Chylous ascites after associating liver partition and portal vein ligation for stage hepatectomy (ALPPS): overview and case report.

Chylous ascites is an uncommon pathology with low incidence following hepato-pancreato-biliary surgery, there are no cases reported in the international literature following the associating liver partition and portal vein ligation for stage hepatectomy (ALPPS) procedure. It is caused by abnormal intraperitoneal accumulation of lymph fluid in the abdominal cavity secondary to obstruction or injury to the chyle cistern or its tributaries. We describe the case of a 49-year-old woman diagnosed with colon cancer and liver metastasis. ALPPS was performed, on a first and second stage, presenting a high drainage output as well as change in the characteristics of the drainage fluid. The diagnosis of chylous ascites was confirmed by finding triglyceride levels in the drainage fluid at 300 mg/dL. Medical treatment was started based on a hyper-protein diet and fat restriction, supplemented with medium-chain triglycerides and somatostatin analog, with fistula resolution. It can be managed with medical treatment.

Myelination dictates axonal viscoelasticity.

During development, dramatic changes in myelination, growth of neural networks and changes in grey-to-white matter ratio build up the astonishingly plastic brain of a child. The progressive increase in myelination insulates the nervous system, which, in turn, modifies the mechanical microenvironment of the brain spatiotemporally. A growing body of evidence demonstrates the role of mechanical forces in growth, differentiation, maturation and electrical properties of neurons. However, due to limitations in imaging resolution, the exact relationship between myelination, axonal organization and the mechanical properties of nerves at the cellular level is still unknown. Here, we propose a novel approach to study the direct relationship between axonal viscoelasticity with changing fibre anisotropy and myelination during development. With the use of atomic force microscopy (AFM) with in situ fluorescent imaging of the primary neuron-oligodendrocyte co-cultures, we found that as axons are progressively myelinated in vitro, their stiffness increases. Direct quantification of myelin along axons using immunofluorescence also demonstrated a positive correlation between increased myelination over time and increased axonal stiffness (p = .001). Notably, AFM measurements along a single axon showed that the Young's modulus measured across myelinated regions were significantly higher than those of adjacent unmyelinated segments at all time points (p < .0001). Force-relaxation analysis also demonstrated that myelin sheath dominates the regulation of viscoelasticity of axons temporally. Collectively, our findings indicate a direct link between myelination, axonal orientation and viscoelasticity, providing important insights about the mechanical environment in the paediatric brain, with direct implications for our understanding of developmental brain disorders and paediatric brain injury.

Atomic Force Microscopy-Based Measurements of Retinal Microvessel Stiffness in Mice with Endothelial-Specific Deletion of CCN1.

Vascular stiffness is an independent predictor of human vascular diseases and is linked to ischemia, diabetes, high blood pressure, hyperlipidemia, and/or aging. Blood vessel stiffening increases owing to changes in the microscale architecture and/or content of extracellular, cytoskeletal, and nuclear matrix proteins. These alterations, while best appreciated in large blood vessels, also gradually occur in the microvasculature and play an important role in the initiation and progression of numerous microangiopathies including diabetic retinopathy. Although macroscopic measurements of arterial stiffness by pulse wave velocity are often used for clinical diagnosis, stiffness changes of intact microvessels and their causative factors have not been characterized. Herein, we describe the use of atomic force microscopy (AFM) to determine stiffness of mouse retinal capillaries and assess its regulation by the cellular communication network (CCN) 1, a stiffness-sensitive gene-encoded matricellular protein. AFM yields reproducible measurements of retinal capillary stiffness in lightly fixed freshly isolated retinal flat mounts. AFM measurements also show significant changes in compliance properties of the retinal microvasculature of mice with endothelial-specific deletion of CCN1, indicating that CCN1 expression, or lack thereof, affects the mechanical properties of microvascular cells in vivo. Thus, AFM has the force sensitivity and the spatial resolution necessary to measure the local modulus of retinal capillaries in situ and eventually to investigate microvascular compliance heterogeneities as key components of disease pathogenesis.

ACTL6a coordinates axonal caliber recognition and myelination in the peripheral nerve.

