Nicotine and cotinine affect the release of vasoactive factors by trophoblast cells and human umbilical vein endothelial cells

OBJECTIVE

To examine nicotine (N) and cotinine (C) effects on trophoblast cells (TCs) and human umbilical vein endothelial cells (HUVEC) secretion of soluble fms-like tyrosine kinase (sFlt-1), soluble endoglin (sENG), placental growth factor (PlGF), transforming growth factor-beta (TGF-beta) and vascular endothelial growth factor (VEGF).

STUDY DESIGN

Human placentas and umbilical cords were collected from uncomplicated pregnancies at term from a total of 24 non-smoking women with a history of normal blood pressure. TCs and HUVEC were cultured for 24 h with C or N (from 10(-12) to 10(-7) M).

MAIN OUTCOME MEASURES

sFlt-1, sENG, PlGF, TGF-beta and VEGF release and messenger RNA (mRNA) expression were evaluated by ELISA and real-time polymerase chain reaction (PCR), respectively.

RESULTS

N and C reduced sFlt-1, sENG and PlGF release by TCs and TGF-beta release by HUVEC. Conversely, N and C increased PlGF secretion, while N alone increased sFlt-1 release by HUVEC. N and C were able to modulate VEGF mRNA expression in HUVEC.

CONCLUSIONS

Our results suggest that N and C affect the balance of some important vasoactive factors released by TCs and HUVEC. This might be one of the possible mechanism through which smoke reduces the risk of hypertensive disorders during pregnancy as well as contributes to the well known detrimental effects of smoking on fetal development.

Characterization of a 2D ion chamber array for the verification of radiotherapy treatments

In this study we investigated the characteristics of a commercial ion chamber array and its performance in the verification of radiotherapy plans. The device was the 2D Array Seven29 model (PTW, Freiburg, Germany). This is a two-dimensional detector array with 729 ionization chambers uniformly arranged in a 27 x 27 matrix with an active area of 27 x 27 cm(2). The detector short-, medium- and long-term reproducibility have been tested through an extensive set of repeated measurements. Short-term reproducibility was well within 0.2%. Medium- and long-term reproducibility were within 1%, including set-up reproducibility errors and linac output fluctuations. Dose linearity was also assessed. The system response to dose was verified to be linear within the range 2-500 MU. Output factors matched very well pinpoint chamber measurements performed in the same experimental conditions with a maximum local percentage difference of 0.4%. Furthermore, the 2D Array sensitivity to millimetric collimator positional changes and to perturbation effect of irradiated area was tested. The comparison with ion chamber data carried out in water was very satisfying. Finally, measurements of wedge-modulated fields and IMRT beam sequence matched very well ion chamber dose profiles acquired in a water tank. The extensive tests performed in this investigation show that the 2D Array Seven29 is a reliable and accurate dosimeter and that it could be a useful tool for the quality assurance and the verification of radiotherapy plans.

Denitrification in tertiary filtration: application of an up-flow filter

The present paper shows the results obtained through an experimental work performed at the wastewater treatment plant of Rome, aimed at studying the performances of a tertiary filter regarding combined removal of suspended solids, COD, and nitrates. The up-flow sand filter was fed by the effluent coming from the secondary settling tank of the plant. The filter bed height was of 80 cm of silica sand. After a start up period, a study of particulate and soluble COD removal process was made, to establish the need of methanol in the denitrification process. Total COD removal efficiency was 60% on average, 55% due by soluble COD removal and 5% by particulate one. In the last phase of the experimental activity methanol was fed as carbon source, sodium sulfite was supplied to produce anoxic environment within the filter and the denitrification efficiency was studied. Nitrates removal rates after an acclimation period of 10 days increased up to 60%, with an effluent NO3-N of 8 mg/L. Denitrification rate was 2.4 kg/m3 d for water temperatures of 25 degrees C. Regarding methanol demand and biologic kinetics, the biomass yield coefficient was 0.3 kg(COD-X)/kg(me). Consequently 2.7 kg of methanol was required per kilogram of denitrified nitrogen.

