Development of a semi-structured questionnaire to analyse supply chain resilience in the post-COVID business era

The COVID-19 pandemic has had and is having devastating effects on the health of the population, but also on the economic health of companies and their supply chains. The old paradigms of the commercial and industrial world have been inevitably disrupted: global supply chains have shifted from a system based on efficiency to one oriented towards resilience. To this regard, the present research paper aims at investigating how Supply Chain Resilience will evolve in the new paradigms of the post-COVID business era. In order to contribute to this investigation, a semi-structured questionnaire is developed, through a structured research approach. Future research lines will be based on conducting this questionnaire as a basis for a targeted survey, analysable through association rules.

Multicenter retro-prospective observational study on chronic hypoparathyroidism and rhPTH (1-84) treatment

PURPOSE

The main purpose of this study was to investigate the effects of 12 months of rhPTH (1-84) (Natpar^®) treatment in a cohort of patients selected according to the indications of hypoparathyroidism guidelines. The use of recombinant human PTH (1-84) [rhPTH (1-84)] is approved as hormonal replacement therapy in patients with hypoparathyroidism not adequately controlled with conventional therapy.

METHODS

It is a multicenter, observational, retro-prospective, open label study. Eleven Italian Endocrinological centers, members of Hypoparathyroidism Working Group of the Italian Society of Endocrinology (HypoparaNET) were involved. Main outcome measures were serum and urinary calcium and phosphate concentration, calcium-phosphate product, renal function, oral calcium and vitamin D doses, and clinical manifestations.

RESULTS

Fourteen adult subjects, affected by chronic hypoparathyroidism, were treated with rhPTH (1-84) for 12 months. At 12 months of rhPTH (1-84) treatment, 61.5% of patients discontinued calcium supplement and 69.2% calcitriol. Mean albumin-adjusted total serum calcium levels quickly normalized after initiation of rhPTH (1-84) treatment compared to baseline (p = 0.009), remaining in the normal range until 12 months. Rare hypo-hypercalcemia episodes were reported. Renal function was maintained normal and no renal complications were reported. Serum and urinary phosphate and urinary calcium were maintained in the normal range. Mean phosphatemia levels linearly decreased from 3 months up to 12 months compared to baseline (p = 0.014). No severe adverse events were described.

CONCLUSIONS

Biochemical and clinical results confirm the efficacy and safety of rhPTH (1-84) therapy, which represents an important option for hypoparathyroid patients unresponsive to conventional therapy.

Polymorphic variants of alkaline phosphatase gene correlate with clinical signs of adult hypophosphatasia?

We analyzed polymorphism of the ALPL gene in patients with low serum levels of tissue-nonspecific alkaline phosphatase (TNAP). The presence of three or more of the less frequent alleles of ALPL polymorphisms was associated with significantly lower TNAP serum level and higher frequencies of metatarsal fractures, which may help confirm a clinical suspicion of adult hypophosphatasia.

INTRODUCTION

Alkaline phosphatases (ALPs) are membrane-bound enzymes that hydrolyze monophosphate esters at a high pH (pH 8-10). Inorganic pyrophosphate, pyridoxal 5-phosphate, the activated form of vitamin B₆ (PLP), and phosphoethanolamine (PEA), are natural substrates of ALPs. Hypophosphatasia (HPP, OMIM 146300, 241500, 241510) is a heterogeneous rare metabolic bone disease caused by loss-of-function mutations in the tissue-nonspecific alkaline phosphatase gene (ALPL; MIM 171760) with a deficiency of TNAP. Clinical presentation of HPP in adults demonstrated a wide range of manifestations, many of which are nonspecific. In the present study, we screened the polymorphic genetic variants of ALPL in 56 subjects presenting low serum levels of TNAP and/or other clinical signs of adult HPP in order to evaluate a possible role of polymorphic variants in the diagnosis and management of HPP in adults.

METHODS

Genomic DNA was extracted from peripheral blood and ALPL gene was sequenced by PCR-based Sanger technique.

RESULTS

Fourteen different polymorphic variants were found in the study population. A lower serum level of TNAP and higher frequencies of metatarsal fractures were observed in patients bearing three or more of the minor frequency alleles (MFAs) of the ALPL polymorphic variants. The presence of some MFAs, mostly as a contemporary presence of three or more of them, was found to be mainly represented in patients having both a significantly lower level of TNAP and a higher level of vitamin B6.

CONCLUSION

The genetic analysis and presence of some polymorphic variants may be an instrument to confirm clinical and biochemical data, consider adult HPP, and help clinicians be cautious in the administration of anti-reabsorption drugs.

Bone health in childhood cancer: review of the literature and recommendations for the management of bone health in childhood cancer survivors

In the past decades, new cancer treatment approaches for children and adolescents have led to a decrease in recurrence rates and an increase in long-term survival. Recent studies have focused on the evaluation of the late effects on bone of pediatric cancer-related treatments, such as chemotherapy, radiation and surgery. Treatment of childhood cancer can impair the attainment of peak bone mass, predisposing to premature onset of low bone mineral density, or causing other bone side-effects, such as bone quality impairment or avascular necrosis of bone. Lower bone mineral density and microarchitectural deterioration can persist during adulthood, thereby increasing fracture risk. Overall, long-term follow-up of childhood cancer survivors is essential to define specific groups at higher risk of long-term bone complications, identify unrecognized long-term adverse effects, and improve patient care. Children and adolescents with a cancer history should be carefully monitored, and patients should be informed of possible late complications of their previous medical treatment. The International Osteoporosis Foundation convened a working group to review the bone complications of pediatric cancer survivors, outlining recommendations for the management of bone health, in order to prevent and treat these complications.

