Insights into the Molecular Mechanism of Endothelial Glycocalyx Dysfunction during Heart Surgery

The endothelial glycocalyx (EGC) is a layer of proteoglycans (associated with glycosaminoglycans) and glycoproteins, which adsorbs plasma proteins on the luminal surface of endothelial cells. Its main function is to participate in separating the circulating blood from the inner layers of the vessels and the surrounding tissues. Physiologically, the EGC stimulates mechanotransduction, the endothelial charge, thrombocyte adhesion, leukocyte tissue recruitment, and molecule extravasation. Hence, severe impairment of the EGC has been implicated in various pathological conditions, including sepsis, diabetes, chronic kidney disease, inflammatory disorders, hypernatremia, hypervolemia, atherosclerosis, and ischemia/reperfusion injury. Moreover, alterations in EGC have been associated with altered responses to therapeutic interventions in conditions such as cardiovascular diseases. Investigation into the function of the glycocalyx has expanded knowledge about vascular disorders and indicated the need to consider new approaches in the treatment of severe endothelial dysfunction. This review aims to present the current understanding of the molecular mechanisms underlying cardiovascular diseases and to elucidate the impact of heart surgery on EGC dysfunction.

Endothelial Dysfunction in Patients Undergoing Cardiac Surgery: A Narrative Review and Clinical Implications

Cardiac surgery is one of the highest-risk procedures, usually involving cardiopulmonary bypass and commonly inducing endothelial injury that contributes to the development of perioperative and postoperative organ dysfunction. Substantial scientific efforts are being made to unravel the complex interaction of biomolecules involved in endothelial dysfunction to find new therapeutic targets and biomarkers and to develop therapeutic strategies to protect and restore the endothelium. This review highlights the current state-of-the-art knowledge on the structure and function of the endothelial glycocalyx and mechanisms of endothelial glycocalyx shedding in cardiac surgery. Particular emphasis is placed on potential strategies to protect and restore the endothelial glycocalyx in cardiac surgery. In addition, we have summarized and elaborated the latest evidence on conventional and potential biomarkers of endothelial dysfunction to provide a comprehensive synthesis of crucial mechanisms of endothelial dysfunction in patients undergoing cardiac surgery, and to highlight their clinical implications.

Collision Lesions: Genuine Collision (Conflict) or not?

By definition, the term "collision lesion" refers to two or more tumors coinciding in the same anatomic position or visceral organ. Collision lesions coexisting on the same skin location are defined as collision skin lesions (CSLs). Although this term implies a conflict between the tumors, this is not the case. CSLs appear to be rare, but still pose a significant diagnostic problem in everyday clinical practice and clinicians should be aware of their existence. The aim of this study was to elucidate the problem of CSLs in clinical practice, with an emphasis on classification of CSLs according to position dependence, tumor histogenesis, etiology, and possible lesion combinations in CSLs, as well as diagnostic possibilities. According to our results, accurate clinical diagnosis could be only rarely reached, requiring lesion excision and pathohistological confirmation of CSLs. Considering the fact that tumors in CSLs can be partially or completely overlying or can even be positioned one within the other, the existence of two or more tumors is extremely difficult to detect.

Kaposi's sarcoma in an HIV-negative chronic lymphocytic leukemia patient without immunosuppressive therapy: A case report

Kaposi’s sarcoma is a neoplasm of endothelial cells. That vascular tumor is usually limited to the skin, but it may involve mucous membranes, visceral organs, and lymph nodes. Serological evidence has shown that human herpesvirus 8 infection is required for the development of Kaposi’s sarcoma. Chronic lymphocytic leukemia is the most common leukemia all over the world. Increased skin cancer risk has been reported for patients with chronic lymphocytic leukemia. The relation between these two pathologies has not yet been clarified. We report a case of Kaposi’s sarcoma along with chronic lymphocytic leukemia in a patient who did not receive therapy for chronic lymphocytic leukemia.

p53 Protein Expression and Cell Proliferation in Non-Neoplastic and Neoplastic Proliferative Skin Diseases

Aims and background

The p53 protein is essential for the regulation of cell proliferation and its aberrant accumulation is usually seen in malignant tumors but also occurs in squamous epithelium of inflammatory skin diseases characterized by hyperproliferation. The aim of this study is to elucidate the role of the p53 tumor suppressor protein in the pathogenesis of different hyperproliferative, non-malignant and malignant skin diseases, and to determine the association between p53 overexpression and cell proliferation. We also investigated the influence of aging on p53 and Ki-67 protein expression.

Methods

One hundred and fifty skin specimens divided into 30 samples each of normal skin (NS), psoriatic skin (PS), keratoacanthomas (KA), basal cell carcinomas (BCC), and squamous cell carcinomas (SCC) were examined immunohistochemically to assess p53 and Ki-67 protein expression.

Results

p53 immunostaining of NS, PS, KA, BCC and SCC was detected in 39.0%, 46.7%, 66.7%, 80% and 86.7% of cases, respectively. Median values and ranges of p53 protein expression were as follows: 0.0% (range, 0.0–1.8%) in NS, 0.0% (range, 0.0–6.5%) in PS, 9.2% (range, 0.0–24.0%) in KA, 19.3% (range, 0.0–48.1%) in BCC and 30.1% (range, 0.0–68.1%) in SCC. p53- and Ki-67-positive cells were present in basal (NS) and suprabasal layers (PS), and not only in cancer nests of KA, BCC and SCC but also in dysplastic and even morphologically normal epidermis adjoining cancers. The positivity of p53 and Ki-67 proteins differed significantly among the groups, with no differences in p53 expression between NS and PS and in Ki-67 expression between PS and KA. Within all groups there was a significant correlation between p53 and Ki-67 expression. Lesion location and patient age, with the exception of location in PS and age in BCC, were significantly related to p53 and Ki-67 expression in all groups.

