Serum and Tissue Biomarkers Associated With Composite of Relevant Endpoints for Sjögren Syndrome (CRESS) and Sjögren Tool for Assessing Response (STAR) to B Cell-Targeted Therapy in the Trial of Anti-B Cell Therapy in Patients With Primary Sjögren Syndrome (TRACTISS)

OBJECTIVE

This study aimed to identify peripheral and salivary gland (SG) biomarkers of response/resistance to B cell depletion based on the novel concise Composite of Relevant Endpoints for Sjögren Syndrome (cCRESS) and candidate Sjögren Tool for Assessing Response (STAR) composite endpoints.

METHODS

Longitudinal analysis of peripheral blood and SG biopsies was performed pre- and post-treatment from the Trial of Anti-B Cell Therapy in Patients With Primary Sjögren Syndrome (TRACTISS) combining flow cytometry immunophenotyping, serum cytokines, and SG bulk RNA sequencing.

RESULTS

Rituximab treatment prevented the worsening of SG inflammation observed in the placebo arm, by inhibiting the accumulation of class-switched memory B cells within the SG. Furthermore, rituximab significantly down-regulated genes involved in immune-cell recruitment, lymphoid organization alongside antigen presentation, and T cell co-stimulatory pathways. In the peripheral compartment, rituximab down-regulated immunoglobulins  and auto-antibodies together with pro-inflammatory cytokines and chemokines. Interestingly, patients classified as responders  according to STAR displayed significantly higher baseline levels of C-X-C motif chemokine ligand-13 (CXCL13), interleukin (IL)-22, IL-17A, IL-17F, and tumor necrosis factor-α (TNF-α), whereas a longitudinal analysis of serum T cell-related cytokines showed a selective reduction in both STAR and cCRESS responder patients. Conversely, cCRESS response was better associated with biomarkers of SG immunopathology, with cCRESS-responders showing a significant decrease in SG B cell infiltration and reduced expression of transcriptional gene modules related to T cell costimulation, complement activation, and Fcγ-receptor engagement. Finally, cCRESS and STAR response were associated with a significant improvement in SG exocrine function linked to transcriptional evidence of SG epithelial and metabolic restoration.

CONCLUSION

Rituximab modulates both peripheral and SG inflammation, preventing the deterioration of exocrine function with functional and metabolic restoration of the glandular epithelium. Response assessed by newly developed cCRESS and STAR criteria was associated with differential modulation of peripheral and SG biomarkers, emerging as novel tools for patient stratification.

Evaluation of Circulating Endothelial Cells as Direct Marker of Endothelial Damage in Allo-Transplant Recipients at High Risk of Hepatic Veno-Occlusive Disease/Sinusoidal Obstruction Syndrome

Sinusoidal obstruction syndrome (SOS), also known as veno-occlusive disease (VOD), is a rare but potentially fatal complication following allogenic hematopoietic cell transplantation (allo-HCT). Timely identification of SOS/VOD to allow for prompt treatment is critical, but identifying a VOD-predictive biomarker remains challenging. Given the pivotal role of endothelial dysfunction in SOS/VOD pathophysiology, the CECinVOD study prospectively evaluated levels of circulating endothelial cells (CECs) in patients undergoing allo-HCT with a myeloablative conditioning (MAC) regimen to investigate the potential of CEC level in predicting and diagnosing SOS/VOD. A total of 150 patients from 11 Italian bone marrow transplantation units were enrolled. All participants were age >18 years and received an MAC regimen, putting them at elevated risk of developing SOS/VOD. Overall, 6 cases of SOS/VOD (4%) were recorded. CECs were detected using the Food and Drug Administration-approved CellSearch system, an immunomagnetic selection-based platform incorporating ferrofluid nanoparticles and fluorescent-labeled antibodies, and were defined as CD146+, CD105+, DAPI+, or CD45-. Blood samples were collected at the following time points: before (T0) and at the end of conditioning treatment (T1), at neutrophil engraftment (T2), and at 7 to 10 days postengraftment (T3). For patients who developed VOD, additional samples were collected at any suspected or proven VOD onset (T4) and weekly during defibrotide treatment (T5 to T8). A baseline CEC count >17/mL was associated with an elevated risk of SOS/VOD (P = .04), along with bilirubin level >1.5 mg/mL and a haploidentical donor hematopoietic stem cell source. Postconditioning regimen (T1) CEC levels were elevated (P = .02), and levels were further increased at engraftment (P < .0001). Additionally, patients developing SOS/VOD after engraftment, especially those with late-onset SOS/VOD, showed a markedly higher relative increase (>150%) in CEC count. Multivariate analysis supported these findings, along with a high Endothelial Activation and Stress Index (EASIX) score at engraftment (T2). Finally, CEC kinetics corresponded with defibrotide treatment. After the start of therapy (T4), CEC levels showed an initial increase in the first week (T5), followed by a progressive decrease during VOD treatment (T6 and T7) and a return to pre-SOS/VOD onset levels at resolution of the complication. This prospective multicenter study reveals a low incidence of SOS/VOD in high-risk patients compared to historical data, in line with recent reports. The results from the CECinVOD study collectively confirm the endothelial injury in allo-HCT and its role in in the development of SOS/VOD, suggesting that CEC level can be a valuable biomarker for diagnosing SOS/VOD and identifying patients at greater risk of this complication, especially late-onset SOS/VOD. Furthermore, CEC kinetics may support treatment strategies by providing insight into the optimal timing for discontinuing defibrotide treatment.

