Curtis L. Cetrulo

Human Mast Cells Express Corticotropin-Releasing Hormone (CRH) Receptors and CRH Leads to Selective Secretion of Vascular Endothelial Growth Factor

Mast cells are critical for allergic reactions, but also for innate or acquired immunity and inflammatory conditions that worsen by stress. Corticotropin-releasing hormone (CRH), which activates the hypothalamic-pituitary-adrenal axis under stress, also has proinflammatory peripheral effects possibly through mast cells. We investigated the expression of CRH receptors and the effects of CRH in the human leukemic mast cell (HMC-1) line and human umbilical cord blood-derived mast cells. We detected mRNA for CRH-R1α, 1β, 1c, 1e, 1f isoforms, as well as CRH-R1 protein in both cell types. CRH-R2α (but not R2β or R2γ) mRNA and protein were present only in human cord blood-derived mast cells. CRH increased cAMP and induced secretion of vascular endothelial growth factor (VEGF) without tryptase, histamine, IL-6, IL-8, or TNF-α release. The effects were blocked by the CRH-R1 antagonist antalarmin, but not the CRH-R2 antagonist astressin 2B. CRH-stimulated VEGF production was mediated through activation of adenylate cyclase and increased cAMP, as evidenced by the fact that the effect of CRH was mimicked by the direct adenylate cyclase activator forskolin and the cell-permeable cAMP analog 8-bromo-cAMP, whereas it was abolished by the adenylate cyclase inhibitor SQ22536. This is the first evidence that mast cells express functional CRH receptors and that CRH can induce VEGF secretion selectively. CRH-induced mast cell-derived VEGF could, therefore, be involved in chronic inflammatory conditions associated with increased VEGF, such as arthritis or psoriasis, both of which worsen by stress.

The evaluation of continuous fetal heart rate monitoring in high-risk pregnancy

Intrapartum electronic fetal heart rate monitoring of the high-risk obstetric patient is thought to improve the perinatal outcome. A prospective randomized study of 483 high-risk obstetric patients in labor was carried out comparing the effectiveness of electronic fetal monitoring with auscultation of fetal heart tones. The infant outcome was measured by neonatal death, Apgar scores, cord blood gases, and neonatal nursery morbidity. There were no differences in the infant outcomes in any measured category between the electronically monitored group and the auscultated group. The cesarean section rate was markedly increased in the monitored group (16.5 vs. 6.8 per cent in the auscultated patients). The presumptive benefits of electronic fetal monitoring for improving fetal outcome were not found in this study.

Flavonols inhibit proinflammatory mediator release, intracellular calcium ion levels and protein kinase C theta phosphorylation in human mast cells

1 Mast cells participate in allergies, and also in immunity and inflammation by secreting proinflammatory cytokines. 2 Flavonoids are naturally occurring polyphenolic plant compounds, one group of which – the flavonols, inhibits histamine and some cytokine release from rodent basophils and mast cells. However, the effect of flavonols on proinflammatory mediator release and their possible mechanism of action in human mast cells is not well defined. 3 Human umbilical cord blood‐derived cultured mast cells (hCBMCs) grown in the presence of stem cell factor (SCF) and interleukin (IL)‐6 were preincubated for 15 min with the flavonols quercetin, kaempferol, myricetin and morin (0.01, 0.1, 1, 10 or 100 μM), followed by activation with anti‐IgE. Secretion was quantitated for IL‐6, IL‐8, tumor necrosis factor‐alpha (TNF‐α), histamine and tryptase levels. 4 Release of IL‐6, IL‐8 and TNF‐α was inhibited by 82–93% at 100 μM quercetin and kaempferol, and 31–70% by myricetin and morin. Tryptase release was inhibited by 79–96% at 100 μM quercetin, kampferol and myricetin, but only 39% by morin; histamine release was inhibited 52–77% by the first three flavonols, but only 28% by morin. These flavonols suppressed intracellular calcium ion elevations in a dose–response manner, with morin being the weakest; they also inhibited phosphorylation of the calcium‐insensitive protein kinase C theta (PKC θ). 5 Flavonol inhibition of IgE‐mediated proinflammatory mediator release from hCBMCs may be due to inhibition of intracellular calcium influx and PKC θ signaling. Flavonols may therefore be suitable for the treatment of allergic and inflammatory diseases.

Breast reconstruction following nipple-sparing mastectomy: predictors of complications, reconstruction outcomes, and 5-year trends.

