Multi-omic lineage tracing predicts the transcriptional, epigenetic and genetic determinants of cancer evolution.

Cancer is a highly heterogeneous disease, where phenotypically distinct subpopulations coexist and can be primed to different fates. Both genetic and epigenetic factors may drive cancer evolution, however little is known about whether and how such a process is pre-encoded in cancer clones. Using single-cell multi-omic lineage tracing and phenotypic assays, we investigate the predictive features of either tumour initiation or drug tolerance within the same cancer population. Clones primed to tumour initiation in vivo display two distinct transcriptional states at baseline. Remarkably, these states share a distinctive DNA accessibility profile, highlighting an epigenetic basis for tumour initiation. The drug tolerant niche is also largely pre-encoded, but only partially overlaps the tumour-initiating one and evolves following two genetically and transcriptionally distinct trajectories. Our study highlights coexisting genetic, epigenetic and transcriptional determinants of cancer evolution, unravelling the molecular complexity of pre-encoded tumour phenotypes.

Studies on metabolically depleted erythrocytes.

Erythrocytes kept outside the blood circulation undergo progressive changes in metabolism, shape and function, which was the topic of this study. For that purpose, blood anticoagulated with either heparin, citrate or EDTA was incubated at temperatures of 5°C, 22°C or 37°C for 0 h, 24 h and 48 h, respectively. A temperature- and time-dependent decrease of glucose and ATP and increase of lactate and LDH were observed. An erythrocyte swelling and echinocytic shape transformation, which was also time- and temperature-dependent, was seen. Density-separated young and old erythrocytes behaved similarly. The degree of echinocytic shape transformation correlated with the increase in blood viscosity at high shear rate. Echinocytosis was partially reversible when erythrocytes were suspended in buffer containing 0.2% albumin. This phenomenon is specific for albumin, since molecules with a similar molecular weight (dextran 70, heat shock protein, protein C) had no effect. These finding may have an impact on blood banking and transfusion medicine.

Applicability of a new robotic walking aid in a patient with cerebral palsy. Case report.

BACKGROUND: Gait training with the help of assistive technological devices is an innovative field of research in neurological rehabilitation. Most of the available gait training devices do not allow free movement in the environment, which would be the most suitable natural and motivating condition for training children with neurological gait impairment. AIM: To evaluate the potential applicability of a new robotic walking aid as a tool for gait training in non-ambulatory children with Cerebral Palsy. DESIGN: Single case study SETTING: Outpatient regimen POPULATION: A 11-years-old child unable to stand and walk independently as a result of spastic tetraplegic cerebral palsy (CP). METHODS: The experimental device was a newly actuated version of a dynamic combined walking and standing aid (NF-Walker®) available in the market which was modified by means of two pneumatic artificial muscles driven by a foot-switch inserted in the shoes. The child was tested at baseline (while maintaining the standing position aided by the non-actuated NF-Walker®) and in the experimental condition (while using the actuated robotic aid). The outcome measures were: 2-minute walking test, 10-metre walking test, respiratory and heart parameters, energy cost of locomotion. RESULTS: At baseline, the child was unable to perform any autonomous form of locomotion. When assisted by the actuated aid (i.e. during the experimental condition), the child was successful in moving around in his environment. His performance was 19.63 m in the 2-minute walking test and 64 s in the 10-metre walking test. Respiratory and heart parameters were higher than healthy age-matched children both at baseline and in the experimental condition. The energy cost of gait, which was not valuable in the baseline condition, was significantly higher than normality during the experimental condition. CONCLUSION: The new robotic walking aid may help children suffering from CP with severe impairment of gait to move around in their environment. CLINICAL REHABILITATION IMPACT: This new robotic walking device may have a potential impact in stimulating the development and in training of gait in children with neurological gait impairment. Future studies are warranted in order to test this hypothesis.

[Pier Luigi Viola and vinyl chloride: notes that were never published]. / Pier Luigi Viola e ii cloruro di vinile: alcuni appunti mai pubblicati.

