[State of the Art Rectal Surgery]

The multimodal treatment of rectal cancer has differentiated considerably over the last decade depending on the characteristics of the tumor and the patient's circumstances. Surgery continues to be an important pillar of therapy, the quality of which is of prognostic relevance for affected patients. This review provides an up-to-date overview of the indications for the various surgical procedures, current developments in perioperative management and the timing of surgery.

Molecular differences of angiogenic versus vessel co-opting colorectal cancer liver metastases at single-cell resolution

BACKGROUND

Colorectal cancer liver metastases (CRCLM) are associated with a poor prognosis, reflected by a five-year survival rate of 14%. Anti-angiogenic therapy through anti-VEGF antibody administration is one of the limited therapies available. However, only a subgroup of metastases uses sprouting angiogenesis to secure their nutrients and oxygen supply, while others rely on vessel co-option (VCO). The distinct mode of vascularization is reflected by specific histopathological growth patterns (HGPs), which have proven prognostic and predictive significance. Nevertheless, their molecular mechanisms are poorly understood.

METHODS

We evaluated CRCLM from 225 patients regarding their HGP and clinical data. Moreover, we performed spatial (21,804 spots) and single-cell (22,419 cells) RNA sequencing analyses to explore molecular differences in detail, further validated in vitro through immunohistochemical analysis and patient-derived organoid cultures.

RESULTS

We detected specific metabolic alterations and a signature of WNT signalling activation in metastatic cancer cells related to the VCO phenotype. Importantly, in the corresponding healthy liver of CRCLM displaying sprouting angiogenesis, we identified a predominantly expressed capillary subtype of endothelial cells, which could be further explored as a possible predictor for HGP relying on sprouting angiogenesis.

CONCLUSION

These findings may prove to be novel therapeutic targets to the treatment of CRCLM, in special the ones relying on VCO.

Different Forms of Tumor Vascularization and Their Clinical Implications Focusing on Vessel Co-option in Colorectal Cancer Liver Metastases

In modern anti-cancer therapy of metastatic colorectal cancer (mCRC) the anti-angiogenic treatment targeting sprouting angiogenesis is firmly established for more than a decade. However, its clinical benefits still remain limited. As liver metastases (LM) represent the most common metastatic site of colorectal cancer and affect approximately one-quarter of the patients diagnosed with this malignancy, its treatment is an essential aspect for patients' prognosis. Especially in the perioperative setting, the application of anti-angiogenic drugs represents a therapeutic option that may be used in case of high-risk or borderline resectable colorectal cancer liver metastases (CRCLM) in order to achieve secondary resectability. Regarding CRCLM, one reason for the limitations of anti-angiogenic treatment may be represented by vessel co-option (VCO), which is an alternative mechanism of blood supply that differs fundamentally from the well-known sprouting angiogenesis and occurs in a significant fraction of CRCLM. In this scenario, tumor cells hijack pre-existing mature vessels of the host organ independently from stimulating new vessels formation. This represents an escape mechanism from common anti-angiogenic anti-cancer treatments, as they primarily target the main trigger of sprouting angiogenesis, the vascular endothelial growth factor A. Moreover, the mechanism of blood supply in CRCLM can be deduced from their phenotypic histopathological growth pattern (HGP). For that, a specific guideline has already been implemented. These HGP vary not only regarding their blood supply, but also concerning their tumor microenvironment (TME), as notable differences in immune cell infiltration and desmoplastic reaction surrounding the CRCLM can be observed. The latter actually serves as one of the central criteria for the classification of the HGP. Regarding the clinically relevant effects of the HGP, it is still a topic of research whether the VCO-subgroup of CRCLM results in an impaired treatment response to anti-angiogenic treatment when compared to an angiogenic subgroup. However, it is well-proved, that VCO in CRCLM generally relates to an inferior survival compared to the angiogenic subgroup. Altogether the different types of blood supply result in a relevant influence on the patients' prognosis. This reinforces the need of an extended understanding of the underlying mechanisms of VCO in CRCLM with the aim to generate more comprehensive approaches which can target tumor vessels alternatively or even other components of the TME. This review aims to augment the current state of knowledge on VCO in CRCLM and other tumor entities and its impact on anti-angiogenic anti-cancer therapy.

