Predictors of non-adherence to an early in-hospital rehabilitation program after surgery for hip fracture in a co-managed orthogeriatric unit.

BACKGROUND: Hip fracture is a common event in older adults, leading to an increased risk of mortality, disability, and higher healthcare costs. Early in-hospital rehabilitation after surgery within orthogeriatric units may improve outcomes with limited incident complications even in the oldest old. We aimed to determine the prevalence and predictors of non-adherence to early rehabilitation in the orthogeriatric unit of an Italian tertiary hospital and its impact on outcomes and setting at discharge. METHODS: Retrospective observational single-centered cohort study. Patients aged ≥ 65 years admitted to the orthogeriatric unit for hip fracture who underwent surgery between April 2019 and October 2020 were considered eligible if able to walk autonomously or with assistance and independent in at least 2 Basic Activities of Daily Living. Along with sociodemographic and geriatric variables, characteristics of surgery and rehabilitation, in-hospital complications and functional outcomes at discharge were collected. The primary outcome was non-adherence to the early in-hospital rehabilitation program. RESULTS: Among 283 older patients (mean age 82.7 years, 28.6% male), non-compliance with physical therapy was assessed in 49 cases (17.3%), characterized by worse pre-fracture clinical, cognitive, and functional status and showing worse outcomes in terms of mobilization at discharge. After multivariable analysis, non-adherence was independently associated with the onset of delirium (OR 5.26, 95%CI 2.46-11.26; p < 0.001) or infections after surgery (OR 3.26, 95%CI 1.54-6.89; p < 0.001) and a systolic blood pressure at admission < 120 mmHg (OR 4.52, 95%CI 1.96-10.43, p < 0.001). CONCLUSIONS: Pre-fracture poor cognitive and functional status, along with lower systolic blood pressure, seem to make some patients more vulnerable to in-hospital complications (mainly delirium and infections) and negatively affect the adherence to physical therapy and, by consequence, clinical outcomes of rehabilitation.

Chemotherapy-induced infiltration of neutrophils promotes pancreatic cancer metastasis via Gas6/AXL signalling axis.

OBJECTIVE: Pancreatic ductal adenocarcinoma (PDAC) is a highly metastatic disease and cytotoxic chemotherapy is the standard of care treatment for patients with advanced disease. Here, we investigate how the microenvironment in PDAC liver metastases reacts to chemotherapy and its role in metastatic disease progression post-treatment, an area which is poorly understood. DESIGN: The impact of chemotherapy on metastatic disease progression and immune cell infiltrates was characterised using flow and mass cytometry combined with transcriptional and histopathological analysis in experimental PDAC liver metastases mouse models. Findings were validated in patient derived liver metastases and in an autochthonous PDAC mouse model. Human and murine primary cell cocultures and ex vivo patient-derived liver explants were deployed to gain mechanistical insights on whether and how chemotherapy affects the metastatic tumour microenvironment. RESULTS: We show that in vivo, chemotherapy induces an initial infiltration of proinflammatory macrophages into the liver and activates cytotoxic T cells, leading only to a temporary restraining of metastatic disease progression. However, after stopping treatment, neutrophils are recruited to the metastatic liver via CXCL1 and 2 secretion by metastatic tumour cells. These neutrophils express growth arrest specific 6 (Gas6) which leads to AXL receptor activation on tumour cells enabling their regrowth. Disruption of neutrophil infiltration or inhibition of the Gas6/AXL signalling axis in combination with chemotherapy inhibits metastatic growth. Chemotherapy increases Gas6 expression in circulating neutrophils from patients with metastatic pancreatic cancer and recombinant Gas6 is sufficient to promote tumour cell proliferation ex vivo, in patient-derived metastatic liver explants. CONCLUSION: Combining chemotherapy with Gas6/AXL or neutrophil targeted therapy could provide a therapeutic benefit for patients with metastatic pancreatic cancer.

Improving photoprotection: 4-methylbenzylidene camphor microspheres.

