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Background Thrombocytopenia is associated with increased mortality in the general population, but few data exist in patients with atrial fibrillation ( AF ) taking oral anticoagulants. We investigated factor determinants of thrombocytopenia in a large cohort of patients affected by AF and its association with total mortality. Methods and Results Multicenter prospective cohort study, including 5215 patients with AF from the START (Survey on Anticoagulated Patients Register) registry, 3877 (74.3%) and 1338 (25.7%) on vitamin K or non–vitamin K antagonist oral anticoagulants, respectively. Thrombocytopenia was defined by a platelet count 9 /L. Determinants of thrombocytopenia were investigated, and all‐cause mortality was the primary survival end point of the study. Thrombocytopenia was present in 592 patients (11.4%). At multivariable logistic regression analysis, chronic kidney disease (odds ratio [ OR], 1.257; P =0.030), active cancer ( OR, 2.065; P =0.001), liver cirrhosis ( OR, 7.635; P OR, 1.234; P =0.046) were positively associated with thrombocytopenia, whereas female sex ( OR, 0.387; P OR, 0.787; P =0.032) were negatively associated. During a median follow‐up of 19.2 months (9942 patient‐years), 391 deaths occurred (rate, 3.93%/year). Mortality rate increased from 3.8%/year to 9.9%/year in patients with normal platelet count and in those with moderate‐severe thrombocytopenia, respectively (log‐rank test, P =0.009). The association between moderate‐severe thrombocytopenia and mortality persisted after adjustment for CHA 2 DS 2 VAS c score (hazard ratio, 2.431; 95% CI, 1.254–4.713; P =0.009), but not in the fully adjusted multivariable Cox regression analysis model. Conclusions Thrombocytopenia is common in patients with AF . Despite an increased incidence of mortality, thrombocytopenia was not associated with mortality at multivariable analysis. Thrombocytopenia may reflect the presence of comorbidities associated with poor survival in AF .

Cysteine and glutathione are involved in the synthesis of many pigments, this process being mediated by cysteinyldopas or glutathionedopas. Although cysteine is the focal compound of organic thiol metabolism, glutathione, a tripeptide, is the most ubiquitous aminothiol. Glutathione reacts with many endogenous metabolites and with exogenously originated electrophilic compounds, forming reduced glutathione (GSH) conjugates. In fact, since GSH combines with reactive electrophilic metabolites of xenobiotics and, hence, protects nucleophilic cell compounds, toxic effects are exerted only after a net depletion of intracellular GSH stores. The effects of N-acetylcysteine and GSH in liver carcinogenesis were investigated by the use of an experimental model in the rat, involving a discontinuous cyclic dietary regimen containing the aromatic amine 2-acetylaminofluorene. Multiple mechanisms are involved in the inhibitory effects of thiols in mutagenesis and carcinogenesis. All the known inhibitors of mutagenesis and carcinogenesis seem to share the dual role of inhibitors and of stimulators, depending on the situation.

This study was conducted during January-April 2010 with the collaboration of 7 clinical microbiology laboratories evenly distributed across the Ligurian area to identify the most frequent Gram negative species and to evaluate their antibiotic susceptibility patterns Overall, 110 consecutive multi-resistant non duplicate Gram negative isolates,were collected and sent to the coordinating laboratory (Sezione di Microbiologia del DISC, University of Genoa, Italy) together with susceptibility data obtained by routine methods. In addition, strains resistant to carbapenems were characterized by PCR. A total of 110 Gram negative multi-resistance strains were found, including 74 and 36 isolated from healthcare or nosocomial settings and community acquired infections, respectively. The most represented pathogens were: A. baumannii (38, 34.5%), E. coli (30, 27.2%), P. aeruginosa (29, 26.3%), K. pneumoniae (9, 8.2%) and P. mirabilis (4, 3.6%). A. baumannii were more frequently collected from healthcare settings or nosocomial samples, while the other strains were generally equally isolated from in- and out-patients. Amikacin was the most active molecule against E. coli and P. mirabilis (96,7% and 100% of susceptible stains respectively). Colistin was the only active molecule agains A. baumanii and P. aeruginosa (100% of susceptible strains). Against K. pneumoniae tigecycline and colistin were the most active molecules (100% of susceptible strains). Imipenem was the most active compound against E. coli and P. mirabilis (100% of susceptible strains). A large number (97.4%) of A. baumannii was resistant to imipenem. K. pneumoniae and P. aeruginosa showed rates of resistance of 88% and 34.4% respectively. A. baumannii, K. pneumoniae and P. aeruginosa isolates resistant to Imipenem, carried OXA-23, KPC and VIM carbapenemases.These data shown a significant spread of multidrug-resistant Gram negative bacteria in hospitals and in communities.The production of carbapenemase in A. baumannii, K. pneumoniae and P. aeruginosa is now an important phenomenon in our region.

