Epigenetics in Glaucoma.

Primary open angle glaucoma (POAG) is defined as a "genetically complex trait", where modifying factors act on a genetic predisposing background. For the majority of glaucomatous conditions, DNA variants are not sufficient to explain pathogenesis. Some genes are clearly underlying the more "Mendelian" forms, while a growing number of related polymorphisms in other genes have been identified in recent years. Environmental, dietary, or biological factors are known to influence the development of the condition, but interactions between these factors and the genetic background are poorly understood. Several studies conducted in recent years have led to evidence that epigenetics, that is, changes in the pattern of gene expression without any changes in the DNA sequence, appear to be the missing link. Different epigenetic mechanisms have been proven to lead to glaucomatous changes in the eye, principally DNA methylation, post-translational histone modification, and RNA-associated gene regulation by non-coding RNAs. The aim of this work is to define the principal epigenetic actors in glaucoma pathogenesis. The identification of such mechanisms could potentially lead to new perspectives on therapeutic strategies.

Efficacy and Safety of Artificial Tears Containing Lipidure and Hypromellose for the Treatment of Moderate Dry Eye Disease in Contact Lens Wearers.

Background and Objectives: Dry eye disease (DED) affects 5-50% of the global population and deeply influences everyday life activities. This study compared the efficacy, tolerability, and safety of novel Respilac artificial tears containing lipidure and hypromellose (HPMC) with the widely used Nextal artificial tears, which are also HPMC-based, for the treatment of moderate DED in contact lenses (CL) wearers. Materials and Methods: In a prospective, single-center, randomized investigation, 30 patients aged ≥18 years, diagnosed with moderate DED, and wearing CL were randomly assigned to the Respilac (n = 15) or Nextal group (n = 15). Patients self-administrated one drop of Respilac or Nextal in both eyes three times daily for 21 days. Changes in the endpoint (visual analogue scale (VAS) score for ocular tolerability, symptom assessment in dry eye (SANDE) score, non-invasive first break-up time (NIF-BUT) results, tear analysis value, meibography results, and CL tolerability results were assessed, comparing treatment groups and time-point evaluations. Adverse events (AEs) were also recorded and evaluated. Results: VAS scores decreased with time (p < 0.001) in both groups, showing no statistically significant difference among them (p = 0.13). Improvements were also detected from screening to end-of-treatment, which were indicated by the SANDE scores for severity and frequency (p < 0.001) and by tear analysis results (p < 0.001) with no observed difference between the Nextal and Respilac arms. NIF-BUT, meibography, and CL tolerability values were shown to be non-significantly affected by treatment and time. There were no AEs detected in this study cohort. Conclusions: Respilac was confirmed to be effective, safe, and well-tolerated. Lipidure-based ophthalmic solution was shown not to be inferior to the currently used Nextal, however, showing improvements in DED symptoms. Within the existing literature, our study is one of the first to report that MPC plus HPMC-containing eye drops are an effective option for the treatment of moderate dry eye disease and desiccation damage prevention in contact lens wearers.

Granular Layer Neurons Control Cerebellar Neurovascular Coupling Through an NMDA Receptor/NO-Dependent System.

Neurovascular coupling (NVC) is the process whereby neuronal activity controls blood vessel diameter. In the cerebellum, the molecular layer is regarded as the main NVC determinant. However, the granular layer is a region with variable metabolic demand caused by large activity fluctuations that shows a prominent expression of NMDA receptors (NMDARs) and nitric oxide synthase (NOS) and is therefore much more suitable for effective NVC. Here, we show, in the granular layer of acute rat cerebellar slices, that capillary diameter changes rapidly after mossy fiber stimulation. Vasodilation required neuronal NMDARs and NOS stimulation and subsequent guanylyl cyclase activation that probably occurred in pericytes. Vasoconstriction required metabotropic glutamate receptors and CYP ω-hydroxylase, the enzyme regulating 20-hydroxyeicosatetraenoic acid production. Therefore, granular layer capillaries are controlled by the balance between vasodilating and vasoconstricting systems that could finely tune local blood flow depending on neuronal activity changes at the cerebellar input stage. SIGNIFICANCE STATEMENT: The neuronal circuitry and the biochemical pathways that control local blood flow supply in the cerebellum are unclear. This is surprising given the emerging role played by this brain structure, not only in motor behavior, but also in cognitive functions. Although previous studies focused on the molecular layer, here, we shift attention onto the mossy fiber granule cell (GrC) relay. We demonstrate that GrC activity causes a robust vasodilation in nearby capillaries via the NMDA receptors-neuronal nitric oxide synthase signaling pathway. At the same time, metabotropic glutamate receptors mediate 20-hydroxyeicosatetraenoic acid-dependent vasoconstriction. These results reveal a complex signaling network that hints for the first time at the granular layer as a major determinant of cerebellar blood-oxygen-level-dependent signals.

