[Incisional hernias: minimally invasive surgical procedures]

BACKGROUND

In recent years many new surgical techniques for minimally invasive treatment of ventral hernias have been developed and introduced. This review article presents these new minimally invasive surgical techniques, such as extended totally extraperitoneal (eTEP) repair, mini or less open sublay (MILOS), endoscopic-assisted linea alba reconstruction (ELAR), the ventral transabdominal preperitoneal patch (TAPP) technique, intraperitoneal onlay mesh (IPOM) plus and laparoscopic intracorporeal rectus aponeuroplasty (LIRA) and discusses recently published results.

RESULTS

Modern minimally invasive techniques for the treatment of ventral hernias have the potential to reduce surgical site infections, lower postoperative pain and lead to a shorter duration of hospital stay compared to the classical open hernia repair; however, especially techniques with a retromuscular mesh position are technically challenging due to the preparation in a limited space and difficult to perform endoscopic sutures and necessitate detailed knowledge of the anatomy of the abdominal wall. The treatment of larger hernias in particular should therefore only be carried out under the prerequisite of extensive experience and case numbers.

CONCLUSION

The new endoscopic and endoscopically assisted techniques for treatment of ventral hernias enable the experienced laparoscopic surgeon to primarily and secondarily treat ventral hernias with minimally invasive techniques.

Robotic hernia repair III. English version : Robotic incisional hernia repair with transversus abdominis release (r‑TAR). Video report and results of a cohort study

The principle of targeted separation or weakening of individual components of the abdominal wall to relieve tension in the median line during major abdominal reconstruction has been known for over 30 years as anterior component separation (aCS) and is an established procedure. In search of alternatives with lower complication rates, posterior component separation (pCS) was developed; transversus abdominis release (TAR) is a nerve-sparing modification of pCS. With the ergonomic resources of robotics (e.g., angled instruments), TAR can be performed in a minimally invasive manner (r-TAR): hernia gaps of up to 14 cm can be closed and a large extraperitoneal mesh implanted. In this video article, the treatment of large incisional hernias using the r‑TAR technique is presented. Exemplary results of a cohort study in 13 consecutive patients are presented. The procedure is challenging, but our own results-as well as reports from the literature-are encouraging. The r‑TAR is becoming the pinnacle procedure for abdominal wall reconstruction.

Robotic hernia repair II. English version : Robotic primary ventral and incisional hernia repair (rv‑TAPP and r‑Rives or r‑TARUP). Video report and results of a series of 118 patients

Endoscopic management of umbilical and incisional hernias has adapted to the limitations of conventional laparoscopic instruments over the past 30 years. This includes the development of meshes for intraperitoneal placement (intraperitoneal onlay mesh, IPOM), with antiadhesive coatings; however, adhesions do occur in a significant proportion of these patients. Minimally invasive procedures result in fewer perioperative complications, but with a slightly higher recurrence rate. With the ergonomic resources of robotics, which offers angled instruments, it is now possible to implant meshes in a minimally invasively manner in different abdominal wall layers while achieving morphologic and functional reconstruction of the abdominal wall. This video article presents the treatment of ventral and incisional hernias with mesh implantation into the preperitoneal space (robot-assisted transabdominal preperitoneal ventral hernia repair, r‑ventral TAPP) as well as into the retrorectus space (r-Rives and robotic transabdominal retromuscular umbilical prosthetic repair, r‑TARUP, respectively). The results of a cohort study of 118 consecutive patients are presented and discussed with regard to the added value of the robotic technique in extraperitoneal mesh implantation and in the training of residents.

Robotic hernia surgery I. English version : Robotic inguinal hernia repair (r‑TAPP). Video report and results of a series of 302 hernia operations

The treatment of inguinal hernias with open and minimally invasive procedures has reached a high standard in terms of outcome over the past 30 years. However, there is still need for further improvement, mainly in terms of reduction of postoperative seroma, chronic pain, and recurrence. This video article presents the endoscopic anatomy of the groin with regard to robotic transabdominal preperitoneal patch plasty (r‑TAPP) and illustrates the surgical steps of r‑TAPP with respective video sequences. The results of a cohort study of 302 consecutive hernias operated by r‑TAPP are presented and discussed in light of the added value of the robotic technique, including advantages for surgical training. r‑TAPP is the natural evolution of conventional TAPP and has the potential to become a new standard as equipment availability increases and material costs decrease. Future studies will also have to refine the multifaceted added value of r‑TAPP with new parameters.

Assessment of the microvasculature in poppers maculopathy

Purpose

To investigate a possible microvascular component of poppers maculopathy (PMP) using optical coherence tomography angiography (OCTA).

