Early detection of inflammation-prone STEMI patients using the CRP Troponin Test (CTT)

Background

Elevated concentrations of C-reactive protein (CRP) early after acute coronary syndrome (ACS) may reflect the magnitude of the inflammatory response to myocardial damage and are associated with worse outcome. However, the routine measurement of both CRP and cardiac troponin simultaneously in the setting of ST segment myocardial infarction (STEMI) is not used broadly. Here, we sought to identify and characterize individuals who are prone to an elevated inflammatory response following STEMI using the CRP Troponin test (CTT) and determine their short- and long-term outcome.

Material and methods

We retrospectively examined 1,186 patients with the diagnosis of acute STEMI, who had at least two successive measurements of combined CRP and cardiac troponin (up to 6 hours apart), all within the first 48 hours of admission. We used Chi-Square Automatic Interaction Detector (CHAID) tree analysis to determine which parameters, timing (baseline vs. serial measurements), and cut-offs should be used to predict mortality.

Results

Patients with high CRP concentrations (above 90th percentile, >33mg/L) had higher 30 day- and all-cause mortality rates regardless of their troponin test status (above or below 118,000 ng/L); 14.4% vs 2.7%, p<0.01. Furthermore, patients with both high CRP and high Troponin levels on their second measurement had the highest 30-day mortality rates compared to the rest of the cohort; 21.4% vs. 3.7%, p<0.01. These patients also had the highest all-cause mortality rates after a median follow up of 4.5 years compared to the rest of the cohort; 42.9% vs 12.7%, p<0.01 (Figure 1).

Conclusions

In conclusion, serial measurements of both CRP and cardiac troponin might detect patients at increased risk for short-and long-term mortality following STEMI. We suggest the future use of the combined CRP Troponin-test (CTT) as a potential early marker for inflammatory-prone patients with worse outcomes following ACS. This sub-type of patients might benefit from early anti-inflammatory therapy such as colchicine and anti-IL-1β agents.

Funding Acknowledgement

Type of funding sources: None.

A model to predict difficult airway alerts after videolaryngoscopy in adults with anticipated difficult airways - the VIDIAC score

A model to classify the difficulty of videolaryngoscopic tracheal intubation has yet to be established. The videolaryngoscopic intubation and difficult airway classification (VIDIAC) study aimed to develop one based on variables associated with difficult videolaryngoscopic tracheal intubation. We studied 374 videolaryngoscopic tracheal intubations in 320 adults scheduled for ear, nose and throat or oral and maxillofacial surgery, for whom airway management was expected to be difficult. The primary outcome was whether an anaesthetist issued a 'difficult airway alert' after videolaryngoscopy. An alert was issued after 183 (49%) intubations. Random forest and lasso regression analysis selected six intubation-related variables associated with issuing an alert: impaired epiglottic movement; increased lifting force; direct epiglottic lifting; vocal cords clearly visible; vocal cords not visible; and enlarged arytenoids. Internal validation was performed by a 10-fold cross-validation, repeated 20 times. The mean (SD or 95%CI) area under the receiver operating characteristic curve was 0.92 (0.05) for the cross validated coefficient model and 0.92 (0.89-0.95) for a simplified unitary score (VIDIAC score with component values of -1 or 1 only). The calibration belt for the coefficient model was consistent with observed alert probabilities, from 0% to 100%, while the unitary VIDIAC score overestimated probabilities < 20% and underestimated probabilities > 70%. Discrimination of the VIDIAC score for patients more or less likely to be issued an alert was better than discrimination by the Cormack-Lehane classification, with mean (95%CI) areas under the receiver operating characteristic curve of 0.92 (0.89-0.95) vs. 0.75 (0.70-0.80), respectively, p < 0.001. Our model and score can be used to calculate the probabilities of difficult airway alerts after videolaryngoscopy.

A core outcome set for pre-eclampsia research: an international consensus development study

OBJECTIVE

To develop a core outcome set for pre-eclampsia.

DESIGN

Consensus development study.

SETTING

International.

POPULATION

Two hundred and eight-one healthcare professionals, 41 researchers and 110 patients, representing 56 countries, participated.

METHODS

Modified Delphi method and Modified Nominal Group Technique.

RESULTS

A long-list of 116 potential core outcomes was developed by combining the outcomes reported in 79 pre-eclampsia trials with those derived from thematic analysis of 30 in-depth interviews of women with lived experience of pre-eclampsia. Forty-seven consensus outcomes were identified from the Delphi process following which 14 maternal and eight offspring core outcomes were agreed at the consensus development meeting. Maternal core outcomes: death, eclampsia, stroke, cortical blindness, retinal detachment, pulmonary oedema, acute kidney injury, liver haematoma or rupture, abruption, postpartum haemorrhage, raised liver enzymes, low platelets, admission to intensive care required, and intubation and ventilation. Offspring core outcomes: stillbirth, gestational age at delivery, birthweight, small-for-gestational-age, neonatal mortality, seizures, admission to neonatal unit required and respiratory support.

