Magnifying chromoendoscopy is a reliable method in the selection of rectal neoplasms for local excision

PURPOSE

Adequate staging of early rectal neoplasms is essential for organ-preserving treatments, but magnetic resonance imaging (MRI) frequently overestimates the stage of those lesions. We aimed to compare the ability of magnifying chromoendoscopy and MRI to select patients with early rectal neoplasms for local excision.

METHODS

This retrospective study in a tertiary Western cancer center included consecutive patients evaluated by magnifying chromoendoscopy and MRI who underwent en bloc resection of nonpedunculated sessile polyps larger than 20 mm, laterally spreading tumors (LSTs) [Formula: see text] 20 mm, or depressed-type lesions of any size (Paris 0-IIc). Sensitivity, specificity, accuracy, and positive and negative predictive values of magnifying chromoendoscopy and MRI to determine which lesions were amenable to local excision (i.e., [Formula: see text] T1sm1) were calculated.

RESULTS

Specificity of magnifying chromoendoscopy was 97.3% (95% CI 92.2-99.4), and accuracy was 92.7% (95% CI 86.7-96.6) for predicting invasion deeper than T1sm1 (not amenable to local excision). MRI had lower specificity (60.5%, 95% CI 43.4-76.0) and lower accuracy (58.3%, 95% CI 43.2-72.4). Magnifying chromoendoscopy incorrectly predicted invasion depth in 10.7% of the cases in which the MRI was correct, while magnifying chromoendoscopy provided a correct diagnosis in 90% of the cases in which the MRI was incorrect (p = 0.001). Overstaging occurred in 33.3% of the cases in which magnifying chromoendoscopy was incorrect and 75% of the cases in which MRI was incorrect.

CONCLUSION

Magnifying chromoendoscopy is reliable for predicting invasion depth in early rectal neoplasms and selecting patients for local excision.

Amino acids L-phenylalanine and L-lysine involvement in trans and cis piperamides biosynthesis in two Piper species

Several Piper species accumulate piperamides as secondary metabolites, and although they have relevant biological importance, many details of their biosynthetic pathways have not yet been described experimentally. Experiments involving enzymatic reactions and labeled precursor feeding were performed using the species Piper tuberculatum and Piper arboreum. The activities of the phenylalanine ammonia lyase (PAL) enzymes, which are involved in the general phenylpropanoid pathway, were monitored by the conversion of the amino acid L-phenylalanine to cinnamic acid. The activity of the 4-hydroxylase (C4H) enzyme was also observed in P. tuberculatum by converting cinnamic acid to p-coumaric acid. L-[UL-14C]-phenylalanine was fed into the leaves of P. tuberculatum and incorporated into piperine (1), 4,5-dihydropiperine (2), fagaramide (4), trans-piplartine (7), and dihydropiplartine (9). In P. arboreum, it was only incorporated into the piperamide 4,5-dihydropiperiline (3). L-[UL-14C]-lysine was successfully incorporated into the 4,5-dihydropiperine piperidine group (2), dihydropyridinone, and trans- (7) and cis-piplartine (8). These data corroborate the proposal of mixed biosynthetic origin of piperamides with the aromatic moiety originating from cinnamic acid (shikimic acid pathway) and key amide construction with amino acids as precursors.

Acute total occlusion of the unprotected left main coronary artery – patient characteristics and outcomes

Background

Acute total occlusion of the unprotected left main coronary artery (ATOLMCA) is a dramatic entity with very high mortality. Owing to its infrequency, there is limited and inconsistent data regarding this population.

Purpose

To describe the clinical presentation, short- and long-term outcomes of patients with ATOLMCA.

Methods

This retrospective multicentric cohort study included all patients presenting with acute (<12h) myocardial infarction (MI) due to ATOLMCA (Thrombolysis In Myocardial Infarction - TIMI=0) between January 2008 and December 2020 in three tertiary hospitals.

Results

In the period of the study, 11,036 emergent coronary angiographies were performed in the participating centers, 59 of which were ATOLMCA (0.5%). Mean age of patients at the time of the event was 61.2 (±12.2) years. Seventy-three percent were male. At presentation, 72.9% of patients were in cardiogenic shock, and aborted cardiac arrest occurred in 27.1%. Right dominance was present in all patients except one, who had a balanced dominance. Primary percutaneous coronary intervention (PCI) was performed in 89.8% of the patients, with angiographic success being achieved in 55.6% of the procedures. Overall, the in-hospital mortality rate was 57.6%. Mortality was significantly higher in patients without angiographic criteria for PCI success (87.5 vs 36.7%, p<0.001). Among survivors, 91.7% were still alive at 1-year and 66.7% at 5 years of follow-up.