Large-Scale Photonic Ising Machine by Spatial Light Modulation

Quantum and classical physics can be used for mathematical computations that are hard to tackle by conventional electronics. Very recently, optical Ising machines have been demonstrated for computing the minima of spin Hamiltonians, paving the way to new ultrafast hardware for machine learning. However, the proposed systems are either tricky to scale or involve a limited number of spins. We design and experimentally demonstrate a large-scale optical Ising machine based on a simple setup with a spatial light modulator. By encoding the spin variables in a binary phase modulation of the field, we show that light propagation can be tailored to minimize an Ising Hamiltonian with spin couplings set by input amplitude modulation and a feedback scheme. We realize configurations with thousands of spins that settle in the ground state in a low-temperature ferromagneticlike phase with all-to-all and tunable pairwise interactions. Our results open the route to classical and quantum photonic Ising machines that exploit light spatial degrees of freedom for parallel processing of a vast number of spins with programmable couplings.

Phosphate wasting disorders in adults

A cause of hypophosphatemia is phosphate wasting disorders. Knowledge concerning mechanisms involved in phosphate wasting disorders has greatly increased in the last decade by the identification of phosphatonins, among them FGF-23. FGF-23 is a primarily bone derived factor decreasing renal tubular reabsorption of phosphate and the synthesis of calcitriol. Currently, pharmacological treatment of these disorders offers limited efficacy and is potentially associated to gastrointestinal, renal, and parathyroid complications; therefore, efforts have been directed toward newer pharmacological strategies that target the FGF-23 pathway. This review focuses on phosphate metabolism, its main regulators, and phosphate wasting disorders in adults, highlighting the main issues related to diagnosis and current and new potential treatments.

Maintenance therapy with decitabine in younger adults with acute myeloid leukemia in first remission: a phase 2 Cancer and Leukemia Group B Study (CALGB 10503)

In this prospective phase 2 clinical trial conducted by Cancer and Leukemia Group B (CALGB, now the Alliance), we studied decitabine as maintenance therapy for younger adults with acute myeloid leukemia (AML) who remained in first complete remission (CR1) following intensive induction and consolidation. Given that decitabine is clinically active in AML and with hypomethylating activity distinct from cytotoxic chemotherapy, we hypothesized that one year of maintenance therapy would improve disease-free survival (DFS) for AML patients <60 years who did not receive allogeneic stem cell transplantation (alloHCT) in CR1. After blood count recovery from final consolidation, patients received decitabine at 20mg/m² IV daily for 4–5 days, every 6 weeks for 8 cycles. One-hundred-thirty-four patients received decitabine, 85 (63%) had favorable risk AML. The median number of cycles received was 7 (range, 1–8), and the primary reason for discontinuation was relapse. DFS at 1-year and 3-years was 79% and 54%, respectively. These results are similar to the outcomes in the historical control comprised of similar patients treated on recent CALGB trials. Thus, maintenance with decitabine provided no benefit overall. Standard use of decitabine maintenance in younger AML patients in CR1 is not warranted. This trial was registered at www.clinicaltrials.gov as NCT00416598.

Expression and polymorphism (rs4880) of mitochondrial superoxide dismutase (SOD2) and asparaginase induced hepatotoxicity in adult patients with acute lymphoblastic leukemia

Asparaginase, which depletes asparagine and glutamine, activates amino acid stress response. Oxidative stress mediated by excessive reactive oxygen species (ROS) causes enhanced mitochondrial permeabilization and subsequent cell apoptosis and is considered a plausible mechanism for drug-induced hepatotoxicity, a common toxicity of asparaginase in adults with acute lymphoblastic leukemia (ALL). Studies investigating the pharmacogenetics of asparaginase in ALL are limited and focused on asparaginase-induced allergic reaction common in pediatric patients. Here, we sought to determine a potential association between the variant rs4880 in SOD2 gene, a key mitochondrial enzyme that protects cells against ROS, and hepatotoxicity during asparaginase-based therapy in 224 patients enrolled on CALGB-10102, a treatment trial for adults with ALL. We report that the CC genotype of rs4880 is associated with increased hepatotoxicity following asparaginase-based treatment. Thus, rs4880 likely contributes to asparaginase-induced hepatotoxicity, and functional studies investigating this SNP are needed to develop therapeutic approaches that mitigate this toxicity.

Targeting leukemia stem cells in vivo with antagomiR-126 nanoparticles in acute myeloid leukemia

Current treatments for acute myeloid leukemia (AML) are designed to target rapidly dividing blast populations with limited success in eradicating the functionally distinct leukemia stem cell (LSC) population, which is postulated to be responsible for disease resistance and relapse. We have previously reported high miR-126 expression levels to be associated with a LSC-gene expression profile. Therefore, we hypothesized that miR-126 contributes to “stemness” and is a viable target for eliminating the LSC in AML. Here we first validate the clinical relevance of miR-126 expression in AML by showing that higher expression of this microRNA (miR) is associated with worse outcome in a large cohort of older (≥60 years) cytogenetically normal AML patients treated with conventional chemotherapy. We then show that miR-126 overexpression characterizes AML LSC-enriched cell subpopulations and contributes to LSC long-term maintenance and self-renewal. Finally, we demonstrate the feasibility of therapeutic targeting of miR-126 in LSCs with novel targeting nanoparticles (NP) containing antagomiR-126 resulting in in vivo reduction of LSCs likely by depletion of the quiescent cell subpopulation. Our findings suggest that by targeting a single miR, i.e., miR-126, it is possible to interfere with LSC activity, thereby opening potentially novel therapeutic approaches to treat AML patients.

Combining superficial femoral artery endovascular treatment with distal vein bypass

AIM

Significant strides have been made using endovascular solutions for the treatment of patients with peripheral vascular disease (PAD) and for tissue loss. But the Trans-Atlantic Inter-Society Consensus (TASC) II classification states that surgery still remains the best solution for C and D lesions, though endovascular management of superficial femoral artery (SFA) can improve inflow for distal origin bypass grafts. Our aim was to evaluate the results of combining endovascular treatment of SFA with distal vein bypass in patients with critical limb ischemia (CLI) and great tissue loss or in the cases where the below-knee endoluminal techniques alone were unable to salvage limbs.