Prospective randomized trial of steroid withdrawal in liver transplant patients: preliminary report

Although steroid withdrawal has been successfully performed in heart and kidney transplant recipients, no controlled studies of SW have been carried out in liver transplant patients. To evaluate this possibility a prospective controlled study was carried out in 46 liver transplant recipients operated on after may 1991. They all received a sequential quadruple immunosuppression consisting of 3 mg/kg antithymocyte globulins (RATG) for the first 5 postoperative days, cyclosporin A (starting from day 3-5 and maintaining parenteral whole-blood trough levels at 200-300 ng/ml during the first month and at 150-250 thereafter), azathioprine (1 mg/kg per day for the first month) and steroids. Prednisone was started at a dose of 200 mg per day 1 and then tapered to 20 mg/day over the first posteroperative week; this dose was maintained until day 90 when the patients were randomly allocated either to long-term steroid therapy (0.1 mg/kg per day) or to steroid withdrawal. Minimum follow-up after randomization was 6 months (6-27 months). Liver biochemistry was checked at regular intervals throughout the follow-up period. Liver biopsies were performed whenever clinically indicated and also in the first 19 patients during readmission for annual review. The incidence ot acute and chronic rejection 90 days from liver transplantation was 2.5% in patients maintained on long-term therapy. No patient in the steroid-withdrawal group had experienced either an acute or a chronic rejection episode so far. Steroid-related complications did not differ significantly between the two groups. The most recent interim analysis showed that steroid withdrawal is a safe undertaking in liver transplant recipients and may be successfully accomplished in almost all patients.

[Carotid stenosis with contralateral occlusion. Surgical indications and results]

Recent American and European trials have clearly defined that surgery provides best treatment for unilateral critical stenosis of internal carotid artery. Isolated reports seem to confirm this trend also in cases with carotid critical stenosis with controlateral occlusion, even if a major surgical risk may be expected. In our experience in the last two years, out of 96 carotid enderterectomies 20 presented a controlateral occlusion. After routine pre-operative assessment, with particular regard to DSA "cross-filling" study, intervention has been performed under general anesthesia with BP+EEG cerebral monitoring in both groups of patients. In the non occluded group temporary shunt has been used in 19.7% of cases, in occluded the incident of shunting was 40%. Operative morbidity and mortality in the second group was surprisingly absent, with cumulative 4.1% complication rate. Our experience confirms that risks and results in carotid endoarterectomy are similar in both groups of patients.

The role of transplantation in small hepatocellular carcinoma complicating cirrhosis of the liver

Of 176 hepatic transplants performed from 1986 to December 1992, 27 patients had small hepatocellular carcinoma (< or = 5 centimeters) complicating cirrhosis of the liver. All patients were asymptomatic for the hepatic malignancy and the diagnosis was established in each instance preoperatively by means of serial sonographic scans and alpha-fetoprotein levels. Cirrhosis was classified as Child's A in eight instances, as Child's B in 16 and Child C's in three. The cause was alcoholic in three patients, posthepatitic in 21 patients (eight hepatitis B virus [HBV] positive and 13 hepatitis C virus [HCV] positive) and undetermined in three. The in-hospital mortality rate was 11 percent (three of 27). Additionally, five patients died at different intervals after transplantation: only two died of neoplastic recurrence at 12 and 32 months, respectively (7.4 percent rate). Actuarial survival rates were 82 percent at one year and 71 percent at three years, with a mean follow-up period of 32 months (range six to 78 months). Morbidity related to the procedure was a relevant problem: 21 percent of the patients had prompt resumption of normal life while 37 percent required repeated hospitalization and 42 percent required strict control on an outpatient basis. The most frequent problem was HBV or HCV reinfection of the grafted liver, which occurred in 42 percent. Based on this experience, transplantation of the liver has shown an excellent oncologic accuracy for small hepatocellular carcinoma in cirrhosis of the liver, thus representing the most rational surgical procedure for patients with Child's B and Child's C cirrhosis classification. The relevant mortality and morbidity rates, strictly related to this procedure, suggest other options as more appropriate in those with Child A cirrhosis at this time.

Dysarthria and cerebellar ataxia: late occurrence of severe neurotoxicity in a liver transplant recipient

Neurological complications of cyclosporin (CyA) therapy are frequent, usually occurring within the 1st month after transplantation. Though leukoencephalopathy is one of them, it is rarely documented. Here we report the case of an anti-HCV-positive patient with cirrhosis who underwent liver transplantation and developed cyclosporin-induced leukoencephalopathy. The presenting symptoms were dysarthria, difficulty walking, and dysphagia. They were first noted 6 months after transplantation in association with an episode of recurrent HCV acute hepatitis. White matter abnormalities were evident on computed tomography (CT) scanning and magnetic resonance (MR) imaging. This condition improved to some degree after cyclosporin withdrawal. To our knowledge this is the second reported case of CyA neurotoxicity occurring late after liver transplantation. Moreover, the association with acute hepatitis suggests the possibility of graft dysfunction as a contributing and triggering factor.