Cells elaborate transcriptional programs in response to external signals. In the peripheral nerves, Schwann cells (SC) sort axons of given caliber and start the process of wrapping their membrane around them. We identify Actin-like protein 6a (ACTL6a), part of SWI/SNF chromatin remodeling complex, as critical for the integration of axonal caliber recognition with the transcriptional program of myelination. Nuclear levels of ACTL6A in SC are increased by contact with large caliber axons or nanofibers, and result in the eviction of repressive histone marks to facilitate myelination. Without Actl6a the SC are unable to coordinate caliber recognition and myelin production. Peripheral nerves in knockout mice display defective radial sorting, hypo-myelination of large caliber axons, and redundant myelin around small caliber axons, resulting in a clinical motor phenotype. Overall, this suggests that ACTL6A is a key component of the machinery integrating external signals for proper myelination of the peripheral nerve.

Pushing myelination - developmental regulation of myosin expression drives oligodendrocyte morphological differentiation.

Oligodendrocytes are the central nervous system myelin-forming cells providing axonal electrical insulation and higher-order neuronal circuitry. The mechanical forces driving the differentiation of oligodendrocyte precursor cells into myelinating oligodendrocytes are largely unknown, but likely require the spatiotemporal regulation of the architecture and dynamics of the actin and actomyosin cytoskeletons. In this study, we analyzed the expression pattern of myosin motors during oligodendrocyte development. We report that oligodendrocyte differentiation is regulated by the synchronized expression and non-uniform distribution of several members of the myosin network, particularly non-muscle myosins 2B and 2C, which potentially operate as nanomechanical modulators of cell tension and myelin membrane expansion at different cell stages.This article has an associated First Person interview with the first author of the paper.

Hyperprogression after first dose of immunotherapy in a patient with radioresistant metastasis from nonsmall cell lung cancer.

Immune checkpoint inhibitors (ICIs) represent a new standard of care for patients with advanced nonsmall cell lung cancer, improving overall survival compared with standard chemotherapy. However, a new pattern of response to ICIs characterized by accelerated tumor growth has been recently described, termed hyperprogressive disease (HPD). We report the case of a 73-year-old patient with advanced lung adenocarcinoma who developed HPD following treatment with a unique dose of atezolizumab for a skin metastasis that was refractory to chemotherapy and radiotherapy. Potential clinical biomarkers related to HPD to ICIs are reviewed.

Acute and chronic demyelinated CNS lesions exhibit opposite elastic properties.

Increased deposition of extracellular matrix (ECM) is a known inhibitor of axonal regrowth and remyelination. Recent in vitro studies have demonstrated that oligodendrocyte differentiation is impacted by the physical properties of the ECM. However, characterization of the mechanical properties of the healthy and injured CNS myelin is challenging, and has largely relied on non-invasive, low-resolution methods. To address this, we have employed atomic force microscopy to perform micro-indentation measurements of demyelinated tissue at cellular scale. Analysis of mouse and human demyelinated brains indicate that acute demyelination results in decreased tissue stiffness that recovers with remyelination; while chronic demyelination is characterized by increased tissue stiffness, which correlates with augmented ECM deposition. Thus, changes in the mechanical properties of the acutely (softer) or chronically (stiffer) demyelinated brain might contribute to differences in their regenerative capacity. Our findings are relevant to the optimization of cell-based therapies aimed at promoting CNS regeneration and remyelination.

Immune-related adverse events and atypical radiological response with checkpoint inhibitor immunotherapy in an elderly patient with high PD-L1 expressing lung adenocarcinoma.

Advances in immunotherapy have changed the therapeutic landscape of non-small cell lung cancer (NSCLC), extending overall survival over standard chemotherapy. However, by removing the protection against autoimmunity, immunotherapy can increase immune-related adverse events (irAEs). In addition, new patterns of radiological response have been observed in patients treated with immune checkpoint inhibitors (ICIs). We report the case of a 77 year-old patient with advanced lung adenocarcinoma, who presented three consecutive different irAEs (nephritis, hepatitis, and pneumonitis) and an atypical radiological response (partial response, dissociated response, and "disease flare") in relation to treatment with the PD-1 inhibitor nivolumab. The role of ICIs in elderly patients, the incidence of consecutive irAEs, and the new patterns of radiological response, are also reviewed.

Preparation of Matrices of Variable Stiffness for the Study of Mechanotransduction in Schwann Cell Development.

Extracellular matrix (ECM) elasticity may direct cellular differentiation and can be modeled in vitro using synthetic ECM-like substrates with defined elastic properties. However, the effectiveness of such approaches depends on the selection of a range of elasticity and ECM ligands that accurately model the relevant tissue. Here, we present a cell culture system than can be used to study Schwann cell differentiation on substrates which model the changes in mechanical ECM properties that occur during sciatic nerve development.

