Transjugular intrahepatic portosystemic shunt in non-cirrhotic portal hypertension related to cystic fibrosis in a lung transplant patient.

Liver involvement is not uncommon in patients with cystic fibrosis (CF). Even if serious complications as non-cirrhotic portal hypertension, cirrhosis and liver failure rarely occur, they are associated with impaired survival and reduced quality of life. Herein, we have reported the first case of a patient with CF and non-cirrhotic portal hypertension who underwent transjugular intrahepatic portosystemic shunt placement for recurrent variceal bleeding after bilateral lung transplantation, and we have reviewed the available literature pertaining to this field.

Can nurses' shift work jeopardize the patient safety? A systematic review.

OBJECTIVE: Medication administration accounts for 40% of the nursing clinical activity in hospitals and nurses play a central role in granting the patient safety, as they are directly responsible for the patient care. This review aims at analyzing the correlation between the clinical risk management and the occurrence of medication errors and the effects of the shift work (such as excessive fatigue and sleep deprivation after a shift in hospital) on inpatient nurses. MATERIALS AND METHODS: This paper adheres to the relevant EQUATOR guidelines. A systematic review was conducted according to the PRISMA statement and pertinent articles were selected based on inclusion criteria and quality assessment factors. Two reviewers searched the bibliographic databases PubMed, Scopus, Cochrane, CINAHL to collect all the available articles in English and Italian issued between 1992 and August 2017. RESULTS: The reviewers analyzed 19 of the 723 initially extracted references, as they focused on the impact of workload, shifts and sleep deprivation on the probability of making medication errors. CONCLUSIONS: The main reasons behind medication errors are stress, fatigue, increased workload, night shifts, nurse staffing ratio and workflow interruptions. These factors can have a significant negative impact on the health and the performance of the employees. It is desirable to extend and deepen the research to identify appropriate measures to minimize medication errors.

Intra-arterial thrombolysis of acute hand ischaemia with or without microcatheter: preliminary experience and comparison with the literature.

PURPOSE: This paper evaluates the indications, techniques, results, and complications of intra-arterial thrombolysis with or without a multihole microcatheter in three cases of acute hand ischaemia in comparison with the literature. MATERIALS AND METHODS: Three men (mean age 39 years) with symptoms and signs of acute hand ischaemia (i.e. pain, pallor, cyanosis, decreased motor or sensory function) were studied with Doppler ultrasound and selective arteriography, which demonstrated acute clotting of wrist and/or hand arteries. They therefore underwent intra-arterial thrombolysis with the administration of urokinase and vasodilators and heparin if necessary, with (n=2) or without (n=1) multihole microcatheters. RESULTS: In all three cases, partial or complete recanalisation of the occluded arteries was achieved, with almost complete remission of clinical symptoms and good recovery of hand function. CONCLUSIONS: Percutaneous intra-arterial thrombolysis is an effective therapeutic approach in cases of acute hand ischaemia and is a valid alternative to surgical thrombectomy. Multihole microcatheters allow the thrombolytic agent to be distributed more evenly into the clot and may help to reduce reactive arterial spasm.

Strategies of endoleak management following endoluminal treatment of abdominal aortic aneurysms in 95 patients: how, when and why.

PURPOSE: This study reviews, on the basis of our experience, the indications and options for treating endoleaks (EL) after endovascular repair of abdominal aortic aneurysms (AAA) by endografting. MATERIALS AND METHODS: Ninety-five patients (M/F =92/3; mean age at time of operation 70.7+/-7.8 years) who underwent endovascular repair of infrarenal AAA between April 1997 and October 2004 were considered. All images of 420 pre-and postoperative computed tomography (CT) studies were reviewed. RESULTS: A total of 37 EL occurred in 33/95 patients (34.7%), four of whom had two EL of different types. Eighteen EL were treated, 16 by endoluminal treatment. Six EL were type I: 2 were treated by percutaneous transluminal angioplasty (PTA) and 4 by cuff deployment (2 proximal cuffs and 2 distal cuffs). Eight EL were type II: 2 were treated by PTA, 2 by cuff deployment, 1 by transcatheter coil embolisation of the inferior mesenteric artery, two by thrombin injection in the aneurysm sac and one underwent surgical conversion during an attempt to treat a concomitant type I EL. Finally, 2 EL were type III: 1 was treated by PTA and 1 by cuff deployment. Endovascular treatment was successful in 12/16 cases (75%), whereas 3/16 cases (18.8%) were converted to open surgery, and 1 patient died of AAA rupture the day after endovascular repair. CONCLUSIONS: EL is the most common complication after endovascular repair of AAA. In type I and type III EL, treatment is mandatory, whereas in type II (and type V) EL, treatment is indicated in the presence of AAA enlargement. Type IV EL generally disappear spontaneously. Endovascular repair is feasible and can be performed with different techniques according to EL aetiology, but it is not always decisive, and in some cases surgical conversion is required.

