A necrotising fasciitis: case report.

Necrotizing fasciitis is one of the most common soft tissue infections, with a high risk of major amputation and a mortality ranging from 6 to 33% which has not changed in the past 20 years. Early surgical resection of necrotic tissue plays a key role in determining the prognosis. Nawijn et al. identified an optimal 6 hours window from presentation to surgery. Symptoms of necrotizing fasciitis mimic those of common skin infections, such as erysipelas and cellulitis, making rapid surgical management difficult. In this context, the aid of point-of-care-ultrasound is a valuable tool for early diagnosis, detecting the presence of subcutaneous thickening, gas and perifascial liquid. Other characteristic ultrasound findings include the "cobblestone" appearance of the subcutaneous soft tissues and reverberation artifacts due to hyperechoic outbreaks, defined as "snow globes" due to the presence of heterogeneous swirling material, and "dirty shadowing" due to the foggy shadow created by the gas.

Clinical and prognostic role of matrix metalloproteinase-2, -9 and their inhibitors in breast cancer and liver diseases: A review.

Matrix metalloproteinases are a family of zinc endopeptidases with proteolytic activity against the extracellular matrix components. In particular, two members of this family named Gelatinase A and B, as amply documented in the literature, play a key role in the process of tumor growth/metastasis in breast and hepatocellular carcinoma. Their activity is regulated by Tissue Inhibitor of metalloproteinases-1 and -2, which are the physiological inhibitor of Gelatinases A and B respectively. The aim of this review is to determine the current understanding of the clinical and prognostic role of Metalloproteinases-2 and -9 and their inhibitors in the course of breast cancer and liver diseases. Forty-one articles were selected from PubMed by entering the following keywords: liver diseases, breast cancer, MMP-2, TIMP-2; all articles were read and notes were made regarding the number of enrolled patients, pathology, measures, results and these data were used to write this review. Over-expression of both gelatinases is associated with the relapse of disease, metastasis, shorter overall survival in breast cancer and hepatocellular carcinoma and invasion and progression to tumors in chronic liver diseases, and MMPs/TIMPs ratio could be useful in the follow-up of these patients.

Tailored ultrasound learning for acute care surgeons: a review of the MUSEC (Modular UltraSound ESTES Course) project.

PURPOSE: The European Society for Trauma and Emergency Surgery (ESTES) identified the need for general and trauma surgeons involved in the management of critically ill surgical patients to embrace and learn both basic and advanced US skills. A steering group was created to address this deficit. METHODS: Modular UltraSound ESTES Course (MUSEC) is a modular blended-learning course. It incorporates pre-test/post-test examinations, pre-course online materials, didactic and interactive lectures, interactive case scenarios discussion with pathological US clips, hands-on practice on healthy volunteer models, and on original phantoms for simulating both pathological US findings and practicing US-guided interventional maneuvers. Four independent modules were provided. Surgical decision-making didactics were also included in the course curriculum. Learning gain (Δ of the rating of pre-test and post-test) was calculated for each module. An anonymous post-course satisfaction survey was also administered (16 questions with a Likert's 5-point scale of evaluation). RESULTS: Twenty-three MUSEC Courses were run in a 30 months period, training 416 doctors from 29 countries. A total of 52 modules were delivered. The mean pre-test and post-test grades were 8.3/12 and 10.7/12, respectively, yielding a significant mean learning gain of 28.9 % (p = 0.001). Post-course satisfaction survey got an overall ranking of 4.5/5. CONCLUSIONS: MUSEC is an effective and original educational format, enjoyed by candidates, that fills an educational gap for tailored US education as a procedural skill to acute care surgeons. Ongoing revisions should reduce the current limitations and increase the educational value, in terms of number of modules and post-course credentialing.

ESTES guidelines: acute mesenteric ischaemia.

