Canadian consensus recommendations on the management of venous thromboembolism in patients with cancer. Part 1: prophylaxis.

Patients with cancer are at increased risk of venous thromboembolism (vte). Anticoagulation therapy has been shown to prevent vte; however, unique clinical circumstances in patients with cancer can often complicate the decisions surrounding the administration of prophylactic anticoagulation. No national Canadian guidelines on the prevention of cancer-associated thrombosis have been published. We therefore aimed to develop a consensus-based, evidence-informed guideline on the topic. PubMed was searched for clinical trials and meta-analyses published between 2002 and 2013. Reference lists of key articles were hand-searched for additional publications. Content experts from across Canada were assembled to review the evidence and make recommendations. Low molecular weight heparin can be used prophylactically in cancer patients at high risk of developing vte. Direct oral anticoagulants are not recommended for vte prophylaxis at this time. Specific clinical scenarios, including renal insufficiency, thrombocytopenia, liver disease, and obesity can warrant modifications in the administration of prophylactic anticoagulant therapy. There is no evidence to support the monitoring of anti-factor Xa levels in clinically stable cancer patients receiving prophylactic anticoagulation; however, factor Xa levels could be checked at baseline and periodically in patients with renal insufficiency. The use of anticoagulation therapy to prolong survival in cancer patients without the presence of risk factors for vte is not recommended.

Canadian consensus recommendations on the management of venous thromboembolism in patients with cancer. Part 2: treatment.

Patients with cancer are at increased risk of venous thromboembolism (vte). Anticoagulation therapy is used to treat vte; however, patients with cancer have unique clinical circumstances that can often make decisions surrounding the administration of therapeutic anticoagulation complicated. No national Canadian guidelines on the management of established cancer-associated thrombosis have been published. We therefore aimed to develop a consensus-based, evidence-informed guideline on the topic. PubMed was searched for clinical trials and meta-analyses published between 2002 and 2013. Reference lists of key articles were hand-searched for additional publications. Content experts from across Canada were assembled to review the evidence and make recommendations. Low molecular weight heparin is the treatment of choice for cancer patients with established vte. Direct oral anticoagulants are not recommended for the treatment of vte at this time. Specific clinical scenarios, including the presence of an indwelling venous catheter, renal insufficiency, and thrombocytopenia, warrant modifications in the therapeutic administration of anticoagulation therapy. Patients with recurrent vte should receive extended (>3 months) anticoagulant therapy. Incidental vte should generally be treated in the same manner as symptomatic vte. There is no evidence to support the monitoring of anti-factor Xa levels in clinically stable cancer patients receiving prophylactic anticoagulation; however, levels of anti-factor Xa could be checked at baseline and periodically thereafter in patients with renal insufficiency. Follow-up and education about the signs and symptoms of vte are important components of ongoing patient care.

Reporte de caso fatal por perforación de divertículo de Meckel / Fatal case report due to perforation of Meckel’s diverticulum

El divertículo de Meckel es una anormalidad congénita del tracto grastrointestinal debida a la falta del cierre del conducto onfalomesentérico y sus complicaciones son raras en los adultos. Se presenta el caso de un hombre de 35 años, quien después de la ingesta de alcohol presentó dolor abdominal y fallece repentinamente. Se le realiza autopsia y estudios histopatológicos donde se evidenció hemoperitoneo masivo originado por la erosión de vasos sanguíneos secundarios a la ulceración de la pared del divertículo de Meckel localizado en el intestino delgado. Esta causa de muerte es infrecuente debido a que la complicación másusual del divertículo es la obstrucción.

IPCS conceptual framework for evaluating a mode of action for chemical carcinogenesis.

The International Programme on Chemical Safety (IPCS) is leading an activity to harmonize approaches to cancer risk assessment as a part of its larger project on the Harmonization of Approaches to the Assessment of Risk from Exposure to Chemicals. Through a series of workshops and the evaluation of case studies, a number of key components of risk assessments relating to harmonization were identified: transparency, terminology, weight of evidence, flexibility, and accessibility/communication. A major impediment to harmonization identified in the consideration of weight of evidence was the evaluation of mode of action. To address this need, a conceptual framework was developed, based on the general principles involved in considering the chemical induction of a specific tumor in animals. This is based partly on the Bradford Hill criteria for causality as modified by Faustman et al. (1997) for developmental toxicity. The framework is described in this paper followed by a worked example. It is recognized that the framework addresses only one stage in the overall characterization of hazard to humans of chemical carcinogens. Another important but separate step is the assessment of relevance to humans. This is a priority area for future work in this project.