Total intravenous anesthesia (TIVA) with propofool and remifentanil during operative endoscopy tracheobronchial laser therapy

Background

The aim of our study was to assess how total intra-venous anaesthesia (TIVA) achieved by propofol and remifentanil continuous infusion could ensure proper success of the endobronchial laser therapy, in optimal conditions for the endoscopist, determining at the same time an adequate hypnosis and a good analgesia.

Methods

We studied 50 patients (28M - 22F), ASA class I-IV, mean age 42 ± 32.5 years , subjected to laser endoscopy to repair tracheal stenosis. TIVA was performed in all patients, and spontaneous breathing was maintained.

Results

10.2% of patients experienced episodes of coughing during induction. The depth of the anaesthesia plan, monitored by BIS, was 55 ± 5. The awakening was fast in all patients, with an Aldrete score of 7.71 ± 1.14 at 1 minute and 9.31 ± 1.12 at 10 minutes.

Conclusion

The results of this study allow us to state that the continuous infusion of propofol and remifentanil proved to be the gold standard in patients ASA I-II-III undergoing endobronchial laser therapy. The use of TIVA has also allowed to perform endoscopic intervention on patients who suffered from a significant decrease of both cardiac and respiratory functions.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

The European Hernia Society Prehabilitation Project: A Systematic Review of Intra-Operative Prevention Strategies for Surgical Site Occurrences in Ventral Hernia Surgery

Background

Ventral hernia repair is one of the most commonly performed surgical procedures worldwide. To reduce the risk of complications, pre- and intra-operative strategies have received increasing focus in recent years. To assess possible preventive surgical strategies, this European Hernia Society endorsed project was launched. The aim of this review was to evaluate the current literature focusing on pre- and intra-operative strategies for surgical site occurrences (SSO) and specifically surgical site infection (SSI) in ventral hernia repair.

Methods

A systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Databases used were Pubmed and Web of Science. Original retrospective or prospective human adult studies describing at least one intra-operative intervention to reduce SSO after ventral hernia repair were considered eligible.

Results

From a total of 4775 results, a total of 18 papers were considered suitable after full text reading. Prehospital chlorhexidine gluconate (CHG) scrub appears to increase the risk of SSO in patients undergoing ventral hernia repair, while there is no association between any type of surgical hat worn and the incidence of postoperative wound events. Intraoperative measures as prophylactic negative pressure therapy, surgical drain placement and the use of quilt sutures seem beneficial for decreasing the incidence of SSO and/or SSI. No positive effect has been shown for antibiotic soaking of a synthetic mesh, nor for the use of fibrin sealants.

Conclusion

This review identified a limited amount of literature describing specific preventive measures and techniques during ventral hernia repair. An advantage of prophylactic negative pressure therapy in prevention of SSI was observed, but different tools to decrease SSIs and SSOs continuously further need our full attention to improve patient outcomes and to lower overall costs.

The European Hernia Society Prehabilitation Project: a systematic review of patient prehabilitation prior to ventral hernia surgery

BACKGROUND

Ventral hernia repair is one of the most commonly performed surgical procedures worldwide. To reduce the risk of complications, patient prehabilitation has received increasing focus in recent years. To assess prehabilitation measures, this European Hernia Society endorsed project was launched. The aim of this systematic review was to evaluate the current literature on patient prehabilitation prior to ventral hernia repair.

METHODS

The strategies examined were optimization of renal disease, obesity, nutrition, physical exercise, COPD, diabetes and smoking cessation. For each topic, a separate literature search was conducted, allowing for seven different sub-reviews.

RESULTS

A limited amount of well-conducted research studies evaluating prehabilitation prior to ventral hernia surgery was found. The primary findings showed that smoking cessation and weight loss for obese patients led to reduced risks of complications after abdominal wall reconstruction.

CONCLUSION

Prehabilitation prior to ventral hernia repair may be widely used; however, the literature supporting its use is limited. Future studies evaluating the impact of prehabilitation before ventral hernia surgery are warranted.

Achieving the learning curve in total thyroidectomy: a prospective evaluation on resident's training by CUSUM and KPSS analysis

INTRODUCTION

Total thyroidectomy (TT) is one of the most common procedures among general and endocrine surgeons worldwide. The conventional approach by neck incision is still the most frequently used, despite the growth of mini-invasive approaches. Controversies exist about the optimal learning curve for resident surgeons approaching this procedure. The aim of this study was to compare TT performed by experienced surgeons and residents in two academic hospitals, to define the correct shape of the specific learning curve.

METHODS

Between January 2016 and December 2018 patients undergoing TT in two academic departments were prospectively enrolled. In each department patients were divided into four groups: a reference group (A), consisting of 50 consecutive patients operated on by a senior surgeon, and three other groups (B, C, D) of 50 patients each where thyroidectomy was carried out by three different general surgery residents in their last 3 years of residency, respectively. Data were analysed by CUSUM and KPSS tests in order to compare operative time (OT) and its stabilisation during the learning curve.

RESULTS

Data from CUSUM test reported that residents could perform TT with OT similar to the senior surgeon after approximately 25-30 procedures, while the KPSS test showed that residents became more stable after 30 procedures, with no increase in perioperative complications.

CONCLUSIONS

This prospective study shows how a specific training in thyroid surgery can be reliable thanks to experienced tutors, and confirmed that the effect of dedicated and programmed training may result in positive outcomes for patients requiring thyroidectomy.