Conclusions

Our findings suggest that p53 overexpression occurs mainly in neoplastic skin lesions, although it may also occur in squamous epithelium of inflammatory skin diseases such as PS, as well as in normal skin epithelium. It is associated with cell proliferation in normal as well as altered epithelium. p53 protein overexpression is an age-related process and significantly associated with sun exposure, especially in NS and PS but also in KA and SCC. Our findings suggest that Ki-67 rate and p53 protein expression reflect the degree of malignancy in the examined cutaneous neoplasms.

Angioimmunoblastic Lymphadenopathy with Dysproteinemia following Doxycycline Administration

Angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) is a primary lymphoproliferative T-cell disorder, currently classified as a peripheral T-cell non-Hodgkin's lymphoma. AILD is characterized by generalized lymphadenopathy, hepatosplenomegaly, immunological abnormalities, polyclonal hypergammaglobulinemia and anemia. We report a case of AILD in an 80-year-old male who presented with a generalized pruritic maculopapular eruption and fever following doxycycline administration. The maculopapular rash progressed to formation of confluent nodules, plaques and finally erythroderma with lymphadenopathy and hepatosplenomegaly. Blood analysis revealed an elevated erythrocyte sedimentation rate and polyclonal hypergammaglobulinemia. Lymph node biopsy showed almost complete effacement of the nodal architecture with diffuse proliferation of small vessels forming an arborizing network, surrounded by atypical lymphocytes, usually CD3+ CD4+ and occasionally CD3 + CD8+. There were also larger cells (immunoblastic shape) that displayed CD20 positively, some scattered plasma cells, and eosinophils. Histology of a cutaneous lesion showed spongiosis and infiltration of the epidermis by atypical lymphocytes with large hyperchromatic nuclei, perivascular dermal lymphocytic infiltrate (CD3+) mixed with plasma cells and occasional large immunoblasts (CD20+). During hospitalization the patient developed hemolytic anemia (Coombs positive) and lung metastases. The prognosis of AILD is generally poor, with a median survival of less than 20 months. Our patient died two and a half months after the diagnosis was made due to sepsis caused by Staphylococcus aureus isolated in hemoculture.

HPV 6-Positive Giant Keratoacanthoma in an Immunocompetent Patient

Keratoacanthoma (KA) is a clinically distinct, rapidly growing lesion that generally presents as a solitary crateriform nodule in sun-exposed areas in elderly, fair-skinned individuals. A KA larger than 20-30 mm is referred to as giant keratoacanthoma, a relatively rare lesion especially in young patients. Such lesions grow rapidly with possible destruction of underlying tissues. In addition to ultraviolet exposure, KAs have also been associated with chemical carcinogens, chemical peels, genetic factors, chronic skin conditions that produce scarring, trauma and thermal burns. Immunosuppressed patients, especially after transplantation, also develop KAs. A viral etiology has been suggested but not confirmed. We encountered a case of giant keratoacanthoma (greater than 50 mm in diameter) with induration of underlying structures on the upper lip of a 39-year-old male sailor. The patient reported sudden appearance and rapid enlargement of the lesion in only three weeks. Biopsy of the cutaneous lesion and the characteristic clinical history suggested the diagnosis of keratoacanthoma. Total excision with primary closure of the defect by a nasolabial advancement flap was performed. Histological examination of the tumor mass confirmed the diagnosis of KA with infiltrative growth and perineural invasion. Immunosuppression was excluded by blood analyses, as were HIV, syphilis and hepatitis infections. Only low-risk genital HPV type 6 was detected in the lesion, suggesting a possible cocarcinogenic effect of HPV and UV light in a chronically sun-exposed patient.

Endothelial dysfunction as assessed with magnetic resonance imaging - A major determinant in chronic heart failure

Chronic heart failure (CHF) is a clinical syndrome resulting from interaction of different structure and functional disturbances leading to decreased heart ability to ensure adequate supply of oxygenized blood to tissues and ensure adequate metabolic needs in the cases of normal or increased afterload. Endothelial dysfunction (ED) is a pathological condition characterized by general imbalance of all major endothelial mechanisms with key role in development and progression of atherosclerotic disease. ED has been associated with most cardiovascular risk factors. There is increasing interest in assessing endothelial function non-invasively, leading to development and evaluation of new diagnostic methods. We suggest that MRI is safe and reliable test that offers important advantages over ultrasound for the detection of ED and monitoring of the expected therapeutic effect. We believe that ED plays a pivotal role in chronic heart failure development and progression, regardless of its etiology, and that MRI should be introduced as a "gold standard" in diagnostic procedure and treatment.

Differences between keratoacanthoma and squamous cell carcinoma using TGF-alpha

Squamous cell carcinoma (SCC) and keratoacanthoma (KA) are skin neoplasms of epithelial origin. In contrast to clearly malignant skin neoplasm SCC, KA is an unusual cutaneous neoplasm with a tendency to regression. The distinction between these two neoplasms, on histological grounds only, is still a challenge. In order to investigate further and to assess the possible differences in transforming growth factor-alpha (TGF-alpha) expression between SCC and KA, 40 of skin tumor specimens, 20 cases of each SCC and KA were analyzed immunohystochemicaly. We have found a significant difference in staining patterns between KA and SCC. In KAs we have detected TGF-alpha staining mainly diffusely (90% of cases) and without peripheral staining of cells in 1-2 layers (60% of cases). Contrary, there was a mostly patchy staining (55% of cases) with peripheral staining of cells in 1-2 layers (100% of cases) in SCCs. Generally, differentiation between KA and SCC can be based on clinical and histological ground, but the distinction between these two skin tumors could sometimes be difficult. We have shown that these skin neoplasms could be differentiated based on staining patterns of TGF-alpha expression, thus this method could aid in differentiation between these two closely related entities in clinical practice.