Conclusion

Patients with ATOLMCA have a dismal prognosis. Most patients present with cardiogenic shock, and a significant number develop cardiac arrest during the acute phase. Despite medical care, in-hospital mortality is high. Patients with left dominance may not even reach the hospital. Among survivors, long term outcomes are reasonable. Further studies are needed in order to improve the management and outcomes of patients with ATOLMCA.

Funding Acknowledgement

Type of funding sources: None.

Breast cancer patients presenting with cardiotoxicity - risk factors and role of cardioprotective drugs

Funding Acknowledgements

Type of funding sources: None.

Introduction

Recent advances in cancer treatment have led to improved survival, albeit with cardiovascular adverse effects being some of the most frequent and feared consequences. Patient’s risk stratification, prevention and treatment are still to be fully elucidated. Our aim was to evaluate the risk and therapy of cardiotoxicity (CT) secondary to cancer treatment in a subset of patients with breast cancer (BC).

Methods

We collected a retrospective cohort of female with BC treated with conventional chemotherapy (CHT) and/or anti-HER2-targeted therapies (AHT) referred to Cardio-oncology consultation from January 2017 to March 2020. All patients were evaluated before CHT and at least at 3, 6 and 12-months with echocardiogram and cardiac biomarkers, namely high sensitivity troponin I (hs-cTnI) and brain natriuretic peptide (BNP). CT was defined as left ventricle ejection fraction (LVEF) under 50% or decline of at least 10% in LVEF during follow-up. As cardioprotective drugs (CPD) we considered renin-angiotensin-aldosterone system inhibitors and beta-blockers.

Results

A total of 203 women were enrolled, with mean age 50.9 ± 10.9 year-old. As for the cardiovascular risk factors, 23.5% had hypertension, 32.4% dyslipidaemia, 9.8% diabetes and 33.0% were smokers or previous smokers. The majority of patients had a high or very-high CT risk score (98.5% with score ≥ 5) and 35.5% were already on CPD before CHT. All patients were submitted to CHT: anthracyclines (AC) and AHT were applied to 83.8% and 41.7% of patients, respectively, with 27.9% of patients on both therapies; 81.4% were submitted to radiotherapy (RT). At presentation, all patients had normal cardiac function with mean LVEF of 62.9% and mean global longitudinal strain (GLS) of -19.4; mean hs-cTnI and BNP were 3.3 ng/L and 33.4 pg/mL, respectively. During a median follow-up of 16 months, 8.5% of patients developed CT, leading to initiation or titration of CPD in 76.9% and treatment interruption in 23.5%; most of them recovered (88.2%). During treatment there was a significantly increase of hs-cTnI (mean 19.7 ng/L at 3 months, p < 0.001) and a decrease of GLS and LVEF at 12 months (decrease of 1.1 and 2.2%, respectively, both p < 0.001). Both AHT and AHT plus AC were significantly associated with CT (p = 0.002 and p < 0.001, respectively), with an extremely high prevalence in the latter group (19.6%). Nor CVRF neither RT raised the risk of CT. Although patients on CPD did not had lower prevalence of CT (5.6% vs 10.2%, p = 0.268), its initiation was associated with a higher rate of cardiac function recovery (100.0% vs 66.7%, p = 0.057).

Conclusion

Patients submitted to AHT or AHT plus AC were at higher risk of developing CT. This and the significant LVEF decline during follow-up highlight the importance of long-term-monitoring of these patients. CPD seemed to be associated with cardiac recovery, although this finding needs further validation.

HER2 positive breast cancer: is there a preventive role of cardioprotective drugs?

Introduction

In patients with breast cancer, anti-HER2-targeted therapies (AHT) are highly associated with cardiotoxicity (CT), being the main reason for treatment interruption in patients receiving adjuvant trastuzumab. Guidelines recommend regular left ventricular ejection fraction (LVEF) assessments and CT's management with cardioprotective drugs (CPD). However, while secondary prevention has already entered clinical practice, primary prevention is still in the research domain. Our aim was to evaluate risk of CT and the role of CPD in a subset of breast cancer patients treated with AHT.

Methods

We retrospectively analyzed a population of breast cancer female patients treated with AHT referred to Cardio-oncology consultation at a tertiary center from January 2017 to March 2020. All patients were evaluated with echocardiogram before treatment initiation and at least at 3, 6, 9 and 12-months. CT was defined as LVEF under 50% or decline of at least 10% in LVEF during follow-up. As CPD we considered renin-angiotensin-aldosterone system inhibitors and beta-blockers.