Hydrolytic degradation of poly(carbonate)-urethanes by monocyte-derived macrophages.

Polycarbonate (PCN)-based polyurethanes (PCNU) are rapidly becoming the chosen polyurethane (PU) for long-term implantation since they have shown decreased susceptibility to oxidation. However, monocyte-derived macrophages (MDM), the cell implicated in biodegradation, also contain hydrolytic activities. Hence, in this study, an activated human MDM cell system was used to assess the biostability of a PCNU, synthesized with 14C-hexane diisocyanate (HDI) and butanediol (BD), previously shown to be susceptible to hydrolysis by cholesterol esterase (CE). Monocytes, isolated from whole blood and cultured for 14 days on polystyrene (PS) to mature MDM, were gently trypsinized and seeded onto 14C-PCNU. Radiolabel release and esterase activity, as measured with p-nitrophenylbutyrate, increased for almost 2 weeks. At 1 week, the increase in radiolabel release and esterase activity were diminished by more than 50% when the protein synthesis inhibitor, cycloheximide, or the serine esterase/protease inhibitor, phenylmethylsulfonylfluoride was added to the medium. This strongly suggests that in part, it was MDM esterase activity which contributed to the PU degradation. In an effort to simulate the potential combination of oxidative and hydrolytic activities of inflammatory cells. 14C-PCNU was exposed to HOCl and then CE. Interestingly, the release of radiolabeled products by CE was significantly inhibited by the pre-treatment of PCNU with HOCl. The results of this study show that while the co-existing roles of oxidation and hydrolysis in the biodegradation of PCNUs remains to be elucidated, a clear relationship is drawn for PCNU degradation to the hydrolytic degradative activities which increase in MDM during differentiation from monocytes, and during activation in the chronic phase of the inflammatory response.

Neutrophil-mediated biodegradation of medical implant materials.

During the acute inflammatory response to implanted medical devices, human neutrophils (PMN) release oxidative and hydrolytic activities which may ultimately contribute to the degradation of the biomaterial. In this study, the biological activities secreted by live PMNs which may contribute to biodegradation were investigated using a 14C label in the monomer unit of a poly(ester-urea-urethane) (PEUU) substrate. By using specific inhibitors, it was possible to propose a mechanism for PMN-mediated biodegradation. PMN, labeled with 3H-arachidonic acid, released significantly more 3H when adherent to PEUU than when adherent to tissue culture grade polystyrene (P<0.05). The phospholipase A2 (PLA2) inhibitors, aristolochic acid (ARIST) and quinacrine (QUIN), decreased the release of 3H and inhibited PEUU biodegradation (>50%, P<0.05). ARIST had no effect on cell viability, whereas QUIN significantly decreased it. The serine protease inhibitor, phenylmethylsulfonylfluoride inhibited biodegradation, but did not decrease cell survival. There is evidence to suggest that activation via the PLA2 pathway caused the release of hydrolytic activities which were able to elicit 14C release from PEUU. The role of oxidative compounds which were released via activation by phorbol myristate acetate (PMA), was not apparent, since PMA inhibited biodegradation and cell survival (>40%, P<0.05). This study has shown that it is possible to find out the differences in PMN activation through the PLA2 pathway when exposed to different material surfaces, making this a model system worthy of further investigation.

Model systems to assess the destructive potential of human neutrophils and monocyte-derived macrophages during the acute and chronic phases of inflammation.