Psoriasis vulgaris - an inflammatory skin disease and/or benign epidermal hyperplasia

Psoriasis vulgaris (PV) is a systemic inflammatory disease in which immune and genetic factors are involved in the pathogenesis. Some treatment approaches in PV patients have been similar to therapy of some tumors. This fact has led to a new scientific approach to PV not only as an inflammatory disease, but also as a benign epidermal hyperplasia or a benign tumor. In this article, we hypothesize that there has been a parallel between some benign tumors and neoplasms and PV. The aim of this article is to present the approach to PV as an inflammatory disease as well as benign epidermal hyperplasia or tumor, and to introduce a new meaning.

Concurrent basal cell and squamous cell carcinomas associated with hydroxyurea therapy

We report a case of a 76-year-old woman with concurrent onset of two primary cutaneous malignancies, one at the fourth finger and another at the dorsum of the same hand. The patient was on long-term therapy with hydroxyurea (HU) for polycythemia vera. Histopathologic and immunohistochemical studies revealed two different malignant cutaneous lesions, i.e. basal cell carcinoma (positive for bcl-2 and negative for vimentin, EMA and CK5/6) and poorly differentiated sarcomatoid squamous cell carcinoma (positive for vimentin, EMA and cytokeratins CK5/6, and negative for bcl-2). In addition, p53 was positive in approximately 50% of squamous cell carcinoma cells and in almost all basal cell carcinoma cells. The presence of low-risk human papillomavirus (HPV, types 6, 11) was verified by polymerase chain reaction, but only in the surrounding normal skin tissue, whereas HPV infection could not be detected in either carcinoma. In this patient, concurrence of two different skin carcinomas on sun-exposed skin, in the absence of HPV, suggest direct involvement of potentially mutagenic HU therapy, through influence on DNA synthesis and repair mechanisms, in conjunction with ultraviolet exposure. Therefore, we suggest that in patients on HU therapy with cutaneous side effects, referral to a dermatologist should be obligatory.

Gorski Kotar--an endemic region for primary gastric non-hodgkin lymphoma?

Primary gastric non Hodgkin lymphoma (PGNHL) is a distinct group of extranodal lymphomas with interesting geographical distribution and variable prevalence in different countries. We analysed epidemiological data of our patients with PGNHL in Primorsko-goranska County. Clinical data of 30 patients with PGNHL diagnosed and treated in Clinical Hospital Center of Rijeka, Croatia between January 1995 and December 2005 were prospectively analyzed. We used statistical analysis (t-test, chi2-test) for small groups. Out of 30 pts with PGNHL, 19 were born in Primorsko-goranska County, part of Croatia situated by the Adriatic sea which consists of three regions: City of Rijeka, Islands and Gorski Kotar. 6 of 19 patients (31.6%) were originally from Gorski Kotar which made incidence rate of PGNHL in Gorski Kotar 7 times higher than in other two regions. Many authors emphasized that relative frequency of PGNHL is very variable in various countries and regions. Geographical distribution of our patients was very surprising because Gorski Kotar is the region with lowest number of citizens, rural area without any known pollutants, and ecologically one of the most preserved microsystem in this part of Croatia. Gorski Kotar is known to be an endemic region for multiple sclerosis and lyme borreliosis. Is it for PGNHL too?

Significance of continuous medical education of general practitioners about common diseases--iron deficiency anemia

Three years long, prospective study was performed in order to evaluate a possible influence of continuing medical education of general practitioners on managing the patients with common diseases such as iron deficiency anemia (IDA). Altogether 1586 patients that were referred to Hematology Outpatient Clinic, University Hospital Center Rtjeka, Croatia due to diagnosis of IDA were examined by clinical hematologist during the first visit and follow up period, were questioned by the means of questionnaire and complete laboratory analyzes were performed in order to: evaluate physical condition and laboratory findings, to assess duration of anemia, possible other specialists' consultation, iron supplementation therapy, and finally, determine the type of anemia present. Initial group of 983 patients was examined during one year period. Following the education campaign the same parameters were analyzed in comparable (final) group of 603 patients during next one year period. Following the education, the number of patients referred to Outpatient Clinic due to diagnosis of IDA was significantly decreased from 983 (61.97%) to 603 (38.02%) (p < 0.05) as was the number of patients referred as having IDA but finally established to have a different type of anemia, from 661 (97.24%) to 149 (24.71%) (p < 0.001). The number of patients started on iron supplementation therapy before establishing the type of anemia was significantly decreased from 543 (55.24%) to 76 (12.60%) (p < 0.001) as well as duration of iron supplementation therapy administered in these cases (21 +/- 9.8 vs. 6 +/- 8.7 weeks) (p < 0.001). We have detected a significant decrease in: time necessary for definitive diagnosis (49 +/- 19.2 vs. 28 +/- 9.1 weeks) (p < 0.001), number of visits to other specialists (2.9 +/- 1.35 vs. 1.1 +/- 0.94) (p < 0.05), duration of anemia before treatment initialization (41 +/- 29.8 vs. 26 +/- 18.7 weeks) (p < 0.001). Average hemoglobin (Hg) level in patients referred to hematologist was significantly lower following education (98.9 +/- 15.5 vs. 82.6 +/- 14.2) (p < 0.05). Continuing medical education of primary care physicians has significant role in diagnosis and treatment of patients with IDA. Education programs result in benefits for the patients and physicians.

Acute phase proteins in psoriasis

Psoriasis is a chronic, relapsing, inflammatory and hyperproliferative skin disorder. The levels of acute phase proteins are suggested to be elevated in those patients with acute disease. The expression of selected acute phase proteins as the parameters of humoral immunity has been analyzed in 70 patients with acute psoriasis and 40 healthy controls. The aim was to evaluate the inflammatory response in the exacerbation of psoriasis and to determine the correlation of these objective inflammatory parameters with clinical features of disease activity. Main demographic and epidemiologic features were, as well, analysed. The plasma levels of C-reactive protein (CRP) (chi2 = 23.61; p < 0.005), and alpha1-acid glycoprotein (alpha1-AGP) (chi2 = 7.42; p < 0.01) were significantly increased in those patients with acute phase of the disease compared to healthy controls. Our results suggest that psoriasis is an inflammatory disease and therefore its worsening seemed to be linked to the increase in the inflammatory response. It seems that CRP and al-AGP levels could serve as important prognostic factors for the worsening of psoriasis.