PURPOSE: Acute mesenteric ischaemia (AMI) accounts for about 1:1000 acute hospital admissions. Untreated, AMI will cause mesenteric infarction, intestinal necrosis, an overwhelming inflammatory response and death. Early intervention can halt and reverse this process leading to a full recovery, but the diagnosis of AMI is difficult and failure to recognize AMI before intestinal necrosis has developed is responsible for the high mortality of the disease. Early diagnosis and prompt treatment are the goals of modern therapy, but there are no randomized controlled trials to guide treatment and the published literature contains a high ratio of reviews to original data. Much of that data comes from case reports and often small, retrospective series with no clearly defined treatment criteria. METHODS: A study group of the European Society for Trauma and Emergency Surgery (ESTES) was formed in 2013 with the aim of developing guidelines for the management of AMI. A comprehensive literature search was performed using the Medical Subject Heading (MeSH) thesaurus keywords "mesenteric ischaemia", "bowel ischaemia" and "bowel infarction". The bibliographies of relevant articles were screened for additional publications. After an initial systematic review of the literature by the whole group, a steering group formulated questions using a modified Delphi process. The evidence was then reviewed to answer these questions, and recommendations formulated and agreed by the whole group. RESULTS: The resultant recommendations are presented in this paper. CONCLUSIONS: The aim of these guidelines is to provide recommendations for practice that will lead to improved outcomes for patients.

Rho GTPase control of protein kinase C-related protein kinase activation by 3-phosphoinositide-dependent protein kinase.

The protein kinase C-related protein kinases (PRKs) have been shown to be under the control of the Rho GTPases and influenced by autophosphorylation. In analyzing the relationship between these inputs, it is shown that activation in vitro and in vivo involves the activation loop phosphorylation of PRK1/2 by 3-phosphoinositide-dependent protein kinase-1 (PDK1). Rho overexpression in cultured cells is shown to increase the activation loop phosphorylation of endogenous PRKs and is demonstrated to influence this process by controlling the ability of PRKs to bind to PDK1. The interaction of PRK1/2 with PDK1 is shown to be dependent upon Rho. Direct demonstration of ternary (Rho.PRK.PDK1) complex formation in situ is provided by the observation that PDK1 is recruited to RhoB-containing endosomes only if PRK is coexpressed. Furthermore, this in vivo complex is maintained after phosphoinositide 3-kinase inhibition. The control of PRKs by PDK1 thus evidences a novel strategy of substrate-directed control involving GTPases.

Apoptosis induced by denied adhesion to extracellular matrix (anoikis) in thyroid epithelial cells is p53 dependent but fails to correlate with modulation of p53 expression.

In normal epithelial cells, impaired cell-matrix contact leads to induction of programmed cell death, a process that has been termed 'anoikis'. We investigated the role of p53 and other apoptotic proteins in anoikis in thyroid epithelial cells. Western blot analysis demonstrated that neither p53 nor Bcl-2, Bcl-XL and Bax protein expression changed during anoikis. However, loss of endogenous p53 activity in cells transfected with a dominant-negative mutated p53 inhibited anoikis demonstrating the involvement of p53-dependent processes. The phosphatase inhibitor sodium orthovanadate opposed anoikis when added to the cells within 6 h, suggesting a role for phosphorylated proteins.

Expression of integrins of the beta1 family in thyroid cells from patients with Graves' disease in vivo and in vitro.

The expression of the beta1 family of integrins was determined in thyroid follicular cells from patients with Graves' disease (GD). Integrin expression was quantitated by flow fluorocytometry of single cell suspensions with antibodies against the common beta1 chain and the alpha1-alpha6 subunits. Results indicated that also in thyroid glands of GD, as previously observed in nodular goiters, two follicular cell populations with different patterns of beta1 integrin expression coexist (VLAalpha3beta1 and VLAalpha1,3,5,6beta1). The VLAalpha1,3,5,6beta1 thyrocyte population in GD was more abundant than in nodular goiters, ranging from 40 to 70% of the total follicular cells and the overall expression of the beta1 integrins was a two-fold higher. In thyrocytes from patients with GD cultured in vitro, alpha3 and alpha2 expression was regulated by cell-to-cell contact as previously described in normal thyroid cells, while the expression of alpha1, alpha5 and alpha6 was quickly lost during the culture. Our data suggest that the integrin profile of the VLAalpha1,3,5,6beta1 thyrocyte population in GD is induced by micro-environmental conditions rather than being the expression of a constitutive phenotype.

