10 were taken from peri-implant soft tissues surrounding failing non-submerged implants. In healthy sites, the endothelial lining cells of the vessels always tested positive for VEGF; also, VEGF intensity was high in most cases. Stromal cells were positive for VEGF in 70% to 90% of samples. The MVD was 60.250 +/- 5.123. In peri-implantitis samples, the cells of the inflammatory infiltrate were positive for VEGF in 80% to 100% of cases, and the VEGF intensity was low in all cases. The stromal cells were positive for VEGF in 90% to 100% of cases, and in most cases the intensity was low. The MVD was 101.800 +/- 11.256. The difference in MVD between healthy sites and peri-implantitis was statistically significant (P = .0158). Expression of VEGF was lower in peri-implantitis samples, and this difference was statistically significant (P = .0373). Because of its extensive presence, VEGF is probably a factor in both the maintenance of periodontal physiology and in the progression of peri-implant inflammatory disease.

Transmission of Helicobacter pyori in an animal model

An experimental murine model was studied to evaluate the orogastrointestinal colonization of Helicobacter pylori and the animal-to-animal transmission. Balb/C mice were infected with H. pylori and housed with uninoculated mice in cages with and without a grate on the floor. Mice were killed after 7, 14, 30, and 45 days, and samples from the esophagus, stomach, small intestine, colon, and rectum were analyzed for H. pylori by PCR and immunohistochemistry and for histological changes. Bacterial colonization was assessed also by culture from stomach samples. H. pylori was cultured by stomach samples of infected mice at 7, 14, and 30 days. Using PCR and immunohistochemistry, H. pylori was detected in inoculated and uninoculated mice in all areas examined, with an high percentage of positive samples in the esophagus and stomach. Moreover transmission was detected, without differences, regardless of whether mice were housed with or without a grate on the floor, supporting an orooral animal transmission.

Microvessel density (MVD) and vascular endothelial growth factor expression (VEGF) in human oral squamous cell carcinoma

BACKGROUND

Carcinogenesis is thought to be dependent on neovascularization. Vascular endothelial growth factor (VEGF) is a glycoprotein that has the capability of increasing vascular proliferation and permeability. VEGF has been found to be expressed in several different types of tumours and it may contribute to the progression of malignant tumours. Increased microvessel density (MVD) has been described in oral squamous cell carcinoma (OSCC) and seems to be related to patient prognosis.

MATERIALS AND METHODS

Fifty-two cases of OSCC were evaluated in the present study. Immunostaining for VEGF and Factor-VIII was performed. The MVD was evaluated in G1, G2 and G3 tumours.

RESULTS

The differences between these 3 groups were statistically significant (p = 0.0331). MVD was also evaluated in lymph-node negative and lymph-node positive cases: the differences between these two groups were statistically significant (p < 0.0001). VEGF expression was evaluated in G1, G2 and G3 tumours. The differences between the 3 groups were not statistically significant (p = 0.289), even if an increasing trend in the VEGF positivity was evident from G1 to G3. The difference of VEGF expression between tumours with and without lymph node metastases was not significant (p = 0.196). No correlation was present between intensity of VEGF positivity and histological grading or lymph-node status and between VEGF and MVD.

CONCLUSION

Our data showed that MVD was correlated with grading and lymph-node status, while no similar correlation was found for VEGF.

[Mucinous adenocarcinoma of the prostate: description of a case]

INTRODUCTION

We report an occasional biopsy of primary mucinous adenocarcinoma of the prostate with review of the literature and discussion about all criteria used to classify this clinical-pathological entity.

MATERIALS AND METHODS

Histochemical (Alcian Blue and P.A.S.) and immunohistochemical (P.A.P. and P.S.A.) stainings were performed.

The use of two species of crayfish as environmental quality sentinels: the relationship between heavy metal content, cell and tissue biomarkers and physico-chemical characteristics of the environment

In systems as heavily disturbed as rivers, the use of biological sentinels is a most interesting way of obtaining continuous assessment of environmental quality. This study seeks to establish the value of such sentinels of two species of crayfish: the native crayfish (Austropotamobius pallipes, Lereboullet 1858) and an introduced species, signal crayfish (Pacifastacus leniusculus, Dana 1852), by comparing the habitat quality (water and sediments) and heavy metal contents in crayfish with the degree of stress manifested by the animals, measured by cell and tissue biomarkers. For this purpose a histological study of the digestive gland was carried out together with measurements of heavy metal contents in samples from various points of the river network of Bizkaia (Spain), selected on the basis of their degree of disturbance. The results establish a positive correlation between these environmental conditions, the cell and tissue biomarkers of the digestive gland (thinning of the digestive epithelium, enlargement of digestive lysosomes) and the heavy metal contents of the animals (converted to an index of pollutant load).

Shock waves in vascular diseases: an in-vitro study

Three human aortic specimens were used for this in-vitro study on the effects of shock waves on the arterial wall. Specimen one was from a normal (for age) healthy aorta. The full abdominal length was used (including mesenteric and renal arteries and the aortoiliac bifurcation), divided into six pieces (3 cm). The pieces were placed and fixed into degassed water. Shock waves (SW) were focused onto the aortic wall by means of a B-mode ultrasound imager. An SW generator (Minilith SL1, Storz Medical AG, Kreuzlingen, Switzerland) was used for setting of energy flux density between 0.03 and 0.5 mJ/mm2. The six aortic pieces (excluding piece 1, placed in water and left untreated as control) were treated with SW at increasing energy levels. A second aortic specimen of a man with arteriosclerotic plaques was also used and the experiment repeated at energy levels 1, 5, and 8. Another specimen of normal thoracic aorta was exposed at energy levels 1 and 8 only. Energy levels delivered onto the aortic walls were selected from theoretically destructive levels to minimal levels known not to alter vascular tissues. High-resolution ultrasounds of the aortic segments were performed with a 10 MHz high-resolution, broad-band (ATL 3000, USA) probe in water before and after SW application to detect structural changes in the wall after SW. Histology was performed with a standard hematoxylin-eosin staining.