CONCLUSIONS

The core outcome set for pre-eclampsia should underpin future randomised trials and systematic reviews. Such implementation should ensure that future research holds the necessary reach and relevance to inform clinical practice, enhance women's care and improve the outcomes of pregnant women and their babies.

TWEETABLE ABSTRACT

281 healthcare professionals, 41 researchers and 110 women have developed #preeclampsia core outcomes @HOPEoutcomes @jamesmnduffy. [Correction added on 29 June 2020, after first online publication: the order has been corrected.].

Malignant Extrarenal Rhabdoid Tumor in a 5-Month-Old Male With Mediastinal and Heart/Great Vessel Involvement

Introduction/Objective

Extrarenal rhabdoid tumor is a high-grade soft-tissue predominately pediatric malignancy with a frequency of 0.15 per million children less than 15 years. It is associated with del(22) (q11.2) with SMARCB1 loss, recognized by loss of INI-1 staining. It has distinct perinuclear hyaline inclusions; however, this feature can be present in other tumors. We describe a malignant extrarenal rhabdoid tumor involving the heart and great vessels to highlight the multiple modalities required for the diagnosis of this tumor in this unusual location.

Methods

We utilized routine histology, immunohistochemistry, and electron microscopy.

Results

This 5 -month -old male presented with respiratory distress due to a mass that invaded the heart, surrounding the great vessels. The tumor was composed of sheets of polygonal large cells with light pink to clear cytoplasm, eccentric nuclei with mild anisonucleosis, peripherally marginating chromatin, prominent nucleoli, with 2 mitoses per 10 high power field. Hyaline perinuclear inclusions were inapparent. There were frequent clusters of lymphocytes and eosinophils, with 10 percent necrosis and moderately increased vascularity. The tumor was positive for vimentin, SMA, EMA, MSA, S-100, keratin, and WT1, and negative for INI-1, CD34, ALK, AFP, PLAP, CD30, myogenin, NeuN1, synaptophysin, chromogranin, and NSE. Electron microscopy demonstrated occasional cells with perinuclear collections of intermediate filaments, some with whorls. The strong positivity for vimentin, keratin, SMA, MSA, S-100, negative staining for INA-1 and CD34, and visualization of perinuclear intermediate filament whorls by electron microscopy helped make the diagnosis of extrarenal rhabdoid tumor.

Conclusion

Malignant extrarenal rhabdomyosarcomas may occur in the middle mediastinum, invade the heart, occur in the first 6 months of life, and not have the typical rhabdoid cells. Diagnoses depend on multiple modalities

Does episiotomy always equate violence in obstetrics? Routine and selective episiotomy in obstetric practice and legal questions

OBJECTIVE

The study's main goal is to figure out whether episiotomy, a widely applied invasive procedure, may constitute a determining factor of liability for practitioners according to the standards of obstetric violence.

MATERIALS AND METHODS

The authors have aimed to analyze laws and documentation issued on the matter by sovereign states, statements and remarks from International health organizations, in addition to scientific article available on the main search engines (PubMed, Scopus, Google Scholar) and legal databases (Lexis, Justia).

RESULTS

The body of research has highlighted the existence of a wide-ranging agreement as to routine episiotomy, deemed to be a scientifically unfounded procedure, and which should, therefore, be avoided. By virtue of that, routine episiotomy might easily give rise to charges and liability for doctors and midwives alike; likewise to claims may stem from a failure to perform an episiotomy when it was actually needed.

CONCLUSIONS

Unlike routine episiotomy, selective episiotomy is far more unlikely to cause charges of obstetric violence against operators. Unfortunately, the criteria in order to establish when a selective episiotomy is indicated are far from consistent and would require an additional effort on the part of scientific societies towards a more clearly defined and shared description.

Role of proton-coupled folate transporter in pemetrexed resistance of mesothelioma: clinical evidence and new pharmacological tools

BACKGROUND

Thymidylate synthase (TS) has a predictive role in pemetrexed treatment of mesothelioma; however, additional chemoresistance mechanisms are poorly understood. Here, we explored the role of the reduced-folate carrier (RFC/SLC19A1) and proton-coupled folate transporter (PCFT/SLC46A1) in antifolate resistance in mesothelioma.