Isolated cell systems of human neutrophils (PMNs) and monocyte-derived macrophages (MDMs) were used to compare the destructive potential of these cells during the acute and chronic phases of inflammation, respectively. The contrast in the damage to poly(urethane)s (PUs) was monitored by measuring radiolabel release elicited from a (14)C-polyester-urea-urethane (PEUU) during incubation with both cell types. Human PMN were seeded onto polymer-coated glass slips and both radiolabel release as well as serine protease activity [assayed with N-benzyloxycarbonyl lysine thiobenzyl ester (BLT)] were measured 18 h later. Human monocytes were cultured on polystyrene tissue culture plates for 14 days, trypsinized, and seeded onto the polymer-coated glass slips; then, radiolabel release and esterase activity [assayed with p-nitrophenylbutyrate (PNB)] were measured after 18 h. Coverslips with MDM were also incubated for an additional 2 weeks. At 18 h postincubation with the PEUU, MDM elicited 25 times more radiolabel release per 10(6) cells than PMN at 18 h and continued to increase more than sevenfold over the 18-h value during the subsequent 14-day period. The BLT activity in PMN did not increase significantly during the 18-h incubation period, whereas the PNB activity in MDM increased more than fourfold. The MDM, but not the PMN elicited radiolabel release, was inhibited by the protein synthesis inhibitor cycloheximide, as was the increase in PNB activity. The data provide evidence for a hydrolytic role for MDM and, to a lesser extent PMN, in the biodegradation of implanted materials. The full implication of the release of polymer-derived chemical agents from this hydrolytic cleavage of the implanted biomaterials, on the propagation of the inflammatory response, remains to be elucidated.

The effect of polyethylene particle chemistry on human monocyte-macrophage function in vitro.

Osteolysis remains the most important problem in orthopedic implant failure. Wear debris from the implant contains polyethylene (PE) particulate which has been shown to activate monocyte-derived macrophages (MDM). Although the response of MDM has been shown to be influenced by the size, shape, and chemical type of PE, the effect of chemically altered PE on MDM has not been studied. In this study, human MDM were seeded onto glass coverslips coated with virgin high density (HD)PE and chemically modified HDPE (impregnated with ppm levels of CoCl(2) and oxidized by heat) mixed with type I collagen and cultured for 96 h. Light microscopic evaluation demonstrated consistent phagocytosis of the HDPE particulate that was confirmed by scanning electron and transmission electron microscopy with little evidence of cytotoxicity. Evaluation of pro-inflammatory mediator secretion by MDMs in response to the virgin and chemically modified HDPE revealed significant differences in interleukin (IL)-1, tumor necrosis factor (TNF)-alpha, and IL-6 secretion. A significant elevation of IL-1 secretion was observed after initial exposure to virgin HDPE particles compared with controls (p = 0.001). IL-1 secretion was also elevated in the low oxidized particle groups (p = 0.001), whereas the highly oxidized particles were not different than controls. Secretion of both IL-6 (p = 0.03) and TNF-alpha (p = 0.007) were significantly elevated by the low oxidized HDPE particles whereas the virgin and highly oxidized groups showed no difference. The different effects on MDM activation when HDPE surface chemistry was altered, highlight the importance of defining the particle properties when studying the role of MDM activation in in vitro systems and extrapolating these observations to the in vivo situation.

The biodegradation of poly(urethane)s by the esterolytic activity of serine proteases and oxidative enzyme systems.

Biodegradation of poly(urethane)s (PU)s using single enzymes in vitro was assessed by measuring radiolabel release from model poly(ester-urea-urethane) (PESU) and poly(ether-urea-urethane) (PETU) materials synthesized with 14C-labelled monomers. Cholesterol esterase (CE), an enzyme found in monocyte-derived macrophages (MDM), has been reported to cause a significant level of radiolabel release from both of these PUs. Previous work has shown that CE activity could be inhibited by the serine protease/esterase inhibitor, phenylmethylsulfonyl fluoride. Since many serine proteases are present in circulating blood and can be released by cells other than MDM, this study investigated the ability of serine proteases relative to that of CE to cause the degradation of PUs. In addition, the possible role of several oxidative enzymes in the breakdown of PUs was investigated. Proteinase K, chymotrypsin and thrombin, when incubated with PESU, coated on glass slips, caused significant radiolabel release, with proteinase K giving the highest values. However, the highest radiolabel release which proteinase K could elicit was ten times less than CE. Thrombin and then chymotrypsin were progressively worse in their biodegradative activity. Only CE, and not the serine proteases, could elicit a detectable radiolabel release from PETU. Although the release of reactive oxygen species and molecular oxygen occur around an implanted biomaterial, several oxidative systems (peroxidase, xanthine oxidase, catalase), known to produce one or more of these molecular species, were unable to induce radiolabel release from these PUs. The process of biodegradation as assessed by radiolabel release appears to be a specific hydrolytic process, while the role of oxidative enzymes remains less clear.