The role of CD4 and CD8 lymphocytes and macrophages in psoriasis vulgaris

Current knowledge of the immunopathogenesis of psoriasis vulgaris is based on the crucial role of CD4 and CD8 lymphocytes. Also, the connection of activated lymphocytes with macrophages, especially dendritic cells and plasmacytoid dendritic cells, is considered to be significant. In the present study, the expression of CD4+ lymphocytes as well as CD8+ lymphocytes (P < 0.001) and macrophages (P < 0.001) was found to be significantly increased in lesional skin epidermis and dermis in psoriasis vulgaris patients as compared with healthy skin. These findings suggested a cascade or chain reaction with cells and cytokines playing an important role to be involved in the immunopathogenesis of psoriasis vulgaris.

Effect of progesterone and pregnancy on the development of varicose veins

The aim of this study was to investigate the contribution of progesterone in the development of primary varicose veins on lower limbs during pregnancy. In 50 primiparae with varicose veins, serum progesterone level was quantitatively determined in the 14th week of pregnancy and results were compared with those obtained in a control group of 25 primiparae without visible varicose veins. The mean serum progesterone concentration recorded in pregnant women with dilated veins (159.9+/-15.8 nmol/L) was significantly higher as compared with the control group (159.9+/-15.8 nmol/L vs. 40.4+/-1.6 nmol/L; P<0.0001). These findings supported the role of hormonal factor in the development of varicose veins in women.

The distinction between lesional and non-lesional skin in psoriasis vulgaris through expression of adhesion molecules ICAM-1 and VCAM-1

Psoriasis vulgaris [pv] is a systemic inflammatory skin disease affecting 2-4% population. It is well known that pv affects some parts of the skin and also whole skin as in erythrodermic form. We still do not know why in pv some parts of the skin are affected and others are not. In our hypothesis we assumed that the whole skin is in <<stand by>> position and non-lesional skin could become in every moment lesional. According to our hypothesis and also other author's research, high expression of adhesion molecules ICAM-1 and VCAM-1 in lesional as well as non-lesional skin in pv, supports this hypothesis, suggesting a significance of these molecules in pathogenesis of pv. Our hypothesis could be proved by immunohistochemical stain of ICAM-1 and VCAM-1 in lesional and non-lesional skin of pv patient in comparison with healthy skin.

Influence of PUVA and UVB radiation on expression of ICAM-1 and VCAM-1 molecules in psoriasis vulgaris

The expression of adhesion molecules Intercellular adhesion molecule-1 (ICAM-1) and Vascular cell adhesion molecule-1 (VCAM-1) is increased in lesional and in non-lesional skin of psoriatic patients, and play role in pathogenesis of the disease. PUVA and UVB therapy are important treatments of psoriasis vulgaris. It has been demonstrated that UVA and UVB therapies reduce expression of these molecules. In this investigation, phototherapy was used to treat psoriatic patients. The expression of these molecules was examined by immunohistochemical method in lesional and non-lesional skin of 10 patients with psoriasis vulgaris before and after treatment. Results showed increased expression of ICAM-1 molecules in keratinocytes, in perivascular infiltrate--lymphocytes, and in endothelial cells. The expression of VCAM-1 molecules was also increased, although with less intensity then ICAM-1. After therapy, the expression of the adhesion molecules decreased together with a marked improvement of the disease. In conclusion, study demonstrated that phototherapy improves psoriasis vulgaris probably through mechanisms acting on the adhesions molecules. Adverse reactions due to intense or long lasting UVA (PUVA) and UVB therapies are immunosuppression and damage of DNA which can lead to development of non-melanocytic skin tumors like basal cell carcinoma and squamous cell carcinoma, as well as melanoma.

Correlation between clinical-dermatoscopic and histopathologic diagnosis of skin tumors in our patients

In this study 103 patients with skin tumors were examined. Among them there were 43 (42%) male patients and 60 (58%) female patients. Working diagnosis was obtained by clinical examination using dermoscope. After excision of lesion, working diagnosis was compared to pathohistological diagnosis. In our study we used dermoscope Heine proper delta 10. The clinical-dermoscopic diagnosis included verrucae seborrhoicae in 26 (25.24%), fibropapilloma in 17(16.5%), naevus pigmentosus in 9 (8.79%), naevus dysplasticus in 4 (3.88%), fibroma molle in 8 (7.76%), Mb. Bowen in 1 (0.97%), basal cell carcinoma in 7 (6.79%), squamous cell carcinoma in 6 (5.82%), haemangiofibroma in 1 (0.97%), haemangioma in 3 (2.91%), keratosis actinica in 5 (4.85%), melanoma malignum in 6 (5.82%), naevus fibromatosus in 2 (1.94%) cases and naevus blue in 1 (0.97%), naevus traumatisatus in 1 (0.97%), verruca vulgaris in 1 (0.97%), lymphocytoma in 1 (0.97%), naevus verrucosus in 1 (0.97%), lentigo solaris in 2 (1.94%) and Reed nevus in 1 (0.97%) case. Dermoscopic diagnosis were conformable with pathohistological diagnosis in 75 cases (72.82%). We presumed that dermatoscoping obtains correct diagnosis of skin tumors.