Liver transplantation for small HCC in cirrhosis

Segmental liver resection is generally considered the treatment of choice for small HCC in cirrhotic livers. Although in selected patients with small encapsulated nodules and low alpha-fetoprotein levels long-term survival can be expected after resection, Western experience is still limited, and follow-up studies too short so that the data presently available cannot be considered satisfactory. The true value of alcoholization as a possible alternative therapy in these patients is still to be ascertained. When using these treatment modalities, the major problem is the high tumour recurrence within the liver. Three main reasons could explain these clinical observations: 1. inadequate resection of the original tumor; 2. unrecognized multifocal HCC; 3. newly generated tumours in the remnant cirrhotic parenchyma. The rationale for liver transplantation is the oncological accuracy of the ablation of the liver, and the possibility of a simultaneous cure of the associated cirrhosis. In our programme of liver transplantation, begun in 1985, we accepted as an indication small HCC in cirrhotic livers. We present here our initial experience with 19 cases.

Somatomedin C (IGF I) plasma levels after orthotopic liver transplantation (OLT) in end-stage cirrhotic patients

Insulin-like growth factors [IGF I and II or somatomedins (SMS)] are polypeptides chemically and biologically correlated with insulin. The main source of synthetic activity and secretion is the liver, although many other tissues have been demonstrated to synthesize SMS. In the circulation, they are not present in a free form, but are mostly bound to a specific carrier protein independently synthesized in the liver. Hepatic or extrahepatic storage organs have not been demonstrated; the half life of the SMS-binding protein complex is between 3 and 4. Synthesis of SMS is regulated by GH, insulin, thyroxine and nutrition (caloric and protein intake, and nitrogen balance). The role of corticosteroids is still a matter of debate: in patients treated with steroids SMS blood levels have been shown to be within normal limits, while biological activity has been demonstrated to be significantly reduced by SMS inhibitors, probably induced by corticosteroid therapy. The biological properties of SMS are related to their structural homology with insulin, and can be summarized as follows: A. Insulin-like activity (glucose oxidation, lipogenesis, glycogen synthesis, inhibition of lipolysis and glycogenolysis); B. Sulphation activity (incorporation of sulphate and leucine into glycosaminglycans of the cartilage); C. Stimulation of fibroblast multiplication; D. Amplification of other hormone activities (GH); E. Complementary anabolic activity with insulin. Low levels of SMS have been demonstrated in hypopituitarism (secondary) or in other diseases independent of GH reduced secretion (primary) such as malnutrition, malabsorption, acute or chronic liver failure and uraemia. Negative nitrogen balance, hypocaloric and/or low protein diets are usually correlated with low levels of SMS. Recently, Schalch et al. reported on the role of orthotopic liver transplantation (OLT) in normalizing SMS blood levels in a group of end-stage liver diseased patients. This preliminary paper deals with changes in IGF-I plasma levels (somatomedin C) in a group of patients affected by end-stage liver cirrhosis before and after OLT.

Reappraisal of surgical treatment of small hepatocellular carcinomas in cirrhosis: clinicopathological study of resection or transplantation

Thirty-two patients with hepatocellular carcinoma (HCC) occurring in individuals with cirrhosis had a potentially curative surgical procedure. Twenty-two had segmental hepatic resections (HR), and 10 underwent orthotopic liver transplantation (OLTx). The diagnosis of hepatic malignancy was established in each case preoperatively, and each case was studied intraoperatively by means of sonography. Postoperatively each surgical specimen was examined pathologically with attention to the possibility of intrahepatic tumor spread. Twenty-three of the 32 patients had single small HCC lesion (less than 5 cm diameter) identified preoperatively. Sixteen of these underwent HR and seven underwent OLTx. Multiple additional neoplastic lesions were found in 19% of the 16 HR cases and in 14% of those undergoing OLTx when the resection specimens were examined pathologically. Vascular invasion was present in 43% of the OLTx patients and in 25% of the HR patients. Subtotal hepatic resection for small HCC occurring in cirrhosis has produced few long-term survivals. Both pre- and intraoperative sonography have been shown to underestimate the extent and distribution of these tumors. Based upon this experience that (1) vascular spread occurs often in HCC and (2) a high risk of postoperative hepatic failure can be expected after HR in cirrhotic individuals, OLTx is the most rational surgical procedure for such cases as it has the potential to cure.

