Management and surgical treatment of parathyroid carcinoma: a 6-year experience of a single centre of endocrine surgery unit

BackgroundParathyroid carcinoma (PC) affects 0.1-0.3% of the general population and represents the rarest malignant neoplasms among endocrinological diseases, comprising less than 1%. The best therapeutic treatment and management methods are still debated in the literature. The aim of this study is to evaluate the management and surgical treatment of parathyroid carcinoma after 6 years of enrolment with the Endocrine Surgery Unit of the University Hospital of Bari.Materials and methodsA retrospective observational study was carried out using a prospectively maintained database of patients affected by primary hyperparathyroidism between January 2017 and September 2022. Consecutive patients over 18 years old with a final histopathological finding of PC were included in the study. Patients with secondary or tertiary hyperparathyroidism, parathyroid hyperplasia, and parathyroid adenoma were excluded. All patients underwent follow-up every 6 months for the first 2 years, and annually thereafter.ResultsIn this study, 9 out of 40 patients affected by hyperparathyroidism were included; 6 (66.6%) were female and 3 (33.3%) were male patients, with a median age of 59 years (IQR 46-62). None had a family history of PC. No mortality was recorded while the incidence of recurrence was 22.2%, with a disease-free survival of 8 and 10 months. Parathyroidectomy was performed in five patients, while four patients underwent parathyroidectomy with concurrent thyroidectomy for thyroid goitre. No intraoperative complications were recorded. Open parathyroidectomy was performed with a mini-cervicotomy in seven patients, while two patients underwent robotic surgery. All patients were discharged on the second postoperative day.ConclusionPC represents a great challenge in terms of preoperative diagnosis, management and treatment. A surgical approach represents the first best option for PC in referral endocrine surgery units. The early identification of risky patients should be the dominant goal to plan an appropriate therapy and to perform adequate en bloc surgery

What is the role of the placebo effect for pain relief in neurorehabilitation? Clinical implications from the Italian consensus conference on pain in neurorehabilitation

Background: It is increasingly acknowledged that the outcomes of medical treatments are influenced by the context of the clinical encounter through the mechanisms of the placebo effect. The phenomenon of placebo analgesia might be exploited to maximize the efficacy of neurorehabilitation treatments. Since its intensity varies across neurological disorders, the Italian Consensus Conference on Pain in Neurorehabilitation (ICCP) summarized the studies on this field to provide guidance on its use. Methods: A review of the existing reviews and meta-analyses was performed to assess the magnitude of the placebo effect in disorders that may undergo neurorehabilitation treatment. The search was performed on Pubmed using placebo, pain, and the names of neurological disorders as keywords. Methodological quality was assessed using a pre-existing checklist. Data about the magnitude of the placebo effect were extracted from the included reviews and were commented in a narrative form. Results: 11 articles were included in this review. Placebo treatments showed weak effects in central neuropathic pain (pain reduction from 0.44 to 0.66 on a 0-10 scale) and moderate effects in postherpetic neuralgia (1.16), in diabetic peripheral neuropathy (1.45), and in pain associated to HIV (1.82). Moderate effects were also found on pain due to fibromyalgia and migraine; only weak short-term effects were found in complex regional pain syndrome. Confounding variables might have influenced these results. Clinical implications: These estimates should be interpreted with caution, but underscore that the placebo effect can be exploited in neurorehabilitation programs. It is not necessary to conceal its use from the patient. Knowledge of placebo mechanisms can be used to shape the doctor-patient relationship, to reduce the use of analgesic drugs and to train the patient to become an active agent of the therapy

What is the role of the placebo effect for pain relief in neurorehabilitation? Clinical implications from the Italian Consensus Conference on Pain in Neurorehabilitation

