Executive summary on the optimization of the multidisciplinary and integrated approach to polymyalgia rheumatica and giant cell arteritis in Madrid region.

Polymyalgia rheumatica and giant cell arteritis can be a medical emergency in which a delay in correct diagnosis and therapeutic management can cause serious complications. With the aim of improving the care of patients with these pathologies in the Community of Madrid, a study was designed to identify the causes and possible solutions to address the problems related to the diagnosis of these pathologies. After the analysis, 11 areas of improvement related to four different aspects of the care process were identified: coordination and protocols, equipment, training and awareness of pathologies, and patient experience. Of all the areas identified, it was considered a priority to resolve those related to the generation of protocols for the comprehensive management of the pathologies, which include all the specialties and levels of care involved. Another crucial aspect is the increase in the degree of clinical suspicion of these pathologies.

Aryl hydrocarbon receptor interacting protein (AIP) significantly influences prognosis of pancreatic carcinoma.

INTRODUCTION: Aryl hydrocarbon receptor (AHR) is a ligand-activated transcription factor. Aryl hydrocarbon receptor interacting protein (AIP) in one of AHR ligands. The aim of this study is to analyze the prognostic influence of AIP in pancreatic carcinoma. MATERIAL AND METHODS: Retrospective case series with immunohistochemical analysis of AIP. We have estimated a multivariate Cox's model for the outcome (progression free and overall survival). RESULTS: 204 patients were included in the study. As expected prognosis was poor and 67.8% died of disease. As for AIP 9.8% of the cases showed nuclear staining of the epithelial tumor cells and 59.4% a cytoplasmic one. Stroma was stained in 53.1% of the cases. Univariate survival analysis revealed a significantly worse prognosis of patients with cytoplasmic AIP expression (stroma and epithelium), but nuclear expression was associated to a better prognosis. In the multivariate analysis stromal AIP expression was an independent prognosticator of progression free survival, together with pT stage, histological grade and history of diabetes. DISCUSSION: AIP Is a conserved cochaperone protein binding to many proteins. AIP has been proposed as a potential tumor suppressor gene. To date, no study has analyzed the immunohistochemical expression of AIP in pancreatic carcinoma. Our results indicate that both epithelial and stromal cytoplasmic expression of AIP is associated to bad prognosis, while nuclear translocation seems to improve prognosis. CONCLUSION: Although we must deepen into the complex signaling pathways underlying this potential association, our results open a way to inhibiting AHR as a potential target against pancreatic carcinoma.

Colorectal cribriform comedo-type adenocarcinoma: a distinct subtype with poor prognosis?

Colorectal cancer is one of the most commonly diagnosed cancers in the world. It is a heterogeneous disease with several histologic subtypes, and some of them are associated with adverse prognostic factors. Cribriform comedo-type adenocarcinoma (CCA) has been included as a colorectal adenocarcinoma subtype in the last World Health Organization (WHO) classification of gastrointestinal system tumors. Some authors have linked this subtype to an adverse prognosis, but to the best of our knowledge there is only one previous report assessing its histologic and prognostic features. We herein review a series of CCA of the colon, emphasizing its clinical and morphological features.

Anal cytology in women: Experience from a single tertiary center.

INTRODUCTION: Anal cytology (AC) can be used as a screening tool for detection of anal HPV associated lesions, mainly in men who have sex with men and in immunosuppressed patients. Our aim is to review our experience with AC in women. MATERIAL & METHODS: We have retrospectively reviewed all AC diagnosed between 2010-2017 in a single tertiary hospital (n = 644) and selected those performed in women (n = 158). RESULTS: 24.53% of AC were performed in women. 14.7% of all women were HIV positive and 56.7% referred anal intercourse. Squamous lesions were found in 27.2% of women, most of them ASCUS and LSIL (14% and 11.5%). HPV DNA was detected in 38.6% of patients, and 63.9% of them showed positivity for multiple high-risk types. Anal biopsy showed high grade lesions in 20% of biopsied patients. We observed a significant relationship between HPV status and receptive anal sex, and the association between HPV status and anal histological diagnosis tended to significance. Sensitivity, specificity, negative predictive value and positive predictive value for anal cytology were 57%; 83%; 28% and 94%, respectively. 70.9% of women had synchronous cervical cytology, and squamous cervical lesions were detected in 46.4% of the cases, most of them LSIL or ASCUS (21.4% and 15.2%). We did not confirm a significant association between cytological diagnosis of cervical and anal samples. CONCLUSIONS: AC is less widely used in women than in homosexual men. However, women show important rates of anal lesions, regardless of their HIV status. More studies should be performed to assess the potential impact of screening protocols in this population.