Synthesis of cholesterol esterase by monocyte-derived macrophages: a potential role in the biodegradation of poly(urethane)s.

Many studies have described the role of monocyte-derived macrophages (MDM) in inflammation leading to atherosclerosis, a process in which alterations in the metabolism of cholesterol esters is well established. On the other hand, the mechanism of MDM activation in response to biomaterial surfaces is still not well understood. Several studies have described the different degrees of activation of monocytes on poly(urethane) surfaces by measuring the release of early markers of differentiation, such as cytokines. It has been possible to decrease MDM activation in contact with materials by modifying the material surface with antioxidants. Therefore, it has been proposed that it is the reactive oxygen species provided by MDM which are responsible for deleterious effects observed in material-derived inflammation. A recent study has shown that one of the markers of the degree of differentiation of MDM is the synthesis of cholesterol esterase (CE), an enzyme demonstrated as causing biodegradation of polyester(urethane)s and more recently polyether- and polycarbonate-poly(urethane)s as well. In this review article, markers used to assess MDM differentiation on material surfaces will be described and related to the activation of MDM. In particular, the CE accumulation in MDM which is associated with atherosclerosis will be related to its degradative potential during chronic inflammation. How this may impact on the biostability of implanted poly(urethane) medical devices is discussed.

Papaverine solutions cause loss of viability of endothelial cells.

OBJECTIVE: The optimal composition of the solution used for irrigation of saphenous veins used for cardiac surgery may influence ultimate graft patency due to potential injurious effects on the vein endothelium of some of the solution constituents. EXPERIMENTAL DESIGN: The viability of cultured saphenous vein endothelial cells was assessed after incubation of saphenous vein endothelial cells with solutions containing saline, saline with papaverine (0.15 M NaCl, 32.5 mg/mL papaverine), culture medium and buffered saline solution (Plasma-Lyte-A). RESULTS: Cell viability was significantly decreased after one hour incubation with solutions containing saline with papaverine (24.4+/-9.4%) as compared to culture medium and buffered saline solutions (medium 100%, Plasma-Lyte-A 86.8+/-6.90%). Loss of viability was directly related to the length of exposure of the cultured cells to papaverine. Morphologic changes of cells incubated with saline: papaverine were also seen including cell retraction and nuclear pyknosis. The cells exposed to medium recovered 100% viability whereas by 4 hours only 22% of the saline: papaverine cells were viable, and by 3 days this viability had fallen to 7.7%. CONCLUSIONS: Loss of viability was shown in cultured saphenous vein endothelial cells exposed to saline solutions containing papaverine, whereas no difference was found between culture medium, saline and balanced salt solutions. Cell death was directly related to the length of exposure of the cells to papaverine. Further, after short- and long-term recovery periods, there was little recovery of cell viability. Although papaverine is a potent vasodilator, exposure to this compound may compromise long-term viability of graft endothelial cells.

Differential synthesis of cholesterol esterase by monocyte-derived macrophages cultured on poly(ether or ester)-based poly(urethane)s.

Monocytes adherent to implanted biomaterials differentiate into macrophages while synthesizing large amounts of degradative enzymes, including cholesterol esterase (CE), which previously has been shown to degrade poly(urethane)s. Human peripheral blood monocytes were cultured on tissue culture grade polystyrene (PS), and two model poly(urethane)s were synthesized from (1) polycaprolactone (PCL) and (2) polytetramethylene oxide (PTMO), both with 2,4-toluene diisocyanate (TDI) and ethylene diamine (ED). The increase in CE and total protein per cell were measured on days 8 and 28 in culture and normalized to the DNA content per cell. At day 8 there consistently were fewer cells remaining on the PTMO-based polymer than on the PCL-based polymer or the PS (p < 0.05). When comparing day 28 to day 8, there was more CE activity and protein per cell on all materials. However, there was a disproportionate synthesis of CE per mg of total protein on PS and TDI/PCL/ED whereas on PTMO there was not. Significantly, there was more protein and CE per cell on PTMO than on PS or TDI/PCL/ED (p < 0.05). This in vitro model system of the chronic phase of inflammation has shown that it is possible to culture monocytes for a month and assess the material surface itself as a potent activator of the differentiation into macrophages without secondary stimulation. Since CE has been shown to degrade poly(ether and ester)-based poly(urethane)s, the differential production of this enzyme relative to the total protein on different surfaces may impact on the potential long-term biostability of an implanted material.