Background: Nipple-sparing mastectomy is increasingly used for treatment and prevention of breast cancer. Few data exist on risk factors for complications and reconstruction outcomes. Methods: A single-institution retrospective review was performed between 2007 and 2012. Results: Two hundred eighty-five patients underwent 500 nipple-sparing mastectomy procedures for breast cancer (46 percent) or risk reduction (54 percent). The average body mass index was 24, and 6 percent were smokers. The mean follow-up was 2.17 years. Immediate breast reconstruction (reconstruction rate, 98.8 percent) was performed with direct-to-implant (59 percent), tissue expander/implant (38 percent), or autologous (2 percent) reconstruction. Acellular dermal matrix was used in 71 percent and mesh was used in 11 percent. Seventy-seven reconstructions had radiotherapy. Complications included infection (3.3 percent), skin necrosis (5.2 percent), nipple necrosis (4.4 percent), seroma (1.7 percent), hematoma (1.7 percent), and implant loss (1.9 percent). Positive predictors for total complications included smoking (OR, 3.3; 95 percent CI, 1.289 to 8.486) and periareolar incisions (OR, 3.63; 95 percent CI, 1.850 to 7.107). Increasing body mass index predicted skin necrosis (OR, 1.154; 95 percent CI, 1.036 to 1.286) and preoperative irradiation predicted nipple necrosis (OR, 4.86; 95 percent CI, 1.0197 to 23.169). An inframammary fold incision decreased complications (OR, 0.018; 95 percent CI, 0.0026 to 0.12089). Five-year trends showed increasing numbers of nipple-sparing mastectomy with immediate reconstruction and more single-stage versus two-stage reconstructions (p < 0.05). Conclusions: Nipple-sparing mastectomy reconstructions have a low number of complications. Smoking, body mass index, preoperative irradiation, and incision type were predictors of complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Wharton’s Jelly stem cells: Future clinical applications

This review focuses on the therapeutic potential of stem cells harvested from the Whartons Jelly of the human umbilical cord. Recently, investigators have found that a potent stem cell population exists within the Whartons Jelly. In this review, the authors define a new subset of stem cells, termed perinatal stem cells, and compare them to other sources of stem cells. Furthermore, cryopreservation of Whartons Jelly stem cells is described for potential use in future cell based therapies and/or regenerative medicine applications. Current evidence of the application of mesenchymal stem cells from various sources in both pre-clinical and clinical trials is reviewed in the context of potential indications of use for Whartons Jelly derived mesenchymal stem cells.

Hyaluronic acid enhances peripheral nerve regeneration in vivo

Hyaluronic acid has been shown to enhance peripheral nerve regeneration in vitro. It has been proposed that, during the fibrin matrix phase of regeneration, hyaluronic acid organizes the extracellular matrix into a hydrated open lattice, thereby facilitating migration of the regenerating axons. Hyaluronic acid solutions and saline control solutions were injected into a nerve guide spanning a transected gap in the sciatic nerve of Sprague‐Dawley rats (five in each group). Nerve conduction velocities were measured at 4 weeks by electromyography (EMG) before sacrifice of the animals. These studies demonstrated increased conduction velocities in the hyaluronic acid group compared with control animals (P = 0.006). After the animals were sacrificed, regenerated axon cables were quantified histologically, and axon branching was delineated by retrograde tracer analysis. In addition, the hyaluronic acid group showed an increase in myelinated axon counts at 4 weeks (P = 0.03). An increase in retrograde flow was demonstrated in the hyaluronic acid groups compared with animals receiving saline solution.

Management of multiple gestation.

The following perinatal intensive care management protocol is suggested to minimize morbidity and mortality in multiple pregnancy. 1. Early diagnosis is essential, with ultrasound examination regarding as invaluable for all pregnant patients. If ultrasound examination has not been done, multiple pregnancy should be suspected in all patients who have a family history of dizygotic births, are large for dates or anemic, or have a low-grade preeclampsia. 2. Maternal care should be provided at a tertiary care (level III) perinatatl center, which is more fully equipped to manage multiple gestation. 3. Bed rest, if instituted early enough (26-29 weeks) appears to be of value, especially in promoting increased birth weight. 4. A liberal approach to performing cesarean birth is suggested when any abnormal presentation exists. 5. Aggressive management, using tocolytic agents to delay premature labor and steroids to accelerate pulmonary maturity, should be strongly considered. 6. The personnel of a neonatal intensive care unit should employ a team approach to the preparation for and management of multiple preterm births.