PATIENTS AND METHODS

PCFT, RFC and TS RNA and PCFT protein levels were determined by quantitative RT-PCR of frozen tissues and immunohistochemistry of tissue-microarrays, respectively, in two cohorts of pemetrexed-treated patients. Data were analyzed by t-test, Fisher's/log-rank test and Cox proportional models. The contribution of PCFT expression and PCFT-promoter methylation to pemetrexed activity were evaluated in mesothelioma cells and spheroids, through 5-aza-2'-deoxycytidine-mediated demethylation and siRNA-knockdown.

RESULTS

Pemetrexed-treated patients with low PCFT had significantly lower rates of disease control, and shorter overall survival (OS), in both the test (N = 73, 11.3 versus 20.1 months, P = 0.01) and validation (N = 51, 12.6 versus 30.3 months, P = 0.02) cohorts. Multivariate analysis confirmed PCFT-independent prognostic role. Low-PCFT protein levels were also associated with shorter OS. Patients with both low-PCFT and high-TS levels had the worst prognosis (OS, 5.5 months), whereas associations were neither found for RFC nor in pemetrexed-untreated patients. PCFT silencing reduced pemetrexed sensitivity, whereas 5-aza-2'-deoxycytidine overcame resistance.

CONCLUSIONS

These findings identify for the first time PCFT as a novel mesothelioma prognostic biomarker, prompting prospective trials for its validation. Moreover, preclinical data suggest that targeting PCFT-promoter methylation might eradicate pemetrexed-resistant cells characterized by low-PCFT expression.

High-frame rate imaging of two-phase flow in a thin rectangular channel using fast neutrons

We have demonstrated the feasibility of performing high-frame-rate, fast neutron radiography of air-water two-phase flows in a thin channel with rectangular cross section. The experiments have been carried out at the accelerator facility of the Physikalisch-Technische Bundesanstalt. A polychromatic, high-intensity fast neutron beam with average energy of 6 MeV was produced by 11.5 MeV deuterons hitting a thick Be target. Image sequences down to 10 ms exposure times were obtained using a fast-neutron imaging detector developed in the context of fast-neutron resonance imaging. Different two-phase flow regimes such as bubbly slug and churn flows have been examined. Two phase flow parameters like the volumetric gas fraction, bubble size and mean bubble velocities have been measured. The first results are promising, improvements for future experiments are also discussed.

Severe hypoxia induces complete antifolate resistance in carcinoma cells due to cell cycle arrest

Antifolates have a crucial role in the treatment of various cancers by inhibiting key enzymes in purine and thymidylate biosynthesis. However, the frequent emergence of inherent and acquired antifolate resistance in solid tumors calls for the development of novel therapeutic strategies to overcome this chemoresistance. The core of solid tumors is highly hypoxic due to poor blood circulation, and this hypoxia is considered to be a major contributor to drug resistance. However, the cytotoxic activity of antifolates under hypoxia is poorly characterized. Here we show that under severe hypoxia, gene expression of ubiquitously expressed key enzymes and transporters in folate metabolism and nucleoside homeostasis is downregulated. We further demonstrate that carcinoma cells become completely refractory, even at sub-millimolar concentrations, to all hydrophilic and lipophilic antifolates tested. Moreover, tumor cells retained sensitivity to the proteasome inhibitor bortezomib and the topoisomerase II inhibitor doxorubicin, which are independent of cell cycle. We provide evidence that this antifolate resistance, associated with repression of folate metabolism, is a result of the inability of antifolates to induce DNA damage under hypoxia, and is attributable to a hypoxia-induced cell cycle arrest, rather than a general anti-apoptotic mechanism. Our findings suggest that solid tumors harboring a hypoxic core of cell cycle-arrested cells may display antifolate resistance while retaining sensitivity to the chemotherapeutics bortezomib and doxorubicin. This study bears important implications for the molecular basis underlying antifolate resistance under hypoxia and its rational overcoming in solid tumors.

Massive conformational changes during thermally induced self-metalation of 2H-tetrakis-(3,5-di-tert-butyl)-phenylporphyrin on Cu(111)

2HTTBPP on Cu(111) behaves almost like a loaded spring which is held by the strong attractive interactions of the iminic nitrogens with the Cu substrate and is released upon metalation.

Caesarean section in the world: a new ecological approach

INTRODUCTION

This study aimed to estimate the most recent caesarean section rates in the world and examine the association between these rates and old and new indicators of health care.

METHODS

Authors analyzed the Caesarean Section (CS) rates, also in geo-economic and economic groups, and correlated them to maternal and neonatal mortality, to births attended by skilled health personnel and to births among adolescents. Analysis of covariance and piecewise regressions were used for the statistical analysis.

