Nutritional Assessment in Patients after Gastric Electrical Stimulation (GES)

BACKGROUND

Gastric electrical stimulation (GES) is used for patients with drug-refractory gastroparesis (Gp) symptoms. Approximately two-thirds of patients with Gp symptoms are either overweight or obese. We aimed to assess symptoms and nutritional status pre-GES and post-GES placement in a large sample of drug-refractory Gp patients.

METHODS

We conducted a chart review of 282 patients with drug-refractory Gp who received temporary followed by permanent GES at an academic medical center. Gastrointestinal symptoms were collected by a traditional standardized PRO (0-4, 0 being asymptomatic and 4 being worst symptoms), baseline nutritional status by BMI plus subjective global assessment (SGA score A, B, C, for mild, moderate, and severe nutritional deficits), ability to tolerate diet, enteral tube access, and parenteral therapy were assessed at baseline and after permanent GES placement.

RESULTS

Comparing baseline with permanent, GES was found to significantly improve upper GI symptoms in all quartiles. Of the 282 patients with baseline body mass index (BMI) information, 112 (40%) patients were severely malnourished at baseline, of which 36 (32%) patients' nutritional status improved after GES. Among all patients, 76 (68%) patients' nutritional status remained unchanged. Many patients with high BMI were malnourished by SGA.

CONCLUSION

We conclude that symptomatic patients of different BMIs showed improvement in their GI symptoms irrespective of baseline nutritional status. Severely malnourished patients were found to have an improvement in their nutritional status after GES therapy. We conclude that BMI, even if high, is not by itself a contraindication for GES therapy for symptomatic patients.

Gastroparesis and Gastroparesis Syndromes as Neuromuscular Disorders

Gastroparesis syndromes (GpS) are a spectrum of disorders presenting with characteristic symptoms increasingly recognized as being gastrointestinal (GI) neuromuscular disorders (NMDs). This review focuses on GpS as a manifestation of neurologic disorders of GI NMD. GpS can be associated with systemic abnormalities, including inflammatory, metabolic, and serologic disorders, as well as autoimmune antibodies via nerve and muscle targets in the GI tract, which can be treated with immunotherapy, such as intravenous immunoglobulin. GpS are associated with autonomic (ANS) and enteric (ENS) dysfunction. Disorders of ANS may interact with the ENS and are the subject of continued investigation. ENS disorders have been recognized for a century but have only recently begun to be fully quantified. Anatomic structural changes in the GI tract are increasingly recognized in GpS. Detailed descriptions of anatomic changes in GpS, and their correlation with physiologic findings, have opened a new era of investigation. The management of GpS, when viewed as GI NMD, has shifted the paradigms of both diagnosis and treatment. This article concludes with current approaches to GpS directed at underlying neuromuscular pathology.

Baseline predictive factors for foregut and hindgut response to long-term gastric electrical stimulation using augmented energy

INTRODUCTION

Gastric electrical stimulation (GES) has been recommended for drug refractory patients with gastroparesis, but no clear baseline predictors of symptom response exist. We hypothesized that long-term predictors to GES for foregut and hindgut symptoms exist, particularly when using augmented energies.

PATIENTS

We evaluated 307 patients at baseline, 1 week post temporary GES, and one year after permanent GES. Baseline measures included upper and lower symptoms by patient-reported outcomes (PRO), solid and liquid gastric emptying (GET), cutaneous, mucosal, and serosal electrophysiology (EGG, m/s EG), BMI, and response to temporary stimulation.

METHODS

Foregut and hindgut PRO symptoms were analyzed for 12-month patient outcomes. All patients utilized a standardized energy algorithm with the majority of patients receiving medium energy at 12 months. Patients were categorized based on change in average GI symptom scores at the time of permanent GES compared to baseline using a 10% decrease over time as the cutoff between improvers versus non-improvers.

RESULTS

By permanent GES implant, average foregut and hindgut GI symptom scores reduced 42% in improved patients (n = 199) and increased 27% in non-improved patients (n = 108). Low BMI, baseline infrequent urination score, mucosal EG ratio, and proximal mucosal EG low-resolution amplitude remained significant factors for improvement status.

CONCLUSIONS

GES, for patients responding positively, improved both upper/foregut and lower/hindgut symptoms with most patients utilizing higher than nominal energies. Low baseline BMI and the presence of infrequent urination along with baseline gastric electrophysiology may help identify those patients with the best response to GES/bio-electric neuromodulation.

The Surgeon's Role in Gastric Electrical Stimulation Therapy for Gastroparesis

INTRODUCTION

Gastroparesis, which can be viewed as a syndrome featuring nausea, vomiting, and abdominal pain, and associated other symptoms and findings, is increasingly seen by surgeons. Gastroparesis is associated with a number of gastrointestinal anatomic and physiologic findings.

MATERIALS AND METHODS

This article reviews the use of bioelectric therapy of neuromodulation, via gastric electrical stimulation, for patients with drug refractory gastroparesis syndromes including surgical aspects of device placement and subsequent management.

RESULTS AND DISCUSSION

In addition to an overall approach to the placement and subsequent management of gastric electrical stimulation devices, several newer concepts are discussed. The role of pyloric dysfunction in gastroparesis is also discussed including how stimulation devices and pyloric therapies may be used in concert. The additions of full-thickness gastrointestinal biopsies along with other physiologic, including GI electrophysiology, as well as some serologic measures, are also discussed. In addition, evolving approaches and emerging technologies for bioelectric neuromodulation of the gastrointestinal tract are introduced.

CONCLUSIONS

Gastroparesis syndromes can be approached in a systematic manner based on known pathophysiology and when indicated can be helped with surgical therapies including neuromodulation.

Pathophysiology of Gastroparesis Syndromes Includes Anatomic and Physiologic Abnormalities

BACKGROUND

Factors underlying gastroparesis are not well defined.

AIMS

We hypothesized that multiple systems may be involved in patients with gastroparesis symptoms and performed a comparative physiologic study.

METHODS

We studied 43 consecutive eligible patients with gastroparetic symptoms categorized by GI symptoms, metabolic status, illness quantification, and gastric physiology. Patients were evaluated by two methods in each of five core areas: inflammatory, autonomic, enteric, electrophysiologic, and hormonal with abnormalities examined by correlations.