METHODS

A retrospective study of the combined interventions carried out from January 2006 and June 2013 was performed. Twenty-seven angioplasties or selective stentings of SFA combined with popliteal-distal bypass in 23 patients with stage 4, 5 or 6 Rutherford classification were performed. There were 14 men and 9 women, four were bilateral. Mean age was 71.5 years (55-91); 21 (91.3%) were diabetic, and in these, there was almost always deep debridement of necrotic or infected tissue. In 17 cases (62.9%) SFA angioplasty was performed alone, a self-expendable stent was released in the other 10 (37.1%). Distal bypass originated from distal SFA in 5 cases (18.5%), from above-knee popliteal artery in 8 (29.6%) and from below-knee popliteal artery in 14 (51.8%). Reversed saphenous vein was used for bypass in all cases. The target vessel was the posterior tibial artery in 6 cases, anterior tibial artery in 10 and dorsalis pedis in eleven. Follow-up ranged from 4 months to 6 years (with a mean of 37 months).

RESULTS

There were no deaths, but two early graft failures and three major amputations during the perioperative period. Primary patency rate of both the endovascular SFA and the bypass was 81.6% (N.=22) and secondary patency was 88.8% (N.=24). Three years primary and secondary patency rate were, respectively, 74.1% (N.=20) and 81.6% (N.=22). One-year limb salvage rate was 88.8%, at three years was 86.1% and fifteen minor amputations were performed in 13 patients.

CONCLUSION

The endovascular treatment of SFA associated with surgical distal vein bypass is a useful and effective strategy in patients with severe lower extremity arterial disease. This strategy allows a good inflow on SFA in selected patients with the opportunity to perform shorter bypass, use of limited autologous conduit and good expectation of patency.

Pharmacological targeting of miR-155 via the NEDD8-activating enzyme inhibitor MLN4924 (Pevonedistat) in FLT3-ITD acute myeloid leukemia

High levels of microRNA-155 (miR-155) are associated with poor outcome in acute myeloid leukemia (AML). In AML, miR-155 is regulated by NF-κB, the activity of which is, in part, controlled by the NEDD8-dependent ubiquitin ligases. We demonstrate that MLN4924, an inhibitor of NEDD8-activating enzyme presently being evaluated in clinical trials, decreases binding of NF-κB to the miR-155 promoter and downregulates miR-155 in AML cells. This results in the upregulation of the miR-155 targets SHIP1, an inhibitor of the PI3K/Akt pathway, and PU.1, a transcription factor important for myeloid differentiation, leading to monocytic differentiation and apoptosis. Consistent with these results, overexpression of miR-155 diminishes MLN4924-induced antileukemic effects. In vivo, MLN4924 reduces miR-155 expression and prolongs the survival of mice engrafted with leukemic cells. Our study demonstrates the potential of miR-155 as a novel therapeutic target in AML via pharmacologic interference with NF-κB-dependent regulatory mechanisms. We show the targeting of this oncogenic microRNA with MLN4924, a compound presently being evaluated in clinical trials in AML. As high miR-155 levels have been consistently associated with aggressive clinical phenotypes, our work opens new avenues for microRNA-targeting therapeutic approaches to leukemia and cancer patients.

Human Preosteoblastic Cell Culture from a Patient with Severe Tumoral Calcinosis-Hyperphosphatemia Due to a New GALNT3 Gene Mutation: Study of In Vitro Mineralization

Human disorders of phosphate (Pi) handling and skeletal mineralization represent a group of rare bone diseases. One of these disease is tumoral calcinosis (TC). In this study, we present the case of a patient with TC with a new GALNT3 gene mutation. We also performed functional studies using an in vitro cellular model. Genomic DNA was extracted from peripheral blood collected from a teenage Caucasian girl affected by TC, and from her parents. A higher capability to form mineralization nodules in vitro was found in human preosteoblastic cells of mutant when compared to wild-type controls. We found a novel homozygous inactivating splice site mutation in intron I (c.516-2a>g). A higher capability to form mineralization nodules in vitro was found in the mutant cells in human preosteoblastic cells when compared to wild-type controls. Understanding the functional significance and molecular physiology of this novel mutation will help to define the role of FGF23 in the control of Pi homeostasis in normal and in pathological conditions.

Strategies to inhibit alloantibody production in alloprimed murine recipients of hematopoietic stem cell grafts

Alloantibody, not primed T cells, is the major barrier to bone marrow (BM) engraftment in allosensitized mice. We have shown that a single intravenous injection of donor splenocytes, to mimic a blood transfusion, results in high, sustained levels of serum alloantibody sufficient to eliminate donor BM within 3 h, resulting in uniform mortality in lethally irradiated allogeneic recipients. Current studies focused preventing and treating allopriming. Blockade of B cell survival signals with mTACI-Ig pre- and postpriming was ineffective, as was the B cell but not plasma cell depleting anti-CD20 mAb. Germinal center formation inhibition by lymphotoxin-beta receptor-Ig (LβR-Ig) diminished allosensitization, although conditional Prmd1 (Blimp-1) deletion in CD19+ cells was highly effective. By combining anti-CD20 mAb to reduce B cells and LTβR-Ig to diminish the frequency of B cells that could form germinal centers pre- and postpriming, allosensitization was precluded, permitting long-term survival in T- and NK-depleted, irradiated allogeneic recipients, whereas combined therapy postpriming alone was ineffective. As evidence of the critical role of B cells, the proteosomal inhibitor, bortezomib, given unencapsulated or encapsulated, proved ineffective in influencing allosensitization. These data extend our understanding of allopriming and provide a potential therapy for patients at risk for allosensitization and BM graft rejection.

