Executive summary of the consensus document for the training and development of clinical ultrasound in Internal Medicine: Recommendations from the Clinical Ultrasound Working Group of the Spanish Society of Internal Medicine (GTECO-SEMI).

INTRODUCTION: Given the increasing adoption of clinical ultrasound in medicine, it is essential to standardize its application, training, and research. OBJECTIVES AND METHODS: The purpose of this document is to provide consensus recommendations to address questions about the practice and operation of clinical ultrasound units. Nineteen experts and leaders from advanced clinical ultrasound units participated. A modified Delphi consensus method was used. RESULTS: A total of 137 consensus statements, based on evidence and expert opinion, were considered. The statements were distributed across 10 areas, and 99 recommendations achieved consensus. CONCLUSIONS: This consensus defines the most important aspects of clinical ultrasound in the field of Internal Medicine, with the aim of standardizing and promoting this healthcare advancement in its various aspects. The document has been prepared by the Clinical Ultrasound Working Group and endorsed by the Spanish Society of Internal Medicine.

Point-of-Care Ultrasound (POCUS) as an Extension of the Physical Examination in Patients with Bacteremia or Candidemia.

BACKGROUND: In general, transthoracic echocardiography (TTE) is the first diagnostic test used for patients with bacteremia or candidemia and clinical signs of Infective Endocarditis (IE). Point-of-care ultrasound (POCUS) may be used in addition to physical examination for the detection of structural heart disease and valve abnormalities. OBJECTIVE: To determine the diagnostic accuracy of POCUS for the detection of signs suggestive of IE, including vegetation, valvular regurgitation, structural heart disease, hepatomegaly, splenomegaly and septic embolisms, in patients with bacteremia or candidemia. DESIGN: Observational, cross-sectional, multicenter study using convenience sampling. SETTING: Six Spanish academic hospitals. PATIENTS: Adult patients with bacteremia or candidemia between 1 February 2018 and 31 December 2020. MEASUREMENTS: The reference test, to evaluate vegetation, valvular regurgitation and structural heart disease, was transesophageal echocardiography (TEE). For patients who did not undergo TEE, transthoracic echocardiography (TTE) was considered the reference test. POCUS was performed by internists, while conventional echocardiography procedures were performed by cardiologists. RESULTS: In 258 patients, for the detection of valvular vegetation, POCUS had sensitivity, specificity, and positive and negative predictive values of 77%, 94%, 82% and 92%, respectively. For valvular regurgitation (more than mild), sensitivity was ≥76% and specificity ≥85%. Sensitivity values for the detection of hepatomegaly and splenomegaly were 92% and 92%, respectively, while those for specificity were 96% and 98%. CONCLUSION: POCUS could be a valuable tool, as a complement to physical examination, at the hospital bedside for patients with bacteremia or candidemia, helping to identify signs suggestive of IE.

Lithium Directs Embryonic Stem Cell Differentiation Into Hemangioblast-Like Cells.

Definitive hematopoietic stem cells (HSCs) derive from specialized regions of the endothelium known as the hemogenic endothelium (HE) during embryonic developmental processes. This knowledge opens up new possibilities for designing new strategies to obtain HSCs in vitro from pluripotent stem cells (PSCs). Previous advances in this field show that the Wnt/ß-catenin signaling pathway plays a crucial role in PSC-derived HSC formation. In this work, lithium, a GSK3 inhibitor, is identified as an element capable of stabilizing ß-catenin and inducing embryonic stem cells (ESCs) differentiation in hemangioblast-like cells, highly consistent with the role of Wnt agonists on ESC differentiation. ESCs treated with 10 mm lithium express CD31+, SCA-1+, Nkx2-5+, CD34+, and FLK1+ cells characteristic of the hemangioblast cells that precede HE development. However, 10 mm Li treated cells remain arrested in a hemangioblast-like phase, which switched into the expression of HE markers after stimulation with maturation medium. The ability of lithium-treated ESCs to further derive into HE is confirmed after defined maturation, resulting in a rapid increase in cells positive for the HE markers RUNX1 and SOX17. The results represent a novel strategy for generating HSC precursors in vitro as a multipotent source of stem cells for blood disease therapies.