Fracture and migration in right atrium of a permanent venous central access system in a elderly patient: case report and literature review

Catheter dislocation and fracture with migration of central venous lines have been reported in the International literature. Catheter fracture with consequent migration has been observed in 0.5-3.0% and may either be consequent to catheter removal or it can occur spontane-ously. Our case report concerns the migration of a Hickman catheter connected to a venous port to the right atrium in a 61-year old patient. A literature up-to-date has been performed to assess the risk of port-a-cath positioning. The position of catheter tip is considered critical for the risk of migration, that is greater as higher the tip localization respect to the carina. The aim of our study is to underline the critical role of X-ray to visualize the exact location of the catheter tip, regard-less of the approach used for catheter positioning.

Transversus abdominis release (TAR) for ventral hernia repair: open or robotic? Short-term outcomes from a systematic review with meta-analysis

PURPOSE

To compare early postoperative outcomes after transversus abdominis release (TAR) for ventral hernia repair with open (oTAR) and robotic (rTAR) approach.

METHODS

A systematic search of PubMed/MEDLINE, EMBASE, SCOPUS and Web of Science databases was conducted to identify comparative studies until October 2020. A meta-analysis of postoperative short-term outcomes was performed including complications rate, operative time, length of stay, surgical site infection (SSI), surgical site occurrence (SSO), SSO requiring intervention (SSOPI), systemic complications, readmission, and reoperation rates as measure outcomes.

RESULTS

Six retrospective studies were included in the analysis with a total of 831 patients who underwent rTAR (n = 237) and oTAR (n = 594). Robotic TAR was associated with lower risk of complications rate (9.3 vs 20.7%, OR 0.358, 95% CI 0.218-0.589, p < 0.001), lower risk of developing SSO (5.3 vs 11.5%, OR 0.669, 95% CI 0.307-1.458, p = 0.02), lower risk of developing systemic complications (6.3 vs 26.5%, OR 0.208, 95% CI 0.100-0.433, p < 0.001), shorter hospital stay (SMD - 4.409, 95% CI - 6.000 to - 2.818, p < 0.001) but longer operative time (SMD 53.115, 95% CI 30.236-75.993, p < 0.01) compared with oTAR. There was no statistically significant difference in terms of SSI, SSOPI, readmission, and reoperation rates.

CONCLUSION

Robotic TAR improves recovery by adding the benefits of minimally invasive procedures when compared to open surgery. Although postoperative complications appear to decrease with a robotic approach, further studies are needed to support the real long-term and cost-effective advantages.

Criticism of learning curve in laparoscopic adrenalectomy: a systematic review

BACKGROUND

Laparoscopic adrenalectomy (LA) has become the treatment of choice for benign adrenal lesions. Lateral Transperitoneal Laparoscopic Adrenalectomy (LTLA) is considered the gold standard. The number of LTLAs a surgeon must perform, in order to complete his learning curve, is not well defined in Literature. Moreover, the few papers dealing with the learning curve for LTLAs show controversial results and consider different evaluation parameters.

METHODS

The systematic review has been carried out according to PRISMA statement. The literature search included PubMed and Scopus database. Hand searching of reference lists of previous review articles and relevant studies was also performed. The search string was "learning curve AND laparoscopic adrenalectomy".

RESULTS

A total of 9 papers met the inclusion criteria out of 94 non duplicate citations. The aim of this systematic review is to provide a multidimensional evaluation by bringing into focus evaluation parameters of surgical performance, (operative time, intraoperative complications, conversion rate and blood loss), factors related to patient's pathology (side, size, adrenal pathology) and surgeon-specific properties.

CONCLUSIONS

Operative time, intraoperative bleeding, intraoperative complications and conversion rate are the main parameters that have been considered for the achievement of learning curve, and for each there are discrepancies, mainly due to the relative rarity of adrenal tumors, and so for difficulties in obtaining approper analysis that could establish an effective learning curve. So, further evaluations in larger experience are needed.

Cyclic nucleotide-dependent relaxation in human umbilical vessels

Umbilical vessels have a low sensitivity to dilate, and this property is speculated to have physiological implications. We aimed to investigate the different relaxing responses of human umbilical arteries (HUAs) and veins (HUVs) to agonists acting through the cAMP and cGMP pathways. Vascular rings were suspended in organ baths for isometric force measurement. Following precontraction with the thromboxane prostanoid (TP) receptor agonist U44069, concentration-response curves to the nitric oxide (NO) donor sodium nitroprusside (SNP), the soluble guanylate cyclase (sGC) stimulator BAY 41-2272, the adenylate cyclase (AC) activator forskolin, the β-adrenergic receptor agonists isoproterenol (ADRB1), salmeterol (ADRB2), and BRL37344 (ADRB3), and the phosphodiesterase (PDE) inhibitors milrinone (PDE₃), rolipram (PDE₄), and sildenafil (PDE₅) were performed. None of the tested drugs induced a relaxation higher than 30% of the U44069-induced tone. Rings from HUAs and HUVs showed a similar relaxation to forskolin, SNP, PDE inhibitors, and ADRB agonists. BAY 41-2272 was significantly more efficient in relaxing veins than arteries. ADRB agonists evoked weak relaxations (< 20%), which were impaired in endothelium-removed vessels or in the presence of the NO synthase inhibitor L-NAME, sGC inhibitor ODQ. PKA and PKG inhibitors impaired ADBR1-mediated relaxation but did not affect ADRB2-mediated relaxation. ADRB3-mediated relaxation was impaired by PKG inhibition in HUAs and by PKA inhibition in HUVs. Although HUA and HUV rings were relaxed by BRL37344, immunohistochemistry and RT-qPCR analysis showed that, compared to ADRB1 and ADRB2, ADRB3 receptors are weakly or not expressed in umbilical vessels. In conclusion, our study confirmed the low relaxing capacity of HUAs and HUVs from term infants. ADRB-induced relaxation is partially mediated by endothelium-derived NO pathway in human umbilical vessels.