We propose a new approach for photoprotection. 4-Methylbenzylidene camphor (4-MBC), one of the most widely used UV filters, was encapsulated in microspheres, with a view to overcoming problems (percutaneous absorption, photodegradation and lack of lasting effect) arising with organic sunscreens, and to achieve safe photoprotection. We focused on this filter in the light of the Cosmetics Europe opinion concerning its possible effects on the thyroid gland. Microspheres were prepared by emulsification-solvent evaporation, using different amounts of 4-MBC and characterized for morphology, encapsulation efficiency and particle size. The particles were then mixed in O/W emulsions. The in vitro sun protection factors, in vitro release and photostability were investigated and compared with emulsions containing the free sunscreen. The new microspheres offer good morphology and loading (up to 40%), and the same photoprotection as the free filter while at the same time protecting it from photodegradation. The systems also give a slower release from the emulsions.

Macrophages Orchestrate the Liver Tumor Microenvironment.

Liver cancer is one of the leading causes of cancer-related mortality. Hepatocellular carcinoma and cholangiocarcinoma are the most common types, and despite numerous advances, therapeutic options still remain poor for these cancer patients. Tumor development and progression strictly depend on a supportive tumor microenvironment (TME). Tumor-associated macrophages (TAMs) are the most abundant immune cells population within a tumorigenic liver; they sustain cancer cells' growth and invasiveness, and their presence is correlated with a poor prognosis. Furthermore, TAM cross-talk with cells and components of the TME promotes immunosuppression, a desmoplastic response, and angiogenesis. In this review, we summarize the latest advances in understanding TAM heterogeneity and function, with a particular focus on TAM modulation of the TME. We also discuss the potential of targeting macrophage subpopulations and how this is now being exploited in current clinical trials for the treatment of liver cancer.

Macrophage-fibroblast JAK/STAT dependent crosstalk promotes liver metastatic outgrowth in pancreatic cancer.

Pancreatic ductal adenocarcinoma (PDAC) is a highly metastatic disease for which better therapies are urgently needed. Fibroblasts and macrophages are heterogeneous cell populations able to enhance metastasis, but the role of a macrophage-fibroblast crosstalk in regulating their pro-metastatic functions remains poorly understood. Here we deconvolve how macrophages regulate metastasis-associated fibroblast (MAF) heterogeneity in the liver. We identify three functionally distinct MAF populations, among which the generation of pro-metastatic and immunoregulatory myofibroblastic-MAFs (myMAFs) critically depends on macrophages. Mechanistically, myMAFs are induced through a STAT3-dependent mechanism driven by macrophage-derived progranulin and cancer cell-secreted leukaemia inhibitory factor (LIF). In a reciprocal manner, myMAF secreted osteopontin promotes an immunosuppressive macrophage phenotype resulting in the inhibition of cytotoxic T cell functions. Pharmacological blockade of STAT3 or myMAF-specific genetic depletion of STAT3 restores an anti-tumour immune response and reduces metastases. Our findings provide molecular insights into the complex macrophage-fibroblast interactions in tumours and reveal potential targets to inhibit PDAC liver metastasis.

Efferocytosis reprograms the tumor microenvironment to promote pancreatic cancer liver metastasis.

Pancreatic ductal adenocarcinoma is a highly metastatic disease and macrophages support liver metastases. Efferocytosis, or engulfment of apoptotic cells by macrophages, is an essential process in tissue homeostasis and wound healing, but its role in metastasis is less well understood. Here, we found that the colonization of the hepatic metastatic site is accompanied by low-grade tissue injury and that efferocytosis-mediated clearance of parenchymal dead cells promotes macrophage reprogramming and liver metastasis. Mechanistically, progranulin expression in macrophages is necessary for efficient efferocytosis by controlling lysosomal acidification via cystic fibrosis transmembrane conductance regulator and the degradation of lysosomal cargo, resulting in LXRα/RXRα-mediated macrophage conversion and upregulation of arginase 1. Pharmacological blockade of efferocytosis or macrophage-specific genetic depletion of progranulin impairs macrophage conversion, improves CD8+ T cell functions, and reduces liver metastasis. Our findings reveal how hard-wired functions of macrophages in tissue repair contribute to liver metastasis and identify potential targets for prevention of pancreatic ductal adenocarcinoma liver metastasis.