Non-Linear Frequency Dependence of Neurovascular Coupling in the Cerebellar Cortex Implies Vasodilation-Vasoconstriction Competition.

Neurovascular coupling (NVC) is the process associating local cerebral blood flow (CBF) to neuronal activity (NA). Although NVC provides the basis for the blood oxygen level dependent (BOLD) effect used in functional MRI (fMRI), the relationship between NVC and NA is still unclear. Since recent studies reported cerebellar non-linearities in BOLD signals during motor tasks execution, we investigated the NVC/NA relationship using a range of input frequencies in acute mouse cerebellar slices of vermis and hemisphere. The capillary diameter increased in response to mossy fiber activation in the 6-300 Hz range, with a marked inflection around 50 Hz (vermis) and 100 Hz (hemisphere). The corresponding NA was recorded using high-density multi-electrode arrays and correlated to capillary dynamics through a computational model dissecting the main components of granular layer activity. Here, NVC is known to involve a balance between the NMDAR-NO pathway driving vasodilation and the mGluRs-20HETE pathway driving vasoconstriction. Simulations showed that the NMDAR-mediated component of NA was sufficient to explain the time course of the capillary dilation but not its non-linear frequency dependence, suggesting that the mGluRs-20HETE pathway plays a role at intermediate frequencies. These parallel control pathways imply a vasodilation-vasoconstriction competition hypothesis that could adapt local hemodynamics at the microscale bearing implications for fMRI signals interpretation.

Dry Eye in Systemic Sclerosis Patients: Novel Methods to Monitor Disease Activity.

BACKGROUND: In systemic sclerosis (SSc) patients, dry eye syndrome (DES) is the most frequent ocular feature. The aim of this study was to investigate ocular DES-related SSc patients and to establish any correlation with the severity of the disease. METHODS: Retrospectively, data from 60 patients with SSc underwent ophthalmic examination, where non-invasive film tear break-up time (NIF-TBUT), tear film lipid layer thickness (LLT), anesthetic-free Schirmer test I, tear osmolarity measurement (TearLab System), and modified Rodnan skin score (mRSS) data were collected. The visual analog scale (VAS) and Symptom Assessment in Dry Eye (SANDE) methods were utilized. The results were correlated with mRSS and the duration of SSc. RESULTS: Severe DES occurred in 84% of cases, and was more severe in women. The eyelids were involved in 86.6%, secondary to meibomian gland disease (MGD). A direct correlation was found between the tear osmolarity (mean 328.51 ± 23.8 SD) and skin score (mRSS) (r = 0.79; p < 0.01). Significantly reduced NIF-TBUT, LLT, and Schirmer test I values were observed in the case of severe skin involvement. CONCLUSIONS: SSc patients show lipid tear dysfunction related to the severity and duration of the disease due to inflammation and the subsequent atrophy of the meibomian glands.

Biliary stent migration into the abdominal wall: a case report.