Globular amyloidosis of the colon.

Gastrointestinal involvement is frequent in systemic amyloidosis. However, amyloidosis can rarely be confined to the gastrointestinal tract or appear as a tumour mass. There have been few reports describing amyloid globular deposits in a variety of locations, as opposed to the usual linear ones. We herein report a rare case of globular amyloidosis involving the large bowel, which to the best of our knowledge is the second reported in the world literature. A 74-year-old man consulted on anaemia. Endoscopy showed ulcerative lesions in the left colon, which were biopsied and diagnosed as ischemic colitis. Under light microscopy, we found globular discrete deposits in the lamina propria which were Congo red-positive and resistant to permanganate digestion. Histopathological diagnosis was globular amyloidosis with AL deposits. The patient underwent further studies, including a haematologic evaluation that discarded systemic involvement. Globular amyloidosis seems to be a rare morphologic type of amyloidosis, but not a distinct entity. Its etiology, pathogenesis and relationship with patient prognosis and disease severity remain largely unknown. When amyloid deposits are confined to the gastrointestinal tract, systemic therapy can be avoided and patients should only be followed periodically. Immunohistochemical classification and clinical correlation are essential to rule out systemic amyloidosis.

Histopathological factors predicting response to neoadjuvant therapy in gastric carcinoma.

BACKGROUND: Neoadjuvant therapy (NAT) is a useful therapeutic option. However, some patients respond poorly to it and can even show tumor progression. It is important to define factors that can predict response to NAT. MATERIALS AND METHODS: This is a retrospective cohort study to define histopathological factors predicting response to NAT in gastric tubular carcinoma. This study has enrolled 80 patients receiving chemotherapy for locally advanced gastric carcinoma. RESULTS: 44.5% of the patients were men; mean age was 64.49 years. Only 5.7% of the patients showed a complete response to therapy, 10% had grade 1, 21.4% grade 2, and 62.9% grade 3 regression. On follow-up, 43.8% of the patients showed recurrence of disease (57.1% distant metastasis) and 33.8% eventually died of it. We found a statistically significant association between response and prognosis. We found a statistically significant association between regression and perineural, vascular, and lymph vessel invasion. Logistic regression model showed that only lymph vessel invasion had independent influence. Lymph vessel invasion not only indicated lack of response to therapy, but also higher incidence of lymph node involvement in the gastrectomy specimen. DISCUSSION: Our study indicates that the presence of vascular or perineural invasion in the endoscopic biopsies and high histopathological grade predict poor response to therapy. This seems peculiar, for undifferentiated tumors are supposed to have better response to therapy. CONCLUSION: Our study indicates that undifferentiated tumors respond worse to therapy. Furthermore, studies are necessary to define lack of response, to help avoid neoadjuvant therapy in unfavorable cases.

CPEB4 immunohistochemical expression is associated to prognosis in stage IV colorectal carcinoma.

The cytoplasmic polyadenylation element binding protein 4 (CPEB4) is a RNA binding protein and translational regulator. It has been associated with tumor growth, vascularization and invasion and with tumor progression in breast, pancreas and lung carcinomas. To the best of our knowledge only one previous report has analyzed the prognostic value of CPEB4 in an experimental model of colorectal carcinoma. We have reviewed the files of patients with stage IV colorectal carcinoma metastatic to the liver. All the patients had received chemotherapy followed by hepatic metastasis resection and subsequent resection of the colon (liver-first approach). We have gathered demographic, analytical and morphological data of the primary tumors. We have performed immunohistochemical analysis of CPEB4 expression in these tumors and analyzed the potential prognostic value of this protein. 50 patients fulfilled inclusion criteria for the present study. All of them received preoperative chemotherapy based on platinum and also postoperative chemotherapy, with or without targeted drugs (18% received anti-epidermal growth factor receptor (EGFR) drugs and 24% anti-vascular endothelial growth factor receptor (VEGFR) drugs. 66% of the primaries were of sigmoid-rectal origin. CPEB4 expression was mainly cytoplasmic and it was scored as intense in 46% of the patients. Survival analysis revealed a significant association between progression free survival (PFS) and overall survival (OS) and CPEB4 immunohistochemical expression, which was independent in the multivariate analysis. CPEB4 behaves as a significant predictor of prognosis in stage IV colorectal carcinoma. The existence of CPEB4 specific inhibitors can open a new way for targeted therapy. Larger prospective studies are needed to confirm our promising results.

Trough to peak ratio of once-daily lisinopril and twice-daily captopril in patients with essential hypertension.