Methods

Twelve patients suffering from poppers maculopathy were included. Health records, optical coherence tomography (OCT), and OCTA data was gathered and compared to a healthy control group (HC). PMP lesion type was determined by manifestation in OCT. OCTA-based evaluation of retinal vascular plexus and choriocapillaris (CC) was executed. Vessel density (VD) and vessel length density (VLD) in superficial and deep capillary plexus (SCP, DCP), as well as flow deficits (FD), within the foveal avascular zone (FAZ) in CC were assessed.

Results

Median age of PMP patients was 40 (min 24; max 64) years, all male. Eleven patients presented with ellipsoid zone-type lesions; one patient showed a vitelliform-type lesion. No qualitative microvascular changes between PMP patients and HC were identified. Quantitative values for VD and VLD of SCP and DCP did not differ in between the two groups. The analysis of FDs in CC showed no deviation from PMP patients to HC.

Conclusions

No vascular anomalies in qualitative and quantitative analysis in OCTA were detected in PMP patients. The constitution of the CC within FAZ of PMP patients does not differ from HC when assessed as FD.

[Robotic hernia repair : Part III: Robotic incisional hernia repair with transversus abdominis release (r-TAR). Video report and results of a cohort study]

The principle of targeted separation or weakening of individual components of the abdominal wall to relieve tension in the median line during major abdominal reconstruction has been known for over 30 years as anterior component separation (aKS) and is an established procedure. In search of alternatives with lower complication rates, posterior component separation (pKS) was developed; transversus abdominis release (TAR) is a nerve-sparing modification of pKS. With the ergonomic resources of robotics (e.g., angled instruments), TAR can be performed in a minimally invasive manner (r-TAR): hernia gaps of up to 14 cm can be closed and a large extraperitoneal mesh implanted. In this video article, the treatment of large incisional hernias using the r‑TAR technique is presented. Exemplary results of a cohort study in 13 consecutive patients are presented. The procedure is challenging, but our own results-as well as reports from the literature-are encouraging. The r‑TAR is becoming the pinnacle procedure for abdominal wall reconstruction.

Excess Body Weight and Abdominal Hernia

Background

Obese patients have an increased incidence of ventral hernias; in over 50% of these cases, patients are symptomatic. At the same time, morbid obesity is a disease of epidemic proportions. The combination of symptomatic hernia and obesity is a challenge for the treating surgeon, because the risk of perioperative complications and recurrence increases with increasing BMI.

Summary

This review outlines this problem and discusses interdisciplinary approaches to the management of affected patients. In emergency cases, the hernia is treated according to the surgeon's expertise. In elective cases, an individual decision must be made whether bariatric surgery is indicated before hernia repair or whether both should be performed simultaneously. After bariatric surgery a weight reduction of 25-30% of total body weight in the first year can be achieved and it is often advantageous to perform a bariatric operation prior to hernia repair. Technically, the risk of complications is lower with minimally invasive procedures than with open ones, but laparoscopy is challenging in obese patients, and meshes can only be implanted in intraperitoneal position. This mesh position has to be questioned because of adhesions, recurrence rate, and risk of contamination during re-interventions in patients who are often still relatively young.

Key Messages

Obese patients with hernia need to be approached in an interdisciplinary manner, in some patients a weight loss procedure may be advantageous before hernia repair. Recent data show the benefits of robotic hernia surgery in obese patients, as not only haptic advantages result, but especially the mesh can be implanted in a variety of extraperitoneal positions in the abdominal wall with low morbidity.

[Robotic hernia repair : Part II: Robotic primary ventral and incisional hernia repair (rv-TAPP and r-Rives or r-TARUP). Video report and results of a series of 118 patients]

Endoscopic management of umbilical and incisional hernias has adapted to the limitations of conventional laparoscopic instruments over the past 30 years. This includes the development of meshes for intraperitoneal placement (intraperitoneal onlay mesh, IPOM), with antiadhesive coatings; however, adhesions do occur in a significant proportion of these patients. Minimally invasive procedures result in fewer perioperative complications, but with a slightly higher recurrence rate. With the ergonomic resources of robotics, which offers angled instruments, it is now possible to implant meshes in a minimally invasively manner in different abdominal wall layers while achieving morphologic and functional reconstruction of the abdominal wall. This video article presents the treatment of ventral and incisional hernias with mesh implantation into the preperitoneal space (robot-assisted transabdominal preperitoneal ventral hernia repair, r‑ventral TAPP) as well as into the retrorectus space (r-Rives and robotic transabdominal retromuscular umbilical prosthetic repair, r‑TARUP, respectively). The results of a cohort study of 118 consecutive patients are presented and discussed with regard to the added value of the robotic technique in extraperitoneal mesh implantation and in the training of residents.

