The data project: a shared approach between stakeholders of the healthcare system in definition of a therapeutic algorithm for inflammatory arthritis.

Rheumatic musculoskeletal diseases or RMD [rheumatoid arthritis (RA) and spondyloarthritis (SpA)] are systemic inflammatory diseases for which there are no biomarkers capable of predicting treatments with a higher likelihood of response in naive patients. In addition, the expiration of the anti-TNF blocking drugs' patents has resulted in the availability of anti-TNF biosimilar drugs with the same efficacy and safety than originators but at significantly reduced prices. To guarantee a personalized therapeutic approach to RMD treatment, a board of rheumatologists and stakeholders from the Campania region, Italy, developed a clinically applicable arthritis therapeutic algorithm to guide rheumatologists (DATA project). The general methodology relied on a Delphi technique forecast to produce a set of statements that summarized the experts' consensus. Selected clinical scenarios were discussed in light of the available evidence, and there were two rounds of voting on the therapeutic approaches. Separate discussions were held regarding rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. The decision-making factors for each disease were clinical presentation, demographics, and comorbidities. In this paper, we describe a virtuous process between rheumatologists and healthcare system stakeholders that resulted in the development of a shared therapeutic algorithm for RMD patients naive to bDMARDs.

Feasibility study of a mixed reality tool for real 3D visualization and planning of left atrial appendage occlusion.

In left atrial appendage occlusion (LAAO), pre-procedural imaging is pivotal to describe the highly variable LAA anatomy and to guide the operator in device sizing and interventional planning. Multiplanar reconstruction and 3D rendering are used for the interpretation of 3D CT datasets. However, this method of review of such imaging, which is mediated by 2D screens, may be limited due to the lack of true 3D visualization of the structures of interest; Mixed Reality (MxR) may further improve the CT-based pre-procedural planning by allowing for real-3D visualizations with holographic replicas of anatomical models. In this manuscript we present a novel software based on MxR and we evaluated its feasibility on different LAA morphologies. The morphological analysis of the holographic anatomical models was successfully applied for all the patients (n â€‹= â€‹4) independently from the morphology and it was performed in less than 10 minutes. Our findings suggest that with further developments MxR could have the potential to become a pivotal tool in LAA occlusion planning thanks to the real-3D perception, possibly leading to a more accurate and faster planning phase.

P594Contrast transthoracic echocardiography as a gatekeeper for patent foramen ovale closure.

BACKGROUND.: The presence of patent foramen ovale (PFO) has been linked to many illness, including cryptogenic stroke, transient ischemic attack, migraine, platypnea-orthodeoxia syndrome and decompression sickness in scuba divers. Transesophageal echocardiography is the gold standard technique for the visualization of atrial septal anatomy, but it is a secondary level exam, not always available, with additional associated costs and not completely free from procedural risks. Standard transthoracic echocardiography (TTE) has a too low sensitivity for PFO screening. PURPOSE.: The aim of the study was to assess the role of TTE associated with agitated saline contrast injection (contrast-TTE) as a gatekeeper for the identification of PFO in a large cohort of patients undergoing selection for percutaneous closure. METHODS.: A total of 200 patients undergoing a diagnostic work-up for the identification of PFO was imaged by contrast-TTE at rest and after provocative maneuvers (PM: Valsalva in all cases). Contrast TTE was graded from 0 to 4 on the bases of bubbles counting (0: no bubbles; 1: < 10 bubbles; 2: 10-30 bubbles; 3: >30 bubbles; 4: complete LV opacification). PFO closure was performed after a consensual clinical decision by the cardiologist and the neurologist taking into account comprehensive imaging, clinical evaluation and thrombophilia screening. PFO closure was always monitored by intracardiac echocardiography. RESULTS.: At baseline contrast TTE was positive (≥2) in 34 patients (17%) while contrast TTE with PM was positive in 94 cases (47%). 27 out of 200 patients (14%) had an interatrial septal aneurysms. PFO closure was performed in 34 cases (17%). All of these had severe right-to-left shunting (≥3) at contrast TTE and 9 cases had also an interatrial septal aneurysms. The procedure was aborted in only 1 patient due to a complex defect anatomy. CONCLUSION.: Contrast TTE with PM may be not only considered an accurate tool for the detection of PFO but may be also inserted in the diagnostic work- up as a primary gatekeeper for percutaneous closure. Severe shunting at contrast TTE influences final decision making in a large cohort of cases undergoing screening for PFO closure.