Borax-loaded injectable alginate hydrogels promote muscle regeneration in vivo after an injury.

Muscle tissue possess an innate regenerative potential that involves an extremely complicated and synchronized process on which resident muscle stem cells play a major role: activate after an injury, differentiate and fuse originating new myofibers for muscle repair. Considerable efforts have been made to design new approaches based on material systems to potentiate muscle repair by engineering muscle extracellular matrix and/or including soluble factors/cells in the media, trying to recapitulate the key biophysical and biochemical cues present in the muscle niche. This work proposes a different and simple approach to potentiate muscle regeneration exploiting the interplay between specific cell membrane receptors. The simultaneous stimulation of borate transporter, NaBC1 (encoded by SLC4A11gene), and fibronectin-binding integrins induced higher number and size of focal adhesions, major cell spreading and actin stress fibers, strengthening myoblast attachment and providing an enhanced response in terms of myotube fusion and maturation. The stimulated NaBC1 generated an adhesion-driven state through a mechanism that involves simultaneous NaBC1/α5ß1/αvß3 co-localization. We engineered and characterized borax-loaded alginate hydrogels for an effective activation of NaBC1 in vivo. After inducing an acute injury with cardiotoxin in mice, active-NaBC1 accelerated the muscle regeneration process. Our results put forward a new biomaterial approach for muscle repair.

Borax induces osteogenesis by stimulating NaBC1 transporter via activation of BMP pathway.

The intrinsic properties of mesenchymal stem cells (MSCs) make them ideal candidates for tissue engineering applications. Efforts have been made to control MSC behavior by using material systems to engineer synthetic extracellular matrices and/or include soluble factors in the media. This work proposes a simple approach based on ion transporter stimulation to determine stem cell fate that avoids the use of growth factors. Addition of borax alone, transported by the NaBC1-transporter, enhanced MSC adhesion and contractility, promoted osteogenesis and inhibited adipogenesis. Stimulated-NaBC1 promoted osteogenesis via the BMP canonical pathway (comprising Smad1/YAP nucleus translocation and osteopontin expression) through a mechanism that involves simultaneous NaBC1/BMPR1A and NaBC1/α5ß1/αvß3 co-localization. We describe an original function for NaBC1 transporter, besides controlling borate homeostasis, capable of stimulating growth factor receptors and fibronectin-binding integrins. Our results open up new biomaterial engineering approaches for biomedical applications by a cost-effective strategy that avoids the use of soluble growth factors.

Engineered 3D hydrogels with full-length fibronectin that sequester and present growth factors.

Extracellular matrix (ECM)-derived matrices such as Matrigel are used to culture numerous cell types in vitro as they recapitulate ECM properties that support cell growth, organisation, migration and differentiation. These ECM-derived matrices contain various growth factors which make them highly bioactive. However, they suffer lot-to-lot variability, undefined composition and lack of controlled physical properties. There is a need to develop rationally designed biomaterials that can also recapitulate ECM roles. Here, we report the development of fibronectin (FN)-based 3D hydrogels of controlled stiffness and degradability that incorporate full-length FN to enable solid-phase presentation of growth factors in a physiological manner. We demonstrate, in vitro and in vivo, the effect of incorporating vascular endothelial growth factor (VEGF) and bone morphogenetic protein 2 (BMP2) in these hydrogels to enhance angiogenesis and bone regeneration, respectively. These hydrogels represent a step-change in the design of well-defined, reproducible, synthetic microenvironments for 3D cell culture that incorporate growth factors to achieve functional effects.

Zinc Maintains Embryonic Stem Cell Pluripotency and Multilineage Differentiation Potential via AKT Activation.