RESULTS

The aortic pieces did not show macroscopic damages at visual examination, and at the ultrasound examination no visible changes were observed even at higher levels of SW energy. Also no effects were seen by histology. In conclusion, no damaging effects were observed, visually, by ultrasound, or by histology. At these energy levels SW appear to be safe and do not produce any damage to the aortic wall. Therefore, SW could be considered a safe, nondamaging procedure for potential treatment (ie, thrombolysis) in which vessel walls could be involved. Theoretically it is possible that functional changes could be observed in vivo including cell permeability modifications and other alterations (including changes in the potential of the cells in SW fields to modify themselves and to divide). At the energy levels described in this study SW could, theoretically be, safely used for vascular applications (ie, treating venous and arterial thrombi or in arterial plaques modification) without altering major, structural, arterial wall characteristics. Lesions or alterations that have a different density from the normal wall (thrombi or plaques) could be differently sensitive to the same dosage of SW. These differences in acoustic impedance characteristics could be used for potential treatments with SW without damaging the arterial wall.

Release and reattachment of the coracoacromial ligament: a cadaveric study

The purpose of this study was to examine the anatomy and ability to reattach the coracoacromial ligament (CAL) after acromioplasty. Twenty-eight fresh cadaveric shoulder specimens were dissected, and the CAL dimensions and pattern of attachment were examined. The ability to reattach the CAL to the anterior acromion after acromioplasty was investigated, comparing release along the anterior acromion (traditional anterior acromioplasty) versus subperiosteal elevation from the acromial undersurface. The influence of CAL length, acromial "type," and amount of acromioplasty on reattachment were examined. In 96% of the specimens (27 of 28) confluent medial and lateral bands of the CAL insertion along the acromion precluded "selective" release. The ability to anatomically reattach the CAL was directly related to the method of ligament release (anterior release versus subperiosteal elevation) (p < 0.0001). When directly released from along the anterior acromion, the CAL could not be anatomically reattached in any specimen. Nonanatomic reattachment to a more medial anterior acromial insertion site, however, was possible in 22 (79%) of 28 specimens. Reattachment required an average medial positioning of 60% (range 16% to 88%) along the anterior acromion from the anterolateral tip. Six (21%) specimens could not be reattached despite attempted medial positioning. In contrast, when subperiosteally elevated from the anterior inferior acromion, the CAL was reattachable in all specimens, anatomically in 26 (93%) of 28. The two nonanatomic reattachments required medially reattaching the ligament's normal acromial insertion by an average of 30%. There was no relationship between specimen sex, age, presence of rotator cuff tear, type of acromion, and CAL reattachment. The confluent anatomy of the CAL does not permit "selective" release of discretely identifiable portions of the CAL (i.e., the lateral band). In cases in which CAL restoration is important, careful subperiosteal elevation from the acromial undersurface will facilitate anatomic reattachment. Standard release of the CAL from the anterior acromion precludes anatomic, and in some cases any, reattachment of the CAL.

[Utero-vesical perforation caused by an IUD]

A rare complication of positioning of an IUD represented by utero-vesical puncture is reported in a woman of 37 who was using this contraceptive technique for the first time. The IUD was removed endoscopically, about 2 years after its positioning. The observation was an almost chance event by echography performed for vague pains in the suprapubic region.

[A case of rapid palatal expansion treated with a double telescopic screw appliance]

A case of maxillary hypoplasia with serious crowding in the upper arch, treated by the utilization of a special telescopic double screw permitting rapid expansion of the palate is described.

[A case of unilateral multiple agenesis]

A case of monolateral multiple congenitally missing permanent teeth orthrodonticallq treated in the first Dept. of Orthodontics, Dental Hospital, Univ. of Turin is presented.

Pericardial effusion mimicking left atrial thrombus after coronary bypass surgery

This report describes a patient in whom pericardial effusion, two months after coronary bypass surgery, mimicked the presence of a left atrial mass on both echocardiography and cardiac angiography.

[Caudal radiography versus computerized axial tomography in the diagnosis of lumbosacral radiculitis]

The advantages and disadvantages of caudoradiography and computed tomography in the diagnosis of compressive sciatic radiculitis are compared. With this in mind, the data on 103 patients admitted to Giaveno Hospital in 1986-1987 are analysed. In this series 99 were subjected to CAT scans, 21 to caudoradiculography (7 to both examinations) and 41 to surgery. Apart from revealing the advantages and defects of the two techniques, the results confirm the preference for CAT expressed elsewhere in the literature.

[Aspects of phosphorus and carbohydrate metabolism in amyotrophic lateral sclerosis]

The behaviour of glycaemia, insulinaemia, phosphoraemia, somatotropinaemia,free glycerol and triglyceridaemia was studied in six patients with A.L.S. following sugar load (1 g/Kg) in fasting. The results of glycaemia and insulinaemia were in tune with published data which have pointed to reduced sugar tolerance and reduced insulin secretion in patients with A.L.S. In the present experiments, particularly significant were the phosphoraemia responses. The failure of inorganic phosphorus values to fall after glucose loading suggests that the glycidic intolerance of these patients is related above all to a reduction in functioning muscular mass rather than to insufficient insulin secretion. The reduction in nervous tissue may also be of importance in this sense. In fact, not all biohumoral parameters investigated were similar to those of diabetes because the behaviour of somatotropinaemia, free glycerol and plasma triglycerides was normal. The changed behaviour of phosphorus would thus indicate altered glucose uptake at peripheral tissue level.