Novel compounds that synergize with aminoglycoside G418 or eRF3 degraders for translational readthrough of nonsense mutant TP53 and PTEN.

The TP53 and PTEN tumour suppressor genes are inactivated by nonsense mutations in a significant fraction of human tumours. TP53 nonsense mutatant tumours account for approximately one million new cancer cases per year worldwide. We have screened chemical libraries with the aim of identifying compounds that induce translational readthrough and expression of full-length p53 protein in cells with nonsense mutation in this gene. Here we describe two novel compounds with readthrough activity, either alone or in combination with other known readthrough-promoting substances. Both compounds induced levels of full-length p53 in cells carrying R213X nonsense mutant TP53. Compound C47 showed synergy with the aminoglycoside antibiotic and known readthrough inducer G418, whereas compound C61 synergized with eukaryotic release factor 3 (eRF3) degraders CC-885 and CC-90009. C47 alone showed potent induction of full-length PTEN protein in cells with different PTEN nonsense mutations. These results may facilitate further development of novel targeted cancer therapy by pharmacological induction of translational readthrough.

Multimodal treatment with curative intent in a germline BRCA2 mutant metastatic ampullary adenocarcinoma: a case report.

BACKGROUND: Cancers of the Vater ampulla (ampullary cancers, ACs) account for less than 1% of all gastrointestinal tumors. ACs are usually diagnosed at advanced stage, with poor prognosis and limited therapeutic options. BRCA2 mutations are identified in up to 14% of ACs and, differently from other tumor types, therapeutic implications remain to be defined. Here, we report a clinical case of a metastatic AC patient in which the identification of a BRCA2 germline mutation drove a personalized multimodal approach with curative-intent. CASE PRESENTATION: A 42-year-old woman diagnosed with stage IV BRCA2 germline mutant AC underwent platinum-based first line treatment achieving major tumor response but also life-threatening toxicity. Based on this, as well as on molecular findings and expected low impact of available systemic treatment options, the patient underwent radical complete surgical resection of both primary tumor and metastatic lesions. Following an isolated retroperitoneal nodal recurrence, given the expected enhanced sensitivity to radiotherapy in BRCA2 mutant cancers, the patient underwent imaging-guided radiotherapy leading to long-lasting complete tumor remission. After more than 2 years, the disease remains radiologically and biochemically undetectable. The patient accessed a dedicated screening program for BRCA2 germline mutation carriers and underwent prophylactic bilateral oophorectomy. CONCLUSIONS: Even considering the intrinsic limitations of a single clinical report, we suggest that the finding of BRCA germline mutations in ACs should be taken into consideration, together with other clinical variables, given their potential association with remarkable response to cytotoxic chemotherapy that might be burdened with enhanced toxicity. Accordingly, BRCA1/2 mutations might offer the opportunity of personalizing treatment beyond PARP inhibitors up to the choice of a multimodal approach with curative-intent.

Utility of Combining High-Sensitive Cardiac Troponin I and PESI Score for Risk Management in Patients with Pulmonary Embolism in the Emergency Department.

BACKGROUND AND OBJECTIVES: Pulmonary embolism (PE) has a major burden of morbidity and mortality, consequently the need for a prompt risk stratification for these subjects is crucial. In order to evaluate the risk management and final disposition of patients with PE in the Emergency Department (ED), we conducted a study that was divided in two phases: Phase I retrospective study (RS), Phase II prospective study (PS). MATERIALS AND METHODS: In Phase I, 291 patients were enrolled while in Phase II, 83 subjects were evaluated. In both study phases, the enrolled subjects were analyzed for final disposition in ED using PESI score, right ventricle (RV) imaging, and high-sensitive cardiac troponin I (hs-cTnI) data. The RS patients were divided into low risk and high risk according to the sPESI score, while PS patients were grouped in low, intermediate, and high risk classes according to PESI score. In both study phases, all the studied patients were further divided into negative (hs-cTnI-) or positive (hs-cTnI+) groups according to hs-cTnI levels within normal or above cutoff values, respectively. For all enrolled subjects, CT pulmonary angiography was analyzed to assess the RV/LV diameter and volume ratio as an indicator of RV involvement. RESULTS: In both RS and PS phases, hs-cTnI+ group showed a higher PESI score. Nevertheless, a significant percentage of hs-cTnI+ patients resulted to be in the low-risk PESI class. Patients with a positive RV/LV ratio were more likely to have a hs-cTnI+ (p < 0.01), while among those with a negative ratio, 24 to 32% showed as hs-cTnI+. In the hs-cTnI+ group from both study phases, patients were more likely to be admitted in an ICU (RR 3.7, IC: 2.1-6.5). CONCLUSIONS: In conclusion, in patients with PE in the ED compared PESI score alone, the combination of hs-cTnI and PESI seems to be of greater utility in improving risk stratification and final disposition decision-making.

