Training the "clinical eye". Rubens' Three Graces: how many pathologies?

Art can serve as a powerful resource for medical students to both train the so called “clinical eye” and to better understand disease [1]. Herein a paleopathological analysis is performed on one of Ruben’s final artworks, “The Three Graces” (1630- 1635; oil on oak panel; 220.5 x 182 cm; Museo del Prado, Madrid). Rubens depicts the three Graces beside a fountain, under a garland of flowers in a landscape. The circular rhythm and elegant undulation are based on classical sculpture. Painted shortly after his marriage, it bears witness to the happiness of the artist’s life. The figure on the left is directly inspired by his second wife, Hélène Fourment (23 years old); the central and right Graces probably illustrate Rubens’ sisters-in-law. Besides overweight, scoliosis, and hyperlordosis observed in all three Graces, the left Grace evidences flat feet; hyperextension of the right metacarpal joints; signs of rheumatoid arthritis (even fibromyalgia has been proposed); lateral deviation of the nipple (Mondor’s disease?); varicose thighs, and right hallux vagus. The central Grace (Clara Fourment?), in turn, shows cellulite and, interestingly, positive Trendelenburg sign. Finally, the Grace on the right -Susanna Fourment- has been subject of a long debate on signs of a locally advanced breast cancer in the left external upper quadrant. In fact, several specialists agree in the observation of signs of an open ulcer; redness of the surrounding skin (an inflammatory sign); nipple retraction; reduction of the left breast volume, and enlarged axillary lymph nodes [2-3]. Rubens was one of main Baroque and realist painters, i.e. he painted whatever his eyes captured. If the Graces were sisters, then they are likely to share genetic traits. The latter, together with all the other signs described, favour the working diagnosis of familial benign hypermobility syndrome. Observation has a key role in clinical medicine; the paleopathological observation in art show us how artists could record abnormalities long before doctors did [2]. Therefore, artworks still represent useful teaching tools for refining visual skills in traditional and innovative medical education. References [1] Hinojosa-Azaloa A. & Alcocer-Varela J. (2014) Art and rheumatology: the artist and the rheumatologist’s perspective. Rheumatology 53: 1725-1731. [2] Dequeker J. (2007) Medicine and the artist. Age and Ageing 37: 4-5. [3] Grau et al. (2001) Breast cancer in Rubens paintings. Breast Ca Res Treat 68: 89-93

Thrombin regulates the ability of Schwann cells to support neuritogenesis and to maintain the integrity of the nodes of Ranvier

Schwann cells (SC) are characterized by a remarkable plasticity that enables them to promptly respond to nerve injury promoting axonal regeneration. In peripheral nerves after damage SC convert to a repair-promoting phenotype activating a sequence of supportive functions that drive myelin clearance, prevent neuronal death, and help axon growth and guidance. Regeneration of peripheral nerves after damage correlates inversely with thrombin levels. Thrombin is not only the key regulator of the coagulation cascade but also a protease with hormone-like activities that affects various cells of the central and peripheral nervous system mainly through the protease-activated receptor 1 (PAR1). Aim of the present study was to investigate if and how thrombin could affect the axon supportive functions of SC. In particular, our results show that the activation of PAR1 in rat SC cultures with low levels of thrombin or PAR1 agonist peptides induces the release of molecules, which favor neuronal survival and neurite elongation. Conversely, the stimulation of SC with high levels of thrombin or PAR1 agonist peptides drives an opposite effect inducing SC to release factors that inhibit the extension of neurites. Moreover, high levels of thrombin administered to sciatic nerve ex vivo explants induce a dramatic change in SC morphology causing disappearance of the Cajal bands, enlargement of the Schmidt-Lanterman incisures and calcium-mediated demyelination of the paranodes. Our results indicate thrombin as a novel modulator of SC plasticity potentially able to favor or inhibit SC pro-regenerative properties according to its level at the site of lesion

The Use of Sonic Frequencies as a Cleaning Agent of Specimens to be Observed by Scanning Electron Microscopy

The presence of mucus and/or cellular debris can obscure the fine morphology of the gastrointestinal or respiratory luminal surface, when observed by scanning electron microscopy. With the intent of obtaining a good cleaning of the mucosal surface without altering the ultrafine morphology of epithelial cells, a new model of sonicator/ultrasonicator is presented. The instrument is supplied with a control system for wave frequency, amplitude and form, and permits a precise regulation of the wave energy. With this instrument it is possible to produce a cleaning effect by using any kind of frequency (either sonic or ultrasonic) and/or amplitude and/or waveform and/or liquid. We report the application of sonic frequencies through water as a fluid for immersion to obtain a gentle and slow removing of mucus and in order to explore the possibility to clean hydrated tissues. With the employment of sonic frequencies (from 5 to 15 kHz modulated by 200 Hz) and water as the immersion fluid, we were able to generate a gentle wave energy which effected an optimal removal of the mucus, with the consequent exposure of a well preserved epithelial surface of rat trachea and small intestine