Background: It is increasingly acknowledged that the outcomes of medical treatments are influenced by the context of the clinical encounter through the mechanisms of the placebo effect. The phenomenon of placebo analgesia might be exploited to maximize the efficacy of neurorehabilitation treatments. Since its intensity varies across neurological disorders, the Italian Consensus Conference on Pain in Neurorehabilitation (ICCP) summarized the studies on this field to provide guidance on its use. Methods: A review of the existing reviews and meta-analyses was performed to assess the magnitude of the placebo effect in disorders that may undergo neurorehabilitation treatment. The search was performed on Pubmed using placebo, pain, and the names of neurological disorders as keywords. Methodological quality was assessed using a pre-existing checklist. Data about the magnitude of the placebo effect were extracted from the included reviews and were commented in a narrative form. Results: 11 articles were included in this review. Placebo treatments showed weak effects in central neuropathic pain (pain reduction from 0.44 to 0.66 on a 0-10 scale) and moderate effects in postherpetic neuralgia (1.16), in diabetic peripheral neuropathy (1.45), and in pain associated to HIV (1.82). Moderate effects were also found on pain due to fibromyalgia and migraine; only weak short-term effects were found in complex regional pain syndrome. Confounding variables might have influenced these results. Clinical implications: These estimates should be interpreted with caution, but underscore that the placebo effect can be exploited in neurorehabilitation programs. It is not necessary to conceal its use from the patient. Knowledge of placebo mechanisms can be used to shape the doctor-patient relationship, to reduce the use of analgesic drugs and to train the patient to become an active agent of the therapy

Female infertility: in vitro maturation of antral oocytes upon a feeder layer of selected cumulus cells improves developmental competence