The objective of this study was to assess the antihypertensive effect and the trough to peak (T:P) ratio of lisinopril and captopril, in patients with essential hypertension. After 2 weeks of placebo, 69 of 115 eligible patients had office diastolic blood pressure (DBP) between 90 and 114 mm Hg and daytime average DBP above 85 mm Hg during a 25-h ambulatory BP monitoring (ABPM) and were randomised to receive lisinopril (20 mg once daily) or captopril (50 mg twice daily) for 4 weeks. Office and ambulatory BP were then repeated. Indices of 24-h BP and T:P ratios were calculated and compared. Both drugs significantly reduced both office and ambulatory BP. The final BP obtained with lisinopril was less than with captopril. On office measurement, 75% of the patients treated with lisinopril and 44% on captopril were controlled (P < 0.001), but responses by ABPM were not significantly different. T:P ratios calculated in all patients were 0.75 and 0.66 for lisinopril and captopril respectively, but in patients who responded to each drug the corresponding ratios were 0.78 and 0.73. In conclusion both 20 mg once-daily lisinopril and 50 mg captopril twice-daily achieve a favourable T:P ratio in patients with essential hypertension.

[Ambulatory blood pressure monitoring in the aged. The EPICARDIAN study. The EPICARDIAN Work Group]. / Monitorización ambulatoria de la presión arterial en ancianos. Estudio EPICARDIAN. Grupo de trabajo EPICARDIAN.

OBJECTIVE: To determine reference values for ambulatory blood pressure in a random sample of Spanish elderly population, and their correlations with office blood pressure measurements. METHODS: A representative random sample was obtained, stratified by sex and age, of 1,227 elderly subjects aged > 65 years, residents in an urban district, Barrio de Salamanca, or Madrid, Spain. In a random subsample (n = 420), two different blood pressure measurement approaches were performed: Office blood pressure and twenty-four hour ambulatory blood pressure (spacelabs 90207) were recorded, and two periods were defined: awake and sleeping, on the basis of the daily activities. Hypertension was defined if the average of casual blood pressure was > or = 140/90 mmHg or if there was current use of antihypertensive drugs. RESULTS: Among the 420 participants, 333 ambulatory blood pressure monitorings were performed, 301 with valid registers, of whom 105 were receiving antihypertensive drug treatment. Office, 24 hour, awake and sleeping pressures averaged 147/84 mmHg, 128/72 mmHg, 132/77 mmHg and 122/66 mmHg respectively. Differences between whole sample and no treated group were not significant (p = 0.2), nor between the whole sample and the treated group (p = 0.7). Office blood pressure was markedly higher than 24 hour and awake averages (20 and 15 mmHg for systolic and 12 and 7 mmHg for diastolic, respectively). The differences between clinic and awake average blood pressures were significantly higher in females (p = 0.001) and increased, in both genders, as age (p = 0.001) and clinic blood pressure values (p < 0.000) increased. Correlation coefficients between office and the average awake period of the ambulatory blood pressures were of 0.60 and 0.48 for systolic and diastolic respectively. The ambulatory blood pressure value equivalent to 140/90 mmHg when obtained by causal measurement, was 15 mmHg lower when considering the 24 h average, or 10 mmHg lower when the awake averages. CONCLUSION: Ambulatory systolic and diastolic blood pressure values in the elderly are markedly lower than office values, specially in the case of systolic blood pressure. Differences in results between the two methods increase with age and with clinic blood pressure values, and are bigger in females. The cut-off point for ambulatory blood pressure monitoring equivalent to 140/90 mmHg in the casual measurement is of 125/75 mmHg for the 24 hour average and of 130/80 mmHg for awake average.

Differential distribution of [3H]sumatriptan binding sites (5-HT1B, 5-HT1D and 5-HT1F receptors) in human brain: focus on brainstem and spinal cord.

We report on the autoradiographic distribution of 5-HT1B, 5-HT1D and 5-HT1F receptor subtypes in human brain, focusing on the brainstem and cervical spinal cord. We have used [3H]sumatriptan as a radioligand in the presence of suitable concentrations of 5-CT (5-carboxamidotryptamine) to define 5-HT1F receptors, and ketanserin, to discriminate between 5-HT1B and 5-HT1D receptors. In the brainstem the highest concentrations of [3H]sumatriptan binding sites were seen in substantia nigra. The spinal trigeminal nucleus, substantia gelatinosa of the spinal cord, nucleus of the tractus solitarius and periaqueductal grey, also showed significant levels of [3H]sumatriptan binding sites. In the brainstem and spinal cord the total population of 5-CT-insensitive receptors, corresponding to 5-HT1F receptors, ranged from 9.8% in the periaqueductal grey to 53.4% in the substantia gelatinosa. This population represented 67.0% of binding in layer V of the frontal cortex. The decrease in [3H]sumatriptan binding in the presence of 200 nM ketanserin, indicative of the presence of 5-HT1D receptors, was very limited throughout the human brain, only reaching 20% of total specific binding over the periaqueductal grey. The proportion of [3H]sumatriptan binding sites displaced by 5-CT and insensitive to ketanserin, corresponding to 5-HT1B receptors, was, in general, the most abundant, ranging from 43.8% in substantia gelatinosa to 69.9% in the periaqueductal grey. Significant levels of 5-HT1B and 5-HT1D receptors found in migraine control pain areas suggest their involvement in antinociceptive mechanisms.