Quality of Life in Patients with Background of Iatrogenic Bile Duct Injury.

BACKGROUND: There are only a few reports regarding the quality of life of patients who underwent a complicated cholecystectomy with an iatrogenic bile duct injury (IBDI); the results have been heterogeneous and realized with unspecific measures. METHODS: The objective was to determine whether the quality of life of the subjects with a history of IBDI repaired with bilioenteric derivation is modified in the long term with respect to a control group, for which a group of patients with a history of IBDI (group A) was compared with a group of patients with a history of uncomplicated cholecystectomy (group B). Two different measures were used: on the one hand, the SF-12 questionnaire and on the other hand, a questionnaire was implemented where the patient could determine by himself which variables define his quality of life. RESULTS: A total of 46 patients were included in group A and 51 in group B. The analysis of the SF-12 questionnaire showed a statistical significant reduction in 4 of 8 of the evaluated parameters (general health, physical functioning, physical role and social functioning) in group A in comparison with group B. If a more specific questionnaire is used, the results are similar, with a statistically significant reduction in the quality of life within the group A (0.03). CONCLUSIONS: We conclude that the quality of life of patients with a history of bilioenteric derivation due to an IBDI decreases significantly compared to patients with uncomplicated cholecystectomy.

Localized Myosin II Activity Regulates Assembly and Plasticity of the Axon Initial Segment.

The axon initial segment (AIS) is the site of action potential generation and a locus of activity-dependent homeostatic plasticity. A multimeric complex of sodium channels, linked via a cytoskeletal scaffold of ankyrin G and beta IV spectrin to submembranous actin rings, mediates these functions. The mechanisms that specify the AIS complex to the proximal axon and underlie its plasticity remain poorly understood. Here we show phosphorylated myosin light chain (pMLC), an activator of contractile myosin II, is highly enriched in the assembling and mature AIS, where it associates with actin rings. MLC phosphorylation and myosin II contractile activity are required for AIS assembly, and they regulate the distribution of AIS components along the axon. pMLC is rapidly lost during depolarization, destabilizing actin and thereby providing a mechanism for activity-dependent structural plasticity of the AIS. Together, these results identify pMLC/myosin II activity as a common link between AIS assembly and plasticity.

Myelinating glia differentiation is regulated by extracellular matrix elasticity.

The mechanical properties of living tissues have a significant impact on cell differentiation, but remain unexplored in the context of myelin formation and repair. In the PNS, the extracellular matrix (ECM) incorporates a basal lamina significantly denser than the loosely organized CNS matrix. Inhibition of non-muscle myosin II (NMII) enhances central but impairs peripheral myelination and NMII has been implicated in cellular responses to changes in the elasticity of the ECM. To directly evaluate whether mechanotransduction plays a role in glial cell differentiation, we cultured Schwann cells (SC) and oligodendrocytes (OL) on matrices of variable elastic modulus, mimicking either their native environment or conditions found in injured tissue. We found that a rigid, lesion-like matrix inhibited branching and differentiation of OL in NMII-dependent manner. By contrast, SC developed normally in both soft and stiffer matrices. Although SC differentiation was not significantly affected by changes in matrix stiffness alone, we found that expression of Krox-20 was potentiated on rigid matrices at high laminin concentration. These findings are relevant to the design of biomaterials to promote healing and regeneration in both CNS and PNS, via transplantation of glial progenitors or the implantation of tissue scaffolds.

Label-free imaging of Schwann cell myelination by third harmonic generation microscopy.

Understanding the dynamic axon-glial cell interaction underlying myelination is hampered by the lack of suitable imaging techniques. Here we demonstrate third harmonic generation microscopy (THGM) for label-free imaging of myelinating Schwann cells in live culture and ex vivo and in vivo tissue. A 3D structure was acquired for a variety of compact and noncompact myelin domains, including juxtaparanodes, Schmidt-Lanterman incisures, and Cajal bands. Other subcellular features of Schwann cells that escape traditional optical microscopies were also visualized. We tested THGM for morphometry of compact myelin. Unlike current methods based on electron microscopy, g-ratio could be determined along an extended length of myelinated fiber in the physiological condition. The precision of THGM-based g-ratio estimation was corroborated in mouse models of hypomyelination. Finally, we demonstrated the feasibility of THGM to monitor morphological changes of myelin during postnatal development and degeneration. The outstanding capabilities of THGM may be useful for elucidation of the mechanism of myelin formation and pathogenesis.

