Demonstration of differences in colonic volumes, transit, chyme consistency, and response to psyllium between healthy and constipated subjects using magnetic resonance imaging

BACKGROUND

In functional gastrointestinal disorders a lack of objective biomarkers limits evaluation of underlying mechanisms. We aimed to demonstrate the utility of magnetic resonance imaging for this task using psyllium, an effective constipation treatment, in patients and controls.

METHODS

Two crossover studies: (i) adults without constipation (controls, n = 9) took three treatments in randomized order for 6 days - maltodextrin (placebo), psyllium 3.5 g t.d.s and 7 g t.d.s., (ii) adults with chronic constipation (patients, n = 20) took placebo and psyllium 7 g t.d.s. for 6 days. MRI was performed fasting and postprandially on day 6. Measurements included small bowel and ascending colon water content, colonic volume, transit time, and MR relaxometry (T1, T2) to assess colonic chyme. Stool water percentage was measured.

RESULTS

7 g psyllium t.d.s. increased fasting colonic volumes in controls from median 372 mL (IQR 284-601) to 578 mL (IQR 510-882), and in patients from median 831 mL (IQR 745-934) to 1104 mL (847-1316), P < .05. Mean postprandial small bowel water was higher in controls and patients after 7 g psyllium t.d.s. vs placebo. Whole gut transit was slower in patients than controls (P < .05). T1 of the descending colon chyme (fasting) was lower in patients (213 ms, 176-420) than controls (440 ms, 352-884, P < .05) on placebo, but increased by 7 g psyllium t.d.s. (590 ms, 446-1338), P < .001. Descending colon T1 correlated with baseline stool water content and stool frequency on treatment.

CONCLUSIONS AND INFERENCES

MRI measurements can objectively demonstrate the mode of action of therapy targeting intestinal fluid content in constipation.

Relationship between Plasma Fibrinolytic Activity and Serum Fibrinogen Degradation Products (FDP) Tested by Various Methods

It was found in the present work that the level of serum fibrinogen degradation products (FDP) determined by the immunoassay method correlated well with the staphylococcal clumping titer in serum (correlation coefficient r = 0.68). The content of FDP in serum of 30 healthy subjects and patients with various diseases did not correlate, however, neither with blood fibrinolytic activity estimated by the euglobulin clot lysis time, nor with fibrinogen content and plasma anticlotting activity. It is concluded, that FDP appear in circulation as a result of local proteolytic degradation of intravascularly deposited fibrin without generalized activation of fibrinolysis.

Molecular Basis of Human Diseases and Targeted Therapy Based on Small-Molecule Inhibitors of ER Stress-Induced Signaling Pathways

The Endoplasmic Reticulum (ER) provides a conserved protein quality control system and plays a fundamental role in cell growth and homeostasis. Disturbances in the ER homeostasis may originate especially from hypoxia, glucose deficiency, presence of mutant proteins, that directly impair protein folding capacity and after deposition of unfolded and misfolded proteins within ER lumen trigger ER stress conditions. This subsequently activates the Unfolded Protein Response (UPR) branches, which have a dual pro-adaptive or pro-apoptotic role depending on the severity and time of duration of ER stress conditions. This review is the first to offer a detailed overview on molecular mechanisms of all major ER stress-dependent signaling branches, that are activated through three specific ER transmembrane receptors of impaired protein folding: Protein kinase RNA (PKR)-like ER kinase (PERK), Inositol-requiring enzyme-1 (IRE1) and Activating transcription factor 6 (ATF6). Molecular crosstalk among ER transmembrane receptors-dependent pathways determines a final UPR response, but the recent data reported that especially PERK over-activation has a significant impact on the development and progression of a wide spectrum of disease entities. Based on these findings, small-molecules, highly specific PERK inhibitors may provide effective, groundbreaking treatment strategy against human diseases. However, after foregoing in vitro cellular and in vivo animal models conducted examination, supplementary investigations of PERK inhibitors are required for their further clinical use. Future research may answer the question of how to minimize toxicity and side effects of characterized small-molecule PERK inhibitors, that may be used, as breakthrough drugs, alone or in combination with currently known models of therapy.