Effectiveness of Vitamin D Supplements among Patients Hospitalized for COVID-19: Results from a Monocentric Matched-Cohort Study.

Objectives: Our study aimed to evaluate the usefulness of Vitamin D3 (VitD3) among patients hospitalized for COVID-19. The primary endpoint was to evaluate the difference in survival rates between patients receiving and not VitD3. The secondary endpoints were to evaluate clinical outcomes, such as needing non-invasive ventilation (NIV), ICU transfer, and laboratory findings (inflammatory parameters). Methods: We conducted a retrospective, monocentric matched-cohort study, including patients attending our ward for COVID-19. Patients were divided into two groups depending on VitD3 administration (Group A) or not (Group B) among patients with low VitD levels (defined as blood levels < 30 ng/mL), which depended on physicians' judgment. Our internal protocol provides VitD3 100,000 UI/daily for two days. Findings: 58 patients were included in Group A, and 58 in Group B. Patients were matched for age, sex, comorbidities, COVID-19-related symptoms, PaO2/FiO2 ratio, blood exams, and medical treatments. Regarding the principal endpoint, there was a statistically significant difference between the two groups in survival rates [Group A vs. Group B = 3 vs. 11 (p = 0.042)]. When considering secondary endpoints, Group A patients were less likely to undergo NIV [Group A vs. Group B = 12 vs. 23 (p = 0.026)] and showed an improvement in almost all inflammatory parameters. Conclusions: The link between VitD3 deficiency and the clinical course of COVID-19 during hospitalization suggests that VitD3 level is a useful prognostic marker. Considering the safety of supplementation and the low cost, VitD3 replacement should be considered among SARS-CoV-2 infected patients needing hospitalization.

The Impact of Sarcopenia on Postoperative Course following Pancreatoduodenectomy: Single-Center Experience of 110 Consecutive Cases.

BACKGROUND: Despite that mortality following pancreatoduodenectomy (PD) has gradually dropped during the past few decades, the incidence of postoperative complications remains high, ranging from 30-60%. Many studies have been focused on identification of perioperative risk factors for morbidity, and in recent years, sarcopenia has been pointed out as a valid predictor of postoperative complication. MATERIALS AND METHODS: Perioperative data from 110 consecutive patients who underwent PD were retrieved, and the presence of sarcopenia was assessed by the measurement of Hounsfield unit average calculation on preoperative CT scans. Postoperative complications were graded according to Clavien-Dindo classification, and the morbidity burden was assessed by comprehensive complication index (CCI) calculation. RESULTS: Sarcopenia was associated with advanced age (72 vs. 66 years; p = 0.014) and lower preoperative albumin levels (3.5 vs. 3.7 g/dL; p = 0.010); it represented an independent risk factor for clinically relevant complications (relative risk: 1.71; p = 0.015) and was related to a higher rate of Grade C postoperative pancreatic fistula (50.0 vs. 11.4%; p = 0.005) and a higher CCI (47.6 vs. 29.6; p = 0.001). CONCLUSIONS: Sarcopenia represents a valid indicator of increased morbidity risk and may play a central role in preoperative risk stratification, allowing the selection of patients who may benefit from prehabilitation programs.

Hepatic focal nodular hyperplasia after pediatric hematopoietic stem cell transplantation: The impact of hormonal replacement therapy and iron overload.