RESULTS

In 47.2% of the countries, the CS rate exceeded 15%. Countries of Latin America and the Caribbean along with Europe, North America and Oceania had the highest values. The analysis showed an inverse association between CS rates and Maternal Mortality (MMR) and Neonatal Mortality (NMR) for all geographical areas except for Europe. The greatest association was observed in lower-middle-income countries. In developing countries only 50% of cases, occur in medical facilities and only half of these are seen by medical, nursing and obstetrical staff. Age of the mother appears to influence the outcome and choice of delivery type. Countries where an high ABR rate is present have low CS use.

CONCLUSIONS

To best evaluate the consequences of the increasing rate of CS, it would be useful to identify the most sensitive outcome indicators.

Surgical technique to avoid bladder flap formation during cesarean section

Cesarean section (CS) is now the most common major surgical procedure performed on women worldwide. A CS can be performed by either suturing or not suturing of the visceral peritoneum. Creation of the bladder flap is an integral step of the standard cesarean section. The bladder flap is made by superficially incising and dissecting the peritoneal lining to separate the urinary bladder from the lower uterine segment. It's still debated whether the formation of bladder flap is advantageous or not. If the uterine incision is made slightly above the vesicouterine peritoneal fold, the loose connective tissue between the uterus and the urinary bladder allows spontaneous descent of the bladder. Evidence on the role of the bladder flap in cesarean section is very limited. At present, it remains to be established whether there is any advantage in dissecting the bladder from the lower uterine segment during cesarean section.

Surface science and model catalysis with ionic liquid-modified materials

Materials making use of thin ionic liquid (IL) films as support-modifying functional layer open up a variety of new possibilities in heterogeneous catalysis, which range from the tailoring of gas-surface interactions to the immobilization of molecularly defined reactive sites. The present report reviews recent progress towards an understanding of "supported ionic liquid phase (SILP)" and "solid catalysts with ionic liquid layer (SCILL)" materials at the microscopic level, using a surface science and model catalysis type of approach. Thin film IL systems can be prepared not only ex-situ, but also in-situ under ultrahigh vacuum (UHV) conditions using atomically well-defined surfaces as substrates, for example by physical vapor deposition (PVD). Due to their low vapor pressure, these systems can be studied in UHV using the full spectrum of surface science techniques. We discuss general strategies and considerations of this approach and exemplify the information available from complementary methods, specifically photoelectron spectroscopy and surface vibrational spectroscopy.

Intrapartum sonography head transverse and asynclitic diagnosis with and without epidural analgesia initiated early during the first stage of labor

PURPOSE

To investigate if early epidural analgesia can influence fetal head engagement into the pelvis and if it can increase the rate of transverse and asynclitic position during labour.

MATERIALS AND METHODS

195 women with combined spinal-epidural analgesia (CSE) or without neuraxial analgesia were studied. CSE was performed using a mixture of ropivacaine 0.02% with 0.3 microg/ml of sufentanil administered in the spinal space. Maintenance of analgesia was managed with intermittent epidural administration of 10-15 ml of ropivacaine (0.07%-0.10%) mixed with 0.5 microg/ml of sufentanil, based on the stage of labour and the degree of pain. 2D transabdominal ultrasound (US) was used. Serial transabdominal US examinations were performed at 45-90 min intervals to detect transverse and asynclitic positions, using the following signs: squint sign, sunset thalamus and cerebellum signs that best details the fetal head station. After delivery, the complete set of clinical and US data obtained by each examination were recorded and compared in women with and without labour analgesia. Data were examined by independent reviewers.

RESULTS

There was no difference in obstetric outcome between women in whom CSE had been used and those who did not request analgesia during labour (p > 0.05).

CONCLUSIONS

Epidural analgesia initiated early during labour and using low doses does not increase the rate of dystocic labors. Transverse fetal head positioning with anterior or posterior asynclitism does not seem to be promoted by drug or technique-related mechanisms, but rather should be the consequence of cephalopelvic disproportion.

Liquid/solid interface of ultrathin ionic liquid films: [C1C1Im][Tf2N] and [C8C1Im][Tf2N] on Au(111)

Ultrathin films of two imidazolium-based ionic liquids (IL), [C(1)C(1)Im][Tf(2)N] (= 1,3-dimethylimidazolium bis(trifluoromethyl)imide) and [C(8)C(1)Im][Tf(2)N] (= 1-methyl-3-octylimidazolium bis(trifluoromethyl)imide) were prepared on a Au(111) single-crystal surface by physical vapor deposition in ultrahigh vacuum. The adsorption behavior, orientation, and growth were monitored via angle-resolved X-ray photoelectron spectroscopy (ARXPS). Coverage-dependent chemical shifts of the IL-derived core levels indicate that for both ILs the first layer is formed from anions and cations directly in contact with the Au surface in a checkerboard arrangement and that for [C(8)C(1)Im][Tf(2)N] a reorientation of the alkyl chain with increasing coverage is found. For both ILs, geometry models of the first adsorption layer are proposed. For higher coverages, both ILs grow in a layer-by-layer fashion up to thicknesses of at least 9 nm (>10 ML). Moreover, beam damage effects are discussed, which are mainly related to the decomposition of [Tf(2)N](-) anions directly adsorbed at the gold surface.