[Robotic hernia surgery : Part I: Robotic inguinal hernia repair (r‑TAPP). Video report and results of a series of 302 hernia operations]

The treatment of inguinal hernias with open and minimally invasive procedures has reached a high standard in terms of outcome over the past 30 years. However, there is still need for further improvement, mainly in terms of reduction of postoperative seroma, chronic pain, and recurrence. This video article presents the endoscopic anatomy of the groin with regard to robotic transabdominal preperitoneal patch plasty (r‑TAPP) and illustrates the surgical steps of r‑TAPP with respective video sequences. The results of a cohort study of 302 consecutive hernias operated by r‑TAPP are presented and discussed in light of the added value of the robotic technique, including advantages for surgical training. r‑TAPP is the natural evolution of conventional TAPP and has the potential to become a new standard as equipment availability increases and material costs decrease. Future studies will also have to refine the multifaceted added value of r‑TAPP with new parameters.

Robotic inguinal hernia repair (rTAPP) – A series of 300 cases

Objective

While inguinal hernia repair using mesh is the recommended standard for most patients, minimal invasive techniques experienced a prolonged process until broad acceptance and sufficient expertise. Lately, a reluctance towards the integration of robotic hernia repair as a standard procedure is observed in Europe compared to the US. Nevertheless, robotic technology is a powerful tool for increasing quality in standardized procedures. We present a large case series of inguinal hernias repaired by robotic surgery.

Methods

All consecutive patients receiving a robotic inguinal hernia repair with a transabdominal approach (rTAPP) in the first 18 months (May 2018 up to October 2019) after introduction of the DaVinci Xi system at our institution were included in this study.

Results

Overall, 302 groin hernias in 225 patients were operated in the defined period. 77 patients presented with bilateral hernias. Mean age of patients was 58.7 years, 87.6% were men. Mean BMI 25.5kg/m2.

Nearly half of all operations were teaching operations making use of the available double consoles. While in the first 6 months only 20.0% of operations were teaching procedures, the rate increased to 60.3% in the last 6 months of the observation period.

While overall 35.6% of procedures were performed as day-surgery, the rate varied over the course of the study with 35.6% in the first 6 months, 46.0% in the second and 33.3% in the last 6 months.

Operation time was 82.6min. (range 40-186) with 72min. (range 40-186) for unilateral repairs and 101.3min. (range 52-169) for bilateral repairs. Further subgroup analysis showed that in bilateral repairs in primary hernias teaching vs. no-teaching operations differed only marginally in time (108.9min., range 66-149 vs. 91.6min., range 52-159).

Follow-up data was available for 93.8% of patients. There were no cases of recurrence; two patients experienced postoperative pain lasting more than 30 days. Seroma was observed in 8.9%, haematoma in 4.4% cases. Urinary retention occurred in 3.6% of patients, PE in 0.4%, DVT in 0.4%, epididymitis in 3.1%.

Conclusion

Robotic inguinal hernia repair is an outstanding and safe procedure. The operative accuracy of the system is impressive. The availability of two consoles makes it an ideal teaching tool, allowing to train residents in inguinal hernia repair, in a high standard of safety and with good outcomes.

Human Pluripotent Stem Cell-Derived Multipotent Vascular Progenitors of the Mesothelium Lineage Have Utility in Tissue Engineering and Repair

In this report we describe a human pluripotent stem cell-derived vascular progenitor (MesoT) cell of the mesothelium lineage. MesoT cells are multipotent and generate smooth muscle cells, endothelial cells, and pericytes and self-assemble into vessel-like networks in vitro. MesoT cells transplanted into mechanically damaged neonatal mouse heart migrate into the injured tissue and contribute to nascent coronary vessels in the repair zone. When seeded onto decellularized vascular scaffolds, MesoT cells differentiate into the major vascular lineages and self-assemble into vasculature capable of supporting peripheral blood flow following transplantation. These findings demonstrate in vivo functionality and the potential utility of MesoT cells in vascular engineering applications.

Laparoscopic right-sided colon resection for colon cancer-has the control group so far been chosen correctly?

Background

The treatment strategies for colorectal cancer located in the right side of the colon have changed dramatically during the last decade. Due to the introduction of complete mesocolic excision (CME) with central ligation of the vessels and systematic lymph node dissection, the long-term survival of affected patients has increased significantly. It has also been proposed that right-sided colon resection can be performed laparoscopically with the same extent of resection and equal long-term results.