[Multimorbidity management and the physician's daily clinical dilemma]

About 20-25% of all persons and about 90% of all patients who are acutely hospitalized in internal medicine departments have multiple acute or chronic diseases. They are multimorbid. The encounter with multimorbid patients has become the most common situation in the health care system. Theoretically, multimorbidity results in an innumerable potential disease constellations. In addition, the likelihood of interactions between diseases (disease-disease interactions, DDI) and the complexity increases overproportionately with each additional disease. However, multimorbidity often occurs in typical diadic, triadic, or higher characteristic combinations, in "disease clusters", e. g., vascular risk factors, heart and lung diseases, Frailty and dementia, psychiatric and somatic disorders. Such combinations lead to a worsening of the overall prognosis. In addition, DDIs are often difficult to treat or are life-threatening. Examples of DDIs include the following: anticoagulation and simultaneous severe bleeding, pain treatment and hypertension or renal insufficiency, depression and reduced medication adherence, chronic obstructive pulmonary disease and depression, Frailty and neurodepressant drugs and frequent falls, and combined psychiatric and somatic disorders. Such DDIs are common. Nevertheless, there are few studies and clinical guidelines that address these issues. The care of multimorbid patients is, therefore, heavily reliant upon guidelines developed mostly for single diseases. However, multimorbidity and serious DDIs are usually not addressed in these. Clinical guidelines can thus inadvertently jeopardize the safety of persons suffering from multiple diseases. In addition, stressful dilemmas arise for physicians encountering DDIs because of difficult treatment decisions.

Optomechanics with a hybrid carbon nanotube resonator

In just 20 years of history, the field of optomechanics has achieved impressive progress, stepping into the quantum regime just 5 years ago. Such remarkable advance relies on the technological revolution of nano-optomechanical systems, whose sensitivity towards thermal decoherence is strongly limited due to their ultra-low mass. Here we report a hybrid approach pushing nano-optomechanics to even lower scales. The concept relies on synthesising an efficient optical scatterer at the tip of singly clamped carbon nanotube resonators. We demonstrate high signal-to-noise motion readout and record force sensitivity, two orders of magnitude below the state of the art. Our work opens the perspective to extend quantum experiments and applications at room temperature.

Chronic Scalp Ulcer 35 Years after Skull Trepanation Surgery and Radiotherapy for Oligodendroglioma: A Further Example of Immunocompromised Cutaneous Districts

BACKGROUND:

Chronic ulcers of the scalp have a variety of underlying pathologies. In case of cancer patients, a second malignancy must be excluded.

CASE REPORT:

A 78-year-old female patient presented to our department with a large soft tissue defect on the frontotemporal left side. The lesion was about 3 cm in diameter with exposed bone and inflammatory soft tissue on the edges of the defect. About 35 years ago, she had undergone a combined neurosurgery with skull trepanation and radiotherapy for an oligodendroglioma. Three years ago, sandwich transplantation with the dermal template and meshed skin graft failed. Now she re-presented with inflammatory ulcer borders. A complex defect repair was performed after exclusion of a second malignancy.

CONCLUSION:

Chronic scalp ulcers may be the result immunocompromised cutaneous districts and need a complex reconstruction.

Ulcerating Lichen Planopilaris - Successful Treatment by Surgery

Lichen planus is a T-cell mediated autoimmune disorder affecting the skin and mucous membranes. Ulcerating lichen planus is uncommon mostly on oral and genital mucosa but not skin. Lichen planopilaris, however, is a subtype of lichen planus affection hair follicles and leading to permanent scarring alopecia. We report a case of lichen planopilaris of the scalp with multiple alopecic patches ulceration – a hitherto unreported clinical feature. The patient was treated surgically, and the defect could be closed by combined tissue advancement and extension.