[Short Review of the History of Radiotherapy for Intraocular Tumours]

For many decades, radiotherapy with its different modalities has proved to be the gold standard in the treatment of benign and malignant intraocular tumours. The various complicated therapeutic developments in this field cover a period of over 100 years and the present year deserves special mention because of the 100th anniversary of the first mention of a successful brachytherapy for a uveal melanoma by R. Deutschmann in Hamburg in 1915.

Development of telehealth dialogues for monitoring suicidal patients with schizophrenia: consumer feedback

Suicide is a health concern among individuals with schizophrenia. A telehealth system for monitoring suicidal patients with schizophrenia was developed using the Health Buddy©. The existing dialogues were improved using an expert panel; the new dialogues were tested in 10 consumers with schizophrenia and a history of suicidal behavior. Using qualitative editing, several themes emerged: (1) Certain topics elicited strong emotional responses; (2) There were concerns with confidentiality; (3) Some content was too vague and (4) There were problems with vocabulary and wording. The process yielded information for improving the intervention and demonstrated that the approach is feasible in this population.

An interpretation procedure for the purpose of incorporation monitoring during decommissioning of nuclear reactors

The incorporation monitoring during decommissioning of nuclear reactors is faced with a complex situation arising from a mixture of radionuclides. The development of an interpretation procedure to enable the application of an optimised incorporation monitoring on conditions of decommissioning of nuclear reactors has been carried out combining results from radionuclide analyses of contaminated or activated materials and the proven methods of incorporation monitoring in the case of the intake of single radionuclides. In this study the radiological requirements, the mathematical elements of the interpretation procedure are presented as well as the application to an activated concrete of biological shielding.

Persistence in patients with breast cancer treated with tamoxifen or aromatase inhibitors: a retrospective database analysis

Compliance and persistence are often underestimated in breast cancer (BC) treatment. The aim of our study was to analyze the persistence with tamoxifen (TAM) and aromatase inhibitors (AI) in postmenopausal women with hormone-receptor-positive BC and to identify determinants of non-persistence. We used data of the Disease Analyzer database (IMS HEALTH, Germany) including 2,067 general practices and 397 gynecological practices. Out of a dataset of 15 million patients, we identified BC patients with a first-time TAM or AI prescriptions from October 2001 to December 2010. For persistence analyses, 12,412 women on tamoxifen, 2,796 on anastrozole, 647 on exemestane, and 1,657 on letrozole met the inclusion/exclusion criteria. Within 3 years of follow-up, the discontinuation rates increased to 52.2 % for tamoxifen, 47 % for anastrozole, 55.1 % for exemestane, and 44.3 % for letrozole treated women. A minor proportion of patients switched to a different endocrine treatment; 33 % tamoxifen, 20 % anastrozole, 22.9 % exemestane, and 23 % letrozole. The multivariate hazard ratios of the cox regression models showed that patients younger than 50 were most likely to discontinue initial therapy when compared with the reference group of women over 70 (p < 0.001). In contrast, patients treated in gynecologist practice had significantly longer persistence than patients who obtained their prescriptions in general practitioner practice (p < 0.001). In addition, the presence of the co morbidities like diabetes (p < 0.001) or depression (p < 0.002) was also associated with decreased risk of treatment discontinuation. Persistence with all endocrine treatments in women with hormone-receptor-positive BC is low and needs to be significantly increased to improved outcome in clinical practice. Further research is required to understand this complex issue.

Exploring aboriginal views of health using fuzzy cognitive maps and transitive closure. A case study of the determinants of diabetes

OBJECTIVES

To demonstrate how fuzzy cognitive maps may be used to extract, present and compare Aboriginal perspectives, using the determinants of diabetes as a case study.