Introduction. An epidemiological study addressed to identify gram-negative bacteria, isolated from laboratories in a Northern area of Italy, and their antibiotic resistance patterns was conducted. Methods. Twelve laboratories distributed on Ligurian territory or neighbouring areacollected all consecutive gram-negative isolates belonging to the Enterobacteriaceae family and non-fermenter group for 2 months and sent them to a reference laboratory. Results. A total of 1880 pathogens were collected, including 899 and 981 strains isolated from nosocomial- and community-acquired infections, respectively. Escherichia coli (63.3% of total) was the most frequently isolated pathogen followed by Pseudomonas aeruginosa (9.6%), Proteus mirabilis (8.9%) and Klebsiella pneumoniae (5.4%). Nosocomial samples were collected mainly from patients in general medicine wards (19.9%) and healthcare settings (14.1%). Urine was the most common clinical sample (79.9% of the total). Other samples were sputum and bronchoaspirates (8%), skin wounds including those from decubitus (5.3%) and blood (4.1%). E. coli and P. mirabilis were collected mainly from urinary tract infection while P. aeruginosa appears more involved in respiratory or other infections. Considering the resistance to representative classes of antibiotics, it was higher (%) for piperacillin-tazobactam in P. mirabilis (30.3), for ceftazidime in Enterobacter aerogenes (40.8) and in Providencia stuartii (40), for imipenem and amikacin in P. aeruginosa (16.2 and 13.7 respectively), for ciprofloxacin in P. stuartii (66.6) and in P. mirabilis (44.7) than in others bacteria. Conclusions. The increasing age of the population in general medical wards and healthcare settings is associated with urinary tract and bedsore infections. E. coli confirms its epidemiologic and pathogenic role, but P. mirabilis and P. aeruginosa are emerging as alternativechallenges.

Introduction. Staphylococcus aureus is a major opportunistic pathogen especially in nosocomial settings. An increasing proportion of strains has intrinsic resistance to methicillin (MRSA) and recent reports documented the emergence of MRSA also in the community.The aim of this study was to evaluate methicillin-resistance in Liguria. Methods. 767 isolates of Staphylococcus spp have been collected from 10 laboratories, including 508 S. aureus: 292 (57.5%) hospital-acquired, 188 (37%) community-acquired, and 28 (5.5%) from healthcare settings; 259 coagulase- negative staphylococci (CNS): (193 (74.5%) hospital-acquired, 56 (21.6%) community-acquired, and 10 (3.9%) healthcare settings. Susceptibility tests were carried out by the disk diffusion method (CLSI, 2006) using cefoxitin (CFX) (Oxoid, Milan). MRSA has been also evaluated by PBP2’ latex agglutination test (Oxoid, Milan) on 52 randomly selected S. aureus. Results. The data obtained indicated an incidence of MRSA in nosocomial settings up to 45.2%, while among the community-acquired isolates the percentage was 6.4%. With respect to CNS the figures were 61,8% and 10,6% for the nosocomial-and community-acquired organisms respectively. A 99% agreement between data of the coordinating centre and the various laboratories was found. Methicillin-resistance was confirmed in 52 S. aureus by PBP2’ latex agglutination test. Conclusions. Present findings indicate that MRSA in community in the Ligurian area exists and this phenomenon requires future surveillance.

This article reviews approximately 700 results reported in the literature with 32 chromium compounds assayed in 130 short-term tests, using different targets and/or genetic end-points. The large majority of the results obtained with Cr(VI) compounds were positive, as a function of Cr(VI) solubility and bioavailability to target cells. On the other hand, Cr(III) compounds, although even more reactive than Cr(VI) with purified nucleic acids, did not induce genotoxic effects in the majority of studies using intact cells. Coupled with the findings of metabolic studies, the large data-base generated in short-term test systems provides useful information for predicting and interpreting the peculiar patterns of Cr(VI) carcinogenicity.

Samples of gastric juice from variously treated subjects efficiently reduced hexavalent chromium and decreased its mutagenicity. Chromium reduction was due to thermostable components of gastric secretions and was favoured by the acidity of the intragastric environment. The circadian monitoring of pH and of chromium reduction, as assessed by colorimetric analysis at hourly intervals, showed a basal activity (less than 10 micrograms/ml gastric juice) during the night and interdigestive periods, and peaks (tens of micrograms/ml) during the 3-4-h periods after each meal. Assays in the Ames reversion test confirmed that the decrease in mutagenicity of sodium dichromate produced by gastric juice was significantly enhanced after meals. This physiological mechanism is expected to provide an important protective barrier against the oral toxicity of this metal, and may explain its lack of oral carcinogenicity.