Breast infiltrating ductal carcinoma: analysis of hormone, HER-2 receptors and Ki-67 proliferation marker

The aim of this study was to analyse breast carcinomas with discordant receptor status, probably hormonal dependent (estrogen receptor (ER) positive, progesterone receptor (PR) negative or ER-PR + subgroup profile) infiltrating ductal breast carcinomas not otherwise specified (IDC NOS). Specimens from 90 IDC NOS were grouped into three categories according to hormonal status: dependent (D) (ER +PR +), probably dependent (PD) (ER +PR- or ER-PR +) and non-dependent (ND) (ER-PR-); they were evaluated considering some established prognostic parameters in breast carcinomas. Statistically significant difference was found between tumor receptor status distribution and menopausal status (p = 0.0235), age of the patients (p = 0.000467), histological grade (p = 0.000003), vascular invasion (p = 0.006), HER-2 status (p = 0.0039) and Ki-67 proliferation rate (p = 0.000311). D tumors were found exclusively in post-menopausal patients (average age 68.9 years), most of which had intermediate (II) grade, without vascular invasion, with HER-2 status score predominantly 0 or 1 + and lower Ki-67 proliferation rate. PD tumors were found predominantly in younger post-menopausal patients (average age 57.5 years), with vascular invasion found in 23% of the cases. ND tumors mostly had higher histological grade, showed the highest percentage of the Ki-67 positive tumor cells and vascular invasion in 30% of the cases. We conclude that the patients with PD breast carcinomas were younger post-menopausal women with the tumors moderately differentiated, HER-2 score 0 or 1+ and with lower Ki-67 proliferation rate.

Cell apoptosis as assessed by M30 expression in keratoacanthoma and squamous cell carcinoma

Involution displayed by keratoacanthoma (KA) represents an important difference between KA and squamous cell carcinoma (SCC). It has been suggested that apoptosis plays a part in process of involution of KA. Altogether 150 specimens were included in this study, 30 cases of each; normal skin (NS), proliferative (pKA) and regressing keratoacanthoma (rKA), well differentiated (wdSCC) and poorly differentiated (pdSCC) squamous cell carcinoma. All samples were examined immunohistochemically for expression of M30 protein. A significantly lower number of M30 positive cells has been detected in NS as compared to skin tumors examined (p<0.001), except for rKA (p=0.057). The highest percentage of M30 positive cells was detected in pdSCC (p<0.001) as compared with all other examined groups. Keratinocytes of normal and changed epidermis expressing higher levels of M30 protein were predominately found in sun-exposed areas (chi2=14.93; p=0.060). There was an increasing trend of M30 protein expression with increasing age of the patient in NS and skin tumors examined. Majority of skin tumors with higher percentage of M30 positive cells tended to display higher Ki-67 expression. M30 expression was highly correlated with bak (r=0.811; p=0.048) and granzyme B expression in rKA (r=0.733; p=0.015). Cell apoptosis as assessed by M30 expression is, generally, increased in examined skin tumors and related to cell proliferation. Cell apoptosis mediated by bak and granzyme B expression could contribute to KA regression.

Maculopapular eruption secondary to itraconazole

Adverse cutaneous reactions to itraconazole are known to be quite rare. We report a case of maculopapular reaction caused by itraconazole. On the 7th day of itraconazole therapy for hand onychomycosis, in a 39-year-old woman pruritus occurred with a subsequent morbiliform, symmetric, maculopapular eruption on the upper torso, neck, trunk and pressure-bearing areas. Eruption progressed, becoming confluent and spreading to extremities. Due to increasing indications for the administration of itraconazole its increased usage as well as the possibility of allergic reactions should be expected even if these are a rare event.

Iron deficiency anaemia influences cognitive functions

Many diseases, different nutritional, metabolic and hormonal changes, ageing and drugs can alter cognitive functions. Anemia via cerebral hypoxia and other possible mechanisms has been suggested to have a great influence on cognition. Iron deficiency anemia, the most common form of anemia, has been suggested to result in cognitive deterioration and alteration of neurological functions. Previous studies resulted in significant discrepancies considering correlation between anemia and cognitive achievement mainly because different or not sensitive enough tests used to measure cognition. We suggest a significant influence of iron deficiency anemia on dynamic properties and functional features of the central nervous system activity. Cognitive achievement is strongly related to hemoglobin level and could be expected in all patients. Higher hemoglobin level results in better CNS function. As a first step in confirming or refuting our hypotheses we suggest standardization of the method used to measure cognition, such as a very sensitive apparatus like Complex reactiometer Drenovac (CRD).

Quantitative analysis of nasal vascularization in allergic patients treated with mometasone furoate

The purpose of this study was to compare vascularization of the nasal mucous membrane among non-allergic, non-treated allergic and allergic patients treated with mometasone furoate, by means of the stereology method in quantitative analysis. Three groups of patients (GP), each containing 10 patients were examined. The first group (GP 1) had a negative inhalatory allergen test while the second (GP 2) and third (GP 3) group both had positive results with the same test. GP 3 included allergic patients treated with mometasone furoate for 15 days before analysis, when a small piece of the nasal mucous membrane was taken from the frontal pole of the lower nasal shell. The specimens were examined immunohistochemically for expression of CD31 and VEGF-C. Vascular phase was determined by using length density (L(v)). Differences in CD31 and VEGF-C expression were compared using one-way ANOVA and Tukey HSD post-hoc tests. CD31 expression in GP 1 had significantly lower values than in the GP 2 and GP 3 groups (p < 0.001). VEGF-C expression in GP 1 was significantly lower than in GP 2 (p = 0.007), but not in GP 3 (p = 0.292). We have shown that 15-day treatment with mometasone furoate results in a significant reduction of the density of vascular elements in allergic patients.

Expression of Bcl-2 family proteins in psoriasis

AIM

To elucidate the mechanisms involved in apoptosis of psoriatic keratinocytes by examining the expression of pro-apoptotic (Bak, Bax) and anti-apoptotic (Bcl-2, Bcl-X) Bcl-2 family of proteins, as well as the expression of p53 and Ki-67 proteins in normal skin, and uninvolved and involved psoriatic skin.