BACKGROUND: The advent of techniques for the assessment of iron overload (liver T2*-MRI) has led to the awareness that focal nodular hyperplasia (FNH) represents a possible incidental finding after hematopoietic stem cell transplantation (HSCT), though its pathogenesis is still unclear. METHODS: We performed a retrospective analysis of the liver T2*-MRI scans performed between 2013 and 2018 in a single pediatric HSCT Unit and recorded the number of patients with FNH (group A). Patients incidentally diagnosed with FNH at imaging performed for different clinical indications were included in group B. RESULTS: Nine of 105 (8.6%) patients from group A were diagnosed with FNH. Group B included three patients. Overall, 12 patients were diagnosed 4.4 ± 3.1 years after HSCT. At univariate analysis, female gender (odds ratio [OR] 3.77, P = .03), moderate-to-severe iron overload (OR 6.97, P = .01), and hormone replacement therapy (HRT) administered for at least 6 months (OR 18.20, P = .0002) exposed patients to a higher risk of developing FNH. The detrimental effect of HRT was significant also at multivariate analysis (OR 7.93, P = .024). MRI-T2* values in affected patients were statistically lower than healthy controls (P < .001). CONCLUSIONS: We confirm the high incidence of FNH among transplanted pediatric patients and demonstrate the potential pathogenic role of HRT and iron overload.

Consequences of Increases in Antibiotic Resistance Pattern on Outcome of Pancreatic Resection for Cancer.

BACKGROUND: The role of drug-resistance infections on surgical outcomes is controversial. The aim of the study was to determine whether increase antibiotic resistance was an independent risk factor for development of major non-infectious postoperative complications. METHODS: This work included a multicenter cohort study of patients who underwent pancreatic resections for cancer over a 3-year interval. The primary outcome was major non-infectious complication rate developing after the occurrence of multi-drug sensitive (MDS) infection, multi-drug-resistant infection (MDR), and extensive drug-resistant (XDR) infection. Multivariate logistic regression models were used to adjust for patient and operative effects. RESULTS: Eligible patients (517) were selected for the analysis. One hundred and thirteen (21.8%) patients had major non-infectious complications with a rate of 12.9% in the no infection group, 29.3% in the MSD, 41.5% in the MDR, and 58.8% in the XDR (p < 0.001). The median time of infection occurrence was postoperative days 4 (2-7 IQR) and 7 (3-12 IQR) non-infectious complications. At multivariate analysis, the risk of having major non-infectious complications was 2.67 (95% CI 1.24-5.77, P = 0.012) for MDR, 5.04 (95% CI 2.35-10.80, P < 0.001) for MDR, and 9.64 (95% CI 2.71-34.28, P < 0.001) for XDR. CONCLUSION: Antimicrobial resistance is significantly associated with the risk of major non-infectious morbidity.

International consensus conference on open abdomen in trauma.

BACKGROUND: A part of damage-control laparotomy is to leave the fascial edges and the skin open to avoid abdominal compartment syndrome and allow further explorations. This condition, known as open abdomen (OA), although effective, is associated with severe complications. Our aim was to develop evidence-based recommendations to define indications for OA, techniques for temporary abdominal closure, management of enteric fistulas, and methods of definitive wall closure. METHODS: The literature from 1990 to 2014 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-analyses] protocol. Seventy-six articles were reviewed by a panel of experts to assign grade of recommendations (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development, and Evaluation] system, and an international consensus conference was held. RESULTS: OA in trauma is indicated at the end of damage-control laparotomy, in the presence of visceral swelling, for a second look in vascular injuries or gross contamination, in the case of abdominal wall loss, and if medical treatment of abdominal compartment syndrome has failed (GoR B, LoE II). Negative-pressure wound therapy is the recommended temporary abdominal closure technique to drain peritoneal fluid, improve nursing, and prevent fascial retraction (GoR B, LoE I). Lack of OA closure within 8 days (GoR C, LoE II), bowel injuries, high-volume replacement, and use of polypropylene mesh over the bowel (GoR C, LoE I) are risk factors for frozen abdomen and fistula formation. Negative-pressure wound therapy allows to isolate the fistula and protect the surrounding tissues from spillage until granulation (GoR C, LoE II). Correction of fistula is performed after 6 months to 12 months. Definitive closure of OA has to be obtained early (GoR C, LoE I) with direct suture, traction devices, component separation with or without mesh. Biologic meshes are an option for wall reinforcement if bacterial contamination is present (GoR C, LoE II). CONCLUSION: OA and negative-pressure techniques improve the care of trauma patients, but closure must be achieved early to avoid complications.