Embryonic stem cells (ESCs) possess remarkable abilities, as they can differentiate into all cell types (pluripotency) and be self-renewing, giving rise to two identical cells. These characteristics make ESCs a powerful research tool in fundamental embryogenesis as well as candidates for use in regenerative medicine. Significant efforts have been devoted to developing protocols to control ESC fate, including soluble and complex cocktails of growth factors and small molecules seeking to activate/inhibit key signaling pathways for the maintenance of pluripotency states or activate differentiation. Here we describe a novel method for the effective maintenance of mouse ESCs, avoiding the supplementation of complex inhibitory cocktails or cytokines, e.g., LIF. We show that the addition of zinc to ESC cultures leads to a stable pluripotent state that shares biochemical, transcriptional and karyotypic features with the classical LIF treatment. We demonstrate for the first time that ESCs maintained in long-term cultures with added zinc, are capable of sustaining a stable ESCs pluripotent phenotype, as well as differentiating efficiently upon external stimulation. We show that zinc promotes long-term ESC self-renewal (>30 days) via activation of ZIP7 and AKT signaling pathways. Furthermore, the combination of zinc with LIF results in a synergistic effect that enhances LIF effects, increases AKT and STAT3 activity, promotes the expression of pluripotency regulators and avoids the expression of differentiation markers.

Simultaneous Boron Ion-Channel/Growth Factor Receptor Activation for Enhanced Vascularization.

Boron ion is essential in metabolism and its concentration is regulated by ion-channel NaBC1. NaBC1 mutations cause corneal dystrophies such as Harboyan syndrome. Here a 3D molecular model for NaBC1 is proposed and it is shown that simultaneous stimulation of NaBC1 and vascular endothelial growth factor receptors (VEGFR) promotes angiogenesis in vitro and in vivo with ultralow concentrations of VEGF. Human umbilical vein endothelial cells' (HUVEC) organization into tubular structures is shown to be indicative of vascularization potential. Enhanced cell sprouting is found only in the presence of VEGF and boron, the effect abrogated after blocking NaBC1. It is demonstrated that stimulated NaBC1 promotes angiogenesis via PI3k-independent pathways and that α5 ß1 /αv ß3 integrin binding is not essential to enhanced HUVEC organization. A novel vascularization mechanism that involves crosstalk and colocalization between NaBC1 and VEGFR receptors is described. This has important translational consequences; just by administering boron, taking advantage of endogenous VEGF, in vivo vascularization is shown in a chorioallantoic membrane assay.

Zinc uptake promotes myoblast differentiation via Zip7 transporter and activation of Akt signalling transduction pathway.

Myogenic regeneration occurs through a chain of events beginning with the output of satellite cells from quiescent state, formation of competent myoblasts and later fusion and differentiation into myofibres. Traditionally, growth factors are used to stimulate muscle regeneration but this involves serious off-target effects, including alterations in cell homeostasis and cancer. In this work, we have studied the use of zinc to trigger myogenic differentiation. We show that zinc promotes myoblast proliferation, differentiation and maturation of myofibres. We demonstrate that this process occurs through the PI3K/Akt pathway, via zinc stimulation of transporter Zip7. Depletion of zinc transporter Zip7 by RNA interference shows reduction of both PI3K/Akt signalling and a significant reduction of multinucleated myofibres and myotubes development. Moreover, we show that mature myofibres, obtained through stimulation with high concentrations of zinc, accumulate zinc and so we hypothesise their function as zinc reservoirs into the cell.

[Positive urine pneumococcal antigen test and vaccination]. / Antigenuria positiva a neumococo y vacunación.

INTRODUCTION AND OBJECTIVE: Although urine pneumococcal antigen is an useful test, it has false positives such as pneumococcal vaccination. MATERIAL AND METHODS: Positive urine pneumococcal antigen in Hospital de Denia (January-February/2015). We studied epidemiological, radiological and microbiological variables as well as previous pneumococcal vaccination (neumo-23 and/or neumo-13). RESULTS: Urine pneumococcal antigen test was positive in 12.4% of 385 cases. Only 33.3% of positive cases had pneumonia in chest X-ray, and 35.4% of patients had previous pneumococcal vaccination. In most cases (87.5%), an antibiotic was prescribed. CONCLUSIONS: Pneumococcal vaccination can produce a false positive result in the urine pneumococcal antigen test in clinical practice, leading to an unnecessary prescription of antibiotics.