RESULTS

Patients had similar GI symptoms regardless of baseline gastric emptying or diabetic/idiopathic status, and all patients demonstrated abnormalities in each of the 5 areas studied. Nearly all patients presented with elevated markers of serum TNFα (88%) and serum IL-6 (91%); elevated cutaneous electrogastrogram frequency (95%); and interstitial cells of Cajal count abnormalities (inner: 97%, outer: 100%). Measures of inflammation correlated with a number of autonomic, enteric anatomy, electrophysiologic and hormonal abnormalities.

CONCLUSIONS

We conclude that patients with the symptoms of gastroparesis have multiple abnormalities, when studied by traditional, as well as newer, diagnostic assessments. Inflammation appears to be a fundamental abnormality that affects other organ systems in symptomatic patients. Future work on gastroparetic syndromes and their treatment may benefit from a focus on the diffuse nature of their illness, diverse pathophysiologic mechanisms involved, especially the possible causes of underlying inflammation and disordered hormonal status.

TRAIL REGISTRY

This study is registered with Clinicaltrials.gov under study # NCT03178370 https://clinicaltrials.gov/ct2/show/NCT03178370 .

Gastric Electrical Stimulation Has an Effect on Gastric Interstitial cells of Cajal (ICC) That is Associated With Mast Cells

Introduction

Gastric electrical stimulation (GES) is an emerging therapy for gastric motility disorders, showing improvement of gastroparesis related symptoms in previous studies. Interstitial cells of Cajal (ICC) and mast cells have been shown to have a relevant role in gastroparesis pathogenesis. However, the exact effects of GES in those cells is relatively unknown.

Methods

Full thickness biopsies (FTBx) of 20 patients with refractory gastroparesis were obtained at the time of GES placement and repeated when the device was exchanged (mean of 22.5 months between biopsies). A patient-reported outcomes survey was obtained during each office visit during this period. All biopsies were stained with cluster of differentiation 117 (CD117), S100, and mast cell tryptase antibodies and were analyzed.

Results

Half of the patients had a significant increase of ICC during the repeated biopsy compared with baseline (p=0.01) and the other half had significant decrease in ICC levels (p=0.006) but there was no noticeable difference in mast cells counts at baseline between groups. Mast cells analysis was performed in two different groups depending on ICC change from the baseline biopsy (CD117 increase vs CD117 decrease). There was only a significant increase of mast cells count within the CD117 worsened ICC group (p=0.007).

Conclusion

No significant increase in the number of mast cells count seen in patients who received a GES may indicate an improvement in overall inflammation in patients with refractory gastroparesis after GES placement.

Gastroesophageal Reflux and Microaspiration in Lung Transplant Recipients: The Utility of a Single Esophageal Manometry and pH Probe Monitoring Study

BACKGROUND

Gastroesophageal reflux (GER) in recipients of lung transplant (LTX) is associated with chronic allograft rejection, presumably via microaspiration that damages airway epithelium. Most LTX programs perform a single post-LTX esophageal study to evaluate for GER; the efficacy of this test is unclear.

METHODS

Patients with 1 year of post-LTX follow-up, including routine bronchoscopies with bronchoalveolar lavage fluid (BALF) samples as well as high-resolution esophageal manometry and pH probe monitoring (HREMpH), were evaluated. BALF samples were analyzed with competitive enzyme-linked immunosorbent assay to detect bile salts, which are indicative of aspiration. These results were compared to results of HREMpH studies post LTX.

RESULTS

Ninety BALF samples were analyzed for bile salts and acted as disease positive for this evaluation. Of the 13 HREMpH cases, 8 were positive for GER, but only 3 were positive for bile salts via assay. Of the 5 HREMpH-negative cases, 2 experienced aspiration. A solitary HREMpH study had 60.0% sensitivity and 37.5% specificity with positive and negative likelihood ratios: 0.96 and 1.07, respectively.

CONCLUSION

Microaspiration appears to be an intermittent phenomenon, and HREMpH screening poorly correlates with BALF evidence of aspiration; which may not be adequate. As aspiration detection is crucial in this population, further analysis is warranted.

Gastric Electrical Stimulation Is an Effective Treatment Modality for Refractory Gastroparesis in a Postsurgical Patient with Pancreatic Cancer

Gastroparesis-related hospital visits contribute significantly to healthcare costs. Gastroparesis can lead to chronic symptoms, such as nausea, vomiting, bloating, early satiety, and abdominal pain. It can result in a significant impairment of quality of life. Diabetes and postsurgery are common causes for gastroparesis, but most cases of gastroparesis are idiopathic in presumed etiology. Malignancy-related gastroparesis has also recently been described in the literature, and pancreatic cancer is a malignancy commonly associated with gastroparesis. Whipple surgery for pancreatic cancer is often complicated by gastroparesis during its postoperative course. We report a case where gastric electrical stimulation was an effective treatment option in the treatment of refractory malignancy-related gastroparesis.

Multi-day, multi-sensor ambulatory monitoring of gastric electrical activity

OBJECTIVE

Bioelectrial signals known as slow waves play a key role in coordinating gastric motility. Slow wave dysrhythmias have been associated with a number of functional motility disorders. However, there have been limited human recordings obtained in the consious state or over an extended period of time. This study aimed to evaluate a robust ambulatory recording platform.

APPROACH

A commercially available multi-sensor recording system (Shimmer3, ShimmerSensing) was applied to acquire slow wave information from the stomach of six humans and four pigs. First, acute experiments were conducted in pigs to verify the accuracy of the recording module by comparing to a standard widely employed electrophysiological mapping system (ActiveTwo, BioSemi). Then, patients with medically refractory gastroparesis undergoing temporary gastric stimulator implantation were enrolled and gastric slow waves were recorded from mucosally-implanted electrodes for 5 d continuously. Accelerometer data was also collected to exclude data segments containing excessive patient motion artefact.