Secondo l’organizzazione mondiale della sanità (WHO) l’infertilità colpisce circa il 20% delle coppie nei paesi occidentali. A questo dato si aggiunge un numero sempre più crescente di donne (280.000/anno, Stati Uniti e 58.000/anno, Italia) che, sottoponendosi a trattamenti chemio/radio terapici, sviluppa sindrome da prematuro decadimento ovarico. L’isolamento e la crioconservazione di oociti immaturi denudati (DOs) è una possibile strategia impiegata per preservare la fertilità di queste pazienti, in particolare quando i DOs sono coltivati fino a metafase II in presenza di un feeder layer di cellule del cumulo (FL-CCs). Durante il mio dottorato, ho messo a punto un nuovo sistema miniaturizzato di coltura in vitro di DOs su un FL di CCs selezionate in base alla loro appartenenza a oociti competenti o incompetenti allo sviluppo. Due sono stati i principali obiettivi della mia ricerca: 1. Testare l’ipotesi che la selezione delle CCs possa avere un effetto migliorativo sulle rese di sviluppo. Classificando CCs in base alla loro associazione con oociti antrali competenti (SN) o incompetenti (NSN) allo sviluppo, abbiamo preparato, in delle micro-Insert 4 well plates, un FL di SN-CCs o NSN-CCs. Abbiamo dimostrato, così, che la maturazione di DOs su FL-SN-CCs contribuisce significativamente all’acquisizione della competenza meiotica e di sviluppo, con una percentuale di blastocisti (26.9%) simile a quella ottenuta dalla maturazione di follicoli integri (28%). Al contrario, quando i DOs sono maturati in assenza di CCs (NO-FL) o su FL-NSN-CCs vanno incontro ad un blocco della ripresa meiotica e dello sviluppo, con arresto degli embrioni agli stadi di 4 cellule o morula. 2. Identificazione dell’intervallo di tempo, durante la fase maturativa, in cui il feeder layer SN-FL-CCs influenza maggiormente l’acquisizione della competenza allo sviluppo dell’oocita. A tal fine, ho coltivato DOs secondo tre diverse condizioni sperimentali: 1. in assenza di FL-SN-CCs per 3 hr e su FL-SN-CCs per le successive 12 hr; 2. in assenza di FL-SN-CCs per 6 hr e su FL-SN-CCs per le successive 9 hr; 3. su SN-FL-CCs per 6 hr ed in assenza di FL-SN-CCs per le successive 9 hr. Quando i DOs sono stati coltivati seguendo il protocollo 1, lo sviluppo da 2 a 4 cellule è rimasto simile a quello ottenuto quando i DOs sono stati coltivati su FL-SN-CCs per tutte le 15 hr di coltura, suggerendo una corretta transizione oocita-embrione. Al contrario, le rese di blastocisti sono diminuite significativamente, indicando un’alterazione di processi chiave dello sviluppo pre-impianto. Inoltre, se l’ assenza di CCs veniva prolungata per 6 hr, nessun embrione raggiungeva lo stadio di blastocisti. Ancor più dannosa è stata l’assenza del FL-SN-CCs nelle ultime 9 hr di coltura, portando ad un completo arresto dello sviluppo a 2 cellule. I risultati di questi tre set di esperimenti suggeriscono la presenza di un importante fattore/i paracrino/i rilasciato da FL-SN-CCs, presumibilmente nel terreno di coltura, la cui assenza risulta esser dannosa per l’acquisizione della competenza allo sviluppo dell’oocita. In conclusione, mentre le cellule SN contribuiscono positivamente nel determinare l’acquisizione della competenza meiotica e di sviluppo embrionale, la mancanza di questo supporto, riscontrabile sia in presenza di un FL di cellule NSN sia in assenza di FL, porta al fallimento della capacità meiotica e di sviluppo dell’oocita. Inoltre, i nostri risultati hanno posto le basi per meglio comprendere quali siano le molecole coinvolte nella comunicazione bidirezionale tra le cellule del cumulo ooforo ed il gamete durante il passaggio dallo stadio di vescicola germinale a quello di metafase II.The World Health Organization (WHO) estimates that infertility affects about 20% of couples in western countries. In addition, one third of women undergoing oncological treatments develops premature ovarian failure as a consequence of aggressive chemo- or radio- therapies. In numbers, 280.000/year in USA (American Cancer Society; cancer.org) and 58.000/year in Italy (Associazione Italiana di Oncologia Medica; registri-tumori.it). The isolation and cryopreservation of denuded antral germinal vesicle oocytes (DOs) has been seen, in recent years, as a strategy for preserving fertility of these patients, particularly when DOs are in vitro matured to metaphase II (MII) in the presence of a feeder layer of cumulus cells (FL-CCs). To this regard, the work I carried out during my PhD was focused on the development of a new miniaturized culture system based on DOs maturation upon a FL of selected CCs. In the pursuit of this goal, two were the main specific aims of my research: 1. To test the hypothesis that improvements could be introduced by a selection of CCs prior to the preparation of the FL. In this study we classified CCs based on their association with developmentally competent (SN) or incompetent (NSN) mouse fully-grown antral oocytes and then, developed a miniaturized system, a micro-Insert 4 well plate, to obtain a FL of SN-CCs or NSN-CCs. We show, for the first time, that maturation of DOs upon FL-SN-CCs significantly better contributes to the acquisition of oocytes meiotic and developmental competence, with a developmental rate to blastocyst (26.9%) equal to that obtained after the maturation of intact cumulus oocyte complexes (28%). Instead, DOs matured in the absence of CCs (NO-FL) or upon FL-NSN-CCs undergo meiotic and developmental failure, with embryos arresting either at the 4-cell or morula stage. 2. The identification of the time-lapse interval, during the germinal vesicle-to-metaphase II transition, in which the SN-FL-CCs mainly influences the acquisition of oocyte developmental competence. To this end, I cultured DOs under three different experimental conditions: V 1. without FL-SN-CCs for 3 hr and upon FL-SN-CCs for further 12 hr; 2. without FL-SN-CCs for 6 hr and upon FL-SN-CCs for further 9 hr; 3. upon an SN-FL-CCs for 6 hours and then without FL-SN-CCs for further 9 hr. When DOs were cultured following protocol 1, the progression to the 2- and 4-cell stages remained similar to that obtained when DOs were cultured upon FL-SN-CCs for the whole 15 hr, suggesting a correct oocyte-to-embryo transition. Instead, the frequency of development to blastocyst decreased significantly, indicating an alteration to key developmental processes. Furthermore, when the initial culture in the absence of CCs was prolonged to 6 hr, none of the embryos reached the blastocyst. Even more detrimental was the absence of FL-SN-CCs during the latest 9 hr culture, with a complete developmental arrest at the 2-cell stage. Overall, the results of these three sets of experiments suggest the presence of an essential paracrine factor/s released from FL-SN-CCs, likely into the culture medium, whose lack is detrimental to the acquisition of a proper developmental competence. In conclusion, the main finding of my study is the demonstration of a positive contribution to the acquisition of the oocyte meiotic and developmental competence of SN-CCs. Lack of this support, either in the absence of CCs (NO-FL) or in the presence of NSN-CCs, results in meiotic and developmental failure. Furthermore, our results set the bases to further improve the protocols of antral oocytes maturation upon a feeder layer of CCs and to unravel the molecules involved in the cross-talk between the gamete and its companion cumulus cells during the germinal vesicle (GV)-to-MII transition