Association of MC1R variants and host phenotypes with melanoma risk in CDKN2A mutation carriers: a GenoMEL study

Background

Carrying the cyclin-dependent kinase inhibitor 2A (CDKN2A) germline mutations is associated with a high risk for melanoma. Penetrance of CDKN2A mutations is modified by pigmentation characteristics, nevus phenotypes, and some variants of the melanocortin-1 receptor gene (MC1R), which is known to have a role in the pigmentation process. However, investigation of the associations of both MC1R variants and host phenotypes with melanoma risk has been limited.

Methods

We included 815 CDKN2A mutation carriers (473 affected, and 342 unaffected, with melanoma) from 186 families from 15 centers in Europe, North America, and Australia who participated in the Melanoma Genetics Consortium. In this family-based study, we assessed the associations of the four most frequent MC1R variants (V60L, V92M, R151C, and R160W) and the number of variants (1, ≥2 variants), alone or jointly with the host phenotypes (hair color, propensity to sunburn, and number of nevi), with melanoma risk in CDKN2A mutation carriers. These associations were estimated and tested using generalized estimating equations. All statistical tests were two-sided.

Results

Carrying any one of the four most frequent MC1R variants (V60L, V92M, R151C, R160W) in CDKN2A mutation carriers was associated with a statistically significantly increased risk for melanoma across all continents (1.24 × 10⁻⁶ ≤ P ≤ .0007). A consistent pattern of increase in melanoma risk was also associated with increase in number of MC1R variants. The risk of melanoma associated with at least two MC1R variants was 2.6-fold higher than the risk associated with only one variant (odds ratio = 5.83 [95% confidence interval = 3.60 to 9.46] vs 2.25 [95% confidence interval = 1.44 to 3.52]; P_trend = 1.86 × 10⁻⁸). The joint analysis of MC1R variants and host phenotypes showed statistically significant associations of melanoma risk, together with MC1R variants (.0001 ≤ P ≤ .04), hair color (.006 ≤ P ≤ .06), and number of nevi (6.9 × 10⁻⁶ ≤ P ≤ .02).

Conclusion

Results show that MC1R variants, hair color, and number of nevi were jointly associated with melanoma risk in CDKN2A mutation carriers. This joint association may have important consequences for risk assessments in familial settings.

Intrapartum sonography for occiput posterior detection in early low dose combined spinal epidural analgesia by sufentanil and ropivacaine

AIM

To evaluate the incidence of occiput posterior position in labour with and without combined spinal epidural analgesia (CSE) by low dose of sufentanyl and ropivacaine.

MATERIAL AND METHODS

This study focused on 132 women subdivided in two groups, patients in spontaneous and in labour analgesia, administered by a low dose CSE by sufentanyl and ropivacaine; all women were evaluated by digital examinations and ultrasound till delivery. All data were collected and analyzed by an independent reviewer.

RESULTS

In the second stage, 79 were persistent occiput posterior position (POPP) fetuses and 36 were translated from anterior to posterior position (TAPP) fetuses. Specifically, in spontaneous labour on 25 women in anterior position, there were 17 TAPP and in CSE analgesia on 28 women in anterior, there were 19 in TAPP, without significant differences. The number of asynclitisms was higher in the POPP group (84%) respect to the TAPP group (75%), so as the rate of caesarean section (67% versus 52.7%).

CONCLUSIONS

The labour with low dose of ropivacaine and sufentanyl does not increase the occiput posterior position during fetal descent, leading to a POPP. Finally, since in the occiput anterior presentation labour analgesia significantly lengthens time to delivery, in the occiput posterior position this is significantly increased, with a prolonged second stage of labour and reduced time of descent of fetal head in obstetric pelvis.

Low-dose sequential combined spinal-epidural anaesthesia in elective Stark caesarean section: a preliminary cohort study

AIM

To compare combined spinal-epidural anaesthesia (CSE) VS spinal anaesthesia (SA) in caesarean section (CS) performed by Stark method.

MATERIAL AND METHODS

200 women were prospectively studied before undergoing to a Stark CS in two groups: 95 patients were assigned to a local anaesthesia by SA (first group) and 105 women to CSE anaesthesia (second group). After a pre-load of 500 ml of plasma expander in both groups, SA was performed at the L1-L2 interspace with an injection of 5 ml of levobupivacaine 0.15%, with a 5 mcg of Sufentanil. The CSE was performed by a spinal-epidural injection at the L1-L2 interspace, primarily by 4 ml of levobupivacaine 0.125% and 5 mcg of Sufentanil, then by 3-7 mL of xilocaine carbonate 0.5% plus 1 mcg/ml of Sufentanil. Successively a CS by Stark method was performed in both groups. The recorded anaesthesiologic side effects in two groups were: motor block, intraoperative discomfort, vomiting, bradycardia and hypotension. Statistical evaluation was by Z-Test referred to the comparison of 2 portions with great, independent samples.