Characterization by morphometric model of liver regeneration in the rat

A new stereological approach to the study of liver regeneration in the rat is described. The method employs a morphometric model consisting of number and size, as well as surface and volume fractions of hepatocytes, their nuclei, cytoplasm, and their relation to the sinusoidal bed. With this technique, it was found that 8 hr after partial hepatectomy, the number of nuclei increased as did the nucleus/cytoplasm ratio, suggesting an early hyperplastic phase. These data, which have not been reported in other studies, underline the importance of evaluating the complex phenomenon of liver regeneration using a stereological approach, which is more representative of all morphometric changes occurring inside and outside the hepatocyte.

Thrombosis of portal vein in absence of hepatic disease

Of 602 patients referred for portal hypertension during a 20 year period, 18 children (mean age of 5.0 years) and 29 adults (mean age of 26.5 years) had thrombosis in the portal bed with a healthy liver (7.8 per cent incidence). In 29 of the 47 patients we studied, the causative factor remained obscure. Variceal hemorrhage occurred in all and was the indication for our observation and treatment. In 11 adult patients (mean age of 22.1 years), surgical treatment was not performed because of reluctance of the patient or because of technical reasons: nine of the patients rebled and one patient died because of massive bleeding. Direct procedures on esophageal varices had a high rate of rebleeding (seven of 11 patients) independent of the age of the patient when the operation was performed. In 13 patients, shunting offered a good chance of long term protection: three of the 13 rebled at a mean follow-up study of 5.7 years. No recurrence of bleeding was observed in 15 patients when variceal eradication had been obtained after chronic endoscopic sclerotherapy at one to eight years of follow-up study (mean of 3.9 years). The data from this study indicate that sclerotherapy should be the first choice of treatment to control recurrent bleeding in extrahepatic portal hypertension caused by thrombotic obstruction, particularly in the young patient.

Pylorus preserving pancreatoduodenectomy versus Whipple procedure for adenocarcinoma of the head of the pancreas

Thirty eight patients underwent pancreatoduodenectomy for histologically confirmed adenocarcinoma of the head of the pancreas. Twenty one underwent a pylorus preserving pancreatoduodenectomy and seventeen the classical Whipple procedure. We undertook this retrospective analysis to compare longterm survival following the two different surgical procedures. Patients in the two groups were comparable for preoperative laboratory data, age and pathological staging. Minor and major morbidity was not different between the two group (33.3% and 35.2% respectively). In the pylorus preservation group a delayed resumption of full oral diet and a consequent prolonged hospital stay has been noted (21.3 days vs 15.4 days, p less than 0.05). Mean survival was 21 months in the pylorus preservation group and 17 in the Whipple group. No statistical difference was observed between the two survival curves. According to these data the pylorus preserving pancreatoduodenectomy represents a reasonable option for adenocarcinoma of the head of the pancreas.

The role of donor and recipient factors in initial renal graft non-function

ATN is a deleterious problem in the outcome of kidney transplantation. This complication is usually related to multiple factors including donor parameters, surgical technique, ischemic time, and recipient variables. In order to develop prophylactic measures, out of 430 kidney transplants performed in our Department, a series of 90 consecutive cadaveric renal allografts has been considered in this study. The overall incidence of IGNF was 23/90 (25.5%). Kidneys from MOD revealed a lower rate of IGNF (7/35 = 20%) when compared with organs from SOD (16/55 = 29%, P = NS). No difference was noted when kidneys were removed together with heart and/or liver and/or pancreas. Out of the donor factors, only CID was significant (17 +/- 9 hours in IGNF v 11 +/- 10 hours in patients with IGF, P = less than .05). Analysis of data concerning the fate of paired kidneys revealed two cases of IGNF in both kidneys from the same donor v 14 cases of IGNF in only one of the two paired grafts (P = NS). We conclude that: 1. Donor factors are clearly associated with a minority of IGNF. 2. The introduction of multiorgan procurement programs does not complicate early function. 3. Recipient factors (immunological events and intraoperative fluid management) provides important additive effects on initial graft nonfunction.

Is thrombocytopenia in liver failure dependent on an inadequate synthesis of thrombopoietic stimulating factor by the liver?

Thrombocytopenia in liver diseases has been considered secondary to portal hypertension or to a consumption mechanism associated with fibrinolytic disorders. Several conflicting clinical reports and evidence from experimental models justify the above mentioned mechanisms only in part. We propose that thrombocytopenia may be consequent to an inadequate synthesis of a factor stimulating thrombopoiesis produced by the liver.

Unstable translocation t(14;21) in a man, inherited as a t(13;14) in one of his daughters

The transmission of a Robertsonian translocation was studied in a family after diagnosis of a t rob. (13;14) in a foetus, in the course of a prenatal diagnosis for maternal age. The father was found to be a carrier of a balanced t rob. (14;21) in mosaicism with a normal karyotype. The t rob(14;21) was inherited from the paternal grandfather. A second prenatal diagnosis, 1 year later, revealed a girl with the paternal t rob(14;21). Mitotic and germinal instability of the paternal t rob.(14;21) is discussed, with relation to the long period of drug addiction.