Preservation of left colic artery with lymph node dissection of IMA root during laparoscopic surgery for rectosigmoid cancer. Results of a retrospective analysis

BACKGROUND

During sigmoid or rectal cancer surgery, dissection of lymph-nodes at the origin of inferior mesenteric artery is mandatory. Nevertheless, ligation of the origin of IMA should compromise blood supply to left colon and affect anastomosis. The aim of this retrospective evaluation is to compare high IMA ligation and low IMA ligation with preservation of LCA and skeletonization of the origin of IMA during laparoscopic colorectal resection.

METHODS

All 120 patients included were affected by clinically M-0 sigmoid or rectal cancer. A laparoscopic colorectal resection with low or high ligature of IMA was performed. Low ligation was carried out with lymphadenectomy of the arterial root. Patients were divided in 2 groups according to type of treatment: Group A, high IMA ligation (N=65), Group B, low ligation with lymphadenectomy of IMA root (N=55).

RESULTS

Preoperatively 59 patients had stage I, 42 patients had stage II  and 19 patients had stage III tumor. A mean of 20.3 +/- 4.5 lymph nodes were removed in group A patients and 18.9 +/- 9.1 in group B patients, and this difference was not statistically significant. Operative time, intraoperative and postoperative complication rates were not different between the two group.

CONCLUSIONS

Low IMA ligation combined with lymph-node dissection at its origin is safe and effective, not time consuming and not associated to increased risk of complications and nerve damage. This technique can be considered as alternative to standard high IMA ligation in selected patients.

Second jejunal loop adenocarcinoma associated with celiac disease: the first case report

INTRODUCTION

Jejunal adenocarcinoma is a very rare disease but the frequency of this rare carcinoma is higher in celiac patients. We report the first case report of a second jejunal loop adenocarcinoma associated with celiac disease.

PRESENTATION OF CASE

A 47-year-old woman, with a history of celiac disease. Computerized tomographic scans of the abdomen and pelvis demonstrated a severe retroperitoneal lymphoadenopathy, para-aortic, inter-aorto-caval, porto-caval, posterior pancreaticoduodenal space, celiac trunk, lesser gastric curvature, lymph node grouping. The patient underwent digiunal resection and regional lymphadenectomy. Diagnosis was poorly differentiated jejunal adenocarcinoma, infiltrating subserosal adipose tissue, metastasing in five out of eight regional lymph nodes. U.I.C.C. 2017 grading = pT3 pN2 G3 R0; Stage IIIB.

DISCUSSION

The jejunum accounts for 11-25% of small bowel adenocarcinoma, that accounts for less than 5% of gastrointestinal cancer, notwithstanding that 90% of the mucosa surface area of the digestive tract is made by small intestine. To the best of our knowledge, this is the first report on a second loop jejunal adenocarcinoma complicating celiac disease. In our study, the diagnosis of cancer was made by computed tomography (CT) of abdomen and the patient was operated. For the diagnosis of small bowel tumour, CT enteroclysis has a sensitivity of 85-95% and a specificity of 90-96%. Complete resection (RO) of the jejunal adenocarcinoma, with regional lymph nodes resection and jejuno-jejunal anastomosis should be performed.

CONCLUSION

After curative surgical resections of small bowel adenocarcinoma, adjuvant chemo-therapy has not shown a clear benefit in retrospective studies. Preoperative Chemo-Radio-therapy and careful Imaging Staging are the first steps to planning surgery.

Right pneumothorax secondary to colonoscopic perforation: a case

AIM

The purpose of this study is to determine the anatomical aspects, mechanisms, risk factors and appropriate management of development of pneumothorax during a routine colonoscopy.

CLINICAL CASE

We report a case of an accidental bowel wall injury during diagnostic colonoscopic with consequent pneumoperitoneum; this was followed by expansion of gas through diaphragmatic fenestration perhaps congenital, in right pleural cavity causing pneumothorax.

DISCUSSION

Rarely, colonic perforation during colonoscopy can occur into the extraperitoneal space, thus leading to the passage and diffusion of air along the fascial planes and large vessels, possibly causing pneumoretroperitoneum, pneumomediastinum, pneumopericardium, pneumothorax, and subcutaneous emphysema. The combination of intraperitoneal and extraperitoneal perforation has also been reported. Pneumothorax following a colonoscopy sigmoid perforation is an extremely rare but severe and often lifethreatening complication.

CONCLUSION

If the patient develops dyspnea and pneumoderma during or after this procedure, a chest radiogram or thoracoabdominal CT should be taken for diagnostic purposes. Urgent treatment, starting with chest tube insertion(s) and laparotomy or laparoscopy could be lifesaving.