RESULTS

In the group with CSE anaesthesia, the prevalence of side effects was less than in the group treated with SA, where the prevalence of the motor block and intraoperative discomfort were greater and statistically significant (p<0.001); so as the vomiting and bradycardia were all in a major percentage in SA group, but only significant for hypotension (p<0.001).

CONCLUSIONS

These preliminary data show that the association between CS and CSE anaesthesia in elective CS by Stark method allow to have less intra and post-operative side effects; further studies need to provide specific details on the anaesthetic and surgical techniques, to tailor and optimize both in each patient to select for surgery.

High extracellular induced sputum haem oxygenase-1 in sarcoidosis and chronic beryllium disease

BACKGROUND

Sarcoidosis and chronic beryllium disease (CBD) are inflammatory conditions in which oxidative stress state may be crucial for disease outcome. This study compares haem oxygenase-1 (HO-1) extracellular activity for the first time in patients with sarcoidosis or CBD and in healthy controls.

MATERIALS AND METHODS

Induced sputum was recovered using a standard protocol. Pulmonary function tests (PFT) were performed by conventional methods. T lymphocyte subsets (CD4 and CD8) were measured by flow activated cell shorter (FACS). The HO-1 and nitrite levels were measured by a bilirubin-biliverdin reductase-dependent reaction and Greiss reaction respectively. Ferritin and iron levels were measured by enzymatic reaction and chemiluminometric immunoassay respectively.

RESULTS

The mean percentage of lymphocytes was significantly higher in the 36 sarcoid patients compared with that in the 17 controls (P=0.001). The mean CD4/CD8 ratio was significantly higher in the sarcoid and the 10 CBD patients compared to that in controls (P=0.000 and 0.002 respectively), as was the mean HO-1 activity (P=0.045 and 0.041 respectively). The HO-1 activity did not differ with the sarcoidosis stage. The HO-1 level and PFT parameters were negatively correlated. The differences in mean nitrite, ferritin and iron levels were non-significant between the three groups. The HO-1 and ferritin levels were correlated (P=0.008).

CONCLUSIONS

We succeeded in non-invasively measuring the activity of HO-1 from cells of airways in spite of its being an intracellular enzyme. The HO-1 levels in sarcoidosis and CBD were abnormally elevated.

Natural orifice surgery on thyroid gland: totally transoral video-assisted thyroidectomy (TOVAT): report of first experimental results of a new surgical method

BACKGROUND

Neck surgery is one of the newest fields of application of minimally invasive surgery. The technique of minimally invasive video-assisted thyroidectomy (MIVAT) developed by Miccoli [1] is the method that has so far become most widespread. Limiting factors of this method include the bothersome 20-mm cervical incision and consequently the specimen size to remove. Several papers describing an access outside the front neck region have been published. Such approaches are via the chest, axillary, a combined axillary bilateral breast, or a bilateral axillary breast approach [2-5]. The development of cervical scarless thyroid surgery is a great step toward better cosmetic outcomes. However, these techniques just moved the scars from the front neck region to the axilla or the chest where they are still visible. And the mentioned minimally invasive accesses as well as the conventional approaches to the thyroid gland do not respect the anatomically given surgical planes. This may result in complaints by the patients, e.g., scar development and swallowing disorders. Furthermore, the extracervical approaches do not comply with the use of the term "minimally invasive," because they are associated with an extensive dissection of the chest and neck region, thus being rather maximally invasive for the patients. The main goal of this project was the introduction of a technique of thyroid resection that fulfills the following criteria: (i. Respecting surgical planes and minimizing surgical trauma in thyroidectomy, ii. The access itself should be close to the thyroid gland to achieve a minimally invasive procedure, iii. Achieving an optimal cosmetic result may only be obtained by performing a scarless operation, iv. This optimal cosmetic result with scarless surgery should be achieved with minimal trauma, v. The minimally invasive character of this approach and the optimal cosmetic result may not be reached at the expense of patient's safety.). The technique that meets all of these criteria is the transoral access because the distance between the sublingual place and the thyroid gland is short, thus avoiding extensive dissection maneuvers. Furthermore, the mouth mucosa can be sutured without difficulties and repairs itself without leaving any visible scars. Feasibility of the transoral access has been recently demonstrated by a member of our group in a porcine model by using a modified axilloscope [6]. However, the described technique is a hybrid one because an additional medial access (3.5-mm incision) 15-mm below the larynx was necessary for the insertion of a fixation forceps through a trocar. The main goal of our project was the investigation and introduction of a technique of totally endoscopic thyroid resection that is minimally invasive and safe for the patient and at the same time cosmetically optimal (scarless).