Results

A total of 85 patients were included with mean age of 52.4±10.2 year-old. Concerning cardiovascular risk factors 11.8% had diabetes, 32.9% dyslipidaemia, 29.4% hypertension and 22.4% were smokers or previous smokers; most patients had a high or very-high CT risk score (98.8% with score ≥5). Besides AHT, 68.2% and 80% were also on anthracyclines and radiotherapy, respectively. Patients were followed for a median follow-up of 16 months. At baseline, mean high sensitivity troponin I was 3.9 ng/L, mean LVEF was 63.1% and mean global longitudinal strain was −19.7, with all patients having normal cardiac function. During follow-up, 15.7% developed CT with a higher prevalence in patients concomitantly on anthracyclines (19.6% vs 7.4%, p=0.151). CPD was initiated or titrated in 84.6% of patients and 30.8% needed to suspend AHT; overall 92.3% of CT patients recovered. Unlike AHT suspension, CPD initiation after CT was associated with a higher rate of cardiac function recovery (100.0% vs 50.0%, p=0.020). When comparing patients already medicated with CPD before cancer treatment (41.7%) to those naïve of CPD, the first group presented a significative lower incidence of CT [2.9% vs 25.0%, p=0.006, OR=0.09 (95% CI 0.01 – 0.72)]. When analysed all sample (with or without CT), patients already on CPD also presented a higher LVEF at 6 months follow-up (62.5% vs 59.2%, t(69)=−2.4, p=0.017 at 6 months), despite a non-significative lower LVEF at baseline (62.3% vs 63.6%, p=0.139). Medication with statins before chemotherapy didn't reduce the risk of CT.

Conclusion

Pre-treatment with CPD was significantly associated with a lower prevalence of CT and a higher LVEF at 6-months follow-up. CPD initiation after CT was associated with cardiac function recovery. These results highlights the importance of cardiac evaluation in HER2+ patients and strengthen the primary prevention field in these patients.

Funding Acknowledgement

Type of funding sources: None.

Myocardial infarction in the absence of obstructive coronary artery disease - can the underlying causes be identified by cardiac magnetic resonance?

Funding Acknowledgements

Type of funding sources: None.

Background

 Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease (MINOCA) is a clinical entity that occurs in up to 15% of all acute coronary syndromes (ACS). It is a "working diagnosis", as it is constituted by several etiologies.

Purpose

To identify the utility of CMR in determining the etiological diagnosis of MINOCA events, with potential impact in the therapeutic management of these patients.

Methods

 Patients with MINOCA who were admitted to the Cardiology department at a tertiary center, between 2015 and 2020, were included. MINOCA was defined as an ACS with non-obstructive (<50%) coronary artery disease and no other clinically specific cause, in accordance with definition adopted in the 2020 ESC Guidelines for the management of ACS in patients presenting without persistent ST-segment elevation. Patients who did not had a coronary exam (either CT or invasive angiogram) or a CMR were excluded.  All CMR exams were performed in a 3 Tesla equipment using a comprehensive protocol (cine, T2-weighted, and late gadolinium sequences). Clinical, electrocardiographic, echocardiographic and CMR data were collected.

Results

In a population of 29 patients, the mean age was 55 ± 17 years-old at the time of the cardiac event, 51.7% were male. Concerning to cardiovascular risk factors, 58.6% of patients had dyslipidaemia, 51.7% had hypertension, 13.7% were diabetic, 41.4% were smokers or previous smokers and 31.0% had obesity. Atrial fibrillation was present in 3.4% of patients. As for the EKG patterns, 41.4% of the patients had ventricular repolarization changes, 13.8% had a transitory ST elevation pattern, 6.9% had a complete left bundle branch block and 37.9% had a normal EKG; most of the ischemic EKG alterations were on the anterior wall (66.7%). The median high sensitivity I troponin levels were 1877.5 (IQR 225.3 – 5985.8) ng/L. The majority of patients (58.6%) had echocardiographic wall motion abnormalities; of those, the most common (41.1%) were on the left anterior descendent artery territory. CMR (performed at a median of 5 days from presentation) was able to identify the cause for the troponin rise in 58.6% of the cases; late gadolinium enhancement and oedema were present in 41.4% and 62.1% of patients, respectively. The mean left ventricle ejection fraction (EF) was 57.7 ± 8.5% and the mean right ventricle EF was 61.5 ± 6.1%. An ischemic pattern was present in 29.4% of the total population. In 17.6% of the patients findings were consistent with Takotsubo syndrome and in 29.4% with myocarditis.

Conclusion

 CMR established the etiological cause in 58.6% of the cases, with potential implications in medical therapy. These findings highlight the importance of CMR in MINOCA diagnosis and the potential improvement in patient care with multi-modality imaging.

Secondary prevention after acute coronary syndrome - can we achieve dyslipidemia guideline targets?

Funding Acknowledgements

Type of funding sources: None.

Lipid control is one of the most important secondary cardiovascular prevention targets. The 4S trialin 1994 was the first study to demonstrate the benefit of statin therapy in coronary artery disease patients. More recently, the FOURIER trial (2017) and the ODYSSEY Outcomes (2018) demonstrated the cardiovascular benefit of adding a PCSK9 inhibitor to optimized antidyslipidemic therapy.

Owing to the growing number of evidence showing the importance of aggressive lipid control, the European Society of Cardiology (ESC) 2019 Dyslipidemia Guidelines changed the recommendation of LDL targets from below 70 mg/dL to below 55 mg/dL in very high risk patients.