MRI assessment of the postprandial gastrointestinal motility and peptide response in healthy humans

BACKGROUND

Feeding triggers inter-related gastrointestinal (GI) motor, peptide and appetite responses. These are rarely studied together due to methodological limitations. Recent MRI advances allow pan-intestinal, non-invasive assessment of motility in the undisturbed gut. This study aimed to develop a methodology to assess pan-intestinal motility and transit in a single session using MRI and compare imaging findings to GI peptide responses to a test meal and symptoms in a healthy volunteer cohort.

METHODS

Fifteen healthy volunteers (29.3±2.7 years and BMI 20.1±1.2 kg m^-2 ) underwent baseline and postprandial MRI scans, symptom questionnaires, and blood sampling (for subsequent GI peptide analysis, Glucagon-like peptide-1 [GLP-1], Polypeptide YY [PYY], Cholecystokinin [CCK]) at intervals for 270 minutes following a 400 g soup meal (204 kcal, Heinz, UK). Gastric volume, gall bladder volume, small bowel water content, small bowel motility, and whole gut transit were measured from the MRI scans.

KEY RESULTS

(mean±SEM) Small bowel motility index increased from fasting 39±3 arbitrary units (a.u.) to a maximum of 87±7 a.u. immediately after feeding. PYY increased from fasting 98±10 pg mL^-1 to 149±14 pg mL^-1 at 30 minutes and GLP-1 from fasting 15±3 μg mL^-1 to 22±4 μg mL^-1 . CCK increased from fasting 0.40±0.06 pmol mL^-1 to 0.94±0.1 pmol mL^-1 . Gastric volumes declined with a T_1/2 of 46±5 minute and the gallbladder contracted from a fasting volume of 19±2 mL^-1 to 12±2 mL^-1 . Small bowel water content increased from 39±2 mL^-1 to 51±2 mL^-1 postprandial. Fullness VAS score increased from 9±5 mm to 41±6 mm at 30 minutes postprandial.

CONCLUSIONS AND INFERENCES

The test meal challenge was effective in inducing a change in MRI motility end-points which will improve understanding of the pathophysiological postprandial GI response.

Impact of potent bioremediation enhancing plant extracts on Raoultella ornithinolytica properties

Long-term contact of microorganisms with different compounds in the environment can cause significant changes in cell metabolism. Surfactants adsorption on cell surface or incorporation in the cell membrane, lead to their modification, which helps microorganisms adopt to the conditions of metabolic stress. The main objective of this study was to investigate the effects of three saponin-reach plant extracts from Hedera helix, Saponaria officinalis and Sapindus mucorossi on growth and adaptation of Raoultella ornithinolytica to high concentrations of these substances. For this purpose we investigated cell surface properties, membrane fatty acids and genetic changes of the microorganisms. The results revealed that prolonged exposure of the microorganisms to high concentrations of these surfactants can induce genetic changes of their genes. Moreover, the adaptation to contact with high concentrations of saponins was also associated with changes in composition of fatty acids responsible for the stabilisation of membrane structure and the increase in membrane permeability. The changes affected also the outer layer of cells. A significant increase (p < 0.05) in the cell surface hydrophobicity of tested strain was also observed. The cells after long-term contact with S. officinalis and S. mucorossi acquire properties that may be favourable in hydrophobic substances bioremediation.

Functional recovery following early mobilization after middle third clavicle osteosynthesis for acute fractures or nonunion: A case-control study

BACKGROUND

Good outcomes have been reported after surgical treatment for acute or nonunion of displaced midshaft clavicle fractures. However, the postoperative rehabilitation and timeline for a complete functional recovery are poorly documented. The purpose of the current study was to evaluate the efficacy of an immediate motion protocol following plate fixation of a midshaft clavicle fracture and to compare functional recovery between acute and nonunion cases.

METHODS

Between October 2011 and July 2015, all patients above the age of 18, having either an acute or a nonunion of the midshaft clavicle fracture, were considered as potentially eligible for inclusion in this prospective case-control study. Postoperatively, no immobilization was recommended and patients were to undergo rehabilitation protocol consisting of hourly stretching.