Vasomotor effects of hydrogen sulfide in human umbilical vessels

Hydrogen sulfide (H₂S) has recently emerged as a biologically active gas with multiple effects on the cardiovascular system. We aimed to investigate the vasomotor actions of sodium sulfide (Na₂S), which forms H₂S and HS^- in solution, in human umbilical artery (HUA) and vein (HUV) rings. In addition, we examined by immunocytochemistry the expression and localization of cystathionine β-synthase (CBS), cystathionine lyase (CSE), and 3-mercaptopyruvate sulphurtransferase (MPST), the enzymes responsible for endogenous H₂S production. Human umbilical vessels were compared with chicken embryo umbilical vessels. HUA and HUV expressed a robust signal for CSE, CBS, and 3-MPST in both endothelial and smooth muscle cells. However, HUA rings did not respond to Na₂S (10^-6M-10^-3M) either at resting tone or during contraction evoked by serotonin or KCl. Similarly, the extraembryonic part of chicken allantoic artery did not respond to Na₂S. In contrast, Na₂S induced a concentration-dependent contraction in HUV rings under resting tone and a concentration-dependent relaxation when the H₂UV rings were contracted with serotonin (42 ± 5% relaxation) or KCl (12 ± 5% relaxation). Na₂S-induced contraction of HUV was impaired following removal of extracellular Ca²⁺, endothelial denudation, NO synthase inhibition (L-NAME), or soluble guanylate cyclase (sGC) inhibition (ODQ). Na₂S-induced relaxation of HUV was impaired by the K_ATP channel inhibitor glibenclamide. In conclusion, H₂S does not have vasomotor effects on HUA but induced contraction (mediated through inactivation of the NO/sGC axis) and relaxation (mediated through K_ATP channels) in HUV. Our data suggest a role for H₂S in the venous side of human umbilical circulation.

Smart Inulin-Based Polycationic Nanodevices for siRNA Delivery

The advances of short interfering RNA (siRNA) mediated therapy provide a powerful option for the treatment of many diseases by silencing the expression of targeted genes including cancer development and progression. Inulin is a very simple and biocompatible polysaccharide proposed by our groups to produce interesting delivery systems for Nucleic Acid Based Drugs (NABDs), such as siRNA, either as polycations able to give polyplexes and polymeric coatings for nanosystems having a metallic core. In this research field, different functionalizing groups were linked to the inulin backbone with specific aims including oligoamine such as Ethylendiammine (EDA), Diethylediamine (DETA), Spermine, (SPM) etc. In this contribution the main Inulin-based nanodevices for the delivery of siRNA have been reported, analysed and compared with particular reference to their chemical design and structure, biocompatibility, siRNA complexing ability, silencing ability.

Design of PNIPAAM covalently grafted on halloysite nanotubes as a support for metal-based catalysts

A thermo-responsive polymer (PNIPAAM) was covalently grafted on the external surface of halloysite nanotubes and used as support for palladium nanoparticles for application as catalyst in Suzuki cross coupling in water under microwave irradiation.

Multicavity halloysite-amphiphilic cyclodextrin hybrids for co-delivery of natural drugs into thyroid cancer cells

Multicavity halloysite nanotube materials were employed as simultaneous carriers for two different natural drugs, silibinin and quercetin, at 6.1% and 2.2% drug loadings, respectively. The materials were obtained by grafting functionalized amphiphilic cyclodextrin onto the HNT external surface. The new materials were characterized by FT-IR spectroscopy, SEM, thermogravimetry, turbidimetry, dynamic light scattering and ζ-potential techniques. The interaction of the two molecules with the carrier was studied by HPLC measurements and fluorescence spectroscopy, respectively. The release of the drugs from HNT-amphiphilic cyclodextrin, at two different pH values, was also investigated by means of UV-vis spectroscopy. Biological assays showed that the new complex exhibits anti-proliferative activity against human anaplastic thyroid cancer cell lines 8505C. Furthermore, fluorescence microscopy was used to evaluate whether the carrier was uptaken into 8505C thyroid cancer cell lines. The successful results revealed that the synthesized multicavity system is a material of suitable size to transport drugs into living cells.

Development of a simple, biocompatible and cost-effective Inulin-Diethylenetriamine based siRNA delivery system

Small interfering RNAs (siRNAs) have the potential to be of therapeutic value for many human diseases. So far, however, a serious obstacle to their therapeutic use is represented by the absence of appropriate delivery systems able to protect them from degradation and to allow an efficient cellular uptake. In this work we developed a siRNA delivery system based on inulin (Inu), an abundant and natural polysaccharide. Inu was functionalized via the conjugation with diethylenetriamine (DETA) residues to form the complex Inu-DETA. We studied the size, surface charge and the shape of the Inu-DETA/siRNA complexes; additionally, the cytotoxicity, the silencing efficacy and the cell uptake-mechanisms were studied in the human bronchial epithelial cells (16HBE) and in the hepatocellular carcinoma derived cells (JHH6). The results presented here indicate that Inu-DETA copolymers can effectively bind siRNAs, are highly cytocompatible and, in JHH6, can effectively deliver functional siRNAs. Optimal delivery is observed using a weight ratio Inu-DETA/siRNA of 4 that corresponds to polyplexes with an average size of 600nm and a slightly negative surface charge. Moreover, the uptake and trafficking mechanisms, mainly based on micropinocytosis and clatrin mediated endocytosis, allow the homogeneous diffusion of siRNA within the cytoplasm of JHH6. Notably, in 16 HBE where the trafficking mechanism (caveolae mediated endocytosis) does not allow an even distribution of siRNA within the cell cytoplasm, no significant siRNA activity is observed. In conclusion, we developed a novel inulin-based siRNA delivery system able to efficiently release siRNA in JHH6 with negligible cytotoxicity thus opening the way for further testing in more complex in vivo models.

Bisphosphonate–polyaspartamide conjugates as bone targeted drug delivery systems

Poly-hydroxy-aspartamide was used as a backbone to synthesize bisphosphonate derivatives thus achieving macromolecular carriers to be potentially used as targeting agents for bone drug delivery.