Biological niches within human calcified aortic valves. Towards understanding of the pathological biomineralization process

Despite recent advances, mineralization site, its microarchitecture, and composition in calcific heart valve remain poorly understood. A multiscale investigation, using scanning electron microscopy (SEM), transmission electron microscopy (TEM), and energy dispersive X-ray spectrometry (EDS), from micrometre up to nanometre, was conducted on human severely calcified aortic and mitral valves, to provide new insights into calcificationp rocess. Our aim was to evaluate the spatial relationship existing between bioapatite crystals, their local growing microenvironment, and the presence of a hierarchical architecture. Here we detected the presence of bioapatite crystals in two different mineralization sites that suggest the action of two different growth processes:a pathological crystallization process that occurs in biological niches and is ascribed to a purely physicochemical process and a matrix- mediated mineralized process in which the extracellular matrix acts as the template for a site-directed nanocrystals nucleation. Different shapes of bioapatite crystallization were observed at micrometer scale in each microenvironment but at the nanoscale level crystals appear to be made up by the same subunit

Fine morphological assessment of quality of human mature oocytes after slow freezing or vitrification with a closed device: a comparative analysis

BACKGROUND: Human mature oocytes are very susceptible to cryodamage. Several reports demonstrated that vitrification might preserve oocyte better than slow freezing. However, this is still controversial. Thus, larger clinical, biological and experimental trials to confirm this concept are necessary. The aim of the study was to evaluate and compare fine morphological features in human mature oocytes cryopreserved with either slow freezing or vitrification. METHODS: We used 47 supernumerary human mature (metaphase II) oocytes donated by consenting patients, aged 27-32 years, enrolled in an IVF program. Thirtyfive oocytes were cryopreserved using slow freezing with 1.5 M propanediol +0.2 M sucrose concentration (20 oocytes) or a closed vitrification system (CryoTip Irvine Scientific CA) (15 oocytes). Twelve fresh oocytes were used as controls. All samples were prepared for light and transmission electron microscopy evaluation. RESULTS: Control, slow frozen/thawed and vitrified/warmed oocytes (CO, SFO and VO, respectively) were rounded, 90-100 mum in diameter, with normal ooplasm showing uniform distribution of organelles. Mitochondria-smooth endoplasmic reticulum (M-SER) aggregates and small mitochondria-vesicle (MV) complexes were the most numerous structures found in all CO, SFO and VO cultured for 3-4 hours. M-SER aggregates decreased, and large MV complexes increased in those SFO and VO maintained in culture for a prolonged period of time (8-9 hours). A slight to moderate vacuolization was present in the cytoplasm of SFO. Only a slight vacuolization was present in VO, whereas vacuoles were almost completely absent in CO. Amount and density of cortical granules (CG) appeared abnormally reduced in SFO and VO, irrespective of the protocol applied. CONCLUSIONS: Even though, both slow freezing and vitrification ensured a good overall preservation of the oocyte, we found that: 1) prolonged culture activates an intracellular membrane "recycling" that causes the abnormal transformation of the membranes of the small MV complexes and of SER into larger rounded vesicles; 2) vacuolization appears as a recurrent form of cell damage during slow freezing and, at a lesser extent, during vitrification using a closed device; 3) premature CG exocytosis was present in both SFO and VO and may cause zona pellucida hardenin

Surgical and Bioengineering Integration in the Anatomy Course of Medicine and Surgery High Technology: Knowledge and Perception of Anatomy

The Locomotor System Anatomy (LSA) course, placed in the first semester of the first year of the new Master’s degree in Medicine and Surgery High Technology (MSHT) at the Sapienza University of Rome, was integrated with surgical and bioengineering content. This study investigated the educational value and the students’ perceptions of the effectiveness of these two types of integration, comparing surgical integration (SI) with engineering integration (EI). Anatomy knowledge and students’ opinions attending the LSA course in MSHT degree (n = 30) were compared with those of students (n = 32) attending another medical and surgery course not comprising EI. Data show that students in the MSHT course like in-depth SI much more than in-depth EI. However, those who like in-depth SI also like in-depth EI. Significant differences were in anatomy knowledge between the two groups in the three sections of the test. There was no significant correlation between the three test scores and the levels of liking, while there was a significant correlation between students liking SI and those liking EI. A statistically significant correlation was also found in students who correctly responded to questions on the head and trunk, with students responding correctly to questions on the upper limbs. This study will be important in optimizing the deepening of SI and EI in the LSA course. Keywords: human anatomy; anatomical sciences education; gross anatomy teaching; locomotor system; neurosurgery; orthopedics; surgical integration; bioengineering integration; technical physician; technical medicin