In Situ Hydroxyapatite Content Affects the Cell Differentiation on Porous Chitosan/Hydroxyapatite Scaffolds.

Highly porous chitosan/hydroxyapatite composite structures with different weight ratios (100/0; 90/10; 80/20; 70/30; 60/40; 50/50; 40/60) have been prepared by precipitation method and freeze-gelation technique using calcite, urea phosphate and chitosan as starting materials. The composition of prepared composite scaffolds was characterized by X-ray diffraction analysis and Fourier transformed infrared spectroscopy, while morphology of scaffolds was imaged by scanning electron microscopy. Mercury intrusion porosimetry measurements of prepared scaffolds have shown different porosity and microstructure regarding to the HA content, along with SEM observations of scaffolds after being immersed in physiological medium. The results of swelling capacity and compressive strength measured in Dulbecco's phosphate buffer saline (DPBS) have shown higher values for composite scaffolds with lower in situ HA content. Viability, proliferation and differentiation of MC3T3-E1 cells seeded on different scaffolds have been evaluated by live dead assay and confocal scan microscopy. Our results suggest that the increase of HA content enhance osteoblast differentiation confirming osteogenic properties of highly porous CS/HA scaffolds for tissue engineering applications in bone repair.

Borax-Loaded PLLA for Promotion of Myogenic Differentiation.

Boron is an essential metalloid, which plays a key role in plant and animal metabolisms. It has been reported that boron is involved in bone mineralization, has some uses in synthetic chemistry, and its potential has been only recently exploited in medicinal chemistry. However, in the area of tissue engineering, the use of boron is limited to works involving certain bioactive glasses. In this study, we engineer poly(l-lactic acid) (PLLA) substrates with sustained release of boron. Then, we analyze for the first time the uniqueness effects of boron in cell differentiation using murine C2C12 myoblasts and discuss a potential mechanism of action in cooperation with Ca(2+). Our results demonstrate that borax-loaded materials strongly enhance myotube formation at initial steps of myogenesis. Furthermore, we demonstrate that Ca(2+) plays an essential role in combination with borax as chelating or blocking Ca(2+) entry into the cell leads to a detrimental effect on myoblast differentiation observed on borax-loaded materials. This research identifies borax-loaded materials to trigger differentiation mechanisms and it establishes a new tool to engineer microenvironments with applications in regenerative medicine for muscular diseases.

Controlled Assembly of Fibronectin Nanofibrils Triggered by Random Copolymer Chemistry.

Fibronectin fibrillogenesis is the physiological process by which cells elaborate a fibrous FN matrix. Poly(ethyl acrylate), PEA, has been described to induce a similar process upon simple adsorption of fibronectin (FN) from a protein solution-in the absence of cells-leading to the so-called material-driven fibronectin fibrillogenesis. Poly(methyl acrylate), PMA, is a polymer with very similar chemistry to PEA, on which FN is adsorbed, keeping the globular conformation of the protein in solution. We have used radical polymerization to synthesize copolymers with controlled EA/MA ratio, seeking to modulate the degree of FN fibrillogenesis. The physicochemical properties of the system were studied using dynamic-mechanical analysis, differential scanning calorimetry, and water contact angle. Both the degree of FN fibrillogenesis and the availability of the integrin binding region of FN directly depend on the percentage of EA in the copolymer, whereas the same total amount of FN was adsorbed regardless the EA/MA ratio. Cell morphology adhesion and differentiation of murine C2C12 were shown to depend on the degree of FN fibrillogenesis previously attained on the material surface. Myogenic differentiation was enhanced on the copolymers with higher EA content, i.e. more interconnected FN fibrils.

Cell migration within confined sandwich-like nanoenvironments.