Functionalized halloysite multivalent glycocluster as a new drug delivery system

A new design for halloysite nanotube materials was obtained by grafting chemically modified cyclodextrin units onto the nanotube surface. In particular, grafted cyclodextrins were decorated with thiosaccharide pendants, in order to mimic the well-known binding of sugars to proteins and the glyco-cluster effect occurring during cellular recognition events. The obtained materials were characterized by using a combination of varied techniques (FT-IR spectroscopy, thermogravimetric analysis, scanning electron microscopy, dynamic light scattering, turbidimetry), and their potential drug-delivery abilities were tested by studying their interactions with the common naturally occurring anticancer agent curcumin. A suitable model describing the interaction between our materials and curcumin is proposed.

Amphiphilic inulin graft co-polymers as self-assembling micelles for doxorubicin delivery

This paper reports the synthesis and characterization of a new amphiphilic inulin graft copolymer able to self-assemble in water into a micelle type structure and to deliver the anticancer model drug doxorubicin. For this aim, inulin was chemically modified in the side chain with primary amine groups (INU-EDA) and these were used as reactive moieties for the conjugation of poly ethylene glycol 2000 and succinyl-ceramide. The CMC of obtained amphiphilic inulin derivatives (INU-ceramide and INU-ceramide-PEG₂₀₀₀) was measured by means of fluorescence analysis using pyrene as the fluorescent probe. The obtained micelles were characterized by DLS and AFM analysis and the ability to release the loaded doxorubicin was studied in different media. Finally the cytotoxicity profile on both cancer (HCT116) and normal (16 HBE) cell lines and in vitro ability to deliver the drug into cancer cells were evaluated.

Fournier's gangrene: early diagnosis. How to diagnose, how to manage it

Fournier's gangrene (FG) is a rare surgical emergency and a life-threatening condition with a rapidly progressive gangrene defined as a necrotizing fasciitis of the perineal or genital areas leading to septic shock and death if untreated. Risk factors are diabetes, immune compromise, obesity, drug use, or genital trauma. Patients are treated by incision and drainage. Aim of the study is to analyze cases of early manifestations of FG and consider aspect of diagnosis based on clinical presentation and the importance of precocious surgical treatment. We had experience of early lesions of FG in 22 cases. We report three cases in which the initial clinical presentation was typical of precocious signs referable to FG. Foley catheter was used in all cases, no diverting colostomy was performed. The patients were treated by artificial i.v. feeding. No extensive demolition of perineal tissues were operated, neither plastic surgery was required. Antibiotic therapy combined to surgical treatment with incision and drainage were performed in all cases. Admission in the intensive care unit was effective when indicated. No mortality was registered in all 22 cases of the series. FG is rare, severe condition requiring a multidisciplinary approach. An early diagnosis and an aggressive surgical treatment, improved by antibiotic therapy, hyperbaric oxygen therapy and proper wound care are the key points of FG management. In selected patients, colostomy or cystostomy must be considered when simple catheterization is not sufficient. Severe cases must be therefore referred to high-volume and specialized centres with specialist professional and intensive care facilities.

Clinical and surgical aspects of high and low ligation of inferior mesenteric artery in laparoscopic resection for advanced colorectal cancer in elderly patients

AIM

Objective of the present study was the evaluation of the efficacy of the low ligation of the inferior mesenteric artery with lymphadenectomy at the root in rectosigmoid resection for advanced cancer by laparoscopic approach.

METHODS

Ninety-two elderly patients with stage III tumors were retrospectively divided into three groups: low ligation of inferior mesenteric artery with and without lymphadenectomy at its root and high ligation. Anastomotic fistula, lymph nodes harvested and oncologic outcome were examined.

RESULTS

Significant differences were registered in the number of lymph nodes comparing high and low ligation with lymphadenectomy to simple low ligation. Only 8.3% of patients treated by lymphadenectomy had metastasis at the root of mesenteric artery. Not significant shorter operative time was observed in the high compared to low ligation. Significantly longer time was observed in low ligation when it was associated to lymphadenectomy. Not significant difference was observed in term of anastomotic leakage. Significant increase in cancer related deaths was observed in the low ligation group without lymphadenectomy. Not significant difference in morbidity was observed in the different groups.

CONCLUSION

Low ligation of the inferior mesenteric artery with lymphadenectomy is a safe and effective procedure in the treatment of advanced rectosigmoid cancer with similar results compared to high ligation. It might be especially indicated in elderly patients with advanced tumors to better define lymph nodes involvement and to improve vascular flow to the anastomosis.

Laparoscopic incisional hernia repair by lightweight polypropylene mesh with resorbable coating. Technical notes, preliminary results

Laparoscopic repair of ventral hernias has gained popularity, since many studies have reported encouraging results. The choice of the mesh and fixation methods are crucial issues in preventing complications and recurrence. 30 laparoscopic ventral hernia repair performed consecutively in 28 patients (11 males, 17 females) for different kinds of incisional hernias from February 2011 to June 2012 were prospectively evaluated. All patients received total laparoscopic incisional hernia repair by the use of the new lightweight polypropylene mesh with resorbable coating (PhysiomeshTM, Ethicon Endo-Surgery, Johnson Johnson, Inc.). No major postoperative complications were reported. Two recurrences were diagnosed after 5 months from the first repair. Both patients received laparoscopic repair by the same kind of mesh. Lightweight polypropylene mesh with resorbable coating, with its properties of easy positioning and bio-compatibility, represents an innovation in laparoscopic incisional hernia repair, and should be considered for clinical intra-operative as well as long term evaluations.