At variance with Cr(III), Cr(VI) compounds easily cross cell membranes and exert genotoxic effects. No metabolic oxidation of Cr(III) could be detected, whereas Cr(VI) reduction was observed in the presence of body fluids and subcellular fractions of various tissues from several animal species. The differential efficiency of this process may account for the selection of target tissues in Cr(VI) carcinogenesis. For instance, reduction by saliva and gastric juice may explain a lack of carcinogenicity by the oral route; reduction inside erythrocytes may explain a lack of carcinogenicity at a distance from administration sites; reduction by the epithelial-lining fluid of terminal airways and by alveolar macrophages may be consistent with the occurrence of thresholds in lung carcinogenesis. Liver preparations displayed the top efficiency in reducing Cr(VI), whereas skeletal muscle, i.e., a typical target in experimental Cr(VI) carcinogenesis, had no detectable activity. Bronchial tree and peripheral lung parenchyma preparations from almost 100 individuals reduced Cr(VI) to a variable extent. The efficiency of lung parenchyma and of isolated alveolar macrophages was enhanced in cigarette smokers. In rats, Cr(VI) reduction by lung preparations was significantly stimulated by the repeated i.t. instillation of Cr(VI) itself. Among the electron donors (chiefly GSH) and enzymatic mechanisms responsible for the intracellular Cr(VI) reduction, such as cytochrome P-450 reductase, glutathione reductase, and aldehyde oxidase, an important role can be ascribed to cytosolic DT diaphorase activity, usually catalyzing a 2-electron reduction.

This article reviews studies and new experimental data concerning the genotoxicity of chromium compounds of different oxidation state in a variety of short‐term test systems, as well as their metabolic fate. The chemical or biochemical reduction of Cr(VI) has been investigated in several body fluids and cell preparations of different tissues from various animal species, including humans. The variability factors involved and the underlying mechanisms have been explored. The selective reduction of Cr(VI) in different sites of the organism may be consistent with its lack of carcinogenicity by the oral route or at distance from administration sites. Also in the lung, Cr(VI) carcinogenicity is likely to be limited by defense mechanisms of the lower respiratory tract, such as those provided by the epithelial‐lining fluid and by alveolar macrophages.

S9 fraction pools of liver biopsy samples, collected from 129 patients in two consecutive studies, were comparatively assayed for their ability to activate aflatoxin B1 (AFB1) and a tryptophan pyrolysate product (Trp-P-2) in a miniaturized Salmonella mutagenicity test system. Metabolic activation was not affected to a significant extent by most of the monitored variability factors, such as sex, alcohol, cigarette smoking and liver histology (minimal changes, chronic persistent (CPH) or active (CAH) hepatitis, CAH steatosis, or cyrrhosis). Conversely, a significant enhancement of activation was observed for AFB1 in cases of mild CAH and especially for Trp-P-2 in hepatitis B virus carriers, irrespective of their histologic diagnosis.

The metabolic activation or detoxification of mutagens and carcinogens of several chemical classes was investigated in the presence of various rat liver and lung subcellular fractions and of dicoumarol, a specific inhibitor of DT diaphorase activity. His- Salmonella typhimurium strains were used as targets of mutagenicity. Dicoumarol partially prevented the metabolic activation of some promutagens, such as the heterocyclic amines 2-amino-3,4-dimethylimidazo[4,5-f]quinoline and 3-amino-1-methyl-5H-pyrido[4,3-b]indole, and a cigarette smoke condensate. Moreover, detailed experiments, also using purified enzyme, confirmed the participation of DT diaphorase in the metabolic reduction of 4-nitroquinoline N-oxide 4NQO and of hexavalent chromium [Cr(VI)] compounds. The results obtained provide evidence for broad involvement of DT diaphorase in the metabolism of both organic and inorganic mutagens and carcinogens. Moreover, they suggest a dual role of this enzyme, providing not only a cellular detoxifying system but also, with a few substrates, an activating mechanism.