Morphological and functional modifications of the aneurysm-endograft complex following endoluminal treatment of abdominal aortic aneurysms.

PURPOSE: The aim of the study was to evaluate quantitatively the main morphological changes of the abdominal aortic aneurysm (AAA)-endograft (EG) complex following endovascular repair of infrarenal AAA and to evaluate the functional consequences of these changes in terms of rate of complications (endoleaks and thrombosis). We also assessed whether these morphological and functional changes were related to the size of the AAA and to the type of EG used. MATERIALS AND METHODS: Eighty-five patients (M/F=82/3; mean age at time of operation 70.5+/-3.5 years, range 49.9-89.6 years) who underwent endovascular treatment of infrarenal AAA between April 1997 and October 2004 with a follow-up of at least 1 month were considered. All images of 408 preoperative and postoperative computed tomography (CT) studies were reviewed. Statistical analysis was performed with log-rank test on the 85 patients grouped according to AAA diameter <50 mm or < or =50 mm, and on 75 patients grouped according to EG device used (AneuRx, Talent or Excluder). RESULTS: Morphological and dimensional changes involved the diameter (six cases) and length (14 cases) of AAA proximal neck, diameter (36 cases) and length (51 cases) of the aneurysm sac and shape of the stent-graft (47 cases). The prevalence of endoleaks was 37.6% whereas endoluminal thrombosis was observed in 27.1% of patients. AAA growth was significantly correlated (p=0.002) with the preprocedural diameter of the aneurysm sac whereas shrinkage was significantly correlated (p=0.0005) with the EG used. CONCLUSIONS: AAA growth was correlated with the diameter of the aneurysm sac while shrinkage was correlated with the EG used. During follow-up after endovascular repair, patients require careful evaluation of the morphological and dimensional features of the AAA and EG to promptly identify any changes that can anticipate major complications and even conversion to conventional surgery.

Peroxisome proliferators induce apoptosis in hepatoma cells.

In the AH-130 hepatoma, a poorly differentiated tumor, maintained by weekly transplantations in rats, a low percentage of cells spontaneously underwent apoptosis, mainly during the transition from logarithmic- to stationary-growth phase. It was possible to induce massive apoptosis of cells by treating them with clofibrate, a peroxisome proliferator and hypolipidemic drug. Similar results were obtained with HepG2 cells. With 1 mM clofibrate, apoptosis began to manifest itself after 1 h of treatment in vitro, and was assessed by morphological analysis, by DNA fragmentation carried out with agarose gel electrophoresis, and with flow cytometric determination of terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling. The mechanisms whereby clofibrate induces apoptosis are still unclear. Since the peroxisome proliferator-activated receptor was expressed at a very low level and was not stimulated by clofibrate in the AH-130 hepatoma cells, its involvement seems unlikely. Moreover, lipid peroxidation was not increased after clofibrate treatment. Phospholipids and cholesterol were significantly decreased. The decreased cholesterol content might suggest an inhibition of the mevalonate pathway and, therefore, of isoprenylation of proteins involved in cell proliferation.

Rapid and extensive lethal action of clofibrate on hepatoma cells in vitro.