Duodenal gastrointestinal stromal tumors: review on clinical and surgical aspects

INTRODUCTION

Gastrointestinal stromal tumors (GISTs) arising in the duodenum represent a rare entity and can be very demanding to manage. The diagnosis can be difficult (as these tumors can be misdiagnosed as pancreatic head tumors), and to treat owing to the complex anatomy of the duodenum and of the pancreatic head. Complete resection may require extensive procedures such as pancreaticodudodenectomy.

METHODS AND RESULTS

An extensive literature review regarding clinico-pathological features, diagnostic investigations and surgical options in the management of duodenal GISTs has been performed.

CONCLUSIONS

Duodenal GISTs have uncertain malignant potential, and they may be asymptomatic, or present with abdominal pain or bleeding. A preoperative diagnosis can be difficult to obtain. Endoscopic ultrasound and fine needle aspiration cytology (FNAC) may be helpful. Surgical R0 resection remains the only curative approach. However, owing to the complex anatomy of the duodenum, limited resection is not always feasible. In these cases, extensive procedures such as pancreaticoduodenectomy or pancreas-preserving duodenectomy are the treatment of choice.

Entrapment of Aβ(1-40) peptide in unstructured aggregates

Recognizing the complexity of the fibrillogenesis process provides a solid ground for the development of therapeutic strategies aimed at preventing or inhibiting protein-protein aggregation. Under this perspective, it is meaningful to identify the possible aggregation pathways and their relative products. We found that Aβ-peptide dissolved in a pH 7.4 solution at small peptide concentration and low ionic strength forms globular aggregates without typical amyloid β-conformation. ThT binding kinetics was used to monitor aggregate formation. Circular dichroism spectroscopy, AFM imaging, static and dynamic light scattering were used for structural and morphological characterization of the aggregates. They appear stable or at least metastable with respect to fiber growth, therefore appearing as an incidental product in the pathway of fibrillogenesis.

Vacuum-assisted closure treatment of leg skin necrosis after angiographic embolization of a giant plexiform neurofibroma

Type 1 neurofibromatosis is a relatively common inherited disease of the nervous system, with a frequency of almost 1 in 3000. It is associated with neurofibromas of various sites. Our case report is about the surgical management of a giant neurofibroma of the right gluteal fold in a 46-year-old male with NF1. The patient presented with increasing edema and accelerated growth of the mass; he underwent percutaneous embolization of lesion vessels that induced necrosis of the neurofibroma. The patient was taken to the operating room, where surgical resection of the bulk of the lesion was undertaken. The postoperative course was complicated by delayed wound closure managed with antibiotics and vacuum-assisted wound closure. Giant neurofibromas similar to this tumor require complex preoperative, intraoperative and postoperative management strategies. Surgical debulk is best managed with preoperative percutaneous embolization that help to avoid surgical bleeding. Postoperative delayed wound closure was managed with the application of negative pressure in a closed environment that triggers granulation and tissue formation.

Usefulness of ultrasounds in the management of breast phyllodes tumors

INTRODUCTION

Breast phyllodes tumors (PT) are uncommon fibroepithelial lesions having potential malignant features. These tumors have characteristic features, like pleomorphism, mitoses and overgrowth of the stroma with possible infiltrative margins. The clinical behaviour could be unpredictable, since the relatively high recurrence rate despite correct surgical strategy. Conventional diagnostic examinations show high sensitivity and specificity, but cannot demonstrate the differences between benign and malignant PT. MRI is not more effective.

PATIENTS AND METHODS

Sixteen patients affected by PT have been surgically treated at our Institution. All patients received mammography and ultrasonography (US) as preoperative diagnostic work-up.

RESULTS

in 13 patients, US was effective in preoperative diagnosis of PT. Mammography was uneffective in detecting breast lesions in 5 cases, while in 11 cases mammographic findings presented benign features, with a round opacity with moderate tissue density and well-defined wall.

CONCLUSION

US remains the most useful diagnostic test in detecting PT. However, there is no test effective in identifying malignat PT. In case of suspicion, fine needle biopsy should be performed.

Retrocaval mass in patient with von Recklinghausen disease: case report

Type I Neurofibromatosis (NF1) is an autosomal-dominant inheritable disorder, with an incidence of 1:3,000, and a prevalence of 1:4,000 to 5,000. Pathogenesis is based on mutations of the NF1 gene, a tumor suppressor gene encoding a cytoplasmic protein named neurofibromin that controls cellular proliferation. Patients affected by NF1 typically present with cutaneous neurofibromas, cafè au lait spots and eye involvement, but they can also be affected by various visceral tumors, such as neurofibromas (nodular or plexiform type), gastrointestinal stromal tumors or endocrine tumors, such as pheochromocytomas. Visceral neurofibromas are often asymptomatic but when growing in size they may present with pain, palpable abdominal mass, symptoms secondary to bowel obstruction or main vessels compression, and even gastrointestinal bleeding when mucosa or submucosa are involved. In these cases surgery becomes mandatory in order to remove all neoplastic tissue. The Authors describe a case of a young man affected by NF1 with associated retrocaval abdominal mass with compression and displacement of the inferior vena cava, thus requiring a complex surgical procedure.

Adrenal ganglioneuroma incidentally discovered in a patient with dysuria: a case report

A case of adrenal ganglioneuroma incidentally discovered during an abdominal ultrasound examination in a 26 year-old woman patient with recurrent episodes of dysuria. After a diagnostic work-up with laboratory and abdomen CT scan, the patient uderwent a laparotomic removal of the adrenal lesion. Histopathological examination of the adrenal mass confirmed the diagnosis.