N-acetylcysteine (NAC) was administered to rats in various combinations with an enzyme inducer (Aroclor 1254) and with depletors of reduced glutathione (GSH), i.e., diethyl maleate (DEM) and buthionine sulfoximine (BSO). NAC increased intracellular glutathione levels in erythrocytes and in liver and lung cells, and replenished its stores following depletion. It did not affect the concentrations nor the spectral properties of cytochromes P-450 in hepatic and pulmonary microsomes, whereas it stimulated, especially in Aroclor-pre-treated animals, cytosolic enzyme activities involved in NADP reduction (glucose 6-phosphate dehydrogenase and 6-phosphogluconate dehydrogenase), in glutathione reduction (GSSG-reductase) and in the reductive detoxication of xenobiotics by-passing formation of reactive oxygen species (DT-diaphorase). In vivo treatment with the drug enhanced detoxication by liver and lung S-12 fractions of direct-acting mutagens (ICR 191, epichlorohydrin, 4-nitroquinolino-N-oxide and dichromate) and counteracted opposite effects triggered by administration of GSH depletors. The metabolic activation of procarcinogens (aflatoxin B1, 2-aminofluorene, cyclophosphamide, benzo[a]pyrene, a tryptophan pyrolysate product and cigarette smoke condensate) was inhibited by NAC in uninduced rats, while it was further stimulated in Aroclor-pre-treated animals. Additional assays, performed also with other enzyme inducers (phenobarbital and 3-methylcholanthrene) suggested that the effect of NAC on the metabolic activation of procarcinogens depends on the balance between an increased production of mutagenic metabolites (prevailing in induced animals) and their binding by intracellular thiols (prevailing under normal conditions). Thus, due to its dual role as a nucleophile and as a SH donor, NAC appears to exert protective effects by modulating glutathione metabolism and the biotransformation of mutagenic/carcinogenic compounds. This may have clinical relevance, since NAC is administered to individuals, such as cigarette smokers, who are more heavily exposed to GSH depletors and to carcinogenic agents.

Reduced glutathione (GSH) is well-known to play a fundamental role in the protection of the organism against toxic, mutagenic and/or carcinogenic agents (see e.g. refs. 1–3 for reviews). Among synthetic aminothiols, acting as analogs and precursors of GSH, N-acetyl-L-cysteine (NAC) is of particular interest, because this molecule is already extensively used in the treatment of chronic respiratory diseases, and is extremely well tolerated in humans4. In addition, NAC is known to possess various antitoxic and antioxidant properties3–5.

N-acetylcysteine (NAC), a precursor of intracellular cysteine and glutathione (GSH)) (1), is extensively used in the treatment of patients suffering from respiratory diseases. Moreover, this synthetic aminothiol has been shown to possess a variety of antitoxic properties in humans, animals and in vitro test systems (2).

Pulmonary alveolar macrophages (PAM), obtained by bronchoalveolar lavage from 47 individuals, reduced hexavalent chromium [Cr(VI)] and decreased its mutagenicity. Their specific activity--mostly mediated by cytosolic, enzyme-catalyzed mechanisms--was significantly higher than in corresponding preparations of mixed-cell populations from human peripheral lung parenchyma or bronchial tree, or from rat lung or liver. At equivalent number of PAM, Cr(VI) reduction, total protein, and some oxidoreductase activities were significantly increased in smokers. No appreciable variation could be detected between lung cancer and noncancer patients. In rats, the Cr(VI)-reducing activity of PAM preparations was induced by Aroclor 1254. Thus, alveolar macrophages provide crucial defense mechanisms not only by phagocytizing metals, but also by metabolically reducing Cr(VI). The epithelial-lining fluid (ELF) also displayed some Cr(VI) reduction. Together with already investigated metabolic processes occurring inside lung cells, these mechanisms are expected to determine thresholds in the pulmonary carcinogenicity of chromium.

There is no doubt that chromium has been the most extensively investigated metal with respect to the assessment of long-term effects and to the evaluation of the underlying mechanisms. Notwithstanding the huge data-base available in the literature, many aspects, bearing both scientific and practical interest, are still unclear or controversial. This paper will briefly discuss some relevant problems, including carcinogenicity and genotoxicity of chromium compounds as related to their valency and solubility, interactions with other compounds, bioavailability to target cells and molecules, interconversion processes between different oxidation states in various body areas and cell compartments, mechanisms of chromium metabolism and carcinogenicity, and existence of thresholds in chromium carcinogenesis.

The thiol N-acetylcysteine (NAC), a precursor of intracellular glutathione (GSH), efficiently prevented the induction of lung tumors in Swiss albino mice, when supplemented to the diet (0.2%) both before and after an i.p. injection of the carcinogen urethan (ethyl carbamate). Irrespective of urethan administration, NAC also significantly enhanced GSH S-transferase activity in liver preparations of the same animals. These data show that, under certain conditions, it is possible to prevent chemically induced cancer by increasing the levels of physiological trapping agents.