The name and work of Pier Luigi Viola (1917-1985) are unequivocally connected with the history of the discovery of the toxic effects of vinyl chloride, cancer in particular. A biography and a bibliography of Professor Viola are still lacking but his work is well documented; equally well known is his professional career as an occupational physician who spent his entire working life as an employee of one single industrial group, Solvay; his work was dedicated firstly to taking care of the health of the workers of the Corporation and not only in Italy, and secondly to organizing the occupational health departments of all Solvay's establishments in Italy. This positive connection between occupational physician and scientist has recently been challenged in certain historical reconstructions of the discovery of vinyl chloride's carcinogenicity: in particular, these reconstructions (which we do not consider to be coherent with the facts) depict Viola as in constant conflict with his employer. As crucial support to this view are offered on the one hand a statement by Viola, in 1980, that "At the basis of every discovery there is frequently the poetical imagination of a researcher who is always alone in facing the difficulties of the research, difficulties that rise up against him like a wall reaching up to the sky"; and on the other the supposed failure to find some of Professor Viola's notes which should reflect his spiritual testimony, and from which should emerge "the suffering, the torments, and the pressures of that initial period". The true history is very different: the notes do exist: they were personally delivered to one of the authors (PB) by Viola's widow a few months after his death; they are in fact the first pages of a planned book on vinyl chloride that Viola never actually succeeded in writing. In these pages Viola developed some personal reflections from which it is clear that he was conscious of having been in the centre ofa fantastic adventure in the field of scientific research in which he also played the principal role; there is no mention whatsoever of any conflict or contrast between Viola and Solvay. In fact, the backdrop to this story reflects the typical dynamics of scientific research. The article continues with the publication of Viola's handwritten notes: in this way the supposed "mistery of the missing notes" is solved.

Acute effects of short-term exposure to second-hand smoke on induced platelet aggregation.

Passive smoking may increase cardiovascular events by yet insufficiently understood mechanisms. We, therefore, tested the hypothesis that passive smoking could affect platelet aggregation. Fourteen healthy non-smoking males were exposed to second-hand smoke during 60 min in a room with smokers, who maintained the CO-concentration between 4.5-7.0 ppm throughout that period. Citrated blood was drawn before and immediately after smoke exposure (which took place between 6 and 7 p.m.). The last 7 individuals had blood taken also at 9.00 a.m. before and the day after smoke exposure. Platelet aggregation was measured (a) in flowing whole blood using the platelet function analyser PFA-100, which determines the closure time (CT) of a collagen coated membrane pore by shear-induced platelet aggregation, and (b) with a Chrono-log 700 Aggregometer, assessing platelet aggregation either by the change of impedance in diluted whole blood or light transmission in platelet-rich plasma. After short term second-hand smoke exposure we did not observe an increase in platelet aggregation with any of the instruments. We conclude that acute exposure to second-hand smoke is unlikely to increase platelet aggregability. Other mechanisms must be involved in the increased risk of cardiovascular events associated with passive smoking.

Reduced incidence of acute myocardial infarction in the first year after implementation of a public smoking ban in Graubuenden, Switzerland.

OBJECTIVE: On March 1st, 2008 a smoking ban in public buildings became effective in the Canton of Graubuenden, Switzerland. The aim of our study was to investigate, whether implementation of this new regulation was followed by a decrease in the incidence of acute myocardial infarction (AMI). PATIENTS AND METHODS: The Kantonsspital Graubuenden serves as a tertiary care hospital, possessing the only cardiac catheterization laboratory in the Canton of Graubuenden. Based on an excellent functioning network including all hospitals in the Canton of Graubuenden, virtually all patients experiencing an AMI in the Canton of Graubuenden are transferred to our hospital for either acute or early coronary angiography. Data of all patients with AMI undergoing coronary angiography at our hospital between March 1st, 2008 and February 28th, 2009 were collected prospectively. The data were then compared with those of the two corresponding 12-month periods preceding implementation of the public smoking ban. RESULTS: In the two years before adoption of smoke-free legislation, the number of patients with AMI was 229 and 242, respectively (p = ns). In the 12 months after implementation of the public smoking ban, the number of AMI patients dropped to 183 (p <0.05 vs. each of the previous 12-month periods), representing an overall 22% reduction in the AMI incidence within the first year after enactment of the new regulation. This reduction was driven by a significant decrease in the AMI incidence in men, nonsmokers, and individuals with established coronary artery disease, including those with prior AMI or prior percutaneous coronary intervention. CONCLUSIONS: Similar to other countries in Europe and various regions of the USA and Canada, implementation of a public smoking ban was followed by a significant early decline in the incidence of AMI in the Canton of Graubuenden, Switzerland.

Clinical efficacy and safety of telmisartan 80 mg once daily compared with enalapril 20 mg once daily in patients with mild-to-moderate hypertension: results of a multicentre study.