Cytoplasmic movements of the early human embryo: imaging and artificial intelligence to predict blastocyst development

Research question: Can artificial intelligence and advanced image analysis extract and harness novel information derived from cytoplasmic movements of the early human embryo to predict development to blastocyst? Design: In a proof-of-principle study, 230 human preimplantation embryos were retrospectively assessed using an artificial neural network. After intracytoplasmic sperm injection, embryos underwent time-lapse monitoring for 44 h. For comparison, standard embryo assessment of each embryo by a single embryologist was carried out to predict development to blastocyst stage based on a single picture frame taken at 42 h of development. In the experimental approach, in embryos that developed to blastocyst or destined to arrest, cytoplasm movement velocity was recorded by time-lapse monitoring during the first 44 h of culture and analysed with a Particle Image Velocimetry algorithm to extract quantitative information. Three main artificial intelligence approaches, the k-Nearest Neighbour, the Long-Short Term Memory Neural Network and the hybrid ensemble classifier were used to classify the embryos. Results: Blind operator assessment classified each embryo in terms of ability to develop to blastocyst, with 75.4% accuracy, 76.5% sensitivity, 74.3% specificity, 74.3% precision and 75.4% F1 score. Integration of results from artificial intelligence models with the blind operator classification, resulted in 82.6% accuracy, 79.4% sensitivity, 85.7% specificity, 84.4% precision and 81.8% F1 score. Conclusions: The present study suggests the possibility of predicting human blastocyst development at early cleavage stages by detection of cytoplasm movement velocity and artificial intelligence analysis. This indicates the importance of the dynamics of the cytoplasm as a novel and valuable source of data to assess embryo viability

Time-lapse imaging of chromatin and cytoplasmic movements occurring during the GV-to-MII transition: in search for markers of mouse oocytes developmental competence

The transition from the germinal vesicle to the metaphase II stage (GV-to-MII transition) is crucial to the acquisition of the oocyte developmental competence. Here, using live, time-lapse, imaging we describe the movements occurring during the GV-to-MII transition to the chromatin (CHR-MOV) and to the cytoplasm (CYTO-MOV) of mouse oocytes of known developmental competence or incompetence. Fully-grown cumulus-oocyte-complexes were punctured from the ovarian surface, the GV oocytes isolated and stained with the supravital Hoechst 33342 fluorochrome (Ho) which allowed the identification of gametes whose nucleolus is surrounded by a ring of Ho-positive chromatin (surrounded nucleolus, SN, oocytes) from those that lack this ring (not surrounded nucleolus, NSN, oocytes). Importantly, when in vitro cultured to MII and inseminated with sperm, whilst SN oocytes may develop to term, NSN oocytes arrest development at the 2-cell stage. The time-lapse observation of CHR-MOV describe distinct chromatin changes in NSN compared to SN oocytes, with a longer GV-to-MII transition in NSN oocytes that reach the M-phase without the gathering of heterochromatin regions around the nucleolus. Furthermore, by coupling bright-field time-lapse observations with the Particle Image Velocimetry method, we analysed the CYTO-MOV of these two types of oocytes. We showed that SN and NSN oocytes exhibit distinct profiles and, at four main time-frame intervals, their CYTO-MOV velocity is significantly different. In addition, we integrated the information of the CYTO-MOV profile of each single oocyte with an artificial neural network analysis that blindly identified the oocyte as SN or NSN with a robust probability. The presence of SN and NSN oocytes in all mammals, including humans, extends the interest of these results to the field of assisted reproductive technologies (ART)

Time-lapse imaging of chromatin and cytoplasmic movements occurring during the GV-to-MII transition: in search for markers of mouse oocytes developmental competence