Effect of superoxide dismutase on liver ischemia-reperfusion injury in the rat: a biochemical monitoring

Oxygen free radicals have been implicated in the pathogenesis of postischemic liver injury. High-dose superoxide dismutase (SOD), a radical scavenging enzyme, has been investigated in a rat model of liver ischemia reperfusion by biochemical monitoring. Blood vessels to the median and left lobe were clamped for 1 h and then reperfusion was allowed. The indices used were serial venous blood levels of AST, ALT, calcium, and ATP determination in liver tissue. In SOD-treated animals (7,5000 U i.v.) a significant attenuation of the rise in enzyme levels was observed as well as the absence of the decrease in calcium level in the early phase after reperfusion as compared with control rats, and furthermore ATP restoration was significantly increased.

[Fibrinolytic therapy in acute myocardial infarction. Coronarographic evaluation of short-term results]

The authors report their experience in fibrinolytic therapy with Urokinase in acute myocardial infarction. There were 3 groups of treatment: 100 patients with intracoronary fibrinolytic therapy; 77 patients with peripheral venous fibrinolytic administration; 31 patients with conventional therapy. The 3 groups underwent, between 21 and 28 days after the acute event, a coronarographic examination to evaluate the persistence of patency of the vessels involved in the myocardial infarction. The short term results show that the fibrinolytic therapy (with the limitations due to the hemorrhagic complications associated with the use of Urokinase), especially via intracoronary, is significantly more useful and reliable than conventional therapy, which appears unsatisfactory. Therapeutic failures are probably due to diffuse atherosclerosis of the vessel and/or to the old age of the thrombus.

Responsiveness to 'autoreceptor' doses of apomorphine inversely correlated with the firing rate of dopaminergic A9 neurons: action of baclofen

Supersensitivity of dopamine (DA) autoreceptors develops soon after acute treatments with baclofen or gamma-butyrolactone, two drugs which suppress DA neuronal firing. We have hypothesized that this effect might reflect a condition associated with the low firing rate of DA cells induced by such treatments rather than a long-term adaptive modification of DA receptor sensitivity. In this study we show that the degree of the intravenous apomorphine-induced inhibition of A9-DA neurons is inversely correlated to the basal firing rate of these neurons. When administered after baclofen, apomorphine further reduced DA cell activities in a manner proportional to the predrug firing rate, as in control rats. Since the minute doses of apomorphine which were used are thought to selectively activate DA autoreceptors, our finding may indicate that DA autoreceptor stimulation is more effective when the activity of the DA neurons is low, or it is decreased by drugs such as baclofen.

Portal thrombosis in cirrhotics. A retrospective analysis

The development of thrombotic obstruction in the portal bed of cirrhotic patients presents special problems in diagnosis and treatment. In the cirrhotic population treated for portal hypertension at our Surgical Department during the period 1967-1983 (512 patients), the incidence of thrombosis in the portal bed was 16.6% (85 patients). Bleeding was the main presenting symptom (70/85), with a mean of four episodes prior to treatment. Careful angiographic studies and intraoperative evaluation are fundamental steps to determine the exact anatomical involvement, the presence of recanalized veins or fresh occluding clots, and the applicability of shunt procedures. A massive portosplenomesenteric involvement often associated with poor surgical possibilities was found in 19 patients (22.3%). The presence of partially recanalized veins and fresh occluding clot suitable for disobliterative techniques prior to shunt was found in 16 patients, and out of 73 operated patients a total of 55 shunt procedures could be performed. Fifty-three patients who bled from varices could be followed up to 5 years: 39 underwent a shunt procedure with a 51.2% 5-year survival rate, while only one of 14 nonshunted or nonoperated survived up to 3 years, and a lethal bleeding was the cause of death in all but one. Disobliterative techniques (Fogarty thrombectomy and endovenectomy of intimal fibrotic thickenings) prior to shunting provided a good long-term patency rate with a 50% protection from lethal bleeding recurrences. Nonshunt procedures and the extensive involvement of the portal bed are associated with bad prognosis. Also, endoscopic sclerotherapy, attempted in patients with massive thrombosis, could not prevent recurrences and death from bleeding. Despite a 30% failure rate in our study, shunting surgery should be considered the only therapeutical possibility of preventing further thrombotic recurrences and consequent life threatening bleeding episodes.