AIM: We introduced sandwich-like culture as a tool to engineer the cellular nanoenvironment by tuning protein presentation and activation of dorsal and ventral receptors. We aim at studying cell migration under more similar conditions to the 3D physiological one. MATERIALS & METHODS: We have investigated different nanoenvironments by changing the protein coating and using materials that adsorb proteins in different conformation, seeking to show their specific role in cell migration. RESULTS: Cell migration within sandwich cultures greatly differs from 2D cultures, shares some similarities with migration within 3D environments and is highly dependent on the protein nanoenvironment. Beyond differences in cell morphology and migration, dorsal stimulation promotes cell remodeling of the extracellular matrix over simple ventral receptor activation in traditional 2D cultures. CONCLUSION: Local(nano) stimulation of dorsal and ventral receptors within sandwich cultures alter cell migration in comparison to standard 2D environments.

Living biointerfaces based on non-pathogenic bacteria to direct cell differentiation.

Genetically modified Lactococcus lactis, non-pathogenic bacteria expressing the FNIII(7-10) fibronectin fragment as a protein membrane have been used to create a living biointerface between synthetic materials and mammalian cells. This FNIII(7-10) fragment comprises the RGD and PHSRN sequences of fibronectin to bind α5ß1 integrins and triggers signalling for cell adhesion, spreading and differentiation. We used L. lactis strain to colonize material surfaces and produce stable biofilms presenting the FNIII(7-10) fragment readily available to cells. Biofilm density is easily tunable and remains stable for several days. Murine C2C12 myoblasts seeded over mature biofilms undergo bipolar alignment and form differentiated myotubes, a process triggered by the FNIII(7-10) fragment. This biointerface based on living bacteria can be further modified to express any desired biochemical signal, establishing a new paradigm in biomaterial surface functionalisation for biomedical applications.

Role of material-driven fibronectin fibrillogenesis in protein remodeling.

Protein remodeling at the cell-material interface is an important phenomenon that should be incorporated into the design of advanced biomaterials for tissue engineering. In this work, we address the relationship between fibronectin (FN) activity at the material interface and remodeling, including proteolytic cascades. To do so, we studied FN adsorption on two chemically similar substrates, poly(ethyl acrylate) (PEA) and poly(methyl acrylate) (PMA), which resulted in different distribution and conformation of the protein at the material interface: FN organized spontaneously upon adsorption on PEA into physiological-like fibrils, through a process called material-driven FN fibrillogenesis. The amount of adsorbed FN and its conformation were investigated in two different coating concentrations (2 and 20 µg/mL). Since FN activity at the material interface determines the initial cellular response, we followed the formation of focal adhesions (vinculin) and subsequent cell signaling by focal adhesion kinase (FAK) expression and its phosphorylation (pFAK). More detailed studies were performed to get further insights into integrin binding by crosslinking and extraction followed by immunofluorescence, as well as protein and gene expression for α5 and αv. To correlate cell adhesion with matrix degradation, gene expression and activity (zymography) of matrix metalloproteinases (MMPs) were measured. Overall, we demonstrated that the material-driven FN fibrillogenesis triggers proteolytic activity: MMP activity was higher on the material-driven FN fibrils, as a compensatory mechanism to the inability of cells to reorganize this FN network.

Functional living biointerphases.

Lactococcus lactis is modified to express a fibronectin fragment (FNIII7₋10) as a membrane protein. This interphase, based on a living system, can be further exploited to provide spatio-temporal factors to direct cell function at the material interface. This approach establishes a new paradigm in biomaterial surface functionalization for biomedical applications.

Dorsal and ventral stimuli in cell-material interactions: effect on cell morphology.