Enhanced lipid extraction from unbroken microalgal cells using enzymes

The marine microalga Nannochloropsis sp. was chosen as a model organism to investigate the feasibility of using cell wall-degrading enzymes to enhance the recovery of intracellular lipids. An enzyme cocktail containing galactomannanase, 1,4-β-cellobiosidase and β-glucosidase as main components was prepared from commercial enzyme preparations. The effects of pretreatment time (P), enzyme dosage (D), pH and temperature (T) on the amount of extracted lipids were investigated using response surface methodology. Under the best conditions (P = 90 min, D = 1.3 mg g–1, pH = 5, T = 36°C) over 70% of the lipids present in the microalga were recovered. SEM and TEM characterization of enzyme-treated microalgae showed extensive cell damage with significant disruption of the cell wall and release of algal material. Overall, the results of this study strongly support the use of commercial enzyme preparations to improve lipid recovery from microalgae and provide useful information on the influence of process conditions on the treatment efficiency

Medical Education in Italy: challenges and opportunities

Italy is a country of 60 million citizens with a high life expectancy, an increasing prevalence of chronic multi-morbidity and a public healthcare system. There are 61 medical schools and more than one thousand postgraduate programs for 50 different specialisations. In this article, we describe the Italian medical educational system and its most recent evolution towards a process of internationalization, alongside pedagogical and cultural changes. The main challenges are in the process of students’ selection, which is still only based on the assessment of basic knowledge, and in the reform of the post-graduate education, which lacks an official, formal definition of the learning outcomes and the aligned methods of assessment. The opportunities come from the increasing awareness of the importance of faculty development programs. The pandemic itself acted as a catalyst of innovation, pushing toward more student-centered teaching-learning activities. Finally, an increase in international collaborations in medical education research could be effective to foster the development of medical education in the country

Mancozeb impairs the ultrastructure of mouse granulosa cells in a dose-dependent manner

Mancozeb, an ethylene bis-dithiocarbamate, is widely used as a fungicide and exerts reproductive toxicity in vivo and in vitro in mouse oocytes by altering spindle morphology and impairing the ability to fertilize. Mancozeb also induces a premalignant status in mouse granulosa cells (GCs) cultured in vitro, as indicated by decreased p53 expression and tenuous oxidative stress. However, the presence and extent of ultrastructural alterations induced by mancozeb on GCs in vitro have not yet been reported. Using an in vitro model of reproductive toxicity, comprising parietal GCs from mouse antral follicles cultured with increasing concentrations of mancozeb (0.001-1 µg/ml), we sought to ascertain the in vitro ultrastructural cell toxicity by means of transmission (TEM) and scanning (SEM) electron microscopy. The results showed a dose-dependent toxicity of mancozeb on mouse GCs. Ultrastructural data showed intercellular contact alterations, nuclear membrane irregularities, and chromatin marginalization at lower concentrations, and showed chromatin condensation, membrane blebbing, and cytoplasmic vacuolization at higher concentrations. Morphometric analysis evidenced a reduction of mitochondrial length in GCs exposed to mancozeb 0.01-1 µg/ml and a dose-dependent increase of vacuole dimension. In conclusion, mancozeb induced dose-dependent toxicity against GCs in vitro, including ultrastructural signs of cell degeneration compatible with apoptosis, likely due to the toxic breakdown product ethylenethiourea. These alterations may represent a major cause of reduced/delayed/missed oocyte maturation in cases of infertility associated with exposure to pesticides

The galectin-3/RAGE dyad modulates vascular osteogenesis in atherosclerosis

Vascular calcification correlates with inflammation and plaque instability in a dual manner, depending on the spotty/granular (micro) or sheet-like/lamellated (macro) pattern of calcification. Modified lipoproteins trigger both inflammation and calcification via receptors for advanced lipoxidation/glycation endproducts (ALEs/AGEs). This study compared the roles of galectin-3 and receptor for AGEs (RAGE), two ALEs/AGEs-receptors with diverging effects on inflammation and bone metabolism, in the process of vascular calcification. We evaluated galectin-3 and RAGE expression/localization in 62 human carotid plaques and its relation to calcification pattern, plaque phenotype, and markers of inflammation and vascular osteogenesis; and the effect of galectin-3 ablation and/or exposure to an ALE/AGE on vascular smooth muscle cell (VSMC) osteogenic differentiation. While RAGE co-localized with inflammatory cells in unstable regions with microcalcification, galectin-3 was expressed also by VSMCs, especially in macrocalcified areas, where it co-localized with alkaline phosphatase. Expression of galectin-3 and osteogenic markers was higher in macrocalcified plaques, whereas the opposite occurred for RAGE and inflammatory markers. Galectin-3-deficient VSMCs exhibited defective osteogenic differentiation, as shown by altered expression of osteogenic transcription factors and proteins, blunted activation of pro-osteoblastogenic Wnt/β-catenin signalling and proliferation, enhanced apoptosis, and disorganized mineralization. These abnormalities were associated with RAGE up-regulation, but were only in part prevented by RAGE silencing, and were partially mimicked or exacerbated by treatment with an AGE/ALE. These data indicate a novel molecular mechanism by which galectin-3 and RAGE modulate in divergent ways, not only inflammation, but also vascular osteogenesis, by modulating Wnt/β-catenin signalling, and independently of ALEs/AGEs