Clofibrate, for a long time in use as a hypolipidemic drug, is a well known peroxisomal proliferator (PP) and hepatocarcinogen in rodents. We show here that in vitro 1 mM clofibrate induces a rapid and massive death of rat AH-130 hepatoma cells. Cell death was prominent already after 4 h of treatment, with a characteristic ;apoptotic' pattern by conventional microscopy. This was further supported by the pronounced chromatin condensation detectable on 4',6-diamine-2'-phenylindole dihydrochloride (DAPI) staining, the clearcut internucleosomal DNA fragmentation on agarose-gel electrophoresis (ladder pattern), and the accumulation of markedly hypochromic cells observed in flow cytometric DNA histograms. Consistently with the apoptotic features of the process, some parameters commonly used to detect cell death, such as plasma membrane permeabilization to trypan blue or propidium iodide, lack of mitochondrial retention of rhodamine 123, or extracellular release of lactate dehydrogenase, were all virtually negative. However, these same parameters became markedly positive after 24 h of treatment, which was suggestive for the occurrence of ;secondary' necrosis among AH-130 cells. By a combination of flow cytometric parameters, after 4 h on 1 mM clofibrate only 41% of the AH-130 cells could still be categorized as viable (i.e., non-apoptotic and non-necrotic), while 46% of cells appeared apoptotic and 13% necrotic. At 24 h, 67% of cells were necrotic, 20% apoptotic and only 13% non-apoptotic and non-necrotic. Apoptosis was also extensive in AH-130 cells treated with another PP such as nafenopin at 1 mM concentration and in human hepatoma HepG2 cells treated with clofibrate. By contrast, clofibrate did not cause apoptosis on primary rat hepatocyte cultures. These observations indicate that: (i) apart from their well-known cell growth-promoting action, PPs such as clofibrate or nafenopin may exert a substantial cytotoxic action on targets such as the AH-130 or HepG2 hepatoma cells; (ii) this cell death evolves from an initial 'apoptotic' to an eventual ;necrotic' pattern; (iii) detection of cell death requires the adoption of a full panel of tests, adequate to cover the whole evolving death pattern, while such tests may even be substantially misleading whenever applied individually; (iv) the cytotoxicity of clofibrate and similar agents on normal and, particularly, tumoural cells may deserve careful reevaluation.

Decreased expression of the high-mobility group protein T160 by antisense RNA impairs the growth of mouse fibroblasts.

The T160 protein belongs to the HMG-1 box protein family and preferentially binds to non-B-DNA conformations with no sequence specificity. Its exact role has yet to be defined, though it seems to participate in processes involving DNA, such as replication, transcription and recombination. We have used an antisense RNA strategy to investigate its role in cell growth and proliferation. T160 expression is strongly suppressed by stable introduction of an antisense construct into NIH3T3 cells, and this decrease is accompanied by substantial changes in the growth properties of the stable transfectants. Impaired growth of T160- cells was mainly related to two mechanisms: i) decreased rates of cell proliferation at normal serum concentration; and ii) occurrence of cell death by apoptosis at low serum concentration, as demonstrated by both flow cytometry and microscopy. The finding that decreased T160 availability affects cell proliferation, provides further evidence of its involvement in a basic cell function, such as DNA replication.

Apoptosis of L929 cells by etoposide: a quantitative and kinetic approach.

Exponentially growing L929 cells were continuously exposed to 1 or 10 microM etoposide (VP-16). The effects of such treatment on cell growth, cycle distribution, morphology, and selected biochemical events were examined. DNA synthesis rates were markedly decreased and the protein/DNA ratio increased (unbalanced growth). Growth was blocked, with most cells being cycle arrested by 24 h in (late S-)G2-M. An asynchronous process of cell death then developed. Cells initially shrank into eosinophilic, trypan blue-excluding bodies, which were then released into the medium, and eventually became permeable to trypan blue. Transmission electron microscopy confirmed that dying cells acquired an apoptotic morphotype, with compaction and margination of chromatin, loss of microvilli, and shrinkage of cytoplasm and nucleus. Tissue transglutaminase activity and intensity of immunostaining rapidly increased in treated cultures. Internucleosomal DNA fragmentation could not be detected by agarose gel electrophoresis, yet flow cytometry revealed that the apoptotic bodies had a very low DNA fluorescence (< or = 10% of the 2n value). In agreement with the microscopic findings, this suggested that extensive DNA degradation had occurred in dead cells. While rates of cell loss from the monolayer amounted to 21 and 57% day(-1) (1 and 10 microM VP-16, respectively), apoptotic indexes largely underestimated the extent of the process. These indexes only measured the accumulation of apoptotic bodies, i.e., the balance between their generation and disposal. The latter occurred by mechanisms similar to those that operate in tissues: "secondary necrosis" or phagocytosis by viable homotypic cells in the monolayer ("homophagy").

Effect of 4-Hydroxynonenal on cell cycle progression and expression of differentiation-associated antigens in HL-60 cells.