Colorectal Liver Metastasis: Can Cytokines Make the Difference?

Colorectal cancer (CRC) is the third leading cause of cancer-related death worldwide. Metastasis is the prime driver of CRC-related mortality, and the liver is the organ most frequently involved. Despite the overall success of current treatments, colorectal liver metastasis (CRLM) is associated with poor prognoses and a survival rate of only 14%. Recent studies have highlighted the importance of the tumor microenvironment (TME) and the crosstalk within it in determining the invasion of distant organs by circulating cancer cells. In the TME, cellular communication is mediated via soluble molecules, among which cytokines have recently emerged as key regulators, involved in every aspect of tumor progression and the metastatic cascade. Indeed, in the serum of CRC patients elevated levels of several cytokines are associated with cancer development and progression. The current review evaluates the role of different cytokines during CRLM development. Additionally, considering the increasing amount of data concerning the importance of cytokine complex networks, we outline the potential of combination treatments using targeted cytokines together with other well-established therapies, such as immune checkpoint blockades, chemotherapy, or gene therapy, to improve therapeutic outcomes.

Chemically vs Enzymatically Synthesized Polyglycerol-Based Esters: A Comparison between Their Surfactancy.

Polyglycerol fatty acid esters (PGFAEs) are gaining interest in several industrial sectors due to their excellent surfactant properties and their wide range of hydrophilic-lipophilic balance (HLB) values. Moreover, they can be prepared from renewable resources, i.e., fatty acids and glycerol. In this study, polyglycerol-2 stearic acid esters (PG2SAEs) were synthesized by the enzymatic esterification of polyglycerol-2 (PG2) and stearic acid (SA) using the immobilized lipase Novozym 435 as a biocatalyst in a solvent-free system. Reaction conditions, i.e., temperature (80 °C), reactant ratio (1:1.8), and enzyme loading (2.7% w/w), were finely optimized; furthermore, biocatalyst recycling was studied by assessing the residual activity of the lipase after each reaction cycle, up to 20 times. The composition of the enzymatically synthesized products (E) was roughly evaluated by chromatographic methods and mass spectrometry and compared with that of the esters obtained by acid-catalyzed esterification (C). Then, the surfactant properties of the prepared polyglycerol-based surfactants were investigated by interfacial tension studies. Specifically, the emulsifying capacity and stability and the rheological behavior of O/W emulsions prepared in the presence of E were deeply investigated in comparison with those of the chemically synthesized and commercially available product C.

Macrophage-Mediated Subversion of Anti-Tumour Immunity.

Despite the incredible clinical benefits obtained by the use of immune checkpoint blockers (ICBs), resistance is still common for many types of cancer. Central for ICBs to work is activation and infiltration of cytotoxic CD8+ T cells following tumour-antigen recognition. However, it is now accepted that even in the case of immunogenic tumours, the effector functions of CD8+ T cells are highly compromised by the presence of an immunosuppressive tumour microenvironment (TME) at the tumour site. Tumour-associated macrophages (TAMs) are among the most abundant non-malignant stromal cell types within the TME and they are crucial drivers of tumour progression, metastasis and resistance to therapy. TAMs are able to regulate either directly or indirectly various aspects of tumour immunity, including T cell recruitment and functions. In this review we discuss the mechanisms by which TAMs subvert CD8+ T cell immune surveillance and how their targeting in combination with ICBs represents a very powerful therapeutic strategy.

A New Method for In Vivo Analysis of the Performances of a Heat and Moisture Exchanger (HME) in Mechanically Ventilated Patients.