The transition from the germinal vesicle to the metaphase II stage (GV-to-MII transition) is crucial to the acquisition of the oocyte developmental competence. Here, using live, time-lapse, imaging we describe the movements occurring during the GV-to-MII transition to the chromatin (CHR-MOV) and to the cytoplasm (CYTO-MOV) of mouse oocytes of known developmental competence or incompetence. Fully-grown cumulus-oocyte-complexes were punctured from the ovarian surface, the GV oocytes isolated and stained with the supravital Hoechst 33342 fluorochrome (Ho) which allowed the identification of gametes whose nucleolus is surrounded by a ring of Ho-positive chromatin (surrounded nucleolus, SN, oocytes) from those that lack this ring (not surrounded nucleolus, NSN, oocytes). Importantly, when in vitro cultured to MII and inseminated with sperm, whilst SN oocytes may develop to term, NSN oocytes arrest development at the 2-cell stage. The time-lapse observation of CHR-MOV describe distinct chromatin changes in NSN compared to SN oocytes, with a longer GV-to-MII transition in NSN oocytes that reach the M-phase without the gathering of heterochromatin regions around the nucleolus. Furthermore, by coupling bright-field time-lapse observations with the Particle Image Velocimetry method, we analysed the CYTO-MOV of these two types of oocytes. We showed that SN and NSN oocytes exhibit distinct profiles and, at four main time-frame intervals, their CYTO-MOV velocity is significantly different. In addition, we integrated the information of the CYTO-MOV profile of each single oocyte with an artificial neural network analysis that blindly identified the oocyte as SN or NSN with a robust probability. The presence of SN and NSN oocytes in all mammals, including humans, extends the interest of these results to the field of assisted reproductive technologies (ART)

The proteoglycan mimecan is associated with carotid plaque vulnerability and increased risk of future cardiovascular death

Background and aims: A vulnerable plaque is an atherosclerotic plaque that is rupture-prone with a higher risk to cause cardiovascular symptoms such as myocardial infarction or stroke. Mimecan or osteoglycin is a small leucine-rich proteoglycan, important for collagen fibrillogenesis, that has been implicated in atherosclerotic disease, yet the role of mimecan in human atherosclerotic disease remains unknown. Methods: 196 human atherosclerotic carotid plaques were immunostained for mimecan. Smooth muscle cells, macrophages and intraplaque haemorrhage were also measured with immunohistochemistry. Neutral lipids were stained with Oil Red O and calcium deposits were quantified. Plaque homogenate levels of MCP-1, IL-6 and MIP-1β were measured using a Proximity Extension Assay and MMP-9 levels were measured using Mesoscale. Glycosaminoglycans, collagen and elastin were assessed by colorimetric assays and TGF-β1, β2 and β3 were measured using a multiplex assay. Mimecan gene expression in THP-1 derived macrophages was quantified by qPCR and protein expression in vitro was visualized with immunofluorescence. Cardiovascular events were registered using medical charts and national registers during follow-up. Results: Mimecan correlated positively with plaque area of lipids, macrophages, intraplaque haemorrhage and inversely with smooth muscle cell staining. Mimecan also correlated positively with plaque levels of MMP-9 and MCP-1. Mimecan was upregulated in THP-1 derived macrophages upon stimulation with MCP-1. Patients with high levels of mimecan (above median) had higher risk for cardiovascular death. Conclusions: This study indicates that mimecan is associated with a vulnerable plaque phenotype, possibly regulated by plaque inflammation. In line, plaque levels of mimecan independently predict future cardiovascular death

Optimization of an Injectable, Resorbable, Bioactive Cement Able to Release the Anti-Osteoclastogenic Biomolecule ICOS-Fc for the Treatment of Osteoporotic Vertebral Compression Fractures

Vertebral compression fractures are typical of osteoporosis and their treatment can require the injection of a cement through a minimally invasive procedure to restore vertebral body height. This study reports the development of an injectable calcium sulphate-based composite cement able to stimulate bone regeneration while inhibiting osteoclast bone resorption. To this aim, different types of strontium-containing mesoporous glass particles (Sr-MBG) were added to calcium sulphate powder to impart a pro-osteogenic effect, and the influence of their size and textural features on the cement properties was investigated. Anti-osteoclastogenic properties were conferred by incorporating into poly(lactic-co-glycolic)acid (PLGA) nanoparticles, a recombinant protein able to inhibit osteoclast activity (i.e., ICOS-Fc). Radiopaque zirconia nanoparticles (ZrO2) were also added to the formulation to visualize the cement injection under fluoroscopy. The measured cement setting times were suitable for the clinical practice, and static mechanical testing determined a compressive strength of ca. 8 MPa, comparable to that of human vertebral bodies. In vitro release experiments indicated a sustained release of ICOS-Fc and Sr2+ ions up to 28 days. Overall, the developed cement is promising for the treatment of vertebral compression fractures and has the potential to stimulate bone regeneration while releasing a biomolecule able to limit bone resorption