Efficacy of extra-peritoneal pelvic packing in hemodynamically unstable pelvic fractures, a Propensity Score Analysis.

BACKGROUND: An option for emergency control of pelvic hemorrhage is Extra-peritoneal Pelvic Packing (EPP), which addresses the retroperitoneal source of exsanguination in pelvic fractures. The aim of this study was to demonstrate the efficacy of early EPP in reducing mortality due to hemorrhage from pelvic fractures, and to evaluate the impact of packing on transfusion requirements within the first 24 h and ICU length of stay (ICU-LOS). All data pertaining trauma patients admitted from October 2002 and December 2103 with hemodynamic instability and pelvic fractures were selected from the Hospital Trauma Registry. Patients with severe brain injury and bleeding from extra-pelvic sources were excluded. Patient population was divided into two groups: EPP group, including patients admitted from 2009 to 2013, with EPP as part of the treatment algorithm, and NO-EPP group, from 2002 to 2008, without EPP as atherapeutic option. Descriptive statistical analysis was performed on allpatients. Twenty-five patients of each group with similar features were matched using Propensity Score Analysis (PSA). RESULTS: Six hundred eighty out of 4659 major trauma (14.6 %) presented a pelvic fracture. In 78 hemodynamically unstable patients (30 in EPP group,48 in NO-EPP group) the major source of bleeding was the pelvis. Among patients selected by PSA early mortality was significantly reduced in EPP group (20 vs 52 %, p = .03) compared to NO-EPP, notwithstanding similar hemodynamic impairment. No difference was observed in transfusion requirements and ICU-LOS. CONCLUSIONS: The EPP is a safe and quick procedure, able to improve hemodynamic stabilization and to reduce acute mortality due to hemorrhage in patients with pelvic fracture, in combination with optimized transfusion protocol. EPP may be useful as a bridge for time-consuming procedures, such as angio-embolization.

Spontaneous hepatic rupture during pregnancy in a patient with peliosis hepatis.

Spontaneous hepatic rupture (SHR) during pregnancy is a rare but well known complication and it usually occurs alongside eclampsia or HELLP syndrome. SHR in uncomplicated pregnancy is extremely rare and can be associated to different undiagnosed pathological conditions. We report the case of a nulliparous woman, 27 weeks pregnant, with a peliosis hepatis, previously unknown, who was admitted to our unit due to SHR and massive hemoperitoneum. The conception was obtained by embryo transfer after multiple attempts of hormone-supported cycles using estrogens and progesterone. After emergency laparotomy the patient was submitted to deliver of the dead foetus and damage control of the hepatic bleeding source. At relaparotomy a right posterior sectionectomy (segments VI and VII) and segmentectomy of segment V were performed. The patient was discharged in good physical conditions after 18 days from admission. If hepatic rupture is suspected in a pregnant patient a collaborative multidisciplinary approach is mandatory. The cornerstones of medical and surgical management are highlighted. At the best of our knowledge this is the first case of SHR in a pregnant woman with peliosis hepatis. A possible correlation of an increased risk for SHR in a pregnant patient who was submitted to several attempts for embryo transfer is discussed. The relevant scientific literature of the possible causative role of the estrogen therapy in inducing politic liver damage is also reviewed.

A population based study of hospitalised seriously injured in a region of Northern Italy.