Primary aldosteronism due to adrenocortical adenoma with concurrent ileum carcinoid tumor: case report

Primary aldosteronism (PA) with synchronous carcinoid syndrome is extremely rare occurrence. In this article, we describe a case of PA due to adrenocortical adenoma ("aldosteronoma") and concurrent malignant carcinoid tumor of ileum. The patient was treated with synchronous right adrenalectomy and resection of the ileum. This case is an example of concomitant presence of two types of tumors, effectively managed surgically. We report a case of a nonclassical form of multiple endocrine neoplasia type 1 (MEN 1) syndrome.

Cystic duplication of transverse colon: an unusual case of abdominal pain and bowel obstruction

Gatrointestinal duplications are rare congenital anomalies, usually detected prenatally or in the first two years of life, although they can be diagnosed even in older age. Within the abdomen, a small bowel location is the most frequent (more than 50% of cases), while colonic site accounts for 17% of patients; transverse colonic location is very rare. These lesions can vary in shape, being cystic or tubular, and typically show the same structure of the adjacent normal bowel, with which they can have direct communication. The most of case of intestinal duplication in adults present with acute abdomen and bowel obstruction, and are more common in the ileum than in the colon. When diagnosed these lesions should be surgically resected to avoid future possible complications. The Authors present a case of cystic duplication of transverse colon in a young adult male, cause of acute abdominal pain and intestinal obstruction, thus requiring urgent surgery.

New pegylated polyaspartamide-based polyplexes as gene delivery vectors

Aims: To synthesize novel polyhydroxyethylaspartamide (PHEA) copolymers containing spermine (Spm) and polyethylene glycol (PEG) moieties in high yields, with the expectation that this material would show stealth properties and the ability to complex DNA by electrostatic interactions. Materials & methods: PHEA–PEG–Spm copolymer was prepared with a two-step reaction. Chemical, physicochemical and biological characterizations of PHEA–PEG–Spm copolymers and their obtained polyplexes with pDNA were performed. Results: The introduction of spermine in PHEA structure allows to obtain a copolymer bearing in the side chains polyamine moieties capable to interact with DNA. On the other hand, the introduction of PEG in polymeric structure increased the DNA condensing ability of PHEA–PEG–Spm copolymer in comparison with the derivatives without PEG (PHEA-Spm), and improved its characteristics of biocompatibility. Conclusions: PHEA–PEG–Spm copolymer shows excellent ability to complex and condense plasmidic DNA giving interpolyelectrolyte complexes to act as gene delivery systems. Moreover, PEGylation confers to the obtained interpolyelectrolyte complexes stealth properties.

[Acute abdomen due to jejunal perforation secondary to metastatic lung carcinoma]

INTRODUCTION

Lung cancer metastases of small bowel are rare (1,1%), often with few or not symptoms. This aspecific onset and the difficult physical-instrumental approach to small bowel, led often to diagnosis at autopsy. This is not true for intestinal metastases that cause complications (haemorrhage, obstruction, perforation); in this cases emergency surgery leds to the diagnosis.

CASE REPORT

We describe a case of a male 56 years old patient with acute abdomen due to perforation (X-ray and CT). He refers, about 6 months before, an upper right lobectomy for lung cancer, followed by adjuvant chemo-radiotherapy, because the presence of brain and bone metastases. During the emergency surgery we found out a perforation of the Treitz tract, treated with intestinal resection and immediate end-to-end anastomosis with manual suture. Histological examination shows the perforation of the intestinal wall tract with lung cancer metastases.

CONCLUSIONS

Our case shows that any acute abdomen in patient with lung cancer can be considered as expression of intestinal metastases. Negative prognosis of this complication imposes to surgeons only a local treatment.

Microwave-assisted synthesis of PHEA–oligoamine copolymers as potential gene delivery systems

Aims: To prepare new copolymers, useful for gene delivery, based on α, β-poly-(N-2-hydroxyethyl)-D, L-aspartamide (PHEA) as a polymeric backbone and bearing an oligoamine such as diethylenetriamine in the side chain. Moreover, in order to reduce solvent volume and make the reaction faster, microwave-assisted heating was used. Materials & methods: PHEA copolymers bearing different amounts of diethylenetriamine were prepared using bis(4-nitrophenyl) carbonate as a condensing agent with the use of microwaves. Chemical, physico–chemical and biological characterization of PHEA–diethylenetriamine copolymers and their complexes obtained with DNA were performed. Results: Copolymers showed good DNA complexing and condensing abilities depending on the oligoamine derivatization degree and good hemocompatibility. Moreover, plasmid DNA/copolymer polyplexes showed very good cytocompatibility on B16F10 and N2A cell lines. Conclusion: Results support the use of these copolymers as gene delivery systems in the future. Finally, the use of microwaves makes the proposed synthetic method advantageous as time and solvents are saved.

Scaffolds based on hyaluronan crosslinked with a polyaminoacid: Novel candidates for tissue engineering application

New porous scaffolds, with a suitable hydrolytic and enzymatic degradation, useful for tissue engineering applications have been obtained by a carbodiimide mediated reaction between hyaluronan (HA) and a synthetic polymer with a polyaminoacid structure such as alpha,beta-polyaspartylhydrazide (PAHy). Scaffolds with a different molar ratio between PAHy repeating units and HA repeating units have been prepared and characterized from a chemical and physicochemical point of view. Tests of indirect and direct cytotoxicity, cell adhesion, and spreading on these biomaterials have been performed by using murine L929 fibroblasts. The new biomaterials showed a good cell compatibility and ability to allow cell migration into the scaffolds as well as spreading on their surface.