Biliary stent migration occurs in about 5% of patients. The most common complications secondary to stent migration are pancreatitis, small bowel perforation and peritonitis. We report the case of a patient presenting with an abdominal wall abscess secondary to migration of a biliary stent. Direct abdominal radiography, abdominal ultrasound and CT scan have proved very useful in the diagnosis, providing the correct localisation of the stent in the left rectus muscle of the abdominal wall that led to a surgical approach under local anaesthesia for the removal, and abscess formation surrounding the stent. The patient was discharged on the day after surgery. After reviewing the literature concerning this rare complication, the Authors conclude that closer monitoring of patients with biliary prostheses is needed to prevent the migration and the consequent serious complications.

Laparoscopic surgical treatment of perforated duodenal ulcer.

Perforation of peptic ulcer is a surgical emergency which still carries a risk of mortality. The main risk factors are delayed diagnosis > 24 hours, ASA-III or ASA-IV, age over 70 years, and associated cardiorespiratory pathologies. There is no unanimous consensus regarding the gold standard treatment of such complications. In this study we report our experience and analyse the literature with the aim of assessing the possible advantages of laparoscopic treatment of perforated duodenal ulcers versus open surgery. From April 2003 to December 2008, 39 patients underwent laparoscopic repair and 7 patients open repair of perforated duodenal ulcer. The following parameters were evaluated in all patients: operative time, duration of hospital stay, time to intestinal canalisation, morbidity and mortality. The conversion rate, in laparoscopic treated patients, was 0%. The mean operative time was longer in the laparoscopic group than in the open group (76.15 +/- 9.49 vs. 63.57 +/- 15.19 minutes; Mann Whitney test p < 0.05). The laparoscopic cases had a shorter mean hospital stay than the open cases (5.8 +/- 1.02 vs. 7.8 +/-1.34 days; Mann Whitney test p < 0.001). The time to canalisation in the two groups of patients was similar. One patient (2.56%) in the laparoscopic group and two (28.57%) in the open repair group presented morbidity in the postoperative period. One patient (ASA IV) in the open group died. Laparoscopic treatment in the emergency setting is a safe, reliable procedure, affording all the advantages of the minimally invasive approach.

Laparoscopic appendectomy for acute appendicitis.

The advantages and applications of the videolaparoscopic technique (VL) versus open surgery in the treatment of acute and complicated appendicitis are not well defined. The aim of this study was to identify which of the two procedures is more suitable. The study examined 124 patients, 73 females (57.5%) and 51 males (42.5%). We compared 62 patients in the laparoscopic group with 62 open surgery patients. We analysed the results of the two groups (VL, open) for age, gender, operative time, hospital stay, complications and costs. The mean patient age was 24.1 years (range: 4-70). The conversion rate was 1.6% (1 case/62). The patients in the laparoscopic group were predominantly female (p < 0.0001). The average age of VL patients compared to open surgery was significantly higher (p < 0.01). The mean operative time was not significantly different between the two groups. The hospitalisation time was shorter for the laparoscopic group (4.77 vs. 6.39 days, p < 0.01). Complications were 0% for VL and 4.81% for the open group. The average operation cost in the open group was 8070.00 euros (+/- 4267) and 6818.00 euros (+/- 1446,00) for VL (p < 0.05). Laparoscopic appendectomy has significant advantages over traditional open surgery and should be the first choice in cases of acute but uncomplicated appendicitis.

[GPs' self-perception of their own role compared with hospital, ambulatory, academic, and health organisation physicians]. / Auto-percezione del ruolo professionale in medicina generale nel confronto con il medico specialista.

Aim of the present study was to explore how the 76 general practitioners (GPs) - serving Carpi district (90,000 residents) - value their own role compared with the hospital, ambulatory, academic, and health organisation physicians'. GPs had a positive self-image only in comparison with health organisation doctors (7 vs 7 grades). GPs disappointed with themselves when comparing their role with ambulatory (-1.6 grades), academic (-1.9 grades) and hospital doctors (-2.2 grades). Secondarily, GPs perceived patients' valuing their professional role mostly 'subordinate' to the other physicians', except health organisation colleagues'.

A novel Ca²âº-mediated cross-talk between endoplasmic reticulum and acidic organelles: implications for NAADP-dependent Ca²âº signalling.