Cells behave differently between bidimensional (2D) and tridimensional (3D) environments. While most of the in vitro cultures are 2D, most of the in vivo extracellular matrices are 3D, which encourages the development of more relevant culture conditions, seeking to provide more physiological models for biomedicine (e.g., cancer, drug discovery and tissue engineering) and further insights into any dimension-dependent biological mechanism. In this study, cells were cultured between two protein coated surfaces (sandwich-like culture). Cells used both dorsal and ventral receptors to adhere and spread, undergoing morphological changes with respect to the 2D control. Combinations of fibronectin and bovine serum albumin on the dorsal and ventral sides led to different cell morphologies, which were quantified from bright field images by calculating the spreading area and circularity. Although the mechanism underlying these differences remains to be clarified, excitation of dorsal receptors by anchorage to extracellular proteins plays a key role on cell behavior. This approach--sandwich-like culture--becomes therefore a versatile method to study cell adhesion in well-defined conditions in a quasi 3D environment.

Effect of topological cues on material-driven fibronectin fibrillogenesis and cell differentiation.

Fibronectin (FN) assembles into fibrillar networks by cells through an integrin-dependent mechanism. We have recently shown that simple FN adsorption onto poly(ethyl acrylate) surfaces (PEA), but not control polymer (poly(methyl acrylate), PMA), also triggered FN organization into a physiological fibrillar network. FN fibrils exhibited enhanced biological activities in terms of myogenic differentiation compared to individual FN molecules. In the present study, we investigate the influence of topological cues on the material-driven FN assembly and the myogenic differentiation process. Aligned and random electrospun fibers were prepared. While FN fibrils assembled on the PEA fibers as they do on the smooth surface, the characteristic distribution of globular FN molecules observed on flat PMA transformed into non-connected FN fibrils on electrospun PMA, which significantly enhanced cell differentiation. The direct relationship between the fibrillar organization of FN at the material interface and the myogenic process was further assessed by preparing FN gradients on smooth PEA and PMA films. Isolated FN molecules observed at one edge of the substrate gradually interconnected with each other, eventually forming a fully developed network of FN fibrils on PEA. In contrast, FN adopted a globular-like conformation along the entire length of the PMA surface, and the FN gradient consisted only of increased density of adsorbed FN. Correspondingly, the percentage of differentiated cells increased monotonically along the FN gradient on PEA but not on PMA. This work demonstrates an interplay between material chemistry and topology in modulating material-driven FN fibrillogenesis and cell differentiation.

Role of surface chemistry in protein remodeling at the cell-material interface.

BACKGROUND: The cell-material interaction is a complex bi-directional and dynamic process that mimics to a certain extent the natural interactions of cells with the extracellular matrix. Cells tend to adhere and rearrange adsorbed extracellular matrix (ECM) proteins on the material surface in a fibril-like pattern. Afterwards, the ECM undergoes proteolytic degradation, which is a mechanism for the removal of the excess ECM usually approximated with remodeling. ECM remodeling is a dynamic process that consists of two opposite events: assembly and degradation. METHODOLOGY/PRINCIPAL FINDINGS: This work investigates matrix protein dynamics on mixed self-assembled monolayers (SAMs) of -OH and -CH(3) terminated alkanethiols. SAMs assembled on gold are highly ordered organic surfaces able to provide different chemical functionalities and well-controlled surface properties. Fibronectin (FN) was adsorbed on the different surfaces and quantified in terms of the adsorbed surface density, distribution and conformation. Initial cell adhesion and signaling on FN-coated SAMs were characterized via the formation of focal adhesions, integrin expression and phosphorylation of FAKs. Afterwards, the reorganization and secretion of FN was assessed. Finally, matrix degradation was followed via the expression of matrix metalloproteinases MMP2 and MMP9 and correlated with Runx2 levels. We show that matrix degradation at the cell material interface depends on surface chemistry in MMP-dependent way. CONCLUSIONS/SIGNIFICANCE: This work provides a broad overview of matrix remodeling at the cell-material interface, establishing correlations between surface chemistry, FN adsorption, cell adhesion and signaling, matrix reorganization and degradation. The reported findings improve our understanding of the role of surface chemistry as a key parameter in the design of new biomaterials. It demonstrates the ability of surface chemistry to direct proteolytic routes at the cell-material interface, which gains a distinct bioengineering interest as a new tool to trigger matrix degradation in different biomedical applications.