Tissue factor expression by cells used for sodding of prosthetic vascular grafts.

Sodding of vascular grafts involves coating the biomaterial with cells prepared from collagenase-digested fat tissue after removal of the adipocytes by centrifugation. The goal of this study was to investigate the staining characteristics of the sodding cells as well as their ability to express the procoagulant protein tissue factor, and to compare these findings to those found with extensively purified microvascular endothelial cells (MEC) prepared from similar tissue. Sodding cells and MEC, isolated using immunomagnetic separation with anti-PECAM antibodies, were prepared from liposuction material and endothelial-specific staining was compared. The expression of tissue factor on these cells was examined using both an ELISA and a chromogenic assay to assess the rate of generation of factor Xa. Sodding cells expressed significantly more tissue factor than the unstimulated MEC in which the expression was undetectable (sodding cells 2466 +/- 830 pg/mL, P < 0.05). There was no further increase in tissue factor expression in the sodding cells with stimulation with lipopolysaccharide (LPS); however, purified MEC expressed significantly more tissue factor after exposure to LPS (1247 +/- 356 pg/mL, P < 0.05). These results were confirmed by the determination of procoagulant activity of the cells whereby the procoagulant activity on unstimulated MEC was significantly less than that found after stimulation of these cells, and it was also less than stimulated and unstimulated sodding cells (absorbance at 405 nm: 0.423 +/- 0.125, unstimulated MEC; 1.000 +/- 0.438, stimulated MEC; 1.129 +/- 0.396, unstimulated sodding cells; 1.171 +/- 0.254, stimulated sodding cells, P < 0.05). Staining of these two cells types also demonstrated significant uptake of acetylated LDL (Ac-LDL) in the purified MEC which was essentially absent in the sodding cells. Further, vWf staining was found to a greater degree in the purified MEC than in the sodding cells. These experiments demonstrated that the cells prepared for cell sodding express large amounts of tissue factor. The sodding cells do not stain for antigens known to be specific for endothelial cells, whereas MEC do and therefore the concentration of endothelial cells in the sodding cells is small. The significance of the tissue factor expression on the surface of sodded grafts is not yet known.

Metalinguistic and pragmatic abilities of participants in adult literacy programs.

The relationship between oral and written language skills was explored in this study involving 97 participants enrolled in an adult literacy program. Pragmatic language skills were assessed in videotaped conversational dyads which were later analyzed for level of conversational assertiveness and responsiveness and for the status of basic interactional skills. Those behaviors which were judged as being most likely to detract from communicative effectiveness were body movement, eye gaze, and facial expression. Metalinguistic/ semantic language skills were assessed with the Test of Word Knowledge (TOWK) (Wiig & Secord, 1991). A significant relationship was found between total scores on the TOWK and reading levels of subjects as they entered the program. Post-testing was conducted approximately 6 to 8 months after the initial testing. These results were available for 22 of the subjects and indicated that, even for adults, some aspects of oral language improve as reading levels increase.

Preservation of cell organelles during storage of human atrial tissue in the University of Wisconsin solution.