AIM: To evaluate the conditioning capabilities of the DAR™ Hygrobac™ S, a Heat and Moisture Exchanger (HME), using a new device to measure the temperature (T) and the absolute humidity (AH) of the ventilated gases in vivo during mechanical ventilation in Intensive Care Unit (ICU) patients. MATERIALS AND METHODS: In 49 mechanically ventilated ICU patients, we evaluated T and AH, indicating the HME efficacy, during the inspiratory phase upstream and downstream the HME and the ratio of inspired AH to expired AH and the difference between expired T and inspired T indicated the HME efficiency. Efficacy and efficiency were assessed at three time points: at baseline (t0, HME positioning time), at 12 hours (t1), and at 24 hours (t2) using a dedicated, ad hoc built wireless device. Differences over time were evaluated using one-way ANOVA for repeated measures, whereas differences between in vivo and laboratory values (declared by the manufacturer according to UNI® EN ISO 9360 international standard) were evaluated using one-sample Student t-test. RESULTS: 49 HMEs were analysed in vivo during mechanical ventilation. T and AH means (SD) of the inspired gas (the efficacy) were 31.5°C (1.54) and 32.3 mg/l (2.60) at t0, 31.1°C (1.34) and 31.7 mg/l (2.26) at t1, and 31°C (1.29) and 31.4 mg/l (2.27) at t2. Both efficiency parameters were constant over time (inspired AH/expired AH=89%, p=0.24; and expired T-inspired T = 2.2°C, p=0.81). Compared with laboratory values, in vivo T and AH indicating efficacy were significantly lower (p<0.01), whereas the efficiency was significantly higher (p<0.01). CONCLUSIONS: HME performances can be accurately assessed for prolonged periods in vivo during routine mechanical ventilation in ICU patients. Temperature and absolute humidity of ventilated gases in vivo were maintained within the expected range and remained stable over time. HME efficacy and efficiency in vivo significantly differed from laboratory values.

Prevalence, predictors and clinical impact of potentially inappropriate prescriptions in hospital-discharged older patients: A prospective study.

AIM: Potentially inappropriate prescriptions (PIP) have been highly reported in older patients, but few studies have investigated their association with adverse clinical outcomes. The present study aimed to evaluate the prevalence and predictors of PIP in hospital-discharged older adults, and to explore the association of PIP with death and rehospitalization. METHODS: We carried out a multicenter prospective cohort study on hospital-discharged patients aged ≥65 years. Each patient underwent a comprehensive geriatric assessment, and the prevalence of PIP was obtained by applying Beers Criteria 2015 to discharge documents. Telephone follow up was carried out at 6 months. RESULTS: The prevalence of PIP was 63%, and was associated with psychiatric-behavioral disorders (OR 1.64), the number of daily taken medications (OR 1.08) and long-term care discharge (OR 1.91), whereas better functional performance was protective (OR 0.93). Neither the presence nor the number of PIP were associated with rehospitalization or mortality at 6 months. However, insulin sliding scale (OR 4.97) and use of drugs inappropriate in heart failure (OR 4.64) were associated with an increased risk of rehospitalization, whereas prescription of digoxin ≥0.125 mg/daily (OR 1.77) and antipsychotics (OR 1.65) were associated with a higher risk of mortality. CONCLUSIONS: Among older hospital-discharged patients, we documented a high prevalence of PIP that was significantly associated with polytherapy, the presence of psychiatric-behavioral disorders and discharge to long-term care facilities. Although the presence and the number of PIP were not associated with adverse outcomes, some specific inappropriate prescriptions were associated with a higher risk of hospital readmission and death. Geriatr Gerontol Int 2018; 18: 561-568.

Macrophage-Derived Granulin Drives Resistance to Immune Checkpoint Inhibition in Metastatic Pancreatic Cancer.