METHODS

For this purpose, a total of five human cadavers were used. In three cadavers, safety and reproducibility to reach and resect the thyroid gland was assessed according to a defined road map. At the end of the procedure, the cadavers were dissected to evaluate all defined anatomical key structures regarding possible injuries and also allow an evaluation of the surgery performed. The TOVAT itself was performed on two more human cadavers with the help of one 5-mm and two 3-mm trocars that were introduced through the mouth floor and the vestibulum of the mouth subplatysmal. A working space was created by insufflating CO(2) at a pressure of 4-6 mmHg ("air dissection"). Surgical dissection of the further working space was realized with 3-mm bipolar scissors. The procedure consists of the following steps: (i. Patient in supine position and nasotracheal intubation, ii. 5-mm small incision between the carunculae sublinguales, iii. Penetration through the mouth floor along the superficial fascia colli with a blunt instrument, iv. Insertion of a 5-mm trocar, v. Blunt dissection subplatysmal by CO(2) insufflation ("air dissection"), vi. CO(2) insufflation (4-6 mmHg) and creation of a working space, vii. Insertion of two 3-mm trocars in the vestibulum oris on the right and left side, viii. Separation of the platysma from the strap muscles approximately at level of the larynx, extending up to the suprasternal notch. Laterally, this dissection can be continued up to the medial border of the sternocleidomastoid muscles, ix. Division of the linea alba coli and exposure of the strap muscles, x. Separation of the strap muscles from the thyroid gland, xi. Isthmus transection and blunt dissection of the thyroid gland from the trachea, xii. Dissection and division of the upper pole arteries and medial thyroid vein closely to the gland, xiii. Division of branches of the inferior thyroid artery closely to the gland, xiv. If necessary, preparation of the retro-thyroidal area, including visualization of the recurrent laryngeal nerve, xv. Thyroid resection from cranial to caudal and transoral removal of the specimen through the 5-mm midline incision. If the gland is too large, the midline incision can be extended longitudinally, xvi. All three incisions are closed with absorbable sutures.)

RESULTS

Description of landmarks of surgical steps and dissection of defined anatomic structures could be achieved. The subplatysmal space could be reached without any major problems within a short time. Anatomical dissection showed intact muscles and vascular structures. One-side subtotal thyroid resection could be successfully performed without any additional skin incision in 60 minutes.

CONCLUSIONS

The minimally invasive aspect and the scarless character of TOVAT form the rationale for the preclinical investigation of this method in human cadavers. We could succeed in defining objective parameters, which describe the procedure in details and also allow an evaluation of the surgery performed. Access and feasibility of TOVAT could be demonstrated. The next step will be its application in living pigs before it may be applied in humans. To our knowledge of the literature, this is the first report on NOS application in thyroid surgery and also the first totally and scarless performed video-assisted thyroidectomy.

036. SEX SPECIFIC FUNCTION OF THE HUMAN PLACENTA: IMPLICATIONS FOR FETAL GROWTH AND SURVIVAL

The placenta plays a central role in the development of the fetus by modulating the supply of nutrients and oxygen throughout pregnancy. We have identified that the placenta adapts to the presence of a maternal pathophysiology in a sexually dimorphic manner which results in differences in fetal growth. We have reported that the female fetus reduces her growth in response to chronic maternal asthma which ensures her survival in the presence of an acute asthma exacerbation. Conversely the male fetus continues to grow normally in the presence of maternal asthma but this is associated with a poor outcome in the presence of an acute exacerbation. We propose that the sexually dimorphic response of the fetus is derived from differences in placental adaptation to a pathophysiological condition. In the presence of a female fetus and maternal asthma, we have observed global gene changes in the placenta accompanied by significant alterations in microRNA expression. Downstream of these alterations we have observed differences in protein expression especially in relation to placental cytokines and the glucocorticoid receptor. In the presence of a male fetus there are fewer changes in global placental gene and microRNA expression, and we have observed no alterations in expression of placental cytokines or the glucocorticoid receptor. These differential adaptations ensure increased survival of the female fetus and continued growth of the male fetus in adverse conditions.