MAIN RESULTS

Slow wave signals and activation times from the Shimmer3 module were closely comparable to a standard electrophysiological mapping system. Slow waves were able to be recorded continuously for 5 d in human subjects. Over the 5 d, slow wave frequency was 2.8  ±  0.6 cpm and amplitude was 0.2  ±  0.3 mV.

SIGNIFICANCE

A commercial multi-sensor recording module was validated for recording electrophysiological slow waves for 5 d, including in ambulatory patients. Multiple modules could be used simultaneously in the future to track the spatio-temporal propagation of slow waves. This framework can now allow for patho-electrophysiological studies to be undertaken to allow symptom correlation with dysrhythmic slow wave events.

Gastroparesis syndromes: Response to electrical stimulation

BACKGROUND AND AIMS

Factors underlying gastroparesis are not well defined, nor is the mechanism of action of gastric electrical stimulation (GES). We hypothesized that GES acts via several mechanisms related to underlying disordered pathophysiology.

METHODS

We studied 43 consecutive eligible patients with gastroparetic symptoms, previously evaluated by two methods in each of five core areas: inflammatory, autonomic, enteric, electrophysiologic, and hormonal; and also categorized by GI symptoms, metabolic status, illness quantification, and gastric physiology. We then studied 41 patients who underwent temporary GES for 5-7 days. Thirty-six of those patients were implanted and 30 were followed up at 6 months after permanent GES.

RESULTS

In previous but separately reported work, patients had similar GI symptoms regardless of baseline gastric emptying or diabetic/idiopathic status and all patients demonstrated abnormalities in each of the five areas studied. After GES, patients showed early and late effects of electrical stimulation with changes noted in multiple areas, categorized by improvement status.

CONCLUSION

Patients with symptoms of gastroparesis have multiple abnormalities, including systemic inflammation and disordered hormonal status. GES affects many of these abnormalities. We conclude electrical stimulation improves symptoms and physiology with (a) an early and sustained anti-emetic effect; (b) an early and durable gastric prokinetic effect in delayed emptying patients; (c) an early anti-arrhythmic effect that continues over time; (d) a late autonomic effect; (e) a late hormonal effect; (f) an early anti-inflammatory effect that persists; and (g) an early and sustained improvement in health-related quality of life. This study is registered with Clinicaltrials.gov under study # NCT03178370 (https://clinicaltrials.gov/ct2/show/NCT03178370).

The Effect of Gastric Electrical Stimulation on Small Bowel Motility in Patients With Gastroparesis and Concomitant Pancreatic and Small Bowel Dysfunction: From Animal Model to Human Application

BACKGROUND/AIMS

Patients with gastroparesis often have biliary/pancreatic and small bowel symptoms but the effects of gastric electrical stimulation on small bowel electrical activity of the mid-gut have not been studied. Animal model aim: Establish gastric and upper small bowel/biliary slow wave activity relationships with electrical stimulation. Human study aim: Demonstrate improvement in symptoms associated with proximal small bowel dysmotility in gastric stimulated patients.

MATERIALS AND METHODS

Animal model: In vivo evoked responses of duodenal and Sphincter of Oddi measures recorded during gastric electrical stimulation in a nonsurvival swine model (N = 3). High-resolution electrical slow wave mapping of frequency, amplitude, and their ratio, for duodenal and Sphincter of Oddi electrical activity were recorded. Human study: Patients (N = 8) underwent temporary gastric stimulation with small bowel electrodes. Subjective and objective data was collected before and after temporary gastric stimulation. Symptom scores, gastric emptying times, and mucosal electrograms via low-resolution mapping were recorded.

RESULTS

Animal gastric stimulation resulted in some changes in electrical activity parameters, especially with the highest energies delivered but the changes were not statistically significant. Human study revealed improvement in symptom and illness severity scores, and changes in small bowel mucosal slow wave activity.

CONCLUSIONS

Gastric electrical stimulation in an animal model seems to show nonsignificant effects small bowel slow wave activity and myoelectric signaling, suggesting the existence of intrinsic neural connections. Human data shows more significance, with possible potential for therapeutic use of electrical stimulation in patients with gastroparesis and pancreato-biliary and small bowel symptoms of the mid-gut. This study was limited by the nonsurvival pig model, small sample size, and open label human study.

Clinical Efficacy of Serum-Derived Bovine Immunoglobulin in Patients With Refractory Inflammatory Bowel Disease

BACKGROUND

Inflammatory bowel disease (IBD) can have autoimmunity and/or intestinal barrier dysfunction as part of pathophysiology and may be refractory to all available treatment options. Serum-derived bovine immunoglobulin (SBI) binds microbial components with postulated downstream effects of normalized gut immune and barrier function, which may be useful for managing IBD. The purpose of our study was to evaluate the effectiveness of SBI in the management of refractory IBD, particularly symptoms of chronic diarrhea and loose stools.

METHODS

We retrospectively analyzed charts for patients diagnosed with IBD (n = 40) who were refractory to standard treatment. Patients received oral SBI 5 g daily for a period of at least 6 weeks. Twelve patients with IBD fulfilled study inclusion criteria. Each patient graded the severity and frequency of gastrointestinal symptoms before starting SBI and at 6 weeks of treatment using a standardized patient assessment form. Means and standard deviations for all symptom scores at baseline and week 6 of treatment were analyzed.

RESULTS

Mean symptom scores decreased significantly for nausea (P = 0.02 for severity and P = 0.03 for mean symptom score) and diarrhea (P = 0.0006, P = 0.0001 and P = 0.0001 for severity, frequency and mean symptom score, respectively).

CONCLUSIONS

Therapy with SBI alleviated some refractory gastrointestinal symptoms in patients with IBD, including nausea and diarrhea. Increased duration, dosage and/or frequency of SBI might provide additional symptom improvement and could be tested through controlled clinical trials with larger sample sizes and longer follow-up.