Insulin-like growth factor I stimulates tyrosine phosphorylation of p130(Cas), focal adhesion kinase, and paxillin. Role of phosphatidylinositol 3'-kinase and formation of a p130(Cas).Crk complex.

Addition of insulin growth factor-I (IGF-I) to quiescent Swiss 3T3 cells rapidly induced tyrosine phosphorylation of the p130Crk-associated substrate (p130(Cas)), a novel adaptor protein localized at focal adhesions. Half-maximal effect was obtained at 0. 6 nM. IGF-I also promoted the formation of a complex between p130(Cas) and c-Crk and elicited a parallel increase in the tyrosine phosphorylation of p125(Fak) and paxillin. IGF-I-induced p130(Cas), p125(Fak), and paxillin tyrosine phosphorylation could be dissociated from mitogen-activated protein kinase kinase, p70(S6K), and protein kinase C activation. In contrast, the structurally unrelated phosphatidylinositol 3-kinase inhibitors wortmannin and LY294002 markedly attenuated the increase in tyrosine phosphorylation of p130(Cas), p125(Fak), and paxillin induced by IGF-I. Cytochalasin D, which disrupts the network of actin microfilaments, completely prevented tyrosine phosphorylation of p130(Cas), p125(Fak), and paxillin and the formation of a p130(Cas). Crk complex in response to IGF-I. Thus, our results identified a phosphatidylinositol 3-kinase-dependent pathway that requires the integrity of the actin cytoskeleton to induce tyrosine phosphorylation of p130(Cas), p125(Fak), and paxillin in response to IGF-I and suggest that tyrosine phosphorylation of these focal adhesion proteins, together with the recruitment of c-Crk into a complex with p130(Cas), may play a novel role in IGF-I signal transduction.

Tyrosine phosphorylation of p130(cas) by bombesin, lysophosphatidic acid, phorbol esters, and platelet-derived growth factor. Signaling pathways and formation of a p130(cas)-Crk complex.

Treatment of Swiss 3T3 cells with bombesin rapidly induced tyrosine phosphorylation of the p130 Crk-associated substrate (p130(cas)). Vasopressin, endothelin, bradykinin, lysophosphatidic acid, sphingosylphosphorylcholine, and phorbol 12,13-dibutyrate also stimulated p130(cas) tyrosine phosphorylation. Bombesin-induced p130(cas) tyrosine phosphorylation could be dissociated from both protein kinase C activation and Ca2+ mobilization from intracellular stores. In contrast, cytochalasin D, which disrupts the network of actin microfilaments, completely prevented tyrosine phosphorylation of p130(cas) by bombesin. Platelet-derived growth factor, at low concentrations (1-5 ng/ml), also induced tyrosine phosphorylation of p130(cas) via a pathway that depended on the integrity of the actin cytoskeleton. The phosphatidylinositol 3'-kinase inhibitors wortmannin and LY294002 prevented tyrosine phosphorylation of p130(cas) in response to platelet-derived growth factor but not in response to neuropeptides, lysophosphatidic acid, sphingosylphosphorylcholine, or phorbol 12,13-dibutyrate. All agonists that induced p130(cas) tyrosine phosphorylation also promoted the formation of a p130(cas).Crk complex in intact Swiss 3T3 cells. Thus, our results identified distinct signal transduction pathways that lead to tyrosine phosphorylation of p130(cas) in the same cells and suggest that p130(cas) could play a role in mitogen-mediated signal transduction.

Integrin binding to immobilized collagen and fibronectin stimulates the proliferation of human thyroid cells in culture.