In the light of this new recommendation, we retrospectively analysed all patients who participated in a Coronary Rehabilitation Program (CRP) after an Acute Coronary Syndrome at a tertiary center from May 2008 to June 2019. The CRP consisted in a multi-disciplinary approach to these patients, including 8 to 12 weekly sessions of phase II rehabilitation, exercise prescription, nutrition counselling and life-style intervention, with Cardiology follow-up at the end of the CRP (3 months), 6 months and 12 months after the event. Lipid profile was requested at baseline, 3 months and 12 months after the event. Dyslipidemia was defined using the ESC Guidelines definition.

In total, 989 patients were enrolled: the mean age was 54 ± 10 years and 15% were female. Concerning to cardiovascular risk factors, 56.7% of patients had dyslipidaemia, 41.5% had hypertension, 18.1% were diabetic, 73.1% were smokers or previous smokers, 26.0% had family history of coronary disease and 14.0% had previous coronary disease.

At hospital admission, mean LDL concentration was 121,7 ± 38,8 mg/dL with 2,9% of the patients with values below 55 mg/dL and 7,6% below 70 mg/dL. The vast majority of patients were medicated with statin at hospital discharge and maintained the prescription during the follow-up (97.5% and 97.1%, respectively).

At the end of the CRP, there was a significant decrease of LDL values (p < 0.001) with 18.7% patients with LDL below 55 mg/dL and 46.3% below 70 mg/dL (mean LDL 76.6 ±23.6 mg/dL). At 1-year follow-up, the lipid control was better than at admission, but inferior than at the end of the rehabilitation program, both findings statistically significant (11.0% patients were below 55 mg/dL and 33.1% were below 70 mg/dL, with a mean LDL of 82.7 ± 28.3 mg/dL; p < 0.001).

In conclusion, our real-life observational cohort showed that guideline recommended LDL target is not achieved in most of very high-risk patients even in a structured coronary rehabilitation program. Of note, the number of patients at LDL-target decreased from 3 months to 1-year follow-up. This state the importance of a sustained healthy lifestyle and therapy adherence, with aggressive pharmacologic therapy.

Does age at aortic coarctation repair have an impact on left ventricle size and function?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Adults with repaired aortic coarctation (CoA) require lifelong follow-up due to late complications, including left ventricular (LV) myocardial dysfunction. Age at the time of CoA repair is an important prognostic factor in these patients (pts).

Purpose

To evaluate LV size, ejection fraction (EF) and global longitudinal strain (GLS) values using 2D speckle tracking echocardiography (STE) in a population of adult pts with repaired CoA and to assess the relationship between these echocardiographic parameters and age at the time of CoA repair.

Methods

Retrospective analysis of adult pts with repaired CoA, followed in a Grown Up Congenital Heart Disease Centre. Pts with hemodynamically significant concomitant cardiac lesions were ruled out. Epidemiologic and clinical data were obtained from clinical records. Transthoracic echocardiograms were reviewed in order to assess GLS using 2DSTE (Echopac Software, GE).

Results

The study population consisted of 63 pts (61.9% male), with a mean age of 35.3 years at the time of the echocardiographic evaluation. The mean age at the time of the CoA repair was 117 months (95% CI 89.8-144.1 months).

Surgical repair was performed in 46 pts (73%): resection with subclavian artery flap aortoplasty (n = 21); patch aortoplasty (n = 15) and head-to-head anastomosis (n = 10). In 10 pts there was no data regarding the type of surgical repair. Seven pts (11.1%) were submitted to percutaneous intervention (6 with aortic stent implantation and 1 with balloon aortic angioplasty).

Mean LVEF was 63.4% (CI 95% 55.6 – 71.2%) and mean LV end-diastolic diameter (LVEDD) was 50mm (CI 95% 43-57mm). Mean GLS was - 17.3 (CI 95% 14.8- 19.8), which is inferior to the mean normal values reported for the software used.

Age at the time of CoA repair had a statistically significant positive linear relationship with LVEDD (r= 0.282; p= 0.026) and a linear negative relationship with both GLS (r= -0,29; p= 0.022) and LVEF (r= -0.33; p= 0.05).

Conclusion

Older age at the time of CoA repair was associated with increased LVEDD and decreased GLS and LVEF. Also, GLS may be an important tool for the identification of subclinical LV dysfunction in adult pts with repaired CoA.

Outcomes of surgical treatment for patients with distal rectal cancer: A retrospective review from a single university hospital

INTRODUCTION AND AIM

Surgery for distal rectal cancer (DRC) can be performed with or without sphincter preservation. The aim of the present study was to analyze the outcomes of two surgical techniques in the treatment of DRC patients: low anterior resection (LAR) and abdominoperineal resection (APR).