Differences in Referral Access to Care Between Gastrointestinal Subspecialty Patients: Barriers and Opportunities

Purpose: Referral access to subspecialty care for patients with gastrointestinal (GI) diseases is not well defined, but has significant importance to patients. We hypothesized that patients experience barriers to care in two common gastroenterology subspecialties, Hepatology and Motility, in a university medical center. Methods: Two hundred thirteen clinic patients (mean age 46.5 years; 66.5% female; 85.6% Caucasians) completed a formatted questionnaire on access to care. Hepatology patients were older (49.7 years, p=0.008); motility patients predominantly female (76.8%, p<0.001). Gender distribution was even for hepatology (51.2% female). Both groups were overweight (mean body mass index 28.4). Results: Patients waited a mean 89.5 days to be seen by a subspecialist. There were differences by subspecialty (107.6 days for motility vs. 64.3 days for hepatology, p=0.022). A larger percentage of motility patients were told nothing was wrong with them (16.8%, p<0.01) and could not be helped (42.1%, p=0.000). Conclusions: Access to care for subspecialty gastroenterology patients in a university center appears to be impacted by a number of variables. While there are similarities, differences exist between these two subspecialties. Motility patients were more likely to have been told they have nothing wrong with them, suffer setbacks financially, and suffer mood problems. Their wait time for appointments was also greater than hepatology patients. Further investigations of referral access for gastroenterology patients may yield additional insights into disease-specific barriers to accessing subspecialty care.

Intravenous immunoglobulin in drug and device refractory patients with the symptoms of gastroparesis-an open-label study

BACKGROUND

Gastroparesis is a complex clinical entity; many aspects of which remain unknown. Although most patients have idiopathic, diabetic, or postsurgical gastroparesis, many are thought to have measurable neuromuscular abnormalities. Immunotherapy has recently been utilized to treat suspected autoimmune gastrointestinal dysmotility.

METHODS

Fourteen patients with symptoms of gastroparesis (Gp) who were refractory to drug/device were selected from 443 Gp patients from 2013 to 2015 who were treated at the University of Louisville motility center. All patients underwent a structural and psychiatric evaluation along with detailed psychological and behavioral examination to rule out eating disorders. We performed detailed neuromuscular evaluation and all 14 patients received at least 12 weeks of intravenous immunoglobulin (400 mg/kg infusion weekly). Response was defined subjectively (symptomatic improvement) using standardized IDIOM score system.

KEY RESULTS

All 14 patients had serological evidence and/or tissue evidence of immunological abnormality. Post-IVIG therapy, there was a significant improvement in symptoms scores for nausea, vomiting, early satiety, and abdominal pain.

CONCLUSIONS AND INFERENCES

Although limited by the absence of placebo group, the data illustrate the role of autoimmunity and neuromuscular evaluation in patients with gastroparesis and support the utility of a diagnostic trial of immunotherapy in an effort to improve therapeutic outcomes for such patients.

Ambulatory gastric mucosal slow wave recording for chronic experimental studies

Dysrhythmic bioelectric slow wave activity have been implicated in major functional motility disorders such as gastroparesis and chronic unexplained nausea and vomiting, but its correlation to symptoms is still unclear. For patients with severe gastroparesis, high-frequency gastric stimulation is offered as a therapy in some centers. Temporary gastric electrical stimulation has also been proposed an approach to screen patients who would benefit from the implantation of a permanent stimulator. In this study we introduced novel methods for recording slow wave activity from the gastric mucosa during the entire temporary stimulation phase of 5 days, in 3 patients. An ambulatory recording system was applied to record 3 channels of mucosal slow wave activity, as well as three axis accelerometer data to monitor when the patient was mobile. Techniques were developed to detect large movements and these time periods were excluded from analyses of mucosal slow waves. The frequency and amplitude of the slow waves was calculated in a 5 min segment, with 75% overlap, for the entire duration. In feasibility studies, the slow wave frequency and amplitude for the patients were 3.0±0.96 cpm and 1.43±1.75 mV. Large variations in slow wave amplitude were seen in comparsion to slow wave frequency, which were concordant with previous studies. The use of the ambulatory system will allow for investigation of pathophysiology, correlation of electrophysiology data to patient symptoms and to determine the effects of post-prandial and noctural slow wave patterns. We anticipate that future use of slow wave information alongside patient symptoms may allow improved selection of patients for stimulaton techniques.

Cysticercosis of the Brain

Incidence and radiologic findings of neurocysticercosis were investigated in a series of 23 800 consecutive head examinations using computed tomography (CT). The condition was diagnosed in 168 cases (0.7%). The parenchymatous form was the most common presentation (96.3%), while the meningeal form corresponded to only 11.9 per cent of cases. These two forms coexisted in some cases. These findings reversed the knowledge on the condition based on conventional radiography. The different CT appearances in the brain are described and a new radiologic protocol for the CT evaluation of the condition is advocated, which includes a follow-up after a trial cure with Praziquantel in the presence of cysts not associated with suggestive brain calcifications. CT was more sensitive than conventional radiography in the differentiation between dead and living larvae, thus having an impact on the therapeutic management of the patients.

Mini-laparotomy with Adjunctive Care versus Laparoscopy for Placement of Gastric Electrical Stimulation

We compared outcomes for two gastric electrical stimulation placement strategies, mini-laparotomy with adjunctive care (MLAC) versus laparoscopy without adjunctive care (LAPA). For electrode placement, the peritoneal cavity was accessed with either a single 2.5 to 3.0 cm midline incision (MLAC) or three trocar incisions (LAPA). For both groups, generator was placed subcutaneously over the anterior rectus sheath. For MLAC, adjunctive pain control measures were used for placement of both electrode and generator (transversus abdominus plane block). For LAPA, those that could not be completed by laparoscopy were converted to traditional open approach and kept in the analysis. MLAC (n = 128) resulted in shorter operative times than LAPA (n = 37) (median operative time: 87.5 vs 137.0 minutes, P ≤ 0.01). Hospital length of stay was also shorter for MLAC than for LAPA (median: 2.0 vs 3.0 days, P ≤ 0.01) without any increase in readmission rates to the hospital within 30 days of discharge (11.0 vs 16.2%, P = 0.39). After equalizing learning curves, these differences were even greater (median operative time: 84.5 vs 137.0 minutes, P < 0.01; median length of stay: 1.0 vs 3.0 days; P < 0.01) without increasing 30-day read-mission rates (9.1 vs 16.2%, P = 0.25). For implantation of gastric electrical stimulators, mini-laparotomy can result in improved outcomes when coupled with adjunctive pain control measures.