The expression of integrins of the beta1 family and their possible biological effects were investigated in normal human thyroid cells in monolayer culture. The expression of beta1 and alpha(1-6) integrin subunits was determined by flow cytofluorometry with specific antibodies. Follicular cells of subconfluent monolayer cultures expressed alpha2beta1 and alpha3beta1 at high levels, while alpha1beta1 was only slightly expressed, and alpha4beta1, alpha5beta1, and alpha6beta1 were never detected. Cell attachment assays were performed in fibronectin-, type I collagen-, and laminin-coated microtiter plates. Thyroid cells, while adherent to collagen and fibronectin, showed poor attachment to laminin despite the abundance of their putative receptors alpha2beta1 and alpha3beta1. In serum-free medium, collagen and fibronectin induced cytoskeletal organization, change of cell shape from round to flat, and cell spreading. [3H]Thymidine incorporation and proliferation assays were used to evaluate the effects of collagen and fibronectin on DNA synthesis and cell growth in the absence of a change in spreading or cell shape. Both substrates, in low serum-containing medium, induced a concentration-dependent increase in [3H]thymidine incorporation partially inhibited by RGD-containing peptides that blocked the cell attachment. Thyrocytes cultured in low serum-containing medium on immobilized fibronectin or collagen showed a dose-dependent stimulation of proliferation. These data indicate that fibronectin and collagen can regulate the cytoskeletal organization and cell shape and stimulate the proliferation of normal human thyroid cells in culture and that integrins mediate these effects of extracellular matrix proteins.

[Secretory IgA of the cervical mucus in neoplastic and nonneoplastic conditions of the uterine cervix]. / IgA secretorie del muco cervicale in condizioni neoplastiche e non neoplastiche della cervice uterina.

In 39 women affected by cervical intraepithelial neoplasia (CIN) concentration of the cervical mucus secretory IgA (sIgA) was significantly higher than in 414 controls matched for age, reproductive status and smoking habit (196 healthy women; 109 with "specific" and "aspecific" cervicitis or cervico-vaginitis; 51 with benign epithelial disorders of the cervix; 40 with adenomatous cervical polyp and 18 with early invasive exocervical squamous carcinoma). CIN carried the highest proportion of cases with sIgA detectable or beyond the cut-off value and sIgA concentration was inversely related to CIN grade. Present data confirm our preliminary investigation on the cervical total IgA and explain that any increased levels of these IgA are induced by the secretory and not serum fraction of this immunoglobulin. We still don't know the exact meaning and value of the present results. It is only possible to suppose that they are the expression of a vigorous local immune activation adverse to CIN, which is elevated for as long as the architecture of cervical glandular epithelia is preserved.

Alexithymia, immunity and cervical intraepithelial neoplasia: replication.

BACKGROUND: In a previous study [Psychother Psychosom 1994;61:199-204] we investigated the relationship between alexithymia, carcinogenesis and immunity in a group of women who were unconscious sufferers from precancerous lesions of the cervix (CIN). The results of this study showed a high level of association between alexithymia and CIN and, an even more interesting fact, between alexithymia and reduced levels of immunity. METHODS: The aim of the present study is to check the results of the previous one by testing a larger group (43 women affected by cervical dysplasia and 67 healthy women) and by the use of a self-administered test for detection of alexithymia, the well-validated Twenty-Item Toronto Alexithymia Scale (TAS-20). RESULTS: The results confirm that women suffering from CIN have higher average TAS-20 ratings (55) than normal women (47.32) and that the level of alexithymia detected in the group of women suffering from dysplasia (42.5%) is higher than that of normal women (12.85%). Moreover, the present study confirms that alexithymic women have lower rates of a number of lymphocyte subsets than non-alexithymic women. CONCLUSIONS: This study fully confirms the results of our previous work and those of a number of other studies: (1) personality might be one of the factors jointly responsible for the outbreak of cancer; (2) the immune system appears to play an important part as a mediator between personality and cancer.

Cell-to-cell contact modulates the expression of the beta 1 family of integrins in primary cultures of thyroid cells.

The expression of the beta 1 family of integrins was studied in normal thyroid tissue cultures and monolayer cell cultures. The expression of the various subunits was measured by flow cytofluorometry with specific monoclonal antibodies and by Northern analysis. In monolayer cell cultures but not in tissue cultures, the expression of the alpha 3 subunit on the cell membrane progressively increased soon after plating, reaching a 30-fold higher intensity. The alpha 2 subunit, not detectable in native follicular cells, was expressed de novo and reached a remarkable high level. Up-regulation of alpha 2 and alpha 3 in monolayer cell cultures was serum-independent and preceded the expression of proliferating cell nuclear antigen, [3H]thymidine incorporation, and cell replication. Northern analysis demonstrated an increased level of beta 1 integrin mRNA. The increase of alpha 2 and alpha 3 was readily reversible since the expression of these molecules returned to a lower level when cultures reached a high cell density. Down-regulation did not occur until cell cultures were confluent. When cells from high cell density and low integrin expression were harvested and sparsely seeded in culture, up-regulation of integrins was observed again, while rapid reaggregation of isolated cells inhibited this phenomenon. Altogether these data suggest that cell-to-cell contact may regulate the expression of beta 1 integrins in thyroid primary cultures.