Rare diseases in clinical endocrinology: a taxonomic classification system

PURPOSE

Rare endocrine-metabolic diseases (REMD) represent an important area in the field of medicine and pharmacology. The rare diseases of interest to endocrinologists involve all fields of endocrinology, including rare diseases of the pituitary, thyroid and adrenal glands, paraganglia, ovary and testis, disorders of bone and mineral metabolism, energy and lipid metabolism, water metabolism, and syndromes with possible involvement of multiple endocrine glands, and neuroendocrine tumors. Taking advantage of the constitution of a study group on REMD within the Italian Society of Endocrinology, consisting of basic and clinical scientists, a document on the taxonomy of REMD has been produced.

METHODS AND RESULTS

This document has been designed to include mainly REMD manifesting or persisting into adulthood. The taxonomy of REMD of the adult comprises a total of 166 main disorders, 338 including all variants and subtypes, described into 11 tables.

CONCLUSIONS

This report provides a complete taxonomy to classify REMD of the adult. In the future, the creation of registries of rare endocrine diseases to collect data on cohorts of patients and the development of common and standardized diagnostic and therapeutic pathways for each rare endocrine disease is advisable. This will help planning and performing intervention studies in larger groups of patients to prove the efficacy, effectiveness, and safety of a specific treatment.

Nursing care complexity in a psychiatric setting: results of an observational study

For nurses working in mental health service settings, it is a priority to perform patient assessments to identify patients' general and behavioural risks and nursing care complexity using objective criteria, to meet the demand for care and to improve the quality of service by reducing health threat conditions to the patients' selves or to others (adverse events). This study highlights that there is a relationship between the complexity of psychiatric patient care, which was assigned a numerical value after the nursing assessment, and the occurrence of psychiatric adverse events in the recent histories of the patients. The results suggest that nursing supervision should be enhanced for patients with high care complexity scores.

A stem cell-like gene expression signature associates with inferior outcomes and a distinct microRNA expression profile in adults with primary cytogenetically normal acute myeloid leukemia

Acute myeloid leukemia (AML) is hypothesized to be sustained by self-renewing leukemia stem cells (LSCs). Recently, gene expression signatures (GES) from functionally defined AML LSC populations were reported, and expression of a 'core enriched' (CE) GES, representing 44 genes activated in LCSs, conferred shorter survival in cytogenetically normal (CN) AML. The prognostic impact of the CE GES in the context of other molecular markers, including gene mutations and microRNA (miR) expression alterations, is unknown and its clinical utility is unclear. We studied associations of the CE GES with known molecular prognosticators, miR expression profiles, and outcomes in 364 well-characterized CN-AML patients. A high CE score (CE(high)) associated with FLT3-internal tandem duplication, WT1 and RUNX1 mutations, wild-type CEBPA and TET2, and high ERG, BAALC and miR-155 expression. CE(high) patients had a lower complete remission (CR) rate (P=0.003) and shorter disease-free (DFS, P<0.001) and overall survival (OS, P<0.001) than CE(low) patients. These associations persisted in multivariable analyses adjusting for other prognosticators (CR, P=0.02; DFS, P<0.001; and OS, P<0.001). CE(high) status was accompanied by a characteristic miR expression signature. Fifteen miRs were upregulated in both younger and older CE(high) patients, including miRs relevant for stem cell function. Our results support the clinical relevance of LSCs and improve risk stratification in AML.

Bcl-xL anti-apoptotic network is dispensable for development and maintenance of CML but is required for disease progression where it represents a new therapeutic target

The dismal outcome of blast crisis chronic myelogenous leukemia (CML-BC) patients underscores the need for a better understanding of the mechanisms responsible for the development of drug resistance. Altered expression of the anti-apoptoticBcl-xL has been correlated with BCR-ABL leukemogenesis; however, its involvement in the pathogenesis and evolution of CML has not been formally demonstrated yet. Thus, we generated an inducible mouse model in which simultaneous expression of p210-BCR-ABL1 and deletion of bcl-x occurs within hematopoietic stem and progenitor cells. Absence of Bcl-xL did not affect development of the chronic phase-like myeloproliferative disease, but none of the deficient mice progressed to an advanced phenotype, suggesting the importance of Bcl-xL in survival of progressing early progenitor cells. Indeed, pharmacological antagonism of Bcl-xL, with ABT-263, combined with PP242-induced activation of BAD markedly augmented apoptosis of CML-BC cell lines and primary CD34(+) progenitors but not those from healthy donors, regardless of drug resistance induced by bone marrow stromal cell-generated signals. Moreover, studies in which BAD or Bcl-xL expression was molecularly altered strongly support their involvement in ABT-263/PP242-induced apoptosis of CML-BC progenitors. Thus, suppression of the antiapoptotic potential of Bcl-xL together with BAD activation represents an effective pharmacological approach for patients undergoing blastic transformation.

Results of surgical repair of carotid in-stent restenosis

AIM

Carotid artery angioplasty and stenting (CAS) has emerged as an alternative treatment for extra cranial carotid artery stenosis in stroke prevention. Nevertheless concerns are remaining about the long-term durability as hemodynamic in-stent restenosis (ISR) after CAS are increasing and usually treated again by endovascular approach. This preliminary study, instead, albeit in a limited series, reports our safe and successful experience of the surgical correction of carotid ISR after CAS.