Mini-laparotomy with Adjunctive Care versus Laparoscopy for Placement of Gastric Electrical Stimulation

We compared outcomes for two gastric electrical stimulation placement strategies, minilaparotomy with adjunctive care (MLAC) versus laparoscopy without adjunctive care (LAPA). For electrode placement, the peritoneal cavity was accessed with either a single 2.5 to 3.0 cm midline incision (MLAC) or three trocar incisions (LAPA). For both groups, generator was placed subcutaneously over the anterior rectus sheath. For MLAC, adjunctive pain control measures were used for placement of both electrode and generator (transversus abdominus plane block). For LAPA, those that could not be completed by laparoscopy were converted to traditional open approach and kept in the analysis. MLAC (n = 128) resulted in shorter operative times than LAPA (n = 37) (median operative time: 87.5 vs 137.0 minutes, P ≤ 0.01). Hospital length of stay was also shorter for MLAC than for LAPA (median: 2.0 vs 3.0 days, P ≤ 0.01) without any increase in readmission rates to the hospital within 30 days of discharge (11.0 vs 16.2%, P = 0.39). After equalizing learning curves, these differences were even greater (median operative time: 84.5 vs 137.0 minutes, P < 0.01; median length of stay: 1.0 vs 3.0 days; P < 0.01) without increasing 30-day readmission rates (9.1 vs 16.2%, P = 0.25). For implantation of gastric electrical stimulators, minilaparotomy can result in improved outcomes when coupled with adjunctive pain control measures.

Autonomic Evaluation of Patients With Gastroparesis and Neurostimulation: Comparisons of Direct/Systemic and Indirect/Cardiac Measures

Background

Disorders of nausea, vomiting, abdominal pain, and related problems often are manifestations of gastrointestinal, neuromuscular, and/or autonomic dysfunction. Many of these patients respond to neurostimulation, either gastric electrical stimulation or electroacupuncture. Both of these therapeutic techniques appear to influence the autonomic nervous system which can be evaluated directly by traditional testing and indirectly by heart rate variability.

Methods

We studied patients undergoing gastric neuromodulation by both systemic autonomic testing (39 patients, six males and 33 females, mean age 38 years) and systemic autonomic testing and heart rate variability (35 patients, seven males and 28 females, mean age 37 years) testing before and after gastric neuromodulation. We also performed a pilot study using both systemic autonomic testing and heart rate variability in a small number of patients (five patients, all females, mean age 48.6 years) with diabetic gastroparesis at baseline to compare the two techniques at baseline. Systemic autonomic testing and heart rate variability were performed with standardized techniques and gastric electrical stimulation was performed as previously described with electrodes implanted serosally in the myenteric plexus.

Results

Both systemic autonomic testing and heart rate variability measures were often abnormal at baseline and showed changes after gastric neuromodulation therapy in two groups of symptomatic patients. Pilot data on a small group of similar patients with systemic automatic nervous measures and heart rate variability showed good concordance between the two techniques.

Conclusions

Both traditional direct autonomic measures and indirect measures such as heart rate variability were evaluated, including a pilot study of both methods in the same patient group. Both appear to be useful in evaluation of patients at baseline and after stimulation therapies; however, a future full head-to-head comparison is warranted.

X-ray structure of a lectin-bound DNA duplex containing an unnatural phenanthrenyl pair

DNA duplexes containing unnatural base-pair surrogates are attractive biomolecular nanomaterials with potentially beneficial photophysical or electronic properties.

Optimisation of a multipartite human immunodeficiency virus based vector system; control of virus infectivity and large-scale production

BACKGROUND

We have previously described a five-plasmid HIV-1 vector system that utilises a codon-optimised gagpol gene. While this system was shown to be safer than systems using proviral type helpers, the titre of virus produced was relatively low. Therefore, a process of optimising all aspects of virus production was initiated.

METHODS

A systematic approach was taken to the optimisation of virus production by transient expression using a five-plasmid packaging system. Codon-manipulation was used to reduce homology between helper and vector constructs. Ultrafiltration and ultracentrifugation were used for large-scale virus production.

RESULTS

We describe codon-optimised reading frames for Tat and Rev and the optimisation of virus production. The optimisation process resulted in an increase in virus titre of 7- to 8-fold. Several other approaches to increasing viral titre described by others proved ineffective in our system after it had been optimised. In addition, we show that by varying the ratio of the GagPol helper construct to vector, the infectivity of the virus could be controlled. The use of a novel codon-optimised HIV-1 GagPol expression construct with reduced homology to vector sequences significantly reduced transfer of gagpol sequences to transduced cells. Virus could be collected in serum-free medium without a significant loss of titre, which facilitated subsequent processing. Processing using a combination of ultrafiltration and ultracentrifugation allowed efficient and rapid processing of litre volumes of virus supernatant.

CONCLUSIONS

By taking a systematic approach to optimising all aspects of our five-plasmid lentiviral vector system we improved titre, safety, large-scale production, and demonstrated that infectivity could be specifically controlled.

Detection of royal jelly adulteration using carbon and nitrogen stable isotope ratio analysis

Stable isotope ratios ((13)C/(12)C and (15)N/(14)N) were measured in royal jelly (RJ) samples by isotope ratio mass spectrometry (IRMS) to evaluate authenticity and adulteration. Carbon and nitrogen isotope contents (given as delta values relative to a standard, delta(13)C, delta(15)N) of RJ samples from various European origins and samples from commercial sources were analyzed. Uniform delta(13)C values from -26.7 to -24.9 per thousand were observed for authentic RJ from European origins. Values of delta(15)N ranged from -1.1 to 5.8 per thousand depending on the plant sources of nectars and pollen. High delta(13)C values of several commercial RJ samples from -20.8 to -13.3 per thousand indicated adulteration with high fructose corn syrup (HFCS) as a sugar source. Use of biotechnologically produced yeast powder as protein source for the adulterated samples was assumed as delta(15)N values were lower, as described for C(4) or CAM plant sources. RJ samples from authentic and from adulterated production were distinguished. The rapid and reliable method is suitable for urgent actual requirements in food monitoring.