METHODS

Patients with advanced DRC that underwent surgical treatment between 2002 and 2012 were evaluated. We compared the outcomes of the type of surgery (APR vs LAR) and analyzed the associations of survival and recurrence with the following factors: age, sex, tumor location, lymph nodes obtained, lymph node involvement, and rectal wall involvement. Patients with distant metastases were excluded.

RESULTS

A total of 148 patients were included, 78 of whom were females (52.7%). The mean patient age was 61.2years. Neoadjuvant chemoradiation therapy was performed in 86.5% of the patients. APR was performed on 86 (58.1%) patients, and LAR on 62 (41.9%) patients. No differences were observed between the two groups regarding clinical and oncologic characteristics. Eighty-seven (62%) patients had pT3-4 disease, and 41 patients (27.7%) had lymph node involvement. In the multivariate analysis, only poorly differentiated tumors (P=.026) and APR (P=.009) correlated with higher recurrence rates. Mean follow-up time was 32 (16-59.9) months. Overall 5-year survival was 58.1%. The 5-year survival rate was worse in patients that underwent APR (46.5%) than in the patients that underwent LAR (74.2%) (P=.009).

CONCLUSIONS

Patients with locally advanced DRC that underwent APR presented with a lower survival rate and a higher local recurrence rate than patients that underwent LAR. In addition, advanced T/stage, lymph node involvement, and poor tumor differentiation were associated with recurrence and a lower survival rate, regardless of the procedure.

Short-term outcome of infliximab and other medications on patients with inflammatory bowel disease undergoing ileostomy reversal

AIM

We evaluated the impact of immunosuppressive drugs on the short-term outcome following loop ileostomy closure in patients with inflammatory bowel disease.

METHOD

Data on 249 patients with inflammatory bowel disease, who underwent loop ileostomy closure from 2001 to 2008, were retrospectively reviewed from a prospectively maintained database. Patients were distributed among groups according to the inflammatory bowel disease drugs used. Comorbidity, diagnosis, intra-operative and postoperative morbidity and length of stay data were analysed. Patients in group (INF) were receiving infliximab with or without other immunosuppressive agents (28), patients in group (S) were receiving only steroids (72) and those, in group III (S&I) were on steroids plus immunosuppressive agents, other than infliximab (35). Patients in group (ND) had not received any immunosuppressive agents for 2 months and served as the control group (114).

RESULTS

Postoperative complication rates (wound infection, hernia, obstruction, intra-abdominal abscess, leakage, enterocutaneous fistula and sepsis) occured in 4.0, 12.0, 14 and 17.0% of patients in the four groups (P > 0.05). Reoperation was needed in 3.0% (2) of patients in group S, 6.0% (2) in S&I and 3.0% (3) in C groups, and the mean hospital stay was 4.6 (± 2.1), 5.6 (± 4.6), 5.2 (± 4.7) and 5.2 (± 6) days in groups INF, S, S&I and ND, respectively. There was no mortality.

CONCLUSION

There were no significantly increased postoperative complications after ileostomy closure in patients who received infliximab or other immunosuppressive medications compared with patients who did not.

Long-term follow up of abdominal rectosigmoidectomy with posterior end-to-side stapled anastomosis for Chagas megacolon

AIM

Chagas' disease is an endemic parasitosis found in Latin America. The disease affects different organs, such as heart, oesophagus, colon and rectum. Megacolon is the most frequent long-term complication, caused by damage to the myoenteric and submucous plexus, ultimately leading to a functional barrier to the faeces. Patients with severe constipation are managed surgically. The study aimed to analyse the 10-year minimum functional outcome after rectosigmoidectomy with posterior end-to-side anastomosis (RPESA).

METHOD

A total of 21 of 46 patients were available for follow up. Patients underwent clinical, radiological and manometric evaluation, and the results were compared with preoperative parameters.

RESULTS

Of the 21 patients evaluated, 81% (17) were female, with a mean age of 60.6 years. Good function was achieved in all patients, with significant improvement in defaecatory frequency (P < 0.0001), usage of enemas (P < 0.0001) and patient satisfaction. Barium enema also showed resolution of the colonic and rectal dilatation in 19 cases evaluated postoperatively.

CONCLUSION

Minimal 10-year follow up of RPESA showed excellent functional results, with no recurrence of constipation.

Laparoscopy for recurrent Crohn's disease: how do the results compare with the results for primary Crohn's disease?

AIM

To assess the feasibility and outcomes of reoperative laparoscopic-assisted surgery for recurrent Crohn's disease compared with index laparoscopic resections.

METHOD

A retrospective analysis of a prospectively maintained database was performed from 2001 to 2008 on patients who had primary laparoscopy (group I) or reoperative laparoscopy for Crohn's disease (group II). Data collection included demographic and surgical data, and postoperative outcomes.