Changes of acute-phase proteins in streptozotocin-induced diabetic rats.

Quantitative and qualitative changes of serum proteins, apart from glycation, have not been sufficiently studied in streptozotocin-induced diabetic rats (D), the most common experimental model for diabetes. Thus, we decided to analyze the serum of diabetic rats by concanavalin A-blotting in comparison with rats with acute inflammation induced by fermented yeast (Y), in which characteristic alterations of serum proteins have been described. Two months after the streptozotocin treatment, the blood glucose levels were highly elevated (456+/-24 vs. 124+/-10 mg/dl, p<0.001, n=12), the body weight was significantly lower than normal (279+/-10 vs. 392+/-6 g, p<0.001, n=12), and serum proteins appeared to be highly glycated (p<0.001) when analyzed by the fructosamine assay, without any significant change in the total serum protein concentration. Analysis by concanavalin A-blotting, revealed a significant decrease of alpha1-inhibitor-3 (alpha1-I3, p<0.05) and an increase of the beta chain of haptoglobin (beta-Hp, p<0.05) in both D and Y rats (n=3) compared with control animals. However, acute inflammation caused a marked rise of two prominent acute phase proteins, alpha2-macroglobulin and hemopexin, which did not change appreciably in diabetic rats. Further work will be necessary to evaluate the physiopathological significance of these phenomena which could result from changes of both concentration and glycosylation of the aforementioned proteins.

Guiding spontaneous tissue regeneration for urethral reconstruction: long-term studies in the rabbit.

We designed long-term in vivo experiments to study rabbit urethral regeneration and remodelling over a hyaluronan biodegradable prosthesis. Seven months after the resection of a 1.5-cm-long tract of the urethra and its substitution with the prosthesis, radiological analysis showed the disappearance of the implant and the re-establishment of urethral continuity along the transmural defect. The regenerated tissue remodelled around the implant and exhibited good distensibility under pressure. Histological evaluation showed that the neo-urethra was lined with transitional epithelium and the stroma contained abundant elastic fibres. An examination of the pattern of the major cytoskeletal and cytocontractile proteins of smooth muscle cells and fibroblasts was able to distinguish fibroblasts from smooth muscle cells and myofibroblasts in the neo-urethra. These experiments provide evidence for the potential, successful use of biocompatible/bioresorbable devices for reconstructive surgery of the urethra.

Functional response of cavernosal tissue to distension.

We studied rabbit isolated erectile tissue responses to changes in preload and to active tension development with norepinephrine. The effects of antagonists of endothelin-1, prostaglandins E2 and F2alpha and of nitric oxide were also tested on normal and de-endothelialized preparations. Tissue distension was found to elicit spontaneous rhythmic contractions. Increase in preload diminished the latency of the spontaneous activity and augmented the developed force. Active tension development and the inhibitor of the Na+,K+ pump, ouabain, opposed the spontaneous activity. A marked reduction in the resting tension with abolition of the spontaneous activity was observed on normal, but not on de-endothelialized tissues, following the addition of the specific prostaglandin E2 and F2alpha receptor antagonist, SC-19220. At 3 x 10(-4) M, the highest concentration used, the endothelin-A receptor antagonist BQ-123 failed to change the pattern of the spontaneous activity and the resting tension of normal tissues. The nitric oxide synthesis inhibitor, L-NAME, did not produce reliable effects. These findings point to a causal relation between cavernosal tissue distension and phasic and tonic contractions. Phasic contractions appear to be elicited by smooth muscle cells through the enzyme Na+,K+-ATPase. Increase in the resting tone could be mediated, at least in part, by the endothelium, through the release of prostaglandins E2 and/or F2alpha but not of endothelins. We discuss the hypothesis that, in cavernosal tissue, mechanotransduction of distension to contractile responses is an important determinant of detumescence.