METHODS

From January 2003 to June 2011 seven patients with severe hemodynamic carotid ISR (three symptomatic, four asymptomatic, mean age 76±2), were submitted to surgical operation to remove the carotid stent. The indications for CAS were primary in five cases, secondary to restenosis after carotid endarterectomy (CEA) in two patients. Standard CEA with complete removal of the stent and the entire atherosclerotic plaque was carried out easy and without technical difficulty in the five primary ISR. In the two patients of ISR in post-CEA restenosis, a common carotid to the distal internal carotid artery (ICA) bypass with polytetrafluoroethylene (PTFE) graft was carried out. Mean operation time was 88±26 min. All interventions were performed under general anesthesia with remifentanil preserved consciousness.

RESULTS

No death or major complications occurred. Temporary vocal cord impairment by deficit of recurrent inferior laryngeal nerve in one patient with ISR after CAS performed to treat post-CEA restenosis was observed. Intimal hyperplasia was the predominant mechanism to ISR. The mean follow-up of 18 months (range, 4 to 36 months) showed a normal patency of the surgical correction without recurrent restenosis on color-coded duplex ultrasounds (US) examinations.

CONCLUSION

The surgical management of carotid ISR appears feasible and effective leading to good long-term outcome.

High-risk patients for carotid endarterectomy: turned down cases are rare

AIM

The increasing use of carotid artery stenting (CAS) is justified in patients at high-risk for carotid endarterectomy (CEA). The aim of this study was to evaluate the hypothesis that the high-risk patients can be submitted to CEA without increased risk of stroke and death.

METHODS

A retrospective analysis of 625 consecutive CEA in 545 patients (M/F 386/159, age 75 ± 7) performed from January 2005 to December 2010 was carried out. Definite anatomical and pathophysiological high-risk cohort of patients (N.=173, 31.7%) was evaluated and compared to normal risk patients. Univariate, multivariate and Kaplan-Meier analysis were used as appropriate. Poisson regression (Pr) model was used to study all univariate criteria in combination. A P value <0.05 was statistically significant.

RESULTS

The overall 30-day stroke and death rate was 0.96%. No difference between high-risk vs. normal patient cohort regarding physiological and anatomical risk factors was detected. Univariate and multivariate analysis did not show statistical difference for 30-day outcome in any of the variables examined. No increase of risk in cases of presence of more risk factors resulted to the Pr analysis. The 24-month survival rate was worse in high-risk patients, especially when more physiologic risk as chronic renal failure, severe pulmonary and cardiac diseases and age over eighty were present.

CONCLUSION

CEA is a safe procedure in patients at high-risk carotid artery disease. A better classification of high-risk patients may be necessary because trials criteria appear ineffective to define the patients at real high surgical risk. Long-term outcome was affected by the presence of severe comorbidities.

Prosthetic carotid bypass graft for in-stent restenosis performed for post-endarterectomy recurrent stenosis: technical details

AIM

Carotid artery stenting (CAS) is the treatment of choice for recurrent stenosis after carotid endarterectomy (CEA). However a significative incidence of in-stent restenosis could be occurred. Despite classical CEA leads to good results, in selective cases bypass graft may be the best treatment of in-stent restenosis.

CASE REPORTS

We describe two cases of carotid bypass graft performed to treat a recurrent in-stent stenosis after CAS for post-CEA restenosis. No death and cardiac complication occurred and no cranial nerves impairment was detected.

CONCLUSION

Prosthetic bypass graft is safe and effective in treatment of in-stent recurrent restenosis after CEA restenosis.

Open and endovascular combined procedures in lower limb arterial reconstructions

INTRODUCTION

The association of open and endovascular procedures in patients with obstructive disease of the lower limbs gives the opportunity to treat in a single step multi-segmental lesions which were currently treated in the past by more demanding open procedures.

PATIENTS AND METHODS

From January 2003 to May 2009, 52 patients with peripheral occlusive chronic arterial disease of the lower limbs were submitted to combined open and endovascular procedures. In 37 patients (71.2%) a femoro-popliteal/pedidial bypass was carried out after Percutaneous Transublimal Arterio (PTA)/stenting of the iliac/femoral arteries, while in the remaining 15 patients (28.8%) the endovascular procedures were performed following open approach, that consisted in a femoro-popliteal bypass. Iliac stenting interested the common iliac artery in 19 patients (51.3%), the common and external iliac artery in 11 patients (29.7%) and the external artery in 7 (19%). In this same group a fem-pop bypass below knee was carried out in 28 (75.6), a fem-pop above knee in 6 (16.2%), a fem-pop and jump on the posterior tibial in 2 (5.4%) and a superficial femoral-pedal in the last one (2.8%). In the other group the fem-pop bypass below knee was followed by a PTA of the tibial vessel in 12 cases (80%) and by a stenting in only 3 cases (20%).

RESULTS

Three patient was lost to follow-up. Three (8.1%) iliac stents became occluded and the sudden onset of an acute ischemia of the limb required in all cases an aorto-femoral bypass. The occlusion of tibial stent in 2 patient (13.3%) was no clinical relevant, and the failure of the PTA procedure in other 4 patients with the reocclusion of the tibial arteries was followed by thight amputation. Occlusion of the femoro-popliteal bypass occurred in 9 of 37 patients (24.3%) submitted to iliac stenting and in 4 of 15 (26.6%) patients with PTA of the tibial vessels. The overall patency rate was 69.2%. Limb salvage was 77.5%

CONCLUSIONS

Combination of the open and endovascular procedures to treat lesions of the lower limbs is effective and durable in terms of patency and complication rate. For validation this new approach needs the recruitment of much more patients and prospective protocol studies.

Short longitudinal versus transverse skin incision for carotid endarterectomy: impact on cranial and cervical nerve injuries and esthetic outcome

AIM

Nerve injuries, wound complications and especially poor cosmetic results still have an important impact on the carotid endarterectomy (CEA) morbidity. Introduction of the mini skin incision in clinical practice seems to be safe with reduction in postoperative pain and superficial and cranial nerves lesions, and better aesthetics outcomes. The objective of this retrospective study was to compare the results between the short longitudinal with the short transverse cervical incision and to evaluate their impact on cranial and cervical nerves and aesthetic outcomes.