Combinatorial actions of Tgfß and Activin ligands promote oligodendrocyte development and CNS myelination.

In the embryonic CNS, development of myelin-forming oligodendrocytes is limited by bone morphogenetic proteins, which constitute one arm of the transforming growth factor-ß (Tgfß) family and signal canonically via Smads 1/5/8. Tgfß ligands and Activins comprise the other arm and signal via Smads 2/3, but their roles in oligodendrocyte development are incompletely characterized. Here, we report that Tgfß ligands and activin B (ActB) act in concert in the mammalian spinal cord to promote oligodendrocyte generation and myelination. In mouse neural tube, newly specified oligodendrocyte progenitors (OLPs) are first exposed to Tgfß ligands in isolation, then later in combination with ActB during maturation. In primary OLP cultures, Tgfß1 and ActB differentially activate canonical Smad3 and non-canonical MAP kinase signaling. Both ligands enhance viability, and Tgfß1 promotes proliferation while ActB supports maturation. Importantly, co-treatment strongly activates both signaling pathways, producing an additive effect on viability and enhancing both proliferation and differentiation such that mature oligodendrocyte numbers are substantially increased. Co-treatment promotes myelination in OLP-neuron co-cultures, and maturing oligodendrocytes in spinal cord white matter display strong Smad3 and MAP kinase activation. In spinal cords of ActB-deficient Inhbb(-/-) embryos, apoptosis in the oligodendrocyte lineage is increased and OLP numbers transiently reduced, but numbers, maturation and myelination recover during the first postnatal week. Smad3(-/-) mice display a more severe phenotype, including diminished viability and proliferation, persistently reduced mature and immature cell numbers, and delayed myelination. Collectively, these findings suggest that, in mammalian spinal cord, Tgfß ligands and ActB together support oligodendrocyte development and myelin formation.

Accelerated repair of demyelinated CNS lesions in the absence of non-muscle myosin IIB.

The oligodendrocyte (OL), the myelinating cell of the central nervous system, undergoes dramatic changes in the organization of its cytoskeleton as it differentiates from a precursor (oligodendrocyte precursor cells) to a myelin-forming cell. These changes include an increase in its branching cell processes, a phenomenon necessary for OL to myelinate multiple axon segments. We have previously shown that levels and activity of non-muscle myosin II (NMII), a regulator of cytoskeletal contractility, decrease as a function of differentiation and that inhibition of NMII increases branching and myelination of OL in coculture with neurons. We have also found that mixed glial cell cultures derived from NMIIB knockout mice display an increase in mature myelin basic protein-expressing OL compared with wild-type cultures. We have now extended our studies to investigate the role of NMIIB ablation on myelin repair following focal demyelination by lysolecithin. To this end, we generated an oligodendrocyte-specific inducible knockout model using a Plp-driven promoter in combination with a temporally activated CRE-ER fusion protein. Our data indicate that conditional ablation of NMII in adult mouse brain, expedites lesion resolution and remyelination by Plp+ oligodendrocyte-lineage cells when compared with that observed in control brains. Taken together, these data validate the function of NMII as that of a negative regulator of OL myelination in vivo and provide a novel target for promoting myelin repair in conditions such as multiple sclerosis.

Identificación de nuevos escenarios epidemiológicos para la enfermedad de Chagas en la región momposina, norte de Colombia / Identification of new epidemiological scenarios for Chagas disease in the Momposina region, North of Colombia

Introducción. La región momposina es una de las zonas de mayor interés en Colombia para estudiar nuevos escenarios epidemiológicos de la enfermedad de Chagas. Objetivo. Determinar el riesgo epidemiológico de infección con Trypanosoma cruzi en seis poblaciones humanas de la región momposina, según el patrón climático bimodal característico de Colombia. Materiales y métodos. Se hicieron cuatro muestreos, dos en época de lluvia y dos en sequía. Las heces de triatominos, como también muestras de sangre de humanos y otros animales mamíferos reservorios, se evaluaron por ELISA, IFI y PCR. Además, para determinar factores de riesgo se analizaron las condiciones de las viviendas, el estado alimentario de triatominos y la participación de los perros en el ciclo de transmisión. Resultados. Los insectos y mamíferos, incluyendo los humanos, presentaron altas tasas de infección por T. cruzi , con diferencias entre las épocas climáticas y según la vegetación asociada. Las tasas de infección por T. cruzi en perros fue de 15 % y, en humanos, de 16,8 %. La gran densidad de población de insectos, el alto porcentaje de insectos alimentados y la alta tasa de infección, indican que en la época seca hay mayor riesgo de infección. Conclusión. Se confirma la presencia y circulación de un foco peridoméstico de T. cruzi y se describen algunos factores de riesgo eco-epidemiológicos para la zona, que sugieren nuevos escenarios epidemiológicos para la enfermedad de Chagas en Colombia.