Reconstructive surgery of the urethra: a pilot study in the rabbit on the use of hyaluronan benzyl ester (Hyaff-11) biodegradable grafts.

We investigated the outcome of reconstructive surgery of the urethra through guides composed of a novel biodegradable and highly biocompatible polymer, Hyaff-11. A tract of about 1.5 cm of the rabbit pendulous urethra was totally resected and replaced by a Hyaff-11 tubular graft. Eleven animals were analysed at each of the time points ranging from 7 days to 4 weeks following surgery. Histological and radiological evaluation showed a satisfactory remodelling of the neo-urethra around the implant. The regenerated connective tissue connected both urethral stumps within the first 7 days. On postoperative week 3, the Hyaff-11 guide had disappeared. At the 4-week time point the retrograde urethrogram showed a good distensibility of the neourethra. The regenerated stroma consisted of fibroblastic cells, and collagenous and elastic fibres. The neo-epithelium was pluristratified and exhibited cells of the cuboidal type.

Physiological aging and penile erectile function: a study in the rat.

Erectile function of adult (8-month-old) and aged (27-month-old) rats was investigated by in vivo and in vitro assays. Reflexogenic tonic erections were evoked in vivo by electrostimulation of the dorsal nerve of the penis. Aged rats developed tendentially low intracavernosal pressures, and the kinetics of erection and detumescence were significantly lower than in adult animals. The erectile tissue isolated from aged rats exhibited poor response to papaverine. When precontracted with norepinephrine, aged tissues required a 3-fold increase of papaverine concentration to full relaxation. Functional measurements were coupled with morphological analysis of elastic fibres of the tunica albuginea. Light microscopy showed degenerative signs of elastic fibres of aged rat specimens. Taken together, the present findings show that physiological aging is associated with penile tissue stiffness and abnormal corporal compliance.

Characterization of in vitro relaxant mechanisms in erectile tissue from rabbits of different ages.

In the present study we investigated the in vitro relaxant response of erectile tissue obtained from rabbits of different ages (3, 7 and 24 months) in order to detect the progression with age of cavernosal activity in response to substances acting via endothelium-dependent or -independent mechanisms. Noradrenaline induced a concentration-dependent contraction (0.1 microM-3 mM), with an increase in the contractility in the 24-month-old group. Acetylcholine produced a concentration-dependent relaxant effect in the three age groups, with a reduction of the maximal relaxant effect in older animals. ATP (10 microM-1 mM) and adenosine (10 microM-1 mM) induced a concentration-dependent relaxant effect that was higher in the older group. The presence of the NO2-synthase inhibitor N omega-nitro-L-arginine methyl ester (L-NAME) (0.1 mM) or of the P2-purinoceptor antagonist suramin did not affect ATP relaxation. Relaxation induced by sodium nitrite and nifedipine was reduced in older animals. In conclusion, aging selectively alters the in vitro responsiveness of rabbit erectile tissue. Purinergic system remains more active despite a decrease in the maximal endothelial cholinergic activity and the direct smooth muscle relaxant component.

Chronic treatment with cyclosporine A in New Zealand rabbit: aortic and erectile tissue alterations.