RESULTS

One hundred and thirty patients were included in this study, distributed as follows: group I, 80 patients with a mean age of 35 years; and group II, 50 patients with a mean age of 42 years. Preoperative American Society of Anesthesiologists score and body mass index were similar in both groups. Patients in group II had a longer period of disease (15.5 vs 8.9 years in groups I and II, respectively; P = 0.0002). Immunosuppressive therapy had been utilized in 66 (82.5%) and in 42 (84%) patients in groups I and II, respectively. Ileocolic resection was the most commonly performed procedure in both groups (82%), followed by subtotal colectomy. Conversion rates were 18.7 and 32% in groups I and II, respectively (P = 0.09). The mean operative time (182 vs 201 min) and mean blood loss (161 vs 202 ml) were not significantly different (P > 0.05); however, the overall incisional length was significantly longer in group II (6.7 vs 11.4 cm, P = 0.045). A stoma was created in 17 and 16% of patients in groups I and II, respectively. Overall, early postoperative complications were not statistically significantly different between the two groups (P > 0.05); anastomotic leak occurred in four (5%) and one (2%) patients (P = 0.65), and abdominal abscess in three (3.75%) and four (8%) patients (P = 0.56), in groups I and II, respectively. Reoperative rates were 10 and 6% (P = 0.53), and mean hospital stay was similar in groups I and II respectively (6.7 vs 7.5 days, respectively; P = 0.3266). There was no mortality.

CONCLUSION

The results of laparoscopic-assisted resection for recurrent Crohn's disease are similar to those for primary resection.

Ileal pouch-anal anastomosis in elderly patients: is there a difference in morbidity compared with younger patients?

AIM

The aim of this study was to review the recent results of ileal pouch-anal anastomosis (IPAA) in elderly patients compared with younger patients.

METHOD

Retrospective evaluation was carried out based on a prospective Institutional Review Board approved database of patients who underwent IPAA from 2001 to 2008. Patients aged ≥ 65 years were matched with a group of patients aged < 65 years by gender, date of procedure, diagnosis and type of procedure performed. Preoperative and intra-operative data and early postoperative complications were obtained.

RESULTS

Thirty-three patients (22 women), 32 with mucosal ulcerative colitis, were included in each group. The elderly group had a mean age of 68.7 years, body mass index of 27 kg/m², duration of disease of 17.4 years, high American Society of Anesthesiologists (ASA) score and high incidence of comorbid conditions (87.9% had one or more). Dysplasia and carcinoma were the indication for the surgery in more than 50% of patients, followed by refractory disease (24.4%). The matched younger group had a mean age of 36.9 years, body mass index of 25.4 kg/m², shorter duration of disease (8.1 years; P = 0.001), lower ASA score (P = 0.0001) and lower comorbidity (42.4%; P = 0.0002). Operative data were similar for both groups. The elderly group had a higher rate of rehospitalization for dehydration (P = 0.02). Other medical complications (30 vs 27%) and surgical postoperative complications (33 vs 24%) were similar for both groups. The long-term function and complications were comparable for the groups.

CONCLUSION

Elderly patients who underwent IPAA had more comorbid conditions than younger patients. Except for rehospitalization for dehydration, medical and surgical postoperative complications were not different in the two groups.

Synchronous collision malignant melanoma and adenocarcinoma of the rectum

"Collision tumors" consist of two independent but coexisting tumors. This uncommon situation might be easily mistaken for a composite tumor where one histogenetic event originates from two apparently distinct neoplasms. Colorectal collisions are particularly unusual; here, we report the exceedingly rare case of a 61-year-old man with malignant melanoma and adenocarcinoma colliding in the rectum. Collision tumors have an idiopathic pathophysiology and in fact "accidental meeting" is accepted by many authors. This article discusses the concepts about cancer development, which are overlooked by this hypothesis, another theory to explain that this rare occurrence involves microenvironment changes.

Isolation, purification and characterization of glycosaminoglycans in the fluids of the mollusc Anodonta cygnea

The isolation, purification and characterization of Anodonta cygnea haemolymph, and extrapallial fluid glycosaminoglycans (Gags), which have high calcium affinity, were carried out in order to better understand the process of nacreous shell biomineralization. Our results show the existence of two different Gags with similar contents in the two fluids, throughout the year, but with significant seasonal variations for both. In the winter months, we identified by electrophoresis, only one kind of Gag chain (hyaluronic acid) while two different Gags (hyaluronic acid and heparan sulphate-like) from both fluids of A. cygnea were found in summer months. Quantification showed the total Gag fractions of both fluids in average, at their highest concentration (79.8 mg/L) in the highest calcification summer period. In contrast, the period of the year with the lowest concentration of total Gags (54.6 mg/L) occurred during the winter when calcification is reduced. This significant decrease between seasons is correlated mainly with the sulphated fraction, being 37.1 mg/L in the summer while only 9.2 mg/L in the winter haemolymph. The present data suggest that a heparan sulphate-like Gag has a relevant role in the biomineralization mechanisms acting as the calcium carbonate nucleator in the shell.