METHODS

A total of 90 skin samples (30 cases of involved and uninvolved psoriatic skin and normal skin) were examined immunohistochemically to determine the protein expression of p53, Ki-67, Bcl-2, Bcl-X, Bax, and Bak. The results were quantified and expressed as a percentage of positive keratinocytes.

RESULTS

There was a significant increase in Ki-67 (17.05 vs 3.65; P<0.001), Bcl-X (40.21 vs 13.97; P<0.001), Bak (89.46 vs 73.36; P<0.001), and Bax (50.00 vs 29.25; P<0.001) expression and a decrease in Bcl-2 (3.23 vs 6.25; P=0.008) expression in involved psoriatic skin, as well as an increase in Bcl-X (25.13 vs 13.97; P<0.001) expression in uninvolved psoriatic skin, when compared to normal skin. Samples with higher percentage of Ki-67 positive cells showed a higher percentage of p53 positive cells (correlation coefficient r=0.75 in involved psoriatic samples, P<0.001; r=0.88 in uninvolved psoriatic samples, P<0.001; and r=0.85 in normal skin samples, P<0.001). Samples with higher percentage of p53 positive cells expressed pro-apoptotic Bak and Bax in higher percentage of cells; the correlation coefficients were r=0.74 and r=0.68 in involved psoriatic samples (P<0.001 for both), r=0.75 and r=0.69 in uninvolved psoriatic samples (P<0.001, for both), and r=0.87 and r=0.70 in normal skin samples (P<0.001, for both).

CONCLUSION

Increased expression of Bcl-X protein was associated with psoriatic epidermal hyperplasia. Strong Bax and Bak expression in involved psoriatic skin are probably inhibitory mechanisms counteracting intensive proliferation.

Erectile dysfunction after myocardial infarction--myth or a real problem?

Erectile dysfunction is a common problem whose relation to cardiovascular diseases has scientifically been proved, but it has not been studied sufficiently in patients recovering from myocardial infarction. The objective of this study was to establish the frequency of erectile dysfunction in patients recovering from myocardial infarction. We examined 89 patients (aged 30 to 75 years) included in the program of cardiac rehabilitation after myocardial infarction. The results were compared with 91 healthy examinees of the same age. Even 82% of the patients who recovered from myocardial infarction have problems with erectile dysfunction, compared to 42.9% of healthy examinees. The prevalence of erectile dysfunction increases with the age in both groups. In the group of patients recovering from myocardial infarction aged 30 do 39 years, the erectile dysfunction decreased after 6 months, while in other age subgroups and between controls, there were no significant changes in erectile dysfunction prevalence during the analysed time period. We concluded that erectile dysfunction is a significant problem in patients recovering from myocardial infarction. It should be recognized on time in order to provide a better life quality for the patient with a multidisciplinary approach.

Lyme borreliosis and multiple sclerosis are associated with primary effusion lymphoma

Multiple sclerosis (MS) is a chronic disease of the central nervous system characterized by chronic inflammation and demyelination. Studies suggested that the viral, especially Epstein-Barr virus infection, and bacterial infections, especially Borrelia burgdorferi infection, play a role in etiology of MS. MS prevalence parallels the distribution of the Lyme disease pathogen B. burgdorferi. Criteria used for diagnosis of MS can also be fulfilled in other conditions such as Lyme disease, a multisystem disorder resulting from infection by the tick-borne spirochete, B. burgdorferi. In the late period of Lyme disease demyelinating involvement of central nervous system can develop and MS can be erroneously diagnosed. A Lyme borreliosis can mimick central nervous system lymphoma. Also, B. burgdorferi has been implicated not only in etiology of MS, but also in etiology of lymphoma. Studies suggested that there is an increased risk of non-Hodgkin lymphoma in patients, who had a history of autoimmune diseases such as MS and that both non-Hodgkin's lymphomas and Hodgkin's disease were associated with Epstein-Barr virus infection. A small group of lymphomas called primary effusion lymphomas (PEL) is a recently individualized form of non-Hodgkin's lymphoma (WHO classification) that exhibit exclusive or dominant involvement of serous cavities, without a detectable solid tumor mass. These lymphomas have also been linked to Epstein-Barr virus and human herpes virus type 8 infections but virus negative cases have been described. Therefore, we propose that MS and neuroborreliosis are linked to central nervous system primary effusion lymphomas. As a first step in confirming or refuting our hypotheses, we suggest a thorough study of CSF in the patients suspected for the diagnosis of MS and Lyme borreliosis.

Expression of cell cycle and apoptosis regulatory proteins and telomerase in melanocitic lesions

To gain insight into the role and association of cell cycle and apoptosis regulatory proteins and telomerase activity in the course of progression of melanocitic lesions we have examined immunohistochemicaly, expression and the distribution of p53, bcl-2, Ki-67 and telomerase in 25 samples of common and dysplastic nevi, and 45 samples of primary invasive melanomas. Protein p53 expression was significantly increased in dysplastic as compared with common nevi and melanomas (p < 0.001). Bcl-2 protein expression was significantly increased in melanomas as compared with common aquired and dysplastic nevi (p = 0.001). Nevi and melanomas exhibited clear-cut differences in terms of Ki-67 expression. Telomerase expression was significantly increased in melanomas as compared with common acquired (p = 0.014) and dysplastic nevi (p < 0.001). Enhanced telomerase activity in association with increased bcl-2 expression in the course of melanoma progression could contribute to development and progression of melanoma.