METHODS

From January 2007 to December 2009 266 patients underwent 300 consecutive primary CEA procedures. Two-hundred nineteen patients were submitted to short longitudinal cervical incision (group A), in eighty one a short transverse cervical skin incision (group B) was performed. The average of skin incision was about 4-5.5 cm. In all cases a preoperative CEA duplex ultrasounds (US) assisted skin marking was carried out. All patients were submitted to the general anesthesia with Remifentanyl conserved consciousness. Routinely synthetic patch and selective policy intraluminal shunts were used. Incisions were extended when shunts were required or in case of high carotid bifurcation. Preoperative and postoperative cranial nerves evaluation was always performed and a questionnaire about the satisfaction of the aesthetic outcome was proposed to all patients to the discharge and six months follow-up. Stroke/TIA, death, wound complications, cranial and cervical nerves injuries and restenosis rate were reported and analyzed through statistical analysis (χ2 and Student's t test).

RESULTS

The 30 days mortality was 0.3% (1/300). The TIA rate was 0.91% in group A and 1.2 % in group B (P>0.9). Wound complications were 1.8% and 1.2 % respectively (P>0.1). No statistically differences were reported in the incidence of cranial and cervical nerves injuries between the two groups (P>0.9). No difference in restenosis rate was detected (P>0.9). In case of lengthening of the incision for high internal carotid (ICA) stenosis and especially to the need of shunt deployment, the longitudinal approach showed unequivocally to be easier and safer.

CONCLUSION

No differences were achieved between short longitudinal and transverse incision in term of stroke, wound complications or nerves impairment. A good cosmetic outcome was gained in both groups. The Duplex US skin markings pre-CEA permitted localization and limits of the plaque with appropriate short incision. A longitudinal cervical approach is to prefer as can lead to an easier proximal and distal lengthening in cases of atherosclerotic extension of the plaque and shunt deployment.

[Renal artery aneurysm. Treatment by ex-vivo reconstruction and autotransplantation: three cases and literature review]

Renal artery aneurysms (RAAs) is a rare clinical entity: the prevalence is approximately 0.01%-1% in the general population. Complex aneurysms of the first ramification of the main renal artery often require nephrectomy for adequate excision. From December 2002 to July 2007, we treated 3 patients with complex RAA. All the patients were treated with ex vivo reconstruction of the renal artery followed by autotransplantation of the kidney into the ipsilateral iliac fossa. Observation is suggested for asymptomatic complex renal artery aneurysms measuring less than 2 cm in diameter. Surgical treatment by aneurysmectomy and reconstruction in vivo or ex vivo technique is indicated for RAA causing renovascular hypertension, dissection, embolization, local expansion and for those in women of childbearing age with a potential for pregnancy, or asymptomatic more than 2 cm in diameter. Ex vivo repair and renal autotransplantation is a safe and effective treatment for the management of complex renal artery aneurysms.

Carotid endarterectomy: general anaesthesia with remifentanyl conscious sedation vs loco-regional anaesthesia

AIM

To retrospectively evaluate and compare the safety and efficacy of general anesthesia with remifentanyl conscious sedation (RCS) vs local-regional anesthesia (LA) for carotid endarterectomy (CEA).

METHODS

From January 2004 to January 2008, 390 CEA performed in 325 patients (M/F 214/111, age 75 +/- 7) were collected in 2 groups: RCS group included 275 consecutive CEA in 230 patients carried out under remifentanyl conscious sedation with stopping of the remifentanyl infusion at the carotid clamping time to evaluate the clinical neurological status; LA group was composed of 115 consecutive CEA in 95 patients, performed under local-regional anesthesia. We evaluated complications, postoperative morbidity and mortality, need for shunt insertion and compared the results by means of Student's t-test and chi2 analysis. P value <0.05 (T=2.28) was considered significant.

RESULTS

The 30 days mortality was 0.35% in the RCS group and 0% for LA group (P=NS). The 30 days stroke rates were 0.3% and 0% respectively (P=NS). TIA/RIND rates were 0.3% for RCS group and 1.7% for LA group (P=0.47); shunt usage was 20% for RCS group and 17% for LA group (P=0.26). We found higher postoperative nausea/vomiting in the RCS group (3.9% vs 0.8%, P<0.05).

CONCLUSIONS

General anesthesia with remifentanyl conscious sedation seems to be a safe technique, allowing monitoring of the neurological status, cerebral protection during arterial clamping, better control of the airway and a good compliance to both the surgeon and the patient. A randomized control trial is needed to prove RCS to be effective as LA.

NPM1 mutations as an independent prognosticator for older cytogenetically normal acute myeloid leukemia (CN AML)

7000

Background: In younger CN AML without FLT3-ITD, NPM1 mutations predict favorable outcome. Their prognostic impact in older [≥60 years (y)] patients (pts) requires further evaluation. Methods: Pretreatment marrow was studied in 189 older CN AML pts [median age 69 y (60 - 83 y); 162 de novo & 27 secondary (s; prior hematologic disorders) cases] enrolled on CALGB 9720 (n=106) & 10201 (n=83). Both protocols had standard-dose (100 mg/m2/d) cytarabine (AraC)/daunorubicin (DN)-based induction; consolidation was based on standard-dose AraC/DN/etoposide (1 cycle) in 9720 & intermediate-dose (2 g/m2/d) AraC (2 cycles) in 10201. Pts transplanted in 1st complete remission (CR) were excluded. Median follow-up was 3.3 y for pts alive. Analyses of NPM1 exon 12 by direct sequencing, gene & microRNA (miR) expression profiling by Affymetrix U133 plus 2.0 & OSU CCC v4.0 arrays, & other markers (FLT3-ITD, FLT3-TKD, WT1mut) were performed centrally. Results: In de novo CN AML, NPM1 mutated (NPM1mut) pts (54%) had more CRs (85% v 45%, P<.0001) & longer relapse-free (RFS) (P=.02; 3 y rates 23% v 10%) & overall survival (OS) (P<.0001; 3 y 34% v 7%) than NPM1 wild-type (NPM1wt) pts. In multivariable models, NPM1 mutations independently predicted favorable outcome (Table) - NPM1mut pts had 10-fold higher odds of CR & 64% reduction in relapse risk. In genome-wide analyses, miR-10 & miR-16 were upregulated in NPM1mut pts, accompanied by highly expressed HOX genes & downregulated BCL2, respectively. NPM1mut were rare in sAML pts (15%), precluding study of their impact. Conclusions: NPM1 mutations independently predict better outcome in older CN AML. Upregulation of proapoptotic microRNAs & downregulation of antiapoptotic microRNA targets may explain the impact of NPM1 mutations.