Identification and characterization of a new serotonergic recognition site with high affinity for 5-carboxamidotryptamine in mammalian brain.

We analyzed the existence of an additional serotonin (5-HT) receptor subtype, sensitive to 5-carboxamidotryptamine, in the mammalian brain. Radioligand binding studies with [3H]5-HT were carried out in rat, guinea pig, and human brain membranes, in the presence of unlabeled drugs to mask the binding to all known 5-HT receptors, with the exception of 5-HT1E sites. Under these conditions, unlabeled 5-carboxamidotryptamine still showed a biphasic competition curve with a nanomolar affinity component. Saturation studies with 5-[3H]carboxamidotryptamine were carried out in the presence of (+/-)-8-hydroxy-2-(di-n-propylamino)tetralin, mesulergine, and ergotamine, to mask the binding to all receptors known to be labeled by 5-carboxamidotryptamine. These studies showed the existence in cortex and hippocampus from guinea pig and human brain of a remaining binding site with high affinity (pK(D) = 7.8-8.1) and a unique pharmacological profile. 5-HT and 5-carboxamidotryptamine showed nanomolar affinity, whereas 5-methoxytryptamine recognized this binding site with intermediate affinity. Other drugs exhibited low or very low potency in inhibiting this binding. The addition of 5'-guanylylimidodiphosphate significantly reduced the number of binding sites labeled by 5-[3H]carboxamidotryptamine, in the presence of the masking drugs described above, indicating the interaction with a GTP-binding protein. Preliminary autoradiographic studies in human brain appear to indicate that this 5-HT binding site is present in areas such as the globus pallidus, neocortex, and hippocampus, among others.

Are Wistar-Kyoto rats a genetic animal model of depression resistant to antidepressants?

Wistar-Kyoto rats are reported to be very passive in the forced swimming test. In addition, they did not respond to acute administration of either desipramine or 8-hydroxy-2-(di-n-propylamino)tetralin (8-OH-DPAT). In the present experiment, it was studied whether or not they respond to acute and chronic administration of imipramine and the possible relationship to down-regulation of beta-adrenoceptors and 5-HT1 and 5-HT2 receptors. Sprague-Dawley and Brown-Norway rats were included in the study as it has been previously demonstrated that the two strains respond to acute desipramine and 8-OH-DPAT administration. Whereas acute administration of imipramine (15 mg/kg, three times in a 24 h period) significantly increased struggling and reduced immobility in Sprague-Dawley and Brown Norway rats, Wistar-Kyoto rats failed to respond to the drug. After chronic treatment with imipramine (13 days plus the acute imipramine treatment at the end of the treatment period), the three strains showed a positive response that was always significantly greater than the response to acute administration, but which was much lower in Wistar-Kyoto than in the other two strains. Down-regulation of both beta-adrenoceptors and 5-HT2 receptors was observed 24 h after the forced swimming test in acutely and chronically imipramine-treated rats of the three strains, except that in Sprague-Dawley rats beta-adrenoceptors did not change after acute imipramine. No significant decrease in 5-HT1 binding sites was observed in any strain. Acute imipramine administration caused a similar anorexia in Wistar-Kyoto as in the other strains and at least the same level of down-regulation of beta-adrenoceptors and 5-HT2 receptors. In addition, serum imipramine levels on the day after the last drug administration were higher in Wistar-Kyoto than in the other two strains. All these data suggest that the subsensitivity to imipramine observed in Wistar-Kyoto rats: (i) can not be primarily explained by pharmacokinetic differences, and (ii) does not appear to be related to the monoaminergic systems. Wistar-Kyoto rats might be therefore not only a good animal model of depressive-like (passive) behavior, but also a model of resistance to antidepressants which could be used to investigate the neurobiological basis of such resistance, which is also observed in some depressed patients.

Autoradiographic distribution of [3H]sumatriptan-binding sites in post-mortem human brain.