Transplanted patients frequently present erectile impotence. In order to test any interference by cyclosporine A (CsA), which is commonly used in the post-transplantation management, we investigated the in vitro contractile and relaxant responses of corpus cavernosum and aorta from rabbits chronically treated with CsA. Male New Zealand White rabbits 6 months of age were treated with CsA (25 mg/kg per day s.c.) or solvent (corn oil) for 3 weeks. Descending thoracic aorta and erectile tissue were studied in vitro at the end of treatment. Isometric tension was recorded. In thoracic aorta, noradrenaline (0.1-30 mM) induced a concentration-dependent contraction with no difference between the two groups. Acetylcholine (30 nM-3 mM) produced relaxation (52 +/- 4% at 1 mM) that was significantly reduced in comparison to controls (67 +/- 4%, P < 0.05). ATP (3-10 mM) relaxation was not significantly different (maximal 78 +/- 10% and 62 +/- 12% in CsA-treated and controls). The relaxation produced by sodium nitrite was reduced in CsA-treated rabbits (at 10 mM and 0.1 mM concentrations). In erectile tissue, no significant variation in the response of isolated erectile tissue to the above drugs was observed between CsA-treated and control animals. These data indicate that chronic treatment with CsA in rabbits, despite alteration of the in vitro response of thoracic aorta, does not directly influence the function of penile tissue with relaxants.

Effects of prostaglandin E1, and papaverine on non-neurogenic and neurogenic contraction of the isolated rabbit erectile tissue.

Experiments were performed to get further insights into the erectogenic mechanism of prostaglandin E1 (PGE1), which was compared to that of papaverine (PAP). PGE1 and PAP were effective in abolishing the contraction induced by N-ethylmaleimide (NEM), an adenylate cyclase blocker. However, preincubation with PGE1 but not with PAP markedly attenuated the amplitude of adrenergic nerve mediated contraction following prolonged electrical field stimulation. Preincubation with PGE1 was ineffective in counteracting the increase in tension due to exogenous norepinephrine. These data together with previous studies corroborate the hypothesis that in the presence of PGE1 a dual erectogenic mechanism takes place in modulating the cyclic-adenosine-monophosphate metabolism of the cavernous smooth muscle cell as well as the release of norepinephrine from the sympathetic terminal.

Bladder function in the aged rat: a functional and morphological study.

This study was designed to characterize urinary bladder function in the aged rat (27 months of age). For comparative purposes, two different control groups were included into the experimental protocol: normal 6-month old and hyperdiuretic 6-month old rats. Increased threshold volume for micturition and increased bladder mass were found in both aged and hyperdiuretic rats. No difference in the amplitude of micturition contractions was detected between groups. In the aged rat, but not in the hyperdiuretic one, augmented threshold volume and bladder mass were associated with increased intravesical pressure at micturition and structural changes of intramural bladder innervation. When activated, the vesicovesical reflex did not show any change in terms of rate of isovolumetric contractions. In the aged rat, altered sensory information on the state of maximum fullness seems to play an important role in determining abnormal cystometric findings.

A simplified in vitro preparation of the corpus cavernosum as a tool for investigating erectile pharmacology in the rat.

This work describes a simple technique for the assessment of corpus cavernosum function in a species, the rat, representing a convenient model for basic research. We obtained measurable and reproducible responses to different pharmacological agents as well as to electrical field stimulation. In view of the present results we conclude that isolation of the erectile tissue together with the septum may constitute a valuable experimental tool for investigating both local erectile mechanisms and the action of drugs, in the rat corpus cavernosum. Data obtained in the presence of N-nitro-L-arginine and methylene blue further reinforce the concept that nitric oxide may be involved in the process of erection in the rats as well as in other animal species.

Ultrastructural analysis of the cavernous and dorsal penile nerves in experimental diabetes.

The present study was designed to investigate whether experimental diabetes determines structural changes in peripheral nerves involved in reflexogenic erection, namely the cavernous and the dorsal nerve of the penis. Myelinated axons were examined in the dorsal nerve of the penis from rats with streptozotocin-induced diabetes (3- and 6-month duration). Morphometric analysis disclosed a significant decrease of myelinated fibre size most likely due to a progressive axonal atrophy. In addition, morphological analysis revealed diffuse accumulation of glycogen within axons, lipid droplets in Schwann cells and pronounced sequestration of axoplasm by adaxonal Schwann cell processes. These signs were particularly prominent in 6-month-diabetic rats. Myelinated and unmyelinated axons of the cavernous nerve were analysed in 6-month-diabetic animals. No substantial ultrastructural abnormalities were found in the cavernous nerves. These results suggest that in experimental diabetes regionally specific structural changes occur in neuronal pathways subserving erectile function.