Structure-function relationship in the tocopherol transfer protein

The role of specific amino acid residues in mediating the biochemical functions of tocopherol transfer protein (TTP) was investigated using site-directed mutagenesis and functional assays. These findings further current understanding of TTP mechanism of action and its role in human health.

226.Regulated expression of adhesion and anti-adhesion molecules in mouse endometrium during early pregnancy

To implant and establish the connections that are vital for further development, the early embryo must attach to and then breech the barrier posed by the epithelium of the maternal tract. Expression of adhesion and anti-adhesion molecules in the luminal epithelium of the endometrium are thought to fluctuate in a temporal pattern to 'frame' the implantation site, with their expression regulated by endocrine and paracrine factors. Anti-adhesion molecules, such as members of the mucin family, provide a barrier to implantation in sites or at times unsuitable for embryo development. Expression of adhesion molecules, or specific integrins, are thought to aid in the adhesion of the embryo, allowing it to induce changes in the underlying tissue promoting embryo invasion and pregnancy. The aim of this study was to quantitate the expression of mRNA encoding the integrins αυ, α4 and β3 and MUC1 and MUC4 from Day 0 (oestrous) to Day 4 of pregnancy (implantation) using quantitative real time RT-PCR. Uterine tissues were collected at oestrous and at Days 1, 2, 3 and 4 of pregnancy (Day 1 corresponding to the presence of a vaginal plug), total RNA was extracted, DNAse treated, reverse transcribed into cDNA, and quantified by real-time PCR using SYBR Green chemistry. All specific primers were designed using GenBank sequences and data were normalised to β-actin mRNA expression. Expression of MUC1 and MUC4 mRNAs was dramatically reduced, with mean values 20-fold and 100-fold less than at oestrous respectively, by Day 4 of pregnancy. In contrast, expression of mRNAs encoding integrins αυ, α4 and β3 was detected throughout early pregnancy. These data demonstrate that adhesion and anti-adhesion molecules are differentially expressed in the murine uterus during early pregnancy and may be key mediators in embryo implantation, promoting attachment of the embryo to the luminal epithelium in an environment conducive to embryo growth and development. Supported by a Clive & Vera Ramaciotti Project Grant to MJ Jasper.

Nonantioxidant functions of alpha-tocopherol in smooth muscle cells

Most tocopherols and tocotrienols, with the exception of alpha-tocopherol, are not retained by humans. This suggests that alpha-tocopherol is recognized uniquely; therefore, it may exert an exclusive function. alpha-Tocopherol possesses distinct properties that are independent of its prooxidant, antioxidant or radical-scavenging ability. alpha-Tocopherol specifically inhibits protein kinase C, the growth of certain cells and the transcription of the CD36 and collagenase genes. Activation events have also been seen on the protein phosphatase 2A (PP(2)A) and on the expression of other genes (alpha-tropomyosin and connective tissue growth factor). Neither ss-tocopherol nor probucol possessed the same specialty functions as alpha-tocopherol. Recently, we isolated a new ubiquitous cytosolic alpha-tocopherol binding protein (TAP). Its motifs suggest that it is a member of the hydrophobic ligand-binding protein family (CRAL-TRIO). TAP may also be involved in the regulation of cellular alpha-tocopherol concentration and alpha-tocopherol-mediated signaling.

[Dural fistulas of the anterior cranial fossa]

Dural arterio-venous shunts (DAVS) of the anterior cranial fossa are quite rare. There are only a few cases reported in the literature. The authors present 5 cases of dural arterio-venous shunts (DAVS) of the anterior cranial fossa, allowing more data for later reviews of this rare and aggressive localisation of DAVS. The clinical set, imaging findings (with emphasis in diagnostic angiography), treatment and outcome in these 5 patients are described. Haemorrhage was the presenting form in 4 patients; the other case presented was investigated for headache. There were bilateral symmetric feeders in two patients, unilateral feeders in another two and unilateral predominant feeders in one; contribution of the external carotid artery, when present, was always minimal. Venous drainage included one or combinations of these: superior sagittal sinus, sylvian veins and cavernous sinus. Three patients had venous aneurysms in anterior cranial fossa; of these, two presented with haemorrhage, but the third one of them has been asymptomatic for 7 years. Three patients were treated by surgical exclusion of the shunt and became clinical and angiographicaly normal. According to the literature, our cases confirm the highly aggressive behaviour of these DAVS. Surgical treatment is an efficacious method of therapy and should be done as soon as possible. Embolization can be attempted but is technically difficult and eventually too expensive.

[Endovascular treatment of dissecting aneurysms of the posterior cerebral artery]

In the literature, there are few reports of posterior cerebral artery aneurysms resulting from isolated dissections. In these cases the treatment is still a matter of discussion and includes anticoagulation, surgical intervention, endovascular techniques and conservative management. We present five cases of Posterior Cerebral Artery (PCA) aneurysms, with angiographic criteria of dissection (double lumen, proximal narrowing), all being situated at the P2 segment, three being close to the P1/P2 junction. In one case, a large aneurysm ruptured during the attempted catheterization with subsequent death of the patient. In three patients occlusion of the parent vessel was performed with Guglielmi detachable coils located proximal to the aneurysm, with no new neurological deficits. In the other case there was spontaneous thrombosis of the aneurysm. Occlusion of the parent vessel by endovascular techniques in dissecting PCA aneurysms has a low probability of neurological deficits and seems to be an appropriate approach for these aneurysms.