Introduction: The Momposina region is one of the most interesting areas to study new epidemiological scenarios for Chagas disease in Colombia. Objectives: To determine the presence of a source of peridomestic transmission of T. cruzi and its epidemiological risk in the Momposina region, based on the bimodal weather pattern characteristic of Colombia. Materials and methods: Four surveys over two years (two in the rainy season and two during the dry one) were conducted. Triatomines feces and blood samples from human and reservoirs were evaluated for presence of antibodies and parasites by ELISA, IFI and PCR. The conditions of housing, feeding triatomine state and involvement of dogs in the transmission were assessed. Results. High rates of infection with T. cruzi in insects and wild animals were found. Infection rates of T. cruzi in dogs (15%) and humans (16.8%) were found. The results obtained in this study indicated that in the dry season there is increased risk of infection with T. cruzi , given the higher population density of insects, the higher percentage of fed insects and the higher rate of infection. Conclusion: These results confirm the presence and movement of a peridomestic outbreak of T. cruzi and describes some risk factors for the eco-epidemiological area, suggesting new epidemiological scenarios for Chagas disease in Colombia.

[Identification of new epidemiological scenarios for Chagas disease in the Momposina region, North of Colombia]. / Identificación de nuevos escenarios epidemiológicos para la enfermedad de Chagas en la región momposina, norte de Colombia.

INTRODUCTION: The Momposina region is one of the most interesting areas to study new epidemiological scenarios for Chagas disease in Colombia. OBJECTIVES: To determine the presence of a source of peridomestic transmission of T. cruzi and its epidemiological risk in the Momposina region, based on the bimodal weather pattern characteristic of Colombia. MATERIALS AND METHODS: Four surveys over two years (two in the rainy season and two during the dry one) were conducted. Triatomines feces and blood samples from human and reservoirs were evaluated for presence of antibodies and parasites by ELISA, IFI and PCR. The conditions of housing, feeding triatomine state and involvement of dogs in the transmission were assessed. RESULTS: High rates of infection with T. cruzi in insects and wild animals were found. Infection rates of T. cruzi in dogs (15%) and humans (16.8%) were found. The results obtained in this study indicated that in the dry season there is increased risk of infection with T. cruzi , given the higher population density of insects, the higher percentage of fed insects and the higher rate of infection. CONCLUSION: These results confirm the presence and movement of a peridomestic outbreak of T. cruzi and describes some risk factors for the eco-epidemiological area, suggesting new epidemiological scenarios for Chagas disease in Colombia.

Myosin II is a negative regulator of oligodendrocyte morphological differentiation.

During their development as myelinating cells, oligodendrocyte progenitors (OPC) undergo dramatic changes in the organization of their cytoskeleton. These changes involve an increase in cell branching and in lamella extension, which is important for the ability of oligodendrocytes to myelinate multiple axons in the CNS. We have previously shown that the levels of the actin-associated motor protein nonmuscle myosin II (NMII) decrease as oligodendrocyte differentiate and that inhibition of NMII activity increases branching and myelination, suggesting that NMII is a negative regulator of oligodendrocyte differentiation. In agreement with this interpretation, we have found that overexpression of NMII prevents oligodendrocyte branching and differentiation and that OPC maturation is accelerated in NMII knockout mice as shown by a significant increase in the percentage of mature MBP(+) cells. Although several pathways have been implicated in oligodendrocyte morphogenesis, their specific contribution to the regulation of NMII activity has not been directly examined. We tested the hypothesis that the activity of NMII in OPC is controlled by Fyn kinase via downregulation of RhoA-ROCK-NMII phosphorylation. We found that treatment with PP2 or knockdown of Fyn using siRNA prevents the decrease in myosin phosphorylation normally observed during OPC differentiation and that the inhibition of branching induced by overexpression of constitutively active RhoA can be reversed by treatment with Y27632 or blebbistatin. Taken together, our results demonstrate that Fyn kinase downregulates NMII activity, thus promoting oligodendrocyte morphological differentiation.