AIM OF THE STUDY: The University of Wisconsin storage solution (UW) (E.I. du Pont de Nemours, Wilmington, DE) has been successful in extending the storage period using some model systems of donor heart preservation for cardiac transplantation. The ability of UW to preserve human cardiac cell organelle (sarcoplasmic reticulum, mitochondria and sarcolemmal) membrane composition (enzyme activity, protein, cholesterol and phospholipid content) was compared to St. Thomas's Hospital Solution (ST) and saline. METHODS: Human atrial appendages were stored at 4 degrees C for 24 h in saline, ST or UW or not stored (controls) and the cell organelles isolated. Each fraction was assayed for enzyme activity (mitochondria: azide sensitive Ca2+ ATPase, cytochrome C oxidase; sarcolemmal membrane: Na+K+ ATPase, p-nitrophenylphosphatase; sarcoplasmic reticulum: CA2+ uptake, Ca2+ ATPase, NADPH cytochrome C reductase), protein, cholesterol and phospholipid content. RESULTS: "Protein yield" proved to be the most sensitive marker for cell organelle preservation. Only the sarcolemmal membrane showed no decrease in either enzyme activities of "protein yield" after storage in saline, ST or UW. Mitochondria showed no decrease in enzyme activities but a decrease in "protein yield" after storage in all 3 solutions. The "protein yield" of sarcoplasmic reticulum was significantly reduced after storage in UW, saline and ST. No correlation could be drawn between cholesterol and phospholipid content and the preservation of cell organelle function. CONCLUSIONS: It is possible to distinguish between the ability of solutions to preserve the membrane composition of human cardiac tissue during hypothermic storage. Using simple assays to assess preservation provides preliminary screening for a superior solution which can then be used in more complicated transplantation models to more fully assess cardiac function.

Assessment of the cytotoxicity of the photosensitizing drug BPD verteporfin using human vascular smooth muscle cells in culture.

Photosensitizing drugs are selectively taken up by lipid-rich lesions such as atheromatous plaque which when exposed to light render the drugs cytotoxic. However, skin photosensitivity which persists for many weeks is a significant side effect. We investigated the cytotoxicity of a new photosensitizing drug, the benzoporphyrin derivative BPD verteporfin (Quadra Logic Technologies), which does not have this deleterious side effect. Vascular smooth muscle cells (VSMC) from normal human mammary and diseased human coronary arteries were grown in culture from explants and characterized with respect to their growth rates. The sensitivity to BPD with and without light was assessed by measuring viability after treatment. The lethal dose of drug for 50% viability loss (LD50) for BPD with light was approximately 12.5 ng/ml for mammary artery, with 52 +/- 8% cell survival (n = 6). The coronary artery VSMC from all patient sources, although differing significantly in growth rate, had a survival of 44 +/- 6% (n = 12) at the same concentration of BPD used for the mammary artery SMC (p = NS). Our results established the LD50 for BPD using human arterial sources of SMC and showed that the growth rates of the cells did not affect the cytotoxicity of the drug.

Use of the University of Wisconsin solution for the preservation of cell organelle activities in rat heart and lungs.

BACKGROUND: The University of Wisconsin storage solution has been successful in some model systems in extending the storage period of heart-lung grafts for transplantation. METHODS: In this study an aerated preparation of rat heart and lung was stored for 24 hours at 4 degrees C in either University of Wisconsin or St. Thomas' Hospital solution. Cell organelles (reticular, mitochondrial, and cell membrane fractions) were isolated from the stored hearts and lungs. Protein yield and enzyme activities were assayed for each cell organelle (reticular fractions: Ca(2+)-ATPase, NADPH-cytochrome C reductase; mitochondria: Ca(2+)-ATPase, cytochrome C oxidase; cell membrane fraction: Na+,K(+)-ATPase, p-nitrophenylphosphatase) as a measure of the recovery of function. RESULTS: Only the cell membrane fraction of heart and lung was not affected by storage in either St. Thomas' Hospital or University of Wisconsin solution with respect to protein yield (milligrams per gram of homogenate) or enzyme activities (nanomole per milligram per minute). The reticular fraction was the most sensitive to storage, with both protein yield and enzyme activities being significantly reduced in both the heart and the lung stored in University of Wisconsin of St. Thomas' Hospital solution (p < 0.05). CONCLUSION: The mitochondrial fraction was not preserved in lung in either St. Thomas' Hospital or University of Wisconsin solution but was preserved in the heart stored in St. Thomas' Hospital solution. These criteria provide preliminary screening for a superior solution that may then be used in more complicated transplantation models to more fully assess cardiac and pulmonary function.