Long-term subcutaneous recombinant interleukin-2 as maintenance therapy: biological effects and clinical implications.

Several trials have evaluated the therapeutic efficacy of rIL-2 combined with more traditional treatments such as chemotherapy and radiotherapy, but the use of IL-2 as adjuvant therapy for minimal residual disease or to maintain clinical response obtained with other standard treatments has yet to be investigated. The aim of the present trial was to study the biological effects of maintenance long-term treatment (6 months) with subcutaneous low-dose IL-2 in 16 patients with different neoplasms previously treated with chemo-immuno therapeutic regimens or with surgery (7 metastatic renal cancers, 5 locally advanced renal cancers previously subjected to radical nephrectomy, 2 metastatic breast cancers, 1 small cell lung cancer, and 1 metastatic melanoma). Clinical tolerability, feasibility and therapeutic implications are also discussed. The IL-2 schedule was as follows: 4.5 million IU/day, 3 times weekly for 6 months. A total of 14 patients completed therapy without requiring dose modifications and are free of progression after a median duration of 8+ months (range: 7+ to 34+) while two patients progressed during therapy (one inflammatory breast cancer and one renal cancer). Important and persistent hemato-immunostimulating effects in both soluble (IL-2, sIL-2R, IL-6) and cellular (lymphocyte subsets, monocytes, eosinophils) parameters were noted during the entire treatment. The IL-2 related toxicity was quite low. Moreover, this long-term IL-2 therapy could control neoplastic growth and thus prolong clinical response obtained with standard treatments. Prospective randomized studies regarding the clinical efficacy have been initiated.

Solitary plasmacytoma of bone and extramedullary plasmacytoma: two different nosological entities?

BACKGROUND: The relationship between solitary plasmacytoma and multiple myeloma is still unclear, but they can be distinguished by their different clinical course. Indicators of disease activity and extension, and of a possible evolution to multiple myeloma, have not been identified as yet. METHODS: Two cases of solitary plasmacytoma are described: one of the mandible and one extramedullary plasmacytoma (EMP) of the rhinopharynx. Pathologic data included immunohistochemical staining for heavy and light Ig chains, and for the proliferating cell nuclear antigen (PCNA). Analysis of the peripheral immunological status and serum parameters (beta 2 microglobulin, thymidine kinase, IL-2, IL-6 and soluble IL-2 receptor) was performed and correlation was made with the clinical status. Flow cytometry analysis of nuclear DNA content and S-phase cell fraction were also studied in both neoplasms. RESULTS: Solitary plasmacytoma of bone (SPB) showed important basal immunologic alterations and a marked increase in all serum parameters considered with respect to EMP. Ploidy analysis demonstrated an almost complete aneuploidy cell population for the SPB patient (80%), whereas in the EMP patient only 2% of the cells were aneuploid. The S-phase cells were 16% and 4%, respectively. PCNA index was 60% in SPB and 10% in EMP. CONCLUSIONS: Solitary plasmacytoma of the bone appeared to be a more aggressive form of plasmacellular neoplasia, distinct from EMP and similar to multiple myeloma. The study of serum parameters, together with analysis of PCNA, ploidy and S-phase fraction, can aid in better understanding disease activity, and in the choice of more adequate treatment. Moreover, serial analysis of some serum factors might be useful markers for monitoring the disease.

Loss of polarity and de novo expression of the beta 1 family of integrins in thyroid tumors.