BACKGROUND: Injury is a public health problem in terms of mortality, morbidity and disability. The implementation of a regionalised trauma system has been proved to significantly reduce the social impact of severe trauma on population. A population-based registry may be useful to obtain reliable epidemiologic data. AIM: To perform an exhaustive analysis of severe trauma patients hospitalised in Lombardia, a region of northern Italy. MATERIALS AND METHODS: The regional Hospital Discharge Registry (HDR) was used to retrieve data of all patients who suffered from serious injuries from 2008 to 2010. ICD9-CM codes of discharge diagnoses were analysed and patients coded from 800.0 to 939.9 or from 950.0 to 959.9 have been retrieved. Femur fractures in elderly and patients with length of hospital stay less than 2 days were excluded. Patients have been considered seriously injured if discharged dead or any of followings: admission or transit in ICU, need of mechanical ventilation, tracheotomy, invasive hemodynamic monitoring. Average reimbursement based on DRG has been evaluated. STATISTICS: Student's t test, ANOVA for continuous data, chi-square test for categorical data were used, and a p value less than 0.05 was considered significant. RESULTS: The severely injured patients hospitalised in Lombardia in three years were 11704, 391 per million per year. Overall mortality was 24.17% and increased with age. Males aging from 18 to 64 years had more occupational injuries, trauma on the road and violence by others. Females were more susceptible to domestic injuries and self inflicted violence, mostly in older ages. Acute mortality was higher after traffic accidents, while late mortality was increased in domestic trauma. Pediatric cases were unusual. A significant increase (+10.18%) in domestic trauma, with a concomitant decrease (-17.76%) in road-related accidents was observed in the three years study period. Reimbursement paid to hospitals for seriously injured was insufficient with regard to estimated costs of care. CONCLUSION: Serious injury requiring hospitalisation in Lombardia is still an healthcare problem, with a trend toward a decrease of traffic accidents, increase in domestic trauma and involvement of older people. These results may help to plan a new regionalised Trauma System.

[The model of the Niguarda Hospital Trauma Team in Milan]. / Il modello organizzativo del Trauma Team dell'Ospedale Niguarda di Milano.

The aim of this work was to describe the model and clinical results obtained by the Niguarda Trauma Team referral center for major trauma, in Milan. The Trauma Team is organized as a trauma service, where general surgeons, anesthesiologists, orthopedic surgeons and neurosurgeons work on a 24 hour rotation. When not in duty in the rotations, specialists work in their specific elective activities. The director of the Trauma Team has the responsibility for discussion and application of protocols, clinical assistance, quality assessment and training. The results of 1334 consecutive cases of major trauma during a 51 month period were reviewed using the trauma registry. 39% overtriage, which increased over the years, and 1.12% undertriage were recorded. Mortality of patients with injury severity scores > 15 was 21%, with a progressive decrease over the years. Blunt trauma accounted for 91.75% and were road-related in most cases. Skeletal injuries were the most frequent findings, but brain and thoraco-abdominal injuries were associated with a higher risk of death. 1476 surgical procedures (16.93% general surgery and 111 interventional angiographic studies) were performed. Quality assessment revealed a significant decrease in preventable deaths within the first 72 hours, after excluding patients admitted in extremis. The results presented in this study demonstrate the possibility of realising a model of organized trauma care in an emergency department in Italy, with patient outcomes comparable to those obtained in Trauma Center in other countries.

Tubulin-based polymorphism (TBP): a new tool, based on functionally relevant sequences, to assess genetic diversity in plant species.

TBP (tubulin-based polymorphism) is a new molecular marker based tool that relies on the presence of intron-specific DNA polymorphisms of the plant beta-tubulin gene family. The multifunctional and essential role of the tubulin proteins is reflected in the conservation of regions within their primary amino acid sequence. The ubiquitous nature of this gene family can be exploited using primers that amplify the first intron of different beta-tubulin isotypes, revealing specific fingerprints. The method is rapid, simple, and reliable and does not require preliminary sequence information of the plant genome of interest. The ability of TBP to discriminate between accessions and species in oilseed rape, coffee, and lotus is shown. In all cases, TBP was able to detect specific genetic polymorphisms in the context of a simplified and readily appreciable pattern of DNA amplification. The application of TBP for assessing genetic diversity and genome origins in disseminated plant landraces rather than in highly inbred cultivated species is also discussed.

AFLP markers and cytotaxonomic analysis reveal hybridisation in the genus Schoenus (Cyperaceae).

Molecular, cytological, and morphological data support the existence of a hybrid population between Schoenus nigricans and Schoenus ferrugineus. This population was found in northeastern Italy, where S. nigricans is central with respect to its natural range and S. ferrugineus is marginal, being most common in the Alps and in central and northern Europe. Molecular marker data show that the putative hybrid population is genetically intermediate between nearby populations of the parent species. Cytological evidence confirmed the hybrid nature of this population, as does the almost complete sterility of plants within the population. Although no seeds were produced by the hybrid population, some possibly fertile pollen grains were produced; this suggests that the possibility of introgression between the two species through the hybrids cannot completely be excluded.