Nicotinic acid adenine dinucleotide phosphate (NAADP) serves as the ideal trigger of spatio-temporally complex intracellular Ca(2+) signals. However, the identity of the intracellular Ca(2+) store(s) recruited by NAADP, which may include either the endolysosomal (EL) or the endoplasmic reticulum (ER) Ca(2+) pools, is still elusive. Here, we show that the Ca(2+) response to NAADP was suppressed by interfering with either EL or ER Ca(2+) sequestration. The measurement of EL and ER Ca(2+) levels by using selectively targeted aequorin unveiled that the preventing ER Ca(2+) storage also affected ER Ca(2+) loading and vice versa. This indicates that a functional Ca(2+)-mediated cross-talk exists at the EL-ER interface and exerts profound implications for the study of NAADP-induced Ca(2+) signals. Extreme caution is warranted when dissecting NAADP targets by pharmacologically inhibiting EL and/or the ER Ca(2+) pools. Moreover, Ca(2+) transfer between these compartments might be essential to regulate vital Ca(2+)-dependent processes in both organelles.

Liver damage after transarterial chemoembolization without embolizing agent in unresectable hepatocellular carcinoma.

AIM AND BACKGROUND: Transarterial chemoembolization represents a therapy for hepatocellular carcinoma, but in cirrhotic patients affected by large or multifocal HCC with poor hepatic functional reserve, the procedure can damage normal parenchyma. We analyzed the effects on hepatic function of a modified chemoembolization consisting of ethiodized oil (Lipiodol Ultra Fluid) and epirubicin without gelatine sponge (C-LIP). METHODS: Of 90 patients with hepatocellular carcinoma observed from January 1995 to December 1999, 16 with a diagnosis of advanced (large or multifocal) disease underwent 19 C-LIP. The 30th post-C-LIP day was considered as a checkpoint of the biochemical parameters for a possible hepatic failure. The value of alpha-fetoprotein and the clinical finding of ascites were also considered after 30 days. RESULTS: Postoperative values of serum aspartate aminotrasferases, as well as alanine aminotransferase, were significantly higher than preoperative values (P = 0.002 and P = 0.019, respectively) (Table 1). In all patients, there was a significant increase in postoperative total serum bilirubin (P = 0.003). Statistical analysis showed a significant finding of postoperative ascites (P = 0.035) and the effectiveness of C-LIP on neoplastic tissue by a decrease of alpha-fetoprotein values at 30 days (P = 0.067). CONCLUSIONS: Transcatether arterial chemoembolization could represent an effective therapy against multifocal or advanced hepatocellular carcinoma, and its effectiveness is probably not decreased by using a modified procedure without embolizing agent (C-LIP). However, even when performing such a safe procedure, the hepatic functional reserve of the individual patient needs to be accurately evaluated in order to avoid liver failure.

Biliary carcinoembryonic antigen in the diagnosis of occult hepatic metastases from colorectal cancer.

BACKGROUND AND OBJECTIVES: Twenty five percent of patients who undergo radical surgical treatment for colorectal cancer have occult hepatic metastases that become evident during the follow-up period. We evaluated whether biliary carcinoembryonic antigen (CEA) measurements could be used in these patients to diagnose occult hepatic metastases. METHODS: Three groups of patients were enrolled in the study. The first group consisted of patients treated for lithiasis of the common bile duct, the second group was affected by colorectal cancer and evident hepatic metastases, and the third group of patients underwent radical surgical treatment for colorectal cancer but had no evident hepatic metastases. RESULTS: In the first study group, mean biliary CEA level was 0.52 ng/mL (normal value: 0-5 ng/mL) (diagnostic accuracy: 100%), 83.3 ng/mL in the second group (diagnostic accuracy: 91%) and 3.9 ng/mL in the third group. We registered only one false-positive result in the third group, whereas biliary CEA level was above normal values in the three patients in whom hepatic metastases developed (diagnostic accuracy: 89.5%). CONCLUSIONS: This study suggests that biliary CEA determination could represent an important method to select patients affected by occult hepatic metastases for inclusion in appropriate treatment protocols.