Photocarcinogenesis--molecular mechanisms

The carcinogenicity (photocarcinogenicity) of sunlight to human skin has been recognized more than a century ago. Last decades numerous experimental studies show that UV rays damage DNA, cause gene mutations leading to the development of malignant tumors such basal cell carcinomas, squamous cell carcinomas and melanomas. The tumors occur most frequently in fair skinned people, and the mutations typically are found at dipyrimidine sites with C-T or / and CC-TT tandem double mutations. The authors briefly summarize their investigation of the p53 suppressor gene, and expose their hypothesis of hTERT involvement in cancerogenesis. Also their underline the importance of UV induced immunosuppression in photocarcinogenesis. Psoriatic patients are exposed to numerous cancerogens in their treatment. A better understanding of the mechanisms of photocarcinogenesis could provide new ways in the treatment of skin tumors.

Apoptosis in skin cancer development and regression

Non-melanoma skin cancers (NMSC) are the most common malignant tumors in white population and their incidence has been increasing worldwide. Molecular events regulating cell survival, apoptosis, growth arrest as well as cell differentiation, are important contributors to the overall kinetics of benign and malignant cell growth and play a role in their development, progression and regression. Failure of these pathways can result in the loss of control over proliferation and lead to tumor development through the inactivation of tumor suppressor genes or the activation of oncogenes. Also, immunological mechanisms have been implicated in a phenomenon of tumor progression as well as spontaneous tumor regression. We have tried to summarize the main events in etiopatogenesis, development, progression and in some cases skin cancer regression. Further studies are needed to elucidate completely the details of apoptotic control in normal skin and determine factors resulting in apoptotic disbalance and disease.

Telomerase in anti-tumor response

Telomerase is responsible for maintaining the length of telomeres at the end of chromosomes. It protects chromosomes from degradation and aberrant recombination during replication prolonging the life span of the cell. Human telomerase reverse transcriptase (hTERT) is highly expressed in >85% of cancer cells but its expression is repressed in most human somatic cells. It has been shown that expression of human telomerase reverse transcriptase greatly extends the life span of both human CD8+ and CD4+ T cells during activation and proliferation. hTERT-positive tumor cells can induce cytotoxic T lymphocyte response as well as T helper response. On the other hand, it is possible that cytotoxic immune response to hTERT-positive tumor cells can cause autoimmune reaction directed against T cells in a tumor bearing host. This could lead to apoptosis and decreased number of activated T cells and insufficient anti-tumor immunity resulting in tumor progression.

The relationship between telomerase activity and proliferation in cutaneous melanoma

Telomerase is a ribonucleoprotein reverse transcriptase which RNA component (TERC) and reverse transcriptase (TERT) function together to elongate telomeres. If cells are to survive and proliferate indefinitely, telomere preservation is essential for the immortalization process. Somatic cells rarely possess TA, but over 90% of tumor cells express active telomerase. Increased cell proliferation and deregulation of cell cycle occur in human cancers, including cutaneous melanoma. The exact nature of links between TA, cell proliferation and apoptosis has not been extensively elucidated in cutaneous melanoma. We hypothesize a relationship between TA and cutaneous melanoma cell proliferation in a way that TA in telomere elongation is only an early event in cell immortalization. The telomere elongation makes their proliferation possible and being, at the same time, one of its limiting factors. But the TA other than telomere elongation (TERC independent) is crucial to initiate or restore melanoma cell proliferation. On the other hand, TA in telomere elongation, together with other factors (for example TNF), has an active anti-apoptotic role. This way melanoma cells overwhelm the apoptotic defense mechanisms, finally resulting in their indefinite proliferation. In evaluation of our hypothesis, we suggest thorough studies of both telomerase activity and proliferation in cutaneous melanoma on multiple checkpoints and targets. We also suggest combined analyses of TA and telomere length. This approach seems inevitable since it is obvious that telomerase is no longer just for the elongation of telomeres and, to our knowledge, most of the studies conducted so far evaluated TA as an expression of a single subunit or associated molecule.

Expression of cell cycle and apoptosis regulatory proteins in keratoacanthoma and squamous cell carcinoma

Some authors view keratoacanthoma (KA) as a variant of squamous cell carcinoma (SCC), while others consider it a separate entity that must be distinguished from SCC. Involution displayed by KA is an important difference between these two entities. It has been suggested that apoptosis plays a role in the involution process of KA, although the exact trigger for it remains unclear. A hundred and fifty specimens were included in this study, 30 cases for each of the following groups: normal skin (NS), proliferative keratoacanthoma (pKA), regressing keratoacanthoma (rKA), well-differentiated squamous cell carcinoma (wdSCC), and poorly differentiated squamous cell carcinoma (pdSCC). They were immunohistochemically examined for the expression of p53, Ki-67, bak, and bcl-2. Significantly higher p53 and Ki-67 expressions were observed in all tumor lesions examined as compared with NS. There was higher bak expression in KAs compared to NS and a significant reduction of bak expression in pdSCC together with a significant reduction of bak expression in SCCs compared to pKA. Bcl-2 expression was similar in NS and SCCs, but was lower in rKA. We found a significant positive correlation between p53 and Ki-67, p53 and Bak in NS and examined skin tumors. Lower bcl-2 expression in conjunction with higher bak expression in rKA suggests a possible role of these apoptosis-regulating proteins in tumor regression. In contrast to this finding, a steady level of bcl-2 expression in pdSCC combined with lower bak expression levels and a high proliferation rate could contribute to progression and aggressiveness in these tumors. Bak and p53 expression is a sun-related and age-dependent process in NS and skin tumors.