4-Hydroxynonenal (HNE) is a highly reactive aldehyde produced by lipid peroxidation of cellular membranes that inhibits growth and induces differentiation in HL-60 cells. Its mechanisms of action were investigated by analyzing the cell cycle distribution and the appearance of differentiated phenotypes in HL-60 cells. Data obtained by exposing cells to DMSO for 7.5 h (same time as for HNE treatment) or for the whole length of the experiments (5 d) were used for comparison. HNE induced a marked increase in the proportion of G0/G1 cells after 1 and 2 d. The brief DMSO treatment did not affect the distribution, whereas continuous exposure led to a progressive accumulation of cells in G0/G1 (maximal at day 5). The proportion of phagocytic cells gradually increased in HNE-treated and DMSO long-exposed cultures from day 2 and peaked at day 5 (35 and 63%, respectively), whereas the effect of the brief DMSO treatment was negligible. The expression of CD11b and CD67 increased in cells treated with HNE or continuously exposed to DMSO, whereas CD36 was expressed at low levels on both treatments. These results indicate that the pathway of the granulocytic differentiation induced by HNE in HL-60 cells differs from that of DMSO: with HNE, growth inhibition precedes the onset of differentiation, whereas in DMSO-treated cells the two processes are chronologically associated.

Role of mitogen-induced calcium influx in the control of the cell cycle in Balb-c 3T3 fibroblasts.

The role of mitogen-activated calcium influx from the extracellular medium in the control of cell proliferation was studied in Balb-c 3T3 fibroblasts. Stimulation of serum-deprived, quiescent cells with 10% foetal calf serum (FCS) induced a long-lasting (up to 70 min) elevation of intracellular free calcium concentration ([Ca2+]i). Both the sustained [Ca2+]i increase and the related inward current, described in a previous paper [Lovisolo D. Munaron L. Baccino FM. Bonelli G. (1992) Potassium and calcium currents activated by foetal calf serum in Balb-c 3T3 fibroblasts. Biochim. Biophys. Acta, 1104, 73-82], could be abolished either by chelation of extracellular calcium with EGTA or by SK&F 96365, an imidazole derivative that can block receptor-activated calcium channels. The effect of the abolition of these ionic signals on FCS-induced proliferation was investigated by adding either EGTA or SK&F 96365 to the culture medium during the first hours of stimulation of quiescent cells with 10% FCS. As measured after 24 h, a 22% inhibition of growth was observed when SK&F 96365 was added for the first hour, and stronger inhibitions, up to 56%, were obtained by adding the blocker for the first 2 or 4 h. Similar effects were observed with addition of 3 mM EGTA, though the inhibition was less marked for the 4 h treatment. By contrast, incubation with either substance in the next 4 h of serum stimulation did not influence cell growth, except for a slight inhibition observed when SK&F 96365 was applied from the 4th to the 8th hour. The reduction in growth resulting from the abolition of the early calcium influx was paralleled by an accumulation of cells in the G2/M phase. Both growth inhibition and G2/M accumulation were reversible, since after further 24 h in 10% FCS cells had fully recovered the exponential growth. These data indicate that the early calcium influx seen in response to mitogen stimulation develops on a timescale long enough to play a significant role in cell cycle progression, and that its block in the early G1 phase can lead to a reduction of proliferation by arresting cells in later stages of the cycle.

Intracellular ionic variations in the apoptotic death of L cells by inhibitors of cell cycle progression.

Treatment with VP-16 (1-50 microM) or excess thymidine (5 mM) caused a block of L cells at different steps in their progression through the replicative cycle. The arrest was followed by an asynchronous process of cell death that conformed to criteria for apoptosis. Careful monitoring of this process in the whole cell population by flow cytometry showed a virtual absence of necrosis, an increase in side light scattering, followed by the occurrence of a population with subdiploid DNA fluorescence as well as reduced forward and side light scattering. The development of apoptosis required sufficient time and adequate ion gradients in the cells. By the combined use of flow cytometry and fluorescence microscopy data were obtained suggesting that (i) intracellular free Ca2+ and pH and/or their drug-induced alterations had to be adequately controlled for the apoptotic process to evolve; (ii) mitochondria were compromised earlier than the plasma membrane or lysosomes; and (iii) K+ extrusion possibly played a role in the final loss of cell volume. Interfering with the control of ion gradients and/or their changes in drug-treated cells resulted in cell death by necrosis.

[Sarcoidosis of oculo-parotid onset. Differential diagnostic considerations]. / La sarcoidosi ad esordio oculo-parotideo. Considerazioni di diagnostica differenziale.

Two cases of sarcoidosis, presenting with parotid gland enlargement and keratoconjunctivitis sicca, are here described. The difficulty encountered in making correct diagnosis is then stressed. The diagnostic value of invasive and non invasive techniques in the study of parotid gland pathology and function in sarcoidosis is then reviewed.