The efficacy and safety of once-daily telmisartan 80 mg vs. once-daily enalapril 20 mg in the treatment of essential hypertension were evaluated in a multicentre, single-blind, placebo-controlled, randomised trial. In total, 68 patients (49 females, 19 males) with mild-to-moderate hypertension, defined as morning supine systolic blood pressure (SBP) 141-149 mmHg, diastolic blood pressure (DBP) 95-114 mmHg, were enrolled. After a 4-week placebo run-in phase, patients were randomly assigned to treatment with telmisartan or enalapril administered once daily in the morning for 8 weeks. No statistically significant differences were found in the baseline characteristics of patients in either group. Both SBP and DBP were decreased in both treatment groups, but the reductions were statistically different in favour of telmisartan (SBP, p = 0.013; DBP, p = 0.002). The incidence of adverse effects was lower in the telmisartan group, with the absence of cough. In conclusion, telmisartan is more effective and better tolerated than enalapril for the treatment of hypertension and has the advantage that it does not cause cough.

Clinical efficacy and safety of telmisartan 80 mg once daily vs. atenolol 50 mg once daily in patients with mild-to-moderate hypertension.

The objective of this open-label, parallel-group comparative study was to assess the clinical efficacy and safety of once-daily treatment for 8 weeks with telmisartan 80 mg in comparison with atenolol 50 mg on systolic blood pressure (SBP) and diastolic blood pressure (DBP) in patients with mild-to-moderate hypertension (morning supine SBP 141-199 mmHg, DBP 95-114 mmHg). A total of 58 patients were enrolled. The comparability of the two treatment groups was statistically documented at the beginning of the study. Telmisartan was more effective than atenolol, with a decrease in SBP of 21.7 mmHg vs. 11.8 mmHg (p = 0.03) and a non-significant decrease in DBP of 14.7 mmHg vs. 10.1 mmHg. The safety profiles of both drugs were very similar; both drugs were well tolerated. In conclusion, once-daily telmisartan 80 mg is more effective than once-daily atenolol 50 mg in lowering SBP with no negative chronotropism. Furthermore, telmisartan was as well tolerated as atenolol in the treatment of mild-to-moderate essential hypertension in adults.

[Catch-up growth and final height in celiac disease].

BACKGROUND: Growth retardation resulting from celiac disease diagnosed in infancy or in early childhood is remediable after introduction of a gluten-free diet. The aim of this study was to evaluate long-term growth, catch-up growth and final height in a group of treated patients with celiac disease. METHODS: The study population consisted of 35 patients (13 M, 22 F) with typical celiac disease. Age at diagnosis was 1.17 (+/- 0.69) years. For each patient, the standard deviation score (SDS) and centile of height at diagnosis, target height and final height were elaborated, and linear regression and correlations between SDS of final height and age at diagnosis, SDS of height at diagnosis and SDS of target height, respectively, were calculated. RESULTS: At diagnosis patients had a general tendency to short stature: mean height was 81.8 cm +/- 22.9 cm (SDS -0.75 +/- 1.61), while target height was 164.3 cm +/- 13.5 cm (SDS -0.14 +/- 1.04) and final height 169.2 cm +/- 7.7 cm (SDS 0.41 +/- 1.04). Linear regression and correlations between SDS of final height and age at diagnosis, SDS of height at diagnosis and SDS of target height, respectively, proved nonsignificant. CONCLUSIONS: Irrespective of age and height at diagnosis, catch-up growth was complete in this group of patients, with satisfactory achievement of final height. Only one patient (age at diagnosis 13 years) failed to reach the target height.

Premature arterial and venous events in three families. Effect of folate levels and MTHFR mutation mediated by family/generation and homocysteine levels.

Plasma homocysteine levels result from the effect of genetic and environmental factors. We investigated the hypothesis of familial association between folates, methylenetetrahydrofolate reductase (MTHFR) and hyperhomocysteinemia with acute events, studying three families through pedigree analysis and log-linear graphical models. In 43 subjects, 13 had homocysteine levels of >15 micromol/l. In Family A, premature venous and arterial events occurred in father and son, respectively. In Family B, several arterial premature events occurred and very high homocysteine level was found in a healthy 18-year-old nephew. In Family C, stroke occurred at the age of 16 in a boy. In all three families, all subjects with premature cardiovascular events had high homocysteine level as well as MTHFR mutation, either homozygous or heterozygous. The present results underline that hyperhomocysteinemia has a direct conditional association with cardiovascular events. Moreover, homocysteine level is a variable that links the indirect association of folates, MTHFR mutation and cardiovascular event.