[Table: see text]

No significant financial relationships to disclose.

MicroRNA 181a (miR-181a) expression as a prognosticator in cytogenetically normal acute myeloid leukemia (CN AML)

7001

Background: We showed recently that CEBPA mutations (mut) in CN AML are associated with better outcome and a unique microRNA expression profile, including miR-181a upregulation. Here we tested if miR-181a expression can predict outcome independently. Methods: We analyzed 187 de novo CN AML adult patients (pts) aged <60 years (y; median 45) similarly treated on CALGB 9621 and 19808. Of these, 122 had molecular high risk [FLT3-ITD or NPM1 wild type (wt)] and 65 low risk (no FLT3-ITD, NPM1 mut) CN AML. FLT3, NPM1, CEBPA, MLL, and WT1 mutations, and ERG and BAALC expression were analyzed centrally. miR-181a expression was measured in pretherapy marrow using OSUCCC v3.0 arrays. The mean of 2 miR-181a probe log intensities was used as a continuous variable for analyses. Results: Higher miR-181a levels (miR-181a↑) were associated with CEBPA mut, NPM1 wt, no FLT3-TKD, lower ERG expression, higher %FAB M1/M2, lower WBC and age, higher blood blasts, and lower % gum hypertrophy. miR-181a↑ tended to associate with more complete remissions (CRs; p = .07) and significantly associated with longer disease-free (DFS; p = .05) and overall (OS; p = .01) survival (median follow-up 6.5 y for pts alive). A stronger prognostic impact of miR-181a was observed in the molecular high risk group, where miR-181a↑ predicted more CRs (p = .03), and longer DFS (p = .0002) and OS (p = .0001). In multivariable analyses of the molecular high risk group, miR-181a↑independently predicted CR, and longer DFS and OS (Table). For descriptive purposes, we dichotomized pts at the median miR-181a expression value. For high v low miR-181a expressers, CR rates were 84% vs 72% and 5 y DFS and OS rates 43% vs 18% and 48% vs 19%, respectively. Conclusions: miR-181a expression is a prognostic marker in CN AML, mainly in the molecular high risk group, where it predicts outcome independently of other variables including CEBPA mutations. As miR-181a↑ confer better treatment response, novel approaches increasing miR-181a levels might benefit not only CN but also other AML pts.

[Table: see text]

No significant financial relationships to disclose.

Improving the molecular risk classification for younger (<60 years) de novo cytogenetically normal acute myeloid leukemia (CN AML) patients (pts)

7002

Background: CN AML pts are currently stratified into Low-risk [FLT3-ITD negative (neg)/NPM1 mutated (mut)] and High-risk [FLT3-ITD positive (pos) or NPM1 wild type (wt)] groups (FLT3-ITD/NPM1-only classification). We recently showed that low ERG expression and CEBPAmut identify pts with better outcome within, respectively, the Low- and High-risk groups, and that WT1mut confers poor outcome regardless of FLT3-ITD/NPM1 status. Here, we assess if adding CEBPA and WT1 mutation and ERG expression testing improves the currently used CN AML molecular risk classification. Methods: FLT3, NPM1, CEBPA and WT1 mutations and ERG and BAALC expression were tested at diagnosis in 143 CN AML adults enrolled on CALGB treatment protocols 9621 and 19808. Pts were divided into two molecular risk groups: i) CALGB Group I that included Low-risk pts with low ERG & High-risk pts with CEBPAmut and ii) CALGB Group II that included WT1mut pts & Low-risk pts with high ERG & High- risk pts with CEBPAwt. Results: CALGB Group I (n=56) v Group II (n=87) had more complete remissions (CRs) (P=.005; 96% v 79%), and longer disease-free (DFS; P<.0001; 5 year (y) 69% v 21%) and overall (OS; P<.0001; 5 y 70% v 31%) survival [median follow-up for pts alive 6 y]. In multivariable (MV) analyses, Group I predicted higher rate of CR (P=.02), and longer DFS (P<.0001) and OS (P=.0002), after correcting for other variables (Table). In contrast, for the same cohort of pts grouped by the FLT3-ITD/NPM1-only classification, CRs were 94% v 82% and 5 y DFS 59% v 32% and OS 67% v 36% in the Low- v High-risk groups. Based on the Akaike Information Criterion, MV models for DFS and OS using the CALGB risk Groups were better than those using the FLT3-ITD/NPM1-only risk groups. Conclusions: Prognostic classification of younger de novo CN AML pts is improved by adding CEBPA and WT1 mutation and ERG expression testing. While mutational analyses are ready for use in clinical trials, quantification of ERG expression is yet to be standardized.

[Table: see text]

No significant financial relationships to disclose.