A novel human tocopherol-associated protein: cloning, in vitro expression, and characterization

Vitamin E (alpha-tocopherol) is an essential dietary nutrient for humans and animals. The mechanisms involved in cellular regulation as well as in the preferential cellular and tissue accumulation of alpha-tocopherol are not yet well established. We previously reported (Stocker, A., Zimmer, S., Spycher, S. E., and Azzi, A. (1999) IUBMB Life 48, 49-55) the identification of a novel 46-kDa tocopherol-associated protein (TAP) in the cytosol of bovine liver. Here, we describe the identification, the molecular cloning into Escherichia coli, and the in vitro expression of the human homologue of bovine TAP, hTAP. This protein appears to belong to a family of hydrophobic ligand binding proteins, which have the CRAL (cis-retinal binding motif) sequence in common. By using a biotinylated alpha-tocopherol derivative and the IASys resonant mirror biosensor, the purified recombinant protein was shown to bind tocopherol at a specific binding site with K(d) 4.6 x 10(-7) m. Northern analyses showed that hTAP mRNA has a size of approximately 2800 base pairs and is ubiquitously expressed. The highest amounts of hTAP message are found in liver, brain, and prostate. In conclusion, hTAP has sequence homology to proteins containing the CRAL_TRIO structural motif. TAP binds to alpha-tocopherol and biotinylated tocopherol, suggesting the existence of a hydrophobic pocket, possibly analogous to that of SEC14.

Specific cellular responses to alpha-tocopherol

In the last 10 years precise cellular functions of alpha-tocopherol, some of which are independent of its antioxidant/radical-scavenging ability, have been revealed. Absorption of alpha-tocopherol from the gut is a selective process. Other tocopherols are not absorbed or are absorbed to a lesser extent. At the post-translational level, alpha-tocopherol inhibits protein kinase C and 5-lipoxygenase and activates protein phosphatase 2A and diacylglycerol kinase. Some genes [platelet glycoprotein IV/thrombospondin receptor/class B scavenger receptor (CD36), alpha-tocopherol transfer protein (alpha-TTP), alpha-tropomyosin, connective tissue growth factor and collagenase] are affected by alpha-tocopherol at the transcriptional level. alpha-Tocopherol also inhibits cell proliferation, platelet aggregation, monocyte adhesion and the oxygen burst in neutrophils. Other antioxidants, such as beta-tocopherol and probucol, do not mimic these effects, suggesting a nonantioxidant, alpha-tocopherol-specific molecular mechanism.

Vitamin E: non-antioxidant roles

Vitamin E was originally considered a dietary factor of animal nutrition especially important for normal reproduction. The significance of vitamin E has been subsequently proven as a radical chain breaking antioxidant that can protect the integrity of tissues and play an important role in life processes. More recently alpha-tocopherol has been found to possess functions that are independent of its antioxidant/radical scavenging ability. Absorption in the body is alpha-tocopherol selective and other tocopherols are not absorbed or are absorbed to a lesser extent. Furthermore, pro-oxidant effects have been attributed to tocopherols as well as an anti-nitrating action. Non-antioxidant and non-pro-oxidant molecular mechanisms of tocopherols have been also described that are produced by alpha-tocopherol and not by beta-tocopherol. alpha-Tocopherol specific inhibitory effects have been seen on protein kinase C, on the growth of certain cells and on the transcription of some genes (CD36, and collagenase). Activation events have been seen on the protein phosphatase PP2A and on the expression of other genes (alpha-tropomyosin and Connective Tissue Growth Factor). Non-antioxidant molecular mechanisms have been also described for gamma-tocopherol, delta-tocopherol and tocotrienols.

Differential regulation of activation-induced cell death in individual human T cell clones

BACKGROUND

Restimulation of T lymphocytes via the TCR/CD3 complex can result in CD95/CD95L-dependent activation-induced cell death (AICD). Although the correlation of AICD sensitivity to the T helper 1 phenotype was confirmed in different studies, the underlying mechanism is still debated. Thus, it has been suggested that in Th2 cells, AICD resistance is controlled by a TCR-induced upregulation of the CD95-associated inhibitory phosphatase, FAP-1. We and others demonstrated that AICD resistance is associated with a reduced surface expression of CD95L upon restimulation.

METHODS

Utilizing RT-PCR, Western blotting and flow cytometry, we analyzed time-dependent changes in levels of CD95L mRNA, cytosolic protein and surface expression in five long-term human T cell clones and polarized helper populations.

RESULTS

We confirm that the inducible CD95L surface expression is lower or absent in all tested AICD-resistant clones as compared to sensitive cells. It is of interest that striking differences with respect to the activation-dependent inducibility of CD95L mRNA expression in individual resistant clones were observed. In addition, alterations in the expression of the inhibitory phosphatase FAP-1 or TCR-dependent changes in CD95 sensitivity in AICD-resistant clones could be ruled out as a mechanism for AICD resistance of human T cell clones.

CONCLUSIONS

(1) The data presented strongly support the previous notion that AICD resistance of human T cell clones is mainly regulated by a differential expression of CD95L. (2) Differential expression of CD95L on individual resistant clones results from a lack of mRNA induction in one set and from a markedly decreased surface expression of translated protein in another set of clones.

Tocopherol-binding proteins: their function and physiological significance

The present review is a continuation of earlier essays on the uptake mechanisms and the biological function of vitamin E. There are eight naturally occurring homologues of vitamin E, which differ in their structure and in biological activity in vivo and in vitro. Various studies have suggested that after normal gastrointestinal absorption of dietary vitamin E specific mechanisms favor the preferential accumulation of one of its homologues, alpha-tocopherol, in the human body. This process is thought to be mediated in part by the alpha-tocopherol transfer protein (alpha-TTP) in the liver cytoplasm. The mechanism and pathway by which alpha-TTP specifically incorporates alpha-tocopherol into plasma lipoproteins is not yet fully understood. Because alpha-tocopherol is widely distributed in tissues in various concentrations but alpha-TTP resides only in liver, its role as intracellular carrier of alpha-tocopherol seems unlikely. However, recent data indicate that a system of alpha-tocopherol-binding proteins is involved in these processes that favor the localization of alpha-tocopherol at the sites where it is required. The current status of the evidence for the regulation of alpha-tocopherol levels and their impact on cellular signaling is discussed.