BMI centile as an indicator of degree of obesity in childhood.

OBJECTIVE: To evaluate body mass index (BMI centile) as an indicator of degree of obesity in childhood. DESIGN: Random. SETTING: Obese and nonobese healthy children were recruited in the Verona University Department of Pediatrics and Division of Pediatrics of the Verona City Hospital. SUBJECTS AND METHODS: 70 males aged 9.7 +/- 2.75 years and 55 females aged 9.9 +/- 3 years. Percentage fat mass was estimated by bioelectrical impedance analysis using Kushner's equation, and Italian BMI charts (A. Luciano et al. 1997) were used to calculate the BMI centile (BMI > 90 degrees in 76 subjects and BMI < 90 degrees in 59 subjects). RESULTS: Linear regression analysis and correlations between percentage fat mass and BMI centile were significant in males (P = 0.000, r = 0.6) and females (P = 0.000, r = 0.7) in both obese and nonobese subjects. CONCLUSIONS: BMI is a reliable, easy-to-use indicator of degree of obesity in childhood. Pediatricians should be encouraged to use BMI centiles to assess childhood obesity and particularly the onset of overweight, its evolution and its response to different types of management.

[Approach to constipation in children]. / L'approccio alla stipsi nel bambino.

This article presents a diagnostic and therapeutic approach to children with constipation. Causes of constipation can be organic or non-organic (functional). Functional constipation may lead to functional fecal retention. The history and physical examination are most important. Laboratory and radiologic examinations are not warranted in the majority of children.

Improving time-sensitive processes in the intensive care unit: the example of 'door-to-needle time' in acute myocardial infarction.

OBJECTIVE: To assess and reduce delays in coronary thrombolysis in patients with acute myocardial infarction. DESIGN: Prospective, descriptive study using statistical process control. SETTING: Interdisciplinary intensive care unit of a 300-bed community hospital. SUBJECTS: Thirty-seven consecutive patients with acute myocardial infarction who were receiving thrombolytic therapy. INTERVENTIONS: To perform an interdisciplinary formal process analysis aimed at detecting delay-causing factors, review of existing house rules, generation and implementation of new practice guidelines. MAIN OUTCOME MEASURES: Comparison of 'door-to-needle times' of patients admitted before, during and after formal process analysis and implementation of new guidelines. RESULTS: Mean 'door-to-needle time' fell significantly from 57 minutes (+/-25.4) in 16 patients studied before, to 32 minutes (+/-9.0) in 16 patients studied after the formal process analysis and the implementation of new guidelines (P < 0.002). An even more pronounced but transient decrease to 24 minutes (+/-3.8) was observed in five patients studied during the phase of formal process analysis (P < 0.004). Delay-causing factors were identified in the areas 'communication', 'people' and 'methods/rules/guidelines'. Equipment failure was never responsible for delays. CONCLUSIONS: Formal process analysis, followed by implementation of revised guidelines resulted in a significant reduction of 'door-to-needle time'. An initial dramatic but transient reduction of 'door-to-needle time' was considered observational and must not be mistaken as the definite new level of performance. We conclude that formal process analysis techniques are suited to improve processes in the intensive care unit.

[Potential drug interactions and number of prescription drugs with special instructions at hospital discharge]. / Potentielle Arzneimittelinteraktionen und Verordnungshäufigkeit von Medikamenten mit speziellem Instruktionsbedarf bei Spitalaustritt.

OBJECTIVE: Up to 6% of all hospitalizations are due to adverse drug reactions and 20% of these are caused by drug-drug interactions. There is only little information on the prescription frequency of drug-combinations with the potential to induce dangerous drug-drug interactions and drugs with the need for special patient instruction (e.g. inhalers). The aim of our study was to investigate the frequency of such drug prescriptions at hospital discharge. PATIENTS AND METHODS: In a retrospective, descriptive study drug prescriptions of 100 patients discharged consecutively from the department of internal medicine of a 300 bed-hospital were analysed. Possible drug-drug interactions were detected using a special computer program. Furthermore, the number of prescriptions warranting patient instruction such as anticoagulants, antidiabetics, hormones, immunosuppressive drugs, chemotherapeutics, antituberculotic and antiepileptic drugs as well as inhalatives and injections was recorded. RESULTS: The mean age of the 100 patients (61 men, 39 women) was 61.7 years, the mean duration of the hospital stay was 9.2 days. At discharge, patients took an average of 3.5 different drugs. Half of the patients were given drug-combinations with the potential for drug-drug interactions, whereby 5% were at risk for the development of interactions of severe and 42% of intermediate degree. All drug-combinations with potentially severe interactions were prescribed deliberately. 31% of all patients took medications with the need for special education, with inhalatives being the most frequent. The prescription of drugs with potential interactions and the necessity for special patient instruction was more frequent in the elderly. CONCLUSIONS: Drug-combinations with the potential of harmful interactions and drugs with the requirement for special patient instruction are frequently prescribed at hospital discharge. The frequency of prescribing these drugs increases with age. Detection of potentially dangerous drug-drug interactions is simplified by special computer programs. Careful patient instruction about the use of certain drugs is a key issue to improve patient compliance and to guarantee an optimal treatment effect.