Efficacy of a novel schedule of decitabine in previously untreated AML, age 60 or older

7010

Background: We established an optimal daily dose of decitabine in AML at 20mg/m2/day based on re-expression of epigenetically silenced genes, with promising clinical activity seen in poor risk older patients (pts) (Blum, J Clin Oncol. 2007). Methods: We designed a phase II study of decitabine for untreated AML pts of age≥60 who were not candidates for intensive chemotherapy (or who refused it). PS was ECOG <3. All pts received induction with decitabine at 20mg/m2 IV on days 1–10 of 4 week cycles. Pts with persistent AML at the end of a cycle received a repeat of the 10 day course, but responding pts received maintenance with abbreviated courses of 3–5 days depending on degree and duration of neutropenia. Results: 33 pts had median age of 74 years (range, 60–83). 15 pts had either secondary or t-AML. Median WBC count was 2400/μL (range, 400–58,800/μL) with marrow blasts of 44% (range, 21–92%). 13 pts had complex karyotype (≥3 abnormalities); 13 had normal karyotype; one pt had t(8;21). 31/33 pts had at least 2 poor-risk factors of age ≥70, antecedent hematologic disorder, unfavorable karyotype, or ECOG 2, and 28/33 had HCT-CI scores of ≥2. 42% of pts achieved CR (14/33). 58% achieved either CR or CRi (19/33). CR occurred in all subsets of disease and cytogenetic risk groups. CR durations to date are 2–14+ months. Median time from initial response to relapse for 6 pts who relapsed after CR was 6.5 months. Median OS has not been reached; median f/u of 19 surviving pts is 8 months. The median number of cycles received to date is 5 (range, 1–10). 9 of 14 pts who achieved CR required only a single 10 day course before initial response was achieved (CR, N = 2; CRi, N = 7). For pts who had CRi as initial response, the median number of additional cycles to achievement of full CR was 1 (range, 1–3). Death within 8 weeks of any cause occurred in 15% of pts (due to infection in each case). Though non-hematologic toxicities were infrequent, infection and/or febrile neutropenia were common (in 24/33 pts). Correlative studies are ongoing. Conclusions: Decitabine in this novel schedule of induction with outcome-adapted modification of maintenance therapy was highly active in this poor risk cohort. Survival results warrant comparison with intensive therapy for pts eligible to receive it. (supported by NO1-CM62207, K23 CA120708–01, RO1CA102031)

[Table: see text]

[Hypoglossal artery and carotid endarterectomy. Case report]

The persistence of hypoglossal artery is a rare malformation. Association of carotid stenosis with persistent hypoglossal artery can lead to cerebral posterior symptoms due to ischemia intolerance. The Authors report a case of unexpected intraoperative detection of this anomaly in a patient with high grade stenosis of the right internal carotid artery. Right carotid endarterectomy was performed, and no shunt was used. The postoperative course was normal. The literature was reviewed.

A novel recessive mutation of fibroblast growth factor-23 in tumoral calcinosis

BACKGROUND

Tumoral calcinosis is a rare disease characterized by hyperphosphatemia due to hypophosphaturia and by ectopic calcifications. Phosphatonins are important hormones that regulate phosphorus homeostasis. Tumoral calcinosis is a rare congenital disorder in which the differential diagnosis from other syndromes associated with extraskeletal calcifications may be difficult. Mutations in the UDP-N-acetyl-alpha-D-galactosamine: polypeptide N-acetylgalactosaminyltransferase-3 (GALNT3) and fibroblast growth factor-23 (FGF23) genes have been described. Mutational analysis is important for the early recognition of the disorder, for prevention of its complications, and for family screening strategies. We examined two unrelated white patients affected by tumoral calcinosis.

METHODS

The first patient was a woman with a history of an ectopic calcification in the left shoulder. The second patient was a man with a history of an ectopic calcification in the right buttock. Routine biochemistry and FGF-23 assays were performed on serum samples. Genomic DNA was extracted from peripheral blood. The FGF23 and GALNT3 genes were analyzed by direct sequencing.

RESULTS

A new homozygous H41Q codon 41, C-->A transversion at position 123 (c.123C>A) in exon 1 of the FGF23 gene was evidenced in both patients. No mutation of the GALNT3 gene was detected in these patients. As determined by an ELISA assay, intact FGF-23 circulating protein was low in both patients.

CONCLUSIONS

This is the fourth mutation of the FGF23 gene described in subjects with tumoral calcinosis.

Prejudices and realities in the use of 'unsuitable' saphenous vein graft for infrapopliteal revascularization

BACKGROUND

Aim of this paper is to evaluate the safety and the patency rate of the infrapopliteal bypass grafts performed with the great saphenous vein (GSV) with small (<2.5 mm) or large calibre (>5 mm).

PATIENTS AND METHODS

Between January 2003 and May 2007, 73 infra-genicular bypass with autologous saphenous vein were performed in patients affected by atherosclerotic femoropopliteal disease. In 8 cases a bypass grafts with small saphenous vein (diameter 2.2-2.5 mm) were performed, in 4 cases a bypass with segmental varicose saphenous vein (diameter 5.7-6.4 mm ) were carried out. In 64 cases the bypass was carried out with the reversed technique, in 9 cases with the in situ technique.

RESULTS

Thirty day mortality was 3/82 (3.6%) and 30 day cumulative patency rate was 95.1% (78/82) with limb salvage of 96.3% (79/82). All the patients with small diameter vein showed a normal patency at the follow-up and at the duplex scan examination no complications occurred. The mean calibre of the arterialized vein increased to 2.6-3,4 mm at 1 week with maintenance during the follow-up. Patients with varicose vein implanted present a mean dilatation of 6.4-7.2 mm at 1 week and no dilatative complication were detected at the follow-up.

CONCLUSION

The risk of stenosis, graft thrombosis or aneurysm degeneration doesn't seem to be higher respect normal GSV either for small or for large veins. Large series and longer follow up are mandatory for an extensive clinical application.