Regulation of IL-1-induced selective IL-6 release from human mast cells and inhibition by quercetin

1 Mast cells are involved in allergic reactions, but also in innate immunity and inflammation. Crosslinkage of mast cell Fc immunoglobulin E receptors (FcɛRI) by multivalent antigen triggers secretion of granule‐stored mediators, as well as de novo synthesis of cytokines, including interleukin (IL)‐6. 2 We showed recently that the proinflammatory cytokine IL‐1 stimulates human leukemic mast cells (HMC‐1) and human umbilical cord blood‐derived cultured mast cells (hCBMCs) to release newly synthesized IL‐6 without tryptase in the absence of degranulation. 3 Here, we investigated several signal‐transduction pathways activated by IL‐1 leading to IL‐6 production by HMC‐1 and hCBMCs. 4 We also investigated the effect of the flavonol quercetin that was recently shown to strongly inhibit IL‐6 secretion in response to allergic stimulation from hCBMCs. 5 IL‐1 stimulated p38, but did not activate extracellular signal‐regulated kinase (ERK) or c‐jun N‐terminal kinase (JNK); it also did not activate protein kinase C (PKC) isozymes α, β, μ and ζ, except for PKC‐θ, which was phosphorylated. 6 The p38 inhibitor SB203580 and the PKC inhibitors Calphostin C and Gö6976 completely inhibited IL‐1‐induced IL‐6 production. 7 Quercetin 1–100 μM inhibited IL‐1‐induced IL‐6 secretion, p38 and PKC‐θ phosphorylation in a dose‐dependent manner. 8 These results indicate that IL‐1‐stimulated IL‐6 production from human mast cells is regulated by biochemical pathways distinct from IgE‐induced degranulation and that quercetin can block both IL‐6 secretion and two key signal transduction steps involved.

Intrauterine fetal demise in multiple gestation.

Fifteen cases were reviewed over a five-year period at a perinatal centre with intrauterine demise of one member of a multiple gestation. Nine cases were monozygotic twin pairs, two were dizygotic, and two were triples . Gestational age ranged from 27 to 39 weeks. The management protocol consisted of delivery in all cases after confirmation of the diagnosis. In 4 cases delivery was immediate because of spontaneous labor. In the other cases elective delivery was performed if the gestational age was 37 weeks or greater or there was evidence of preeclampsia or if amniocentesis revealed a mature lecithinsphingomyelin (L/S) ratio. Steroids were given if the L/S was immature or the attempt at amniocentesis was unsuccessful and delivery was performed 48 hours after initiation of steroid therapy. Cesarean section was the mode of delivery in 14 of the 15 cases. All of the cotwins and cotriplets survived. One survivor of a monozygous twin pair has multicystic encephalomalacia possibly implicating perinatal arterial occlusion or in utero disseminated intravascular coagulation (DIC). The intrauterine deaths are categorized into possibly avoidable deaths (2/15), unavoidable due to congenital anomalies (3/15), and unknown or unavoidable deaths (8/15).

Infection following implant-based reconstruction in 1952 consecutive breast reconstructions: salvage rates and predictors of success.

Background: Few studies address salvage rates for infection in implant-based breast reconstruction. An understanding of success rates and clinical predictors of failure may help guide management. Method: A retrospective analysis of multisurgeon consecutive implant reconstructions from 2004 to 2010 was performed. Results: Immediate implant-based reconstructions (n = 1952) were performed in 1241 patients. Ninety-nine reconstruction patients (5.1 percent) were admitted for breast erythema and had a higher incidence of smoking (p = 0.007), chemotherapy (p = 0.007), radiation therapy (p = 0.001), and mastectomy skin necrosis (p < 0.0001). There was no difference in age, body mass index, or acellular dermal matrix usage. With intravenous antibiotics, 25 (25.3 percent) reconstruction patients cleared the infection, whereas 74 (74.7 percent) underwent attempted operative salvage (n = 18) or explantation (n = 56). Patients who failed to clear infection had a higher mean white blood cell count at admission (p < 0.0001). Of the attempted operative salvage group, 12 cleared the infection with immediate implant exchange and six eventually lost the implant. Patients who failed implant salvage were more likely to have methicillin-resistant Staphylococcus aureus (p = 0.004). The total explantation rate was 3.2 percent. Following explantation, 32 patients underwent attempted secondary tissue expander insertion. Twenty-six were successful and six had recurrent infection and implant loss. There were no differences in time interval to tissue expander insertion between successful and unsuccessful secondary operations. Conclusions: Salvage with intravenous antibiotics and implant exchange was successful in 37.3 percent of patients. Smoking, irradiation, chemotherapy, and mastectomy skin necrosis were predictors for developing infection. Patients with a higher white blood cell count at admission and methicillin-resistant S. aureus were more likely to fail implant salvage. There was no association with time interval to tissue expander insertion and secondary explantation.(Plast. Reconstr. Surg. 131: 1223, 2013.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.