METHODS

Participants from the Mohawk Community of Akwesasne and the Miawpukek First Nation in Conne River created fuzzy cognitive maps (FCMs) (N=3) detailing their views of "the causes of diabetes in their community", through a facilitated, group mapping session. For each FCM, the net causal effect of every determinant (direct or indirect) on diabetes was calculated from its transitive closure. The net causal effects were then compared across the set of FCMs to identify strong, weak and controversial determinants.

RESULTS

Comparison of FCMs revealed significant heterogeneity in the perspectives of diabetes. The Akwesasne participants focused heavily on social, traditional and spiritual factors, while Conne River participants placed more importance on direct personal and lifestyle factors. There was, however, a core of strong, validated determinants related primarily to healthy diet and physical activity.

CONCLUSIONS

This work demonstrates how FCM may be used to extract and represent different perspectives of complex issues allowing for comparisons among stakeholders or knowledge groups. Comparison of multiple FCM employing the transitive closure may then be used to identify areas of agreement and controversy.

High performances, temperature resistant and stable OLED structures

In the present work, a particular emphasis is put on the stability of the OLED devices obtained as well as on their ability to keep their good initial performances even in a severe environment. Moreover, the operation voltage of these devices turns out to be rather low.

Relationship between high weight and caries frequency in German elementary school children

OBJECTIVE

Most industrialized countries experienced a change in dietary habits within the last 10 years. Growing obesity may result in an increased incidence of metabolic diseases as well as in a higher caries frequency.

METHODS

In an interdisciplinary study, 842 elementary school children (414 girls and 428 boys, age: 6-11 years; elementary grades 1-4) we examined. The dental examination included the determination of caries frequency (DF-T-/ df-t-values) and the medical evaluation assessed the pupils general health (i.e. the height and body weight; body mass index).

RESULTS

The study showed that 33.7% of all school children had no decayed or filled teeth (38% of the girls, 30% of the boys). 73.9% of all pupils were within the normal weight range (74.3% of the boys, 73.4% of the girls), 12.9% of the children were overweight (12.4% of the boys, 13.5% of the girls), and 13.2% were even obese (13.3% of the boys, 13% of the girls). 35.5% of the pupils with normal weight had healthy teeth, whereas the number dropped to 27.5% in children that were overweight, and to 29.7% in the obese children. The caries prevalence (DF-T-, df-t-values) also showed a significant association to weight (Fisher-Test, p = 0.022 for df-t-distribution and p = 0.011 for DF-T-distributions). Children with normal weight were found to have average df-t-values of 2.09 (DF-T: 0.57), overweight children an average df-t-value of 2.48 (DF-T-value: 0.91), and obese children showed 3.3 (DF-T.value:0.88).

CONCLUSIONS

Since this study showed an association between an increase of dental caries and high weight in elementary school children, the importance of nutrition with respect to high weight should be considered in future preventive programs, in addition to oral hygiene measures.

Safety and immunogenicity of live recombinant Salmonella enterica serovar Typhi Ty21a expressing urease A and B from Helicobacter pylori in human volunteers

Helicobacter pylori urease was expressed in the common live typhoid vaccine Ty21a yielding Ty21a(pDB1). Nine volunteers received Ty21a(pDB1) and three control volunteers received Ty21a. No serious adverse effects were observed in any of the volunteers. Ten out of 12 volunteers developed humoral immune responses to the Salmonella carrier as detected by antigen-specific antibody-secreting cells but only two volunteers seroconverted. A total of five volunteers showed responses in one or two out of three assays for cellular responses to the carrier (proliferation, IFN-gamma-secretion, IFN-gamma-ELISPOT). Three of the volunteers that had received Ty21a(pDB1) showed a weak but significant T-cell response to Helicobacter urease, while no volunteer had detectable humoral responses to urease. Ty21a(pDB1) is a suitable prototype to optimize Salmonella-based vaccination for efficient cellular responses that could mediate protective immunity against Helicobacter.