Rapid access to genes of biotechnologically useful enzymes by partial genome sequencing: the thermoalkaliphile Anaerobranca gottschalkii

Anaerobranca gottschalkii strain LBS3 T is an extremophile living at high temperature (up to 65 degrees C) and in alkaline environments (up to pH 10.5). An assembly of 696 DNA contigs representing about 96% of the 2.26-Mbp genome of A. gottschalkii has been generated with a low-sequence-coverage shotgun-sequencing strategy. The chosen sequencing strategy provided rapid and economical access to genes encoding key enzymes of the mono- and polysaccharide metabolism, without dilution of spare resources for extensive sequencing of genes lacking potential economical value. Five of these amylolytic enzymes of considerable commercial interest for biotechnological applications have been expressed and characterized in more detail after identification of their genes in the partial genome sequence: type I pullulanase, cyclodextrin glycosyltransferase (CGTase), two alpha-amylases (AmyA and AmyB), and an alpha-1,4-glucan-branching enzyme.

[The natural orifice surgery concept. Vision and rationale for a paradigm shift]

BACKGROUND

During the 20th Century, laparoscopic surgery achieved high standards and significantly reduced morbidity. In order to make surgery simpler and safer, a new concept, natural orifice surgery (NOS), has recently been introduced. The approach to the abdominal cavity may be transoral-transgastric, transvaginal-transdouglas or transanal-transrectal. This article describes the logic behind this approach and the expected challenges.

METHODS

In order to realize this goal, we founded the first European based working group on NOS. This group concentrates on the development of transdouglas procedures in women by using the transdouglas endoscopic device (TED). This is a wide, multi-channel instrument, which will enable surgery to be performed via a single entry.

RESULTS

Simulation of various intra-abdominal operations, such as staging, cholecystectomy, appendectomy, myomectomy und ovarectomy, using TED has already been carried out. Practical studies are planned in the near future.

CONCLUSION

The feasibility of NOS has been demonstrated in various experimental studies. We believe that this technique will create a spectrum of innovative and high quality operations and will improve patient safety.

Mutation of the tumour suppressor p33ING1b is rare in melanoma

BACKGROUND

The p33ING1b gene is involved in the p53-dependent response to DNA damage following exposure to ultraviolet radiation, and has recently been reported to be mutated in 20% of melanoma tumours.

OBJECTIVES

We sought to assess the p33ING1b mutation rate in our large panels of fresh melanomas and melanoma cell lines.

METHODS

We screened 83 primary melanomas and 55 melanoma cell lines for mutations in p33ING1b by single-strand conformational polymorphism analysis and by direct sequencing.

RESULTS

In contrast to previous reports, we found no somatic p33ING1b mutations in our panel of melanomas. We found that some of the discrepancy between our results and previously published studies may be due to inadvertent amplification of the ING1 pseudogene (INGX), and/or contamination of some samples with murine Ing1.

CONCLUSIONS

p33ING1b mutations in melanoma are rare. We have highlighted the importance of allele-specific primer design to avoid pseudogene amplification, and also the necessity to confirm the genetic identity and species of origin of individual cell lines. Further studies are needed to clarify the possible role of p33ING1b in melanoma tumorigenesis.

Chaos in dynamic atomic force microscopy

In tapping mode atomic force microscopy (AFM) the highly nonlinear tip-sample interaction gives rise to a complicated dynamics of the microcantilever. Apart from the well-known bistability under typical imaging conditions the system exhibits a complex dynamics at small average tip-sample distances, which are typical operation conditions for mechanical dynamic nanomanipulation. In order to investigate the dynamics at small average tip sample gaps experimental time series data are analysed employing nonlinear analysis tools and spectral analysis. The correlation dimension is computed together with a bifurcation diagram. By using statistical correlation measures such as the Kullback-Leibler distance, cross-correlation and mutual information the dataset can be segmented into different regimes. The analysis reveals period-3, period-2 and period-4 behaviour, as well as a weakly chaotic regime.

Activation of the MAPK pathway is a common event in uveal melanomas although it rarely occurs through mutation of BRAF or RAS

In contrast to cutaneous melanoma, there is no evidence that BRAF mutations are involved in the activation of the mitogen-activated protein kinase (MAPK) pathway in uveal melanoma, although there is increasing evidence that this pathway is activated frequently in the latter tumours. In this study, we performed mutation analysis of the RAS and BRAF genes in a panel of 11 uveal melanoma cell lines and 19 primary uveal melanoma tumours. In addition, Western blot and immunohistochemical analyses were performed on downstream members of the MAPK pathway in order to assess the contribution of each of these components. No mutations were found in any of the three RAS gene family members and only one cell line carried a BRAF mutation (V599E). Despite this, mitogen-activated protein kinase/extracellular signal-regulated kinase kinase (MEK), ERK and ELK were constitutively activated in all samples. These data suggest that activation of the MAPK pathway is commonly involved in the development of uveal melanoma, but occurs through a mechanism different to that of cutaneous melanoma.