The anatomical distribution of [3H]sumatriptan-binding sites was analysed in brain tissue sections from 11 subjects. Relevant concentrations of [3H]sumatriptan-binding sites were seen in areas such as visual cortex > locus niger > globus pallidus > layers IV-V of the frontal cortex > subiculum > entorhinal cortex > nucleus tractus solitarius > nucleus trigeminalis caudalis. This distribution of [3H]sumatriptan-binding sites in the human brain shows some differences when compared with that of 5HT1D receptors, confirming that, besides 5HT1D, sumatriptan also binds to 5HT1F receptor subtype. Some species differences are evident between the distribution of [3H]sumatriptan-binding sites in the human brain and that reported for guinea-pig and rat brains, emphasizing that caution is needed in extrapolating experimental data from animals to humans. Furthermore, these data help to explain some of the therapeutic actions of sumatriptan. The remarkable levels of binding found in areas as nucleus tractus solitarius and nucleus trigeminalis caudalis suggest that in migraine attacks sumatriptan could exert its specific anti-emetic effects and, partly at least, induce analgesia by directly acting over these brain nuclei.

[3H]Sumatriptan binding sites in human brain: regional-dependent labelling of 5-HT1D and 5-HT1F receptors.

The general properties of [3H]sumatriptan binding sites in postmortem human brain tissue sections are described. High concentrations of autoradiographic grains were seen in globus pallidus = substantia nigra > cortex > putamen > hippocampus. While 5-HT (5-hydroxytryptamine) displaced in all regions more than 90% of [3H]sumatriptan binding, the level of binding inhibited by 5-CT (5-carboxamidotryptamine) varied in each region. Although the binding inhibited by 5-CT in some regions such as globus pallidus and substantia nigra was equivalent to that obtained with 5-HT, in cortical areas, such as frontal cortex and hippocampus, a substantial level of binding insensitive to 5-CT was seen. In addition, in membrane binding assays, 10 nM metergoline displaced most [3H]sumatriptan specific binding in striatum and only 16% in frontal cortex. In the human brain sumatriptan binds to at least two 5-HT1 receptors, 5-HT1D and 5-HT1F.

Ontogenetic development of 5-HT1D receptors in human brain: an autoradiographic study.

The pattern of pre- and postnatal appearance of 5-HT1D receptors throughout the different areas of the human brain was studied by quantitative in vitro autoradiography, using [125I]GTI (serotonin O-carboxymethyl-glycyl-[125I]tyrosinamide) as a ligand. The anatomical distribution of 5-HT1D receptors in neonatal, infant and children's brain was in good agreement with that observed in the adult, the basal ganglia and substantia nigra being the most intensely labelled areas. The development of these receptors throughout the human brain was mainly postnatal: low densities of [125I]GTI binding sites were observed at the fetal/neonatal stage in most regions analyzed, in contrast with the high levels of labelling found in infant and children's brains. Indeed, in a number of regions, including the globus pallidus, substantia nigra and visual cortex, a peak of overexpression of 5-HT1D receptors was observed in the first decade of life. Such overexpression could support a regulatory role for 5-HT1D receptors in advanced periods of the CNS developmental process. Our results also indicate that the administration of drugs acting on 5-HT1D receptors during the early postnatal period of life could result in modifications of their properties, as these receptors are already functional in this period.

Autoradiographic demonstration of increased alpha 2-adrenoceptor agonist binding sites in the hippocampus and frontal cortex of depressed suicide victims.

To examine directly in the brain the status of alpha 2-adrenoceptors in major depression, the specific binding of the agonist [3H]UK 14304 was measured by quantitative receptor autoradiography in the hippocampus and frontal cortex of suicide victims (n = 17) with a retrospective diagnosis of depression (n = 7) or other psychiatric disorders (n = 10) as well as of matched control subjects (n = 9). In suicide victims, a significant increase in the number of alpha 2-adrenoceptors was found in the CA1 field (40%) and dentate gyrus (20%) of the hippocampus and in the external layers I (33%) and II (31%) of the frontal cortex, compared with that in matched controls. In depressed suicide victims, the increase in alpha 2-adrenoceptors in the CA1 field (57%) was significantly greater (24%, p < 0.05) than that observed in the group of suicide victims with other diagnoses (26%). In the same depressed suicide victims, the increase in cortical alpha 2-adrenoceptors was restricted to layer I (34%) and it was equivalent to that found in layer I (33%) of suicide victims with other diagnoses. The results indicate that suicide is associated with increases in the high-affinity state of brain alpha 2-adrenoceptors adrenoceptors and that there is a pronounced localized increase of this inhibitory receptor in the hippocampus of depressed suicide victims.