The expression and cell-membrane distribution of the beta 1 family of integrins (very-late-activation antigens, VLA) were investigated in benign and malignant human thyroid tumors. We compared tissue samples of normal glands, nodular goiters, adenomas and carcinomas. We also examined 3 thyroid-carcinoma cell lines cultured in vitro. The expression of subunits of the beta 1 family of integrins was assessed by flow cytometry and specific antibodies in dispersed single-cell suspensions and by immunofluorescence on frozen tissue sections. In contrast to the heterogeneity of the expression of beta 1 integrins observed in other tumors, thyroid neoplastic lesions showed a remarkably constant VLA profile. In all tumors, benign as well as malignant, and in carcinoma cell lines, all sub-units of beta 1 integrins were expressed at high levels. While sub-units alpha 1, alpha 3, alpha 5, alpha 6 and occasionally alpha 2 were also present in a cell sub-set of normal glands and nodular goiters, expression of alpha 4 was restricted to neoplastic lesions; this integrin can be therefore considered an antigen associated with thyroid tumors. It has been reported that in normal glands and in nodular goiters, the expression of beta 1 integrins is restricted to the basal-cell membrane. Immunofluorescence on tissue sections showed instead that, in adenomas and carcinomas, the polarized distribution of these integrins on the cell membrane is lost.

Alexithymia, immunity and cervical intraepithelial neoplasia: a pilot study.

Alexithymia and circulating lymphocyte subsets were studied in 62 women [36 healthy women and 26 women affected by cervical intraepithelial neoplasia (CIN I, II, III) who were not aware of their status] in order to assess a possible relationship between alexithymia, CIN and immunological lymphocytic functions. Alexithymia was estimated by the 20-item Schalling-Sifneos Personality Scale and then correlated with peripheral blood lymphocyte subsets. The results of our study report an association between alexithymia and CIN. Alexithymic women show lower rates of almost all lymphocytic subsets compared to nonalexithymic ones. The difference was also found between alexithymic women affected by CIN and alexithymic women with an unsuspicious Pap smear. On the whole, these preliminary results seem to confirm data reported by other authors who hypothesized that a certain personality trait characterized by emotional inhibition is related to a greater cancer vulnerability. Such relationships might be mediated by certain lymphocytic functions as the result of the alexithymic status. Results reported here need more extensive surveys, in order to control potentially confounding factors related to the personality assessment of the subjects in this study.

Multiple meningiomas in a patient with constitutional ring chromosome 22.

We report on a patient with multiple congenital anomalies and ring chromosome 22 who died at age 16 years of bronchopneumonia. Autopsy documented multiple psammomatous meningiomas of the spinal dura and tentorium. Tumor tissue for cytogenetic analysis was not available. Although abnormalities of chromosome 22 in tumor tissue have been reported, to our knowledge, this is only the third report of a constitutional chromosome 22 abnormality associated with the development of meningiomas. Thus, a constitutional chromosome 22 abnormality may predispose to the development of meningiomas.

[Lymphocytic subpopulations in malignant ascites of ovarian origin. Flow cytometric analysis]. / Sottopopolazioni linfocitarie nell'ascite neoplastica di origine ovarica. Analisi in citometria di flusso.

A flow-cytometric analysis of ascitic fluid (AF) and peripheral blood lymphocyte subpopulations (LS) was performed on 16 patients with ovarian malignancy (OM) and 5 with metastatic peritoneal carcinomatosis (MPC). AF lymphocytes are 58% of total leukocytes in OM patients, 37% in MPC patients, while blood lymphocytes are 14% and 17%, respectively. AF absolute lymphocyte count (total and individual LS) is higher in OM patients. OM patients AF lymphocytes are: T = 70%, CD4+ = -37%, CD8+ = 32% (CD4/CD8 = 1.39), B = 5%, NK cells = 4-10%, CD25+ = 20%, CD69+ = 15%, CD71+ = 3%. In MPC patients the values are generally similar, though CD4+ cells are +7%, CD8+ cells = -14% (CD4/CD8 = 3.17), CD69+ cells = -8%. Untreated OM patients have a AF total and percent lymphocyte count higher than treated ones. Among the latter, however, the CD4/CD8 ratio as well as the number of CD4+, inducer, CD25+ and CD71+ cells are higher. In terms of percent values, the most striking differences involve total T and B lymphocytes (81-87% vs 56-62%, and 10% vs 2%, respectively). With the only exception of absolute NK cell count, OM patients show no correlation between AF and peripheral blood LS pattern. These results agree only partially with data from the literature. Pathophysiologic and clinical considerations support the practical usefulness of LS analysis in AF from OM patients.