Thermodynamic characterisation of the mutated isoenzyme A of beta-N-acetylhexosaminidase in GM2-gangliosidosis B1 variant

Here we report the determination of the activation energies of the plasma isoenzymes of beta-N-acetylhexosaminidase (Hex, EC 3.2.1.52), isolated by chromatography in DEAE-cellulose, using the neutral chromogenic substrate 3,3'dichlorophenylsulfonphthaleinyl-N-acetyl-beta-D-glucosaminide. The activation energy of mutated Hex A isoenzyme (Ea approximately 71.5 kJ/mol) from a patient with GM2-gangliosidosis B1 variant, homozygote for the G533-->A (Arg178His) mutation, was significantly higher than that of normal Hex A (Ea approximately 41.8 kJ/mol) and analogous to that of Hex B isoenzyme (Ea approximately 75.1 kJ/mol). The determination of this thermodynamic variable of Hex in different biological specimens could allow for a straightforward biochemical characterisation of the GM2-gangliosidosis B1 variant.

Characterization of the isoenzyme profile of beta-N-acetylhexosaminidase in the urine of newborns

The urinary isoenzymes of beta-N-acetylhexosaminidase (Hex) in newborn infants were characterised by chromatography, electrophoresis, thermodynamic analysis and through substrate specificity. No qualitative difference was found for the major Hex A and Hex B isoenzymes between full-term or premature newborns and adults, although in the latter group the relative proportion of Hex B is much lower (18.5 +/- 2.7% vs. 36.3 +/- 1.0%). An additional minor enzyme form was found in some premature newborns, which eluted from the DEAE-cellulose column at a higher concentration of NaCl than Hex A and, like this isoenzyme, is able to hydrolyse 4-methylumbellipheryl-2-acetamido-2-deoxy-beta-D-glucopyranoside-6 -sulphate, which would suggest that it has alpha subunits in its molecule. These results do not confirm the hypothesis of other authors about the existence of a unique fetal Hex isoenzyme in neonatal urine which eluted before the application of the NaCl gradient, similarly to the Hex B.

Clinical, enzymatic, and molecular characterisation of a Portuguese family with a chronic form of GM2-gangliosidosis B1 variant

Mutations in the hexosaminidase A gene (HEXA) causing the B1 variant of GM2-gangliosidosis result in the presence of a mutant enzyme protein with a catalytically defective alpha subunit. A rare and panethnically distributed mutation, transition G533A (Arg178His), is known to be a common allele among Portuguese patients with the subacute phenotype. We now report the presence of an Arg178His allele in three Portuguese sibs with a chronic form of the disease, who carry the transition G755A (Arg252His) on the second allele. This novel mutation is the first B1 allele to be associated with an adult phenotype.

Association of surfactant protein C with isolated alveolar type II cells

Surfactant protein C (SP-C) is a small hydrophobic protein that is synthesized and secreted by alveolar type II cells. The mechanism of clearance of SP-C from the alveolar airspace is not well understood, although previous studies demonstrated that recombinant SP-C instilled into the lungs of spontaneously breathing anaesthetized rats was taken up by type II cells and incorporated into lamellar bodies. The current investigation was undertaken to characterize the interaction of a complex of SP-C and surfactant-like lipids with freshly isolated rat alveolar type II cells under conditions in which the extracellular milieu can be regulated. SP-C was isolated from alveolar proteinosis lavage fluid and radiolabeled with 125I-Bolton-Hunter reagent. The radiolabeled protein retained its ability to facilitate adsorption of phospholipids to an air/liquid interface. Labeled human SP-C associated with isolated type II cells in a concentration-dependent manner that was also dependent upon temperature and time. The association of labeled SP-C with isolated type II cells did not saturate up to 150 micrograms/ml. SP-A significantly enhanced the association of SP-C with isolated type II cells. Under the experimental conditions tested, SP-C was not degraded to TCA-soluble products. These results are consistent with the hypothesis that association or uptake of SP-C by type II cells may be enhanced by SP-A and that like SP-A, SP-C is recycled by type II cells.

Uptake of pulmonary surfactant protein C into adult rat lung lamellar bodies

Previous studies have provided evidence that a large proportion of secreted surfactant lipids is taken up from the alveolar air space by type II cells, incorporated into lamellar bodies, and resecreted. Our goal was to characterize the clearance of exogenously administered recombinant surfactant protein C (SP-C) and to determine if SP-C is taken up by type II cells and incorporated into lamellar bodies. SP-C was radiolabeled by alkylation with [3H]iodoacetic acid and retained its ability to enhance phospholipid adsorption to an air-liquid interface. A mixture of 100 micrograms phospholipid radiolabeled with [14C]dipalmitoylphosphatidylcholine and 10 micrograms SP-C was instilled into the lungs of spontaneously breathing anesthetized adult rats. At later times, the lungs were lavaged and subcellular organelles were isolated. The radioactivity of both phospholipids and SP-C (expressed as disintegrations per minute per microgram phospholipid) in lamellar body fractions increased up to 4 h postinstillation and began to decline after approximately 4 h. The results of this study suggest that SP-C and dipalmitoylphosphatidylcholine are taken up promptly from the alveolar air space and are incorporated into lamellar bodies with time courses that do not differ greatly.