Effect of streptozotocin-induced diabetes on electrically evoked erection in the rat.

This study was designed to investigate whether experimental diabetes in rats could functionally affect reflexogenic erection. Erection was elicited by means of electrical stimulation of the dorsal nerves of the penis and recorded as intracorporeal pressure. Rats were examined 1, 3 and 6 months after diabetes induction by streptozotocin. Three and 6 month diabetes caused a significant decrease of latency for erection and a slower phase of detumescence when compared to age-matched controls. In addition, a trend for a lower developed intracorporeal pressure was present in the 6 month diabetes group. Our results indicate that experimental diabetes is associated with alterations of reflexogenic erection.

Electrical stimulation of the dorsal nerve of the penis evokes reflex tonic erections of the penile body and reflex ejaculatory responses in the spinal rat.

An animal model using the spinal rat was characterized. Electrical stimulation of the dorsal nerve of the penis elicited reflex tonic erections of the penile body and reflex bulbospongiosus muscle activity, flips and ejaculations. The tonic erections of the penile body are independent from contractions of the bulbospongiosus muscle and appear to be the result of a neurovascular process. Our observations suggest that reflex bulbospongiosus muscle activity, flips and ejaculations are a single complex reflex response, which we define as reflex ejaculatory response. Two parameters predicted the occurrence and type of reflex response. The visualization of bulbospongiosus muscle activity during surgical isolation of the dorsal nerve of the penis was sufficient to anticipate the elicitability of reflex ejaculatory responses. The latter, together with a systemic systolic pressure > or = 73 mmHg., warranted the elicitability of reflex tonic erections. The similarities found in the physiology of rat tonic penile body erections and of human erections make this model promising for further elucidation of sexual function. Moreover, the present model may prove useful for the investigation of neurogenic erectile dysfunction, and of neurogenic ejaculatory disorders.

Functional responses of hindlimb circulation in aged normal and WHHL rabbits.

Normal New Zealand and Watanabe heritable hyperlipidemic (WHHL) rabbits, about 24 months old, were prepared, under anaesthesia, for recording blood pressure and hindlimb blood flow. Changes in hindlimb vascular resistance were measured after local intra-arterial bolus injection of increasing doses of acetylcholine, bradykinin, serotonin, sodium nitroprusside and phenylephrine. In WHHL rabbits basal hindlimb blood flow was reduced (from 22.6 +/- 3.0 to 12.5 +/- 1.8 ml/min; P less than 0.05) and hindlimb vascular resistance was increased (from 4.6 +/- 0.5 to 8.2 +/- 1.5 mmHg/ml per min; P less than 0.05). No difference was observed in response to acetylcholine, serotonin, sodium nitroprusside and phenylephrine. The only marked alteration found in WHHL rabbits was a clear deficit to bradykinin stimulation. Morphological analysis, using scanning and transmission electron microscopy, indicated a clear damage of the femoral artery, like the presence of atherosclerotic plaques, and an abnormal distribution of patent microvessels in the WHHL muscles of the leg. Peripheral circulation in WHHL rabbits shows some peculiar features, like increased basal vascular resistance and a selective impairment of bradykinin responses. Together with these abnormalities, it seems that responses to various other dilating or contracting agents are normal, suggesting that in this interesting animal model of atherosclerosis the alterations are more specific than in other models.

Urine retention due to intra-spinal cord injection of colchicine in rats: improved recovery of bladder function by monosialoganglioside GM1 and nerve growth factor administration.

Intra-spinal cord injection of a low dose of colchicine (2 micrograms/rat) at the lumbar level affects the micturition reflex leading to voiding suppression, bladder hypertrophy and overflow incontinence which lasts about four weeks. The administration of nerve growth factor and monosialoganglioside GM1 normalizes urine output within 3 days and improves recovery of the bladder contraction tested by a cystometric analysis.