Vitamin E mediated response of smooth muscle cell to oxidant stress

Oxidant stress is associated with diminution of antioxidant molecules, such as alpha-tocopherol. Alpha-tocopherol specifically decreases, in a concentration dependent way, the proliferation of vascular smooth muscle cells. At the same concentrations (10-50 microM) it induces inhibition of protein kinase C (PKC) activity. The latter event is not due to a decrease in PKC level or to alpha-tocopherol binding to PKC, but it results from increase of protein phosphatase 2A1 activity. In vitro data, as well as at a cellular level, demonstrates that protein phosphatase 2A1 is activated, in its trimeric structure--but not as a dimer by alpha-tocopherol. This activation is followed by PKC-alpha dephosphorylation. The activation of protein phosphatase 2A1 and deactivation of PKC-alpha affect the AP1 transcription factor, resulting in a change in the composition and the binding of this factor to DNA. By transfecting smooth muscle cell with a construct containing three TRE (TPA responsive elements), the promoter thymidine kinase and the reporter gene chloramphenicol-acetyl-transferase a modulation of gene expression by alpha-tocopherol is observed. Beta-tocopherol does not cause any of the responses observed with alpha-tocopherol and R,R,R-alpha-tocopherol is twice as potent as all-rac-alpha-tocopherol. When added together, beta-tocopherol prevents the effects of alpha-tocopherol indicating that the mechanism involved is not related to the radical-scavenging properties of these two molecules, which are essentially equal. By differential display analysis it has been found that several genes of smooth muscle cells are differentially transcribed in the presence of alpha-tocopherol but not beta-tocopherol. In particular, the gene of alpha-tropomyosin shows a transient enhancement of transcription as a function of the cell cycle time. Alpha-tropomyosin translation is also increased by alpha-tocopherol and not by beta-tocopherol. Because no changes of mRNA stability can be observed in the presence of alpha-tocopherol, the data supports the conclusion of a transcriptional control exerted by alpha-tocopherol on alpha-tropomyosin. Generally, the data strongly suggests the existence of a ligand/receptor type of mechanism at the basis of alpha-tocopherol action. It is concluded that an oxidative stress-induced diminution of alpha-tocopherol in smooth muscle cell activates a reaction cascade leading to changes in gene expression and increase in cell proliferation by a non-antioxidant mechanism.

Covalent flavinylation of L-aspartate oxidase from Escherichia coli using N6-(6-carboxyhexyl)-FAD succinimidoester

L-Aspartate oxidase is a flavoprotein catalyzing the first step in the de novo biosynthesis of pyridine nucleotides in E. coli. Binding of FAD to L-aspartate oxidase is relatively weak (K(d) 6.7 x 10(-7) M), resulting in partial loss of the coenzyme under many experimental conditions. Only the three-dimensional structure of the apo-enzyme has been obtained so far. In order to probe the flavin-binding site of the enzyme, apo-L-aspartate oxidase has been reacted with N6-(6-carboxyhexyl)-FAD succinimidoester. The structural characterization of the resulting N6-(6-carbamoylxyhexyl)FAD-L-aspartate oxidase shows the covalent incorporation of 1 FAD-analog/monomer. Residue Lys38 was identified as the target of the covalent modification. N6-(6-carbamoylxyhexyl)-FAD-L-aspartate oxidase shows only 2% catalytic activity as compared to the native enzyme. Comparison of some properties of the flavinylated and native enzymes suggests that, although the flavin is covalently bound to the former in the region predicted from molecular modeling studies, the microenvironment around the isoallossazine is different in the two forms.

Identification of a novel cytosolic tocopherol-binding protein: structure, specificity, and tissue distribution

Alpha-tocopherol plays an important role as a lipid-soluble antioxidant. It is present in all major mammalian cell types and shows tissue-specific distribution. This suggests the presence of specific proteins involved in intracellular distribution or metabolism of alpha-tocopherol. A diminution of tocopherol plasma concentrations contributes to the development of diseases such as vitamin E deficiency (AVED), atherosclerosis, and prostate cancer. Further evidence has been obtained for the existence of sites in cellular metabolism and signal transduction where alpha-tocopherol potentially plays a regulatory role. A signal transduction modulation specific for alpha-tocopherol has been described in several model systems. Using radioactively labeled alpha-tocopherol as tracer, we have isolated a new alpha-tocopherol-associated protein (TAP) from bovine liver. This protein has a molecular mass of 46 kDa and an isoelectric point of 8.1. From its partial amino acid sequence, a human gene has been identified with high homology to the newly described protein. Sequence analysis has established that the new TAP has structural motifs suggesting its belonging to a family of hydrophobic ligand-binding proteins (RALBP, CRALBP, alpha-TTP, SEC 14, PTN 9, RSEC 45). Human TAP has been cloned into Escherichia coli, and its tissue-specific expression has been assessed by Northern blot analysis.

Endovascular treatment of an intracranial dural arteriovenous fistula with spinal venous drainage. A case report

SUMMARY

A case of type V intracranial dural arteriovenous fistula (DAVF) is reported because of its unusual rapidly progressive paraparesis, Despite this clinical presentation, the diagnosis of DAVF was made and precocious endovascular treatment was instituted, Angiographic normalization was obtained after embolisation and the patient significantly improved within the first weeks, although at the six month control MRI there still was a hyperintense signal of the cord in T2 weighted images, but less extensive than originally.

Signalling functions of alpha-tocopherol in smooth muscle cells

alpha-Tocopherol but not beta-tocopherol, activates protein phosphatase 2A, decreases protein kinase C activity and attenuates smooth muscle cell proliferation at physiological concentrations. beta-Tocopherol prevents the effects of alpha-tocopherol. Inhibition of protein kinase C alpha, but not of the other isoforms, by the inhibitor Gö6976 prevents the effect of alpha-tocopherol. Protein kinase C alpha, immunoprecipitated from alpha-tocopherol treated cells, is less phosphorylated and inactive. It is proposed that the specific activation of protein phosphatase 2A by alpha-tocopherol results in dephosphorylation and inactivation of protein kinase C alpha. Finally, this cascade of events leads to smooth muscle cell proliferation inhibition.

The substrate specificity of tocopherol cyclase

The substrate specificity of the enzyme tocopherol cyclase from the blue-green algae Anabaena variabilis (Cyanobacteria) was investigated with 11 substrate analogues revealing the significance of three major recognition sites: (i) the OH group at C(1) of the hydroquinone, (ii) the (E) configuration of the double bond, and (iii) the length of the lipophilic side chain. Experiments with two affinity matrices suggest that substrates approach the enzyme's active site with the hydrophobic tail.