The ability of disseminated cancer cells to evade the immune response is a critical step for efficient metastatic progression. Protection against an immune attack is often provided by the tumor microenvironment that suppresses and excludes cytotoxic CD8+ T cells. Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive metastatic disease with unmet needs, yet the immunoprotective role of the metastatic tumor microenvironment in pancreatic cancer is not completely understood. In this study, we find that macrophage-derived granulin contributes to cytotoxic CD8+ T-cell exclusion in metastatic livers. Granulin expression by macrophages was induced in response to colony-stimulating factor 1. Genetic depletion of granulin reduced the formation of a fibrotic stroma, thereby allowing T-cell entry at the metastatic site. Although metastatic PDAC tumors are largely resistant to anti-PD-1 therapy, blockade of PD-1 in granulin-depleted tumors restored the antitumor immune defense and dramatically decreased metastatic tumor burden. These findings suggest that targeting granulin may serve as a potential therapeutic strategy to restore CD8+ T-cell infiltration in metastatic PDAC, thereby converting PDAC metastatic tumors, which are refractory to immune checkpoint inhibitors, into tumors that respond to immune checkpoint inhibition therapies.Significance: These findings uncover a mechanism by which metastatic PDAC tumors evade the immune response and provide the rationale for targeting granulin in combination with immune checkpoint inhibitors for the treatment of metastatic PDAC.Graphical Abstract: http://cancerres.aacrjournals.org/content/canres/78/15/4253/F1.large.jpg Cancer Res; 78(15); 4253-69. ©2018 AACR.

Chemoresistance in Pancreatic Cancer Is Driven by Stroma-Derived Insulin-Like Growth Factors.

Tumor-associated macrophages (TAM) and myofibroblasts are key drivers in cancer that are associated with drug resistance in many cancers, including pancreatic ductal adenocarcinoma (PDAC). However, our understanding of the molecular mechanisms by which TAM and fibroblasts contribute to chemoresistance is unclear. In this study, we found that TAM and myofibroblasts directly support chemoresistance of pancreatic cancer cells by secreting insulin-like growth factors (IGF) 1 and 2, which activate insulin/IGF receptors on pancreatic cancer cells. Immunohistochemical analysis of biopsies from patients with pancreatic cancer revealed that 72% of the patients expressed activated insulin/IGF receptors on tumor cells, and this positively correlates with increased CD163+ TAM infiltration. In vivo, we found that TAM and myofibroblasts were the main sources of IGF production, and pharmacologic blockade of IGF sensitized pancreatic tumors to gemcitabine. These findings suggest that inhibition of IGF in combination with chemotherapy could benefit patients with PDAC, and that insulin/IGF1R activation may be used as a biomarker to identify patients for such therapeutic intervention. Cancer Res; 76(23); 6851-63. ©2016 AACR.

Macrophage-secreted granulin supports pancreatic cancer metastasis by inducing liver fibrosis.

Pancreatic ductal adenocarcinoma (PDAC) is a devastating metastatic disease for which better therapies are urgently needed. Macrophages enhance metastasis in many cancer types; however, the role of macrophages in PDAC liver metastasis remains poorly understood. Here we found that PDAC liver metastasis critically depends on the early recruitment of granulin-secreting inflammatory monocytes to the liver. Mechanistically, we demonstrate that granulin secretion by metastasis-associated macrophages (MAMs) activates resident hepatic stellate cells (hStCs) into myofibroblasts that secrete periostin, resulting in a fibrotic microenvironment that sustains metastatic tumour growth. Disruption of MAM recruitment or genetic depletion of granulin reduced hStC activation and liver metastasis. Interestingly, we found that circulating monocytes and hepatic MAMs in PDAC patients express high levels of granulin. These findings suggest that recruitment of granulin-expressing inflammatory monocytes plays a key role in PDAC metastasis and may serve as a potential therapeutic target for PDAC liver metastasis.

The alternative splicing factor Nova2 regulates vascular development and lumen formation.

Vascular lumen formation is a fundamental step during angiogenesis; yet, the molecular mechanisms underlying this process are poorly understood. Recent studies have shown that neural and vascular systems share common anatomical, functional and molecular similarities. Here we show that the organization of endothelial lumen is controlled at the post-transcriptional level by the alternative splicing (AS) regulator Nova2, which was previously considered to be neural cell-specific. Nova2 is expressed during angiogenesis and its depletion disrupts vascular lumen formation in vivo. Similarly, Nova2 depletion in cultured endothelial cells (ECs) impairs the apical distribution and the downstream signalling of the Par polarity complex, resulting in altered EC polarity, a process required for vascular lumen formation. These defects are linked to AS changes of Nova2 target exons affecting the Par complex and its regulators. Collectively, our results reveal that Nova2 functions as an AS regulator in angiogenesis and is a novel member of the 'angioneurins' family.