Possible key role of granzyme B in keratoacanthoma regression

It is still controversial whether keratoacanthoma is to be considered as a well differentiated variant of squamous cell-carcinoma or a separate entity. As opposed to malignant potential of squamous cell-carcinoma, keratoacanthoma is characterized by a spontaneous regression. However, in some cases, otherwise typical keratoacanthoma can behave aggressively showing the signs of perineural and perivascular invasion and metastases in regional lymph nodes. The most important feature that separates these two closely related entities is a tendency of keratoacanthoma to regress. Causes and detailed mechanism of this regression are still not completely elucidated. Within the past few years, it has become evident that the molecular events regulating cell survival and apoptosis are important contributors to the overall kinetics of benign and malignant cell growth. Immunological mechanisms have been implicated in a phenomenon of spontaneous tumor regression. Recent studies suggested that the tumor regression is dependent mainly on the immune response mediated by cytotoxic T lymphocytes (CD8+), together with helper T cells (CD4+). Cytotoxic T lymphocytes can kill tumor cells and mediate tumor regression in vivo through two distinct molecular mechanisms: Fas/Fas ligand and granzyme B/perforin mediated pathways. Tumor cells are capable of developing different escape mechanisms in order to overcome their sensitivity to apoptotic signals. However, granzyme B, contained in cytolytic granules released upon target cell recognition, can also cause tumor cell death and consequently tumor regression by direct damage to non-nuclear structures through a caspase-independent pathway. Therefore, we propose a key role of plasticity in the granzyme B mediated cell death pathway in the killing of changed tumor cells, resulting in keratoacanthoma regression through apoptosis or direct damage of tumor cells. On the other hand, insufficient activation of cytotoxic T lymphocytes and decreased release or activity of granzyme B could be responsible for squamous cell-carcinoma progression and occasional aggressive behavior in keratoacanthomas. As a first step in confirming or refuting our hypothesis, we suggest a thorough immunohistochemical study of the presence of granzyme B and its activity in keratoacanthoma and squamous cell-carcinoma samples. To our knowledge, no such study has been performed so far.

Expression of p53 and apoptosis in discoid lupus erythematosus

AIM

To investigate whether p53 expression and apoptosis play a role in the pathogenesis of discoid lupus erythematosus (DLE) and whether they are associated with a hyperproliferative state in the epidermis of DLE lesions and epidermal atrophy.

METHODS

A total of 70 skin biopsy specimens, 35 DLE and 35 normal, were used. Expression of protein p53 and Ki-67 was examined immunohistochemically. Apoptotic cells were identified by terminal deoxynucleotidyl transferase (TdT)-mediated nick end labeling (TUNEL). Histopathological examination of hematoxylin-eosin-stained sections of DLE included analysis and scoring of epidermal atrophy and other histopathological parameters.

RESULTS

p53 expression was greater in DLE than in normal skin (14.5 vs 0.6%, P<0.001). Ki-67 expression was also greater in DLE than in normal skin (8.0 vs 3.1%, P<0.001). A significant positive correlation between p53 and Ki-67 expression was found in both groups (normal skin, r=0.46, P<0.009; DLE, r=0.72, P<0.001). A significant negative correlation (r=-0.75, P<0.001) between Ki-67 expression and the intensity of epidermal atrophy was found. The degree of apoptosis in the epidermis of DLE lesions with higher Ki-67 and p-53 expression was higher than when the expression of these molecules was low (3.0+/-1.8 vs 1.6+/-1.5 on a scale from 0-5; P=0.048).

CONCLUSION

Aberrant p53 expression occurs in the keratinocytes of DLE and is associated with keratinocyte hyperproliferation and epidermal atrophy. Accumulation of p53 protein, together with an extensive apoptosis, suggests that the activation of a p53-induced apoptotic pathway may play a role in the pathogenesis of skin lesions in DLE.

Recurrent pleomorphic adenoma of epipharynx following irradiation therapy

We present a case of a 67-year-old female patient having a pleomorphic adenoma of epipharynx with intact fibrous capsula, which despite its benignity recurred and, moreover, responded quite well to irradiation therapy. The patient, at first, refused any therapy. Three years later, when the CT showed tumor enlargement she accepted only irradiation therapy, resulting in significant reduction of tumor size. Five years later the tumor recurred but without malignant transformation. She still refused surgery, but accepted re-irradiation therapy. After a three-year follow-up the patient has no symptoms of the tumor enlargement. This case shows that the irradiation therapy might be quite effective in the treatment of pleomorphic adenoma of epipharynx, but it is clear that much better results could be accomplished in combination with the surgery. In cases when the surgery is rejected or not possible because of the vicinity of the vital structures, we recommend the irradiation therapy as a therapy of the choice.

Heliomarinotherapy in psoriasis

Heliomarinotherapy is an important therapeutic option in the treatment of psoriasis. Investigations on heliomarinotherapy carried out in Veli Losinj, Croatia showed that the remissions of psoriasis after such treatment were long lasting, side effects slight, and use of corticosteroids not necessary.

Protein p53--structure, function, and possible therapeutic implications

Cell cycle is driven by a number of positive and negative regulatory phosphorylation and dephosphorylation events that ultimately influence the activity of transcription factors. Normal skin architecture depends on the regulation mechanisms of cell proliferation and differentiation and on apoptosis. Complex interaction of different factors in the regulation of these mechanisms, aimed at maintaining constant desquamation, is often changed in skin diseases. The main difference between normal cells and tumor cells results from discrete changes in specific genes important for cell proliferation control mechanisms and tissue homeostasis. These genes are mainly proto-oncogenes or tumor-suppressor genes, and their mutation could play a role in cell hyperproliferation and carcinogenesis. Tumor-suppressor genes normally function as a physiological barrier against clonal expansion or mutation accumulation in the genome. They also control and arrest growth of the cells that hyperproliferate due to oncogene activity. Alteration or DNA damage in tumor-suppressor genes and oncogenes are considered key events in human carcinogenesis. Tumor-suppressor protein p53 is an important transcription factor, which plays a central role in the cell cycle regulation mechanisms and cell proliferation control, and its inactivation is considered a key event in human carcinogenesis. The role of p53 protein in the cell cycle, high proportion of tumors with mutated p53 gene, and accumulation of significant amount of knowledge on molecular biology of this protein make this molecule especially attractive for development of new therapeutic approaches. Main strategies for development of new antineoplastic therapies are based on "wild-type" p53 protein acting as a tumor suppressor, selective apoptosis inductor, and a protein able to arrest cell cycle.