The chemical composition of African haze

The LAMMA technique (Laser Microprobe Mass Analyzer) is a valuable and powerful technique for the analysis and characterization of particulate air pollutants. At seven sites in Zimbabwe, Africa, dust particles were collected and 200 single particles were analyzed for each sampling point. The main chemical species present in the particles are Na+, K+, Cl, NO3+ and SO4(2-). Beside these, soot particles, containing carcinogenic polynuclear aromatic hydrocarbons were found. Biomass burning was identified as the major source of the dust particles what is in accordance with the assumed air quality for our sampling period.

Sleep EEG changes in psychotic disorders: gender and age effects

The aim of this study was to examine gender-related differences in electroencephalographic (EEG) sleep in inpatients with psychotic disorders. We investigated the effects of gender and age as well as gender-by-age interactions on sleep continuity, architecture and intranight distributions in 38 male and 23 female patients with functional psychoses. No gender effects were seen for any sleep parameters. However, older psychotic males had less slow-wave sleep than older psychotic females. On the other hand, female psychotic patients showed a significant decline in automated REM counts with age. It is possible that gender-related differences in neurodevelopment and/or aging could account for these findings.

Cardiac exercise hemodynamics late after partial left ventriculectomy

BACKGROUND

Although some patients report favorable activity levels late after partial left ventriculectomy (PLV), their exercise physiology has not been well described.

METHODS AND RESULTS

We performed upright bicycle hemodynamics in 10 patients (9 men) aged 56+/-12 years at 1.7 years after PLV. Ejection fraction was 25+/-4%. Patients biked 10+/-7 minutes. With exercise, the mean pulmonary arterial pressure rose from 36+/-12 to 52+/-10 mm Hg (P:=0.0003). The mean pulmonary capillary wedge pressure rose from 25+/-14 to 36+/-9 mm Hg (P:=0.0566), and the cardiac index rose from 2.2+/-0.5 to 3.8+/-1.6 L. min(-1). m(-2) (P:=0.0077). The mixed venous oxygenation with exercise declined from 44+/-9% to 24+/-17% (P:=0. 0220), and the pulmonary vascular resistance increased from 2.0+/-0. 9 to 2.3+/-1.1 Wood units (P:=0.5566).

CONCLUSIONS

In late follow-up after PLV with exercise, the cardiac index is significantly augmented. However, there are further rises in pulmonary artery and pulmonary capillary wedge pressures, suggesting abnormal compliance, with marked decline in mixed venous oxygenation. Elucidating late physiology after PLV may help pave the way for future innovative heart failure surgeries.

Immunogenicity of mutations induced by nucleoside reverse transcriptase inhibitors for human immunodeficiency virus type 1-specific cytotoxic T cells

The impact of drug resistance mutations induced by nucleoside reverse transcriptase (RT) inhibitors (NRTI) on cytotoxic T-lymphocyte (CTL) recognition of human immunodeficiency virus type 1 strain LAI (HIV-1(LAI)) RT was addressed in 35 treated or untreated patients. Two HIV-1(LAI) RT regions encompassing mutation M41L, L74V, M184V, and T215Y/F were recognized in 75 and 83% mutated and in 33 and 42% unmutated samples, respectively. A total of 41 new CTL epitopes overlapping these mutations were predicted. Mutations enhanced HLA-binding scores of 17 epitopes, decreased scores of 5, and had no effect in 19. Four predicted epitopes containing mutations 41, 74, and 184 were tested and recognized by CD8 cells from mutated or unmutated samples, with frequencies up to 270 gamma interferon spot-forming cells per 10(6) peripheral blood mononuclear cells. Therefore, RT mutations induced by NRTI can increase the immunogenicity of RT for CTL and might allow a better immune control of resistant viruses in vivo, suggesting that specific immune therapy might help prevent these mutations.