[Current role of antidopaminergic drugs in pediatrics]. / Il ruolo attuale degli antidopaminergici in età pediatrica.

The treatment of gastrointestinal disorders in pediatrics is based on the use of prokinetic agents; amongst these prokinetic compounds, cholinomimetic drugs and dopamine antagonists (metoclopramide, domperidone) are principally available. Metoclopramide is an antidopaminergic benzamide with mainly antiemetic effects, due to the interaction with dopamine receptors in the central trigger zone. Another effect is to enhance the transit of material through the gastrointestinal tract. Disadvantages in the use of metoclopramide are neurological effects (asthenia, sleepiness), extrapyramidal dyskinetic reactions and/or neuroendocrine side effects (galactorrhea). Domperidone is a pure dopaminantagonist that accelerates gastric emptying. It is useful in the treatment of acute nausea and vomiting caused by different agents. There are adverse effects only if it is used in parenteral way.

Serum from patients with severe heart failure downregulates eNOS and is proapoptotic: role of tumor necrosis factor-alpha.

BACKGROUND: Cytokine activation and endothelial dysfunction are typical phenomena of congestive heart failure (CHF). We tested the hypothesis that incubating human umbilical vein endothelial cells with serum from patients with CHF will downregulate endothelial constitutive nitric oxide synthase (eNOS) and induce apoptosis. METHODS AND RESULTS: We studied 21 patients with severe CHF. Levels of tumor necrosis factor-alpha (TNF-alpha) and several neuroendocrine parameters were assessed. eNOS was measured by Western Blot analysis and apoptosis by optical microscopy and flow cytometry. We observed (1) eNOS downregulation (difference versus healthy subjects at 24 hours [P<0.05] and 48 hours [P<0.001]), (2) nuclear morphological changes typical of apoptosis; and (3) a high apoptotic rate with propidium iodide (increasing from 2.1+/-0.4% to 11.3+/-1.2% at 48 hours; P<0.001 versus healthy subjects) and annexin V. An anti-human TNF-alpha antibody did not completely counteract these effects. A strong correlation existed between eNOS downregulation and apoptosis (r = -0.89; P<0.001). CONCLUSIONS: Serum from patients with severe CHF downregulates eNOS expression and increases apoptosis. High levels of TNF-alpha likely play a role, but they cannot be the only factor responsible.

[A preliminary appraisal of the new Italian immigration law]. / La nuova legge italiana sull'immigrazione: una prima lettura.

PIP: Italian Law no. 40, of March 6, 1998, on immigration and foreigners, which entered into force on March 27, 1998, is a complex and detailed document. The objectives of the law were a more efficacious programming of the immigrant labor flow; the increase of prevention and containment of illegal immigration; and the expansion of the measures for effective integration of foreigners with regular permits to stay. The new law also provides annual planning for the immigration flow on the basis of an appropriate quota established by the government. Various types of wages are also determined for menial jobs and every year Italians and foreigners with regular residence permits may apply within the first 60 days from the publication of the annual quota for these jobs. The new law is extremely strict in the matter of prevention and containment of illegal immigration dealing with not only new arrivals at the border, but also with those already illegally in the country. Temporary centers are also set up for their accommodation (but no longer than 30 days) until the expulsions are carried out. The part allowing public security authorities to accompany foreigners to the border for expulsion without prior judiciary review is in violation of the constitutional premise of personal freedom. An illegal alien may also be penalized by immediate expulsion from the country and prohibition of re-entry for at least 5 years. It was estimated that there were 200,000 illegal aliens in Italy in 1998. They are supposed to be expelled within 15 days, although this can be appealed in the case of minors, pregnant women or women with children less than 6 months old, the persecuted, or persons living with Italian citizens. Another new feature is the residency card.^ieng