RESULTS

Forty-two patients were included (31 with acute and 11 with delayed fixation) at a mean follow-up of 33months (range, 12 to 78months). Surgical complications consisted of one transient frozen shoulder, one delayed union, and two superficial infections. All patients returned to work, retrieved full shoulder range of motion (ROM), and returned to heavy sports and activities. Function returned faster in the acute group compared to the nonunion group based on the SANE score at 2weeks (73±21 vs. 45±26 respectively, P=0.01), SANE score at 6weeks (89±15 vs. 66±23 respectively, P=0.01), SANE score at 3months (96±10 vs. 85±14 respectively, P=0.03), and based on return of full ROM (17±25 vs. 44±31 days respectively, P=0.01). A trend was observed for nonunion cases needing more time to return to work and sports activities.

CONCLUSION

Functional outcome is excellent following the treatment of both acute and non-united clavicle fractures, but recovery occurs earlier following acute treatment. An early mobilization rehab protocol can be safely recommended for both types of conditions and may result in substantial healthcare cost-savings, without increasing complication rate and decreasing patient satisfaction.

LEVEL OF EVIDENCE

Level III; case-control study; treatment study.

Impact of immunosuppressive therapy on therapy-neutralizing antibodies in transplanted patients with Fabry disease

BACKGROUND

Inhibitory antibodies towards enzyme replacement therapy (ERT) are associated with disease progression and poor outcome in affected male patients with lysosomal disorders such as Fabry disease (FD). However, little is known about the impact of immunosuppressive therapy on ERT inhibition in these patients with FD.

METHODS

In this retrospective study, we investigated the effect of long-term immunosuppression on ERT inhibition in male patients with FD (n = 26) receiving immunosuppressive therapy due to kidney (n = 24) or heart (n = 2) transplantation.

RESULTS

No ERT-naïve transplanted patient (n = 8) developed antibodies within follow-up (80 ±72 months) after ERT initiation. Seven (26.9%) patients were tested ERT inhibition positive prior to transplantation. No de novo ERT inhibition was observed after transplantation (n = 18). In patients treated with high dosages of immunosuppressive medication such as prednisolone, tacrolimus and mycophenolate-mofetil/mycophenolate acid, ERT inhibition decreased after transplantation (n = 12; P = 0.0160). Tapering of immunosuppression (especially prednisolone) seemed to re-increase ERT inhibition (n = 4, median [range]: 16.6 [6.9; 36.9] %; P = 0.0972) over time. One ERT inhibition-positive patient required interventions with steroid therapy and increased doses of tacrolimus, which also lowered ERT inhibition.

CONCLUSION

We conclude that the immunosuppressive maintenance therapy after transplantations seems to be sufficient to prevent de novo ERT inhibition in ERT-naïve patients. Intensified high dosages of immunosuppressive drugs are associated with decreased antibody titres and decreased ERT inhibition in affected patients, but did not result in long-term protection. Future studies are needed to establish ERT inhibition-specific immunosuppressive protocols with long-term modulating properties to warrant an improved disease course in ERT inhibition-positive males.

Very Rare Amelanotic Lentigo Maligna Melanoma with Skull Roof Invasion

BACKGROUND

Lentigo malignant melanoma is a melanoma subtype of chronic sun-damaged skin in elderly Caucasians. Amelanotic variants of lentigo malignant are extremely rare.

CASE PRESENTATION

This is a case report of an 80-year-old male patient who presented with a non-pigmented exophytic tumour of his bald head. After complete surgical excision under the suspicion of squamous cell carcinoma, three-dimensional histologic examination confirmed an amelanotic lentigo malignant melanoma with a tumour thickness of 1.76 mm, resected R0. Five years later he developed the first relapse, the other year a satellite metastasis was surgically removed. One year later, this patient had developed a large relapsing lentigo malignant melanoma with skull roof invasion. There was no evidence of distant metastatic spread. Amelanotic lentigo malignant melanoma is a very rare tumour.

CONCLUSIONS

Serial excision or slow Mohs and Mohs micrographic surgery are the treatments of choice especially in the head and neck area. These tumours may be locally very aggressive as it is shown by skull invasion in the present case.