Type 1 Gaucher disease: molecular, biochemical, and clinical characterization of patients from northern Portugal

We report the study of 16 catholic type 1 Gaucher disease patients originating from a well-defined region in the north of Portugal where a relatively high incidence is observed. The patients were screened for mutations: 3060G-->A, 5841A-->G, 5976C-->G, and 6433T-->C, which enabled the identification of 27 of the 32 mutated alleles. Four different genotypes were identified, namely 5841G/6433C (n = 6), 5841G/5841G (n = 5), 5841G/? (n = 4), and 6433C/? (n = 1). All but one of the patients carried at least one 5841G mutated allele, making its frequency 62.5%, which is similar to that described for Ashkenazi Jewish patients. The 5841G homozygotes presented an overall milder clinical profile, whereas no clear genotype/phenotype correlation could be established for heterozygous patients. On the basis of residual glucocerebrosidase activity, no distinction could be made between 5841G homozygotes and 5841G/6433C compound heterozygotes. Patients that had at least one 5841G allele (encoding the Ser 370 mutated enzyme) all presented a cell-type-specific residual glucocerebrosidase activity as well as an increased molecular activity when measured in the presence of the physiological activators.

Polishing after debracketing: its influence upon enamel surface

The effect of different time periods of polishing, after debonding orthodontic brackets, upon enamel surface was investigated. Nine brackets were bonded onto nine healthy human teeth, extracted for severe periodontal disease. The brackets were removed after twenty-four hours and the composite was removed from the dental surface with a tungsten carbide bur. Three of these teeth were polished with a rubber cup, pumice and water for 30 seconds. Three others had the same procedure for 10 seconds and the last group did not received any polishing. The three groups were examined at the Scanning Electron Microscope and compared with the sound enamel of the same teeth. The results showed that pumicing is necessary after debracketing, although, even after 30 seconds of polishing, composite is still found on the enamel surface. The three procedures did not provide a surface equal to the sound enamel, but better results were obtained by increasing polishing time.

Biochemical characterization of beta-hexosaminidase in different biological specimens from eleven patients with GM2-gangliosidosis B1 variant

GM2-gangliosidosis B1 variant is thought to be a rare disorder with a wide geographical and ethnic distribution. We report the biochemical findings obtained in different specimens from a group of 11 B1 variant patients originating from the north of Portugal. The biochemical data obtained seem to indicate that only one of these patients is a genetic compound presenting a clinical and biochemical pattern similar to the majority of B1 variant patients described in the literature, but somewhat different from the profile presented by the other patients reported here, who are homozygous for the 'DN-allele'.

Heterogeneity in human acid beta-glucosidase revealed by cellulose-acetate electrophoresis

Cellulose-acetate gel electrophoresis, a technique commonly used for the separation of human acid hydrolases, was applied to study heterogeneity in acid beta-glucosidase (EC 3.2.1.45). With this technique, three forms of beta-glucosidase were distinguishable in extracts of several tissues. The most anodic beta-glucosidase activity (band 3) represents the broad-specificity beta-glucosidase that is not deficient in Gaucher disease and is not inhibited by conduritol B-epoxide (CBE). The beta-glucosidase activity was deficient in Gaucher disease. A third beta-glucosidase activity with an intermediate mobility (band 2) was also inhibited by CBE and deficient in Gaucher disease. Band 1 and band 2 beta-glucosidase thus represent different forms of glucocerebrosidase. By adding phosphatidylserine and sphingolipid activator protein (SAP-2), monomeric glucocerebrosidase could be completely converted into a form that comigrated with band 2 beta-glucosidase of tissue extracts. The addition of phosphatidylserine only also resulted in a changed mobility of the monomeric enzyme, but the migration in this case differed from that of band 2 beta-glucosidase of tissue extracts. The electrophoretic profile of beta-glucosidase activity of tissue extracts changed upon ethanol/chloroform extraction: the two glucocerebrosidase forms were converted into a band with a mobility identical to that of band 1 beta-glucosidase. Our findings indicate that the interaction of glucocerebrosidase with phospholipid and SAP-2 has major effects on the mobility of the enzyme in the cellulose-acetate gel electrophoresis system. The findings with the cellulose-acetate gel electrophoretic system are discussed in relation to the heterogeneity in glucocerebrosidase observed with sucrose density gradient analysis, immunochemical methods and isoelectric focussing studies.