Significant post-transplant hypogammaglobulinemia in six heart transplant recipients: an emerging clinical phenomenon?

BACKGROUND

The recent development of powerful agents such as mycophenolate mofetil and tacrolimus has altered current regimens for the prevention and treatment of allograft rejection. Questions have been raised about these newer regimens in terms of susceptibility to opportunistic infections and effects on host defenses. Severe hypogammaglobulinemia has been infrequently described in solid organ transplant recipients, but has been recently noted in six heart transplant recipients at one center, of whom five were receiving a combination of tacrolimus, mycophenolate mofetil, and prednisone.

METHODS

Case summaries of six recent heart transplant recipients with total immunoglobulin G (IgG) levels of less than 310 mg/dl, five of whom had cytomegalovirus (CMV) infection and three of whom had multiple infections including Nocardia, invasive Trichophyton, and Acinetobacter bacteremia. Previous literature was reviewed with the aid of a Medline search using the search terms hypogammaglobulinemia; kidney, liver, heart, lung, and organ transplantation; mycophenolate mofetil; tacrolimus; cyclosporine; azathioprine; and nocardiosis.

RESULTS

We here report six cardiac transplant recipients seen over a period of one year who were found to have immunoglobulin G levels of 310 mg/dl or below (normal: 717-1400 mg/dl). The first five patients were diagnosed because of evaluation for infections; the sixth, who was asymptomatic with an IgG level of 175, was found during screening for hypogammaglobulinemia instituted as a result of these first five patients. All six patients had received steroid pulses for rejection; all received mycophenolate mofetil; and 5/6 had been switched from cyclosporine to tacrolimus because of steroid-resistant rejection. Transient neutropenia (absolute neutrophil count less than 1000) was observed in 2/6; 3/6 had received OKT3 therapy for refractory rejection. These six patients were treated with a combination of antimicrobials, immunoglobulin replacement, and decrease in immunosuppressive therapy.

CONCLUSION

The finding of unexpected hypogammaglobulinemia and concomitant infectious complications in six heart transplant recipients highlights a possible complication in a subset of patients receiving newer immunosuppressive agents. A larger prospective study is underway to determine risk factors for development of post-transplant hypogammaglobulinemia and to assess pre-transplant immune status of these recipients. Monitoring of immunoglobulin levels in high-risk patients receiving intensified immunosuppressive therapy for rejection may help to prevent infectious complications.

Comparative proteome analysis of Helicobacter pylori

Helicobacter pylori, the causative agent of gastritis, ulcer and stomach carcinoma, infects approximately half of the worlds population. After sequencing the complete genome of two strains, 26695 and J99, we have approached the demanding task of investigating the functional part of the genetic information containing macromolecules, the proteome. The proteins of three strains of H. pylori, 26695 and J99, and a prominent strain used in animal models SS1, were separated by a high-resolution two-dimensional electrophoresis technique with a resolution power of 5000 protein spots. Up to 1800 protein species were separated from H. pylori which had been cultivated for 5 days on agar plates. Using matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS) peptide mass fingerprinting we have identified 152 proteins, including nine known virulence factors and 28 antigens. The three strains investigated had only a few protein spots in common. We observe that proteins with an amino acid exchange resulting in a net change of only one charge are shifted in the two-dimensional electrophoresis (2-DE) pattern. The expression of 27 predicted conserved hypothetical open reading frames (ORFs) and six unknown ORFs were confirmed. The growth conditions of the bacteria were shown to have an effect on the presence of certain proteins. A preliminary immunoblotting study using human sera revealed that this approach is ideal for identifying proteins of diagnostic or therapeutic value. H. pylori 2-DE patterns with their identified protein species were added to the dynamic 2D-PAGE database (http://www.mpiib-berlin.mpg.de/2D-PAGE/). This basic knowledge of the proteome in the public domain will be an effective instrument for the identification of new virulence or pathogenic factors, and antigens of potentially diagnostic or curative value against H. pylori.