Methods

A retrospective evaluation of a prospectively expanded database on right-sided colorectal cancer or adenoma treated at the University Hospital of Wuerzburg between 2009 and 2016 was performed. All patients underwent CME. This data was analyzed alone and in comparison to the published data describing laparoscopic right-sided colon resection for colon cancer.

Results

The database contains 279 patients, who underwent right-sided colon resection due to colorectal cancer or colorectal adenoma (255 open; 24 laparoscopic). Operation data (time, length of stay, time on ICU) was equal or superior to laparoscopy, which is comparable to the published results. Surprisingly, the surrogate parameter for correct CME (the number of removed lymph nodes) was significantly higher in the open group. In a subgroup analysis only including patients who were feasible for laparoscopic resection and had been operated with an open procedure by an experienced surgeon, operation time was significantly shorter and the number of removed lymph nodes is significantly higher in the open group.

Conclusion

So far, several studies demonstrate that laparoscopic right-sided colon resection is comparable to open resection. Our data suggests that a consequent CME during an open operation leads to significantly more removed lymph nodes than in laparoscopically resected patients and in several so far published data of open control groups from Europe. Further prospective randomized trials comparing the long-term outcome are urgently needed before laparoscopy for right-sided colon resection can be recommended ubiquitously.

The Transcription Factor NFATc1 Supports the Rejection of Heterotopic Heart Allografts

The immune suppressants cyclosporin A (CsA) and tacrolimus (FK506) are used worldwide in transplantation medicine to suppress graft rejection. Both CsA and FK506 inhibit the phosphatase calcineurin (CN) whose activity controls the immune receptor-mediated activation of lymphocytes. Downstream targets of CN in lymphocytes are the nuclear factors of activated T cells (NFATs). We show here that the activity of NFATc1, the most prominent NFAT factor in activated lymphocytes supports the acute rejection of heterotopic heart allografts. While ablation of NFATc1 in T cells prevented graft rejection, ectopic expression of inducible NFATc1/αA isoform led to rejection of heart allografts in recipient mice. Acceptance of transplanted hearts in mice bearing NFATc1-deficient T cells was accompanied by a reduction in number and cytotoxicity of graft infiltrating cells. In CD8⁺ T cells, NFATc1 controls numerous intracellular signaling pathways that lead to the metabolic switch to aerobic glycolysis and the expression of numerous lymphokines, chemokines, and their receptors, including Cxcr3 that supports the rejection of allogeneic heart transplants. These findings favors NFATc1 as a molecular target for the development of new strategies to control the cytotoxicity of T cells upon organ transplantation.

Evaluation of a Miniaturized Biologically Vascularized Scaffold in vitro and in vivo

In tissue engineering, the generation and functional maintenance of dense voluminous tissues is mainly restricted due to insufficient nutrient supply. Larger three-dimensional constructs, which exceed the nutrient diffusion limit become necrotic and/or apoptotic in long-term culture if not provided with an appropriate vascularization. Here, we established protocols for the generation of a pre-vascularized biological scaffold with intact arterio-venous capillary loops from rat intestine, which is decellularized under preservation of the feeding and draining vascular tree. Vessel integrity was proven by marker expression, media/blood reflow and endothelial LDL uptake. In vitro maintenance persisted up to 7 weeks in a bioreactor system allowing a stepwise reconstruction of fully vascularized human tissues and successful in vivo implantation for up to 4 weeks, although with time-dependent decrease of cell viability. The vascularization of the construct lead to a 1.5× increase in cellular drug release compared to a conventional static culture in vitro. For the first time, we performed proof-of-concept studies demonstrating that 3D tissues can be maintained within a miniaturized vascularized scaffold in vitro and successfully implanted after re-anastomosis to the intrinsic blood circulation in vivo. We hypothesize that this technology could serve as a powerful platform technology in tissue engineering and regenerative medicine.

Impact of extended lymphadenectomy on morbidity and regional recurrence-free survival in melanoma patients

Introdurction: Current guidelines for malignant melanoma do not set a concrete cutoff limit for the number of lymph nodes to be resected during regional lymph node dissection (LND). Here, we investigate if extended LND (ext-LND) has an impact on surgical morbidity and oncological outcome in melanoma patients.

MATERIAL AND METHODS

A total of 245 melanoma patients receiving axillary or inguinal LND in curative intention were investigated retrospectively. Ext-LND was defined as axillary LND with 20 or more and inguinal LND with 10 or more resected lymph nodes. Surgical morbidity and regional recurrence-free survival were investigated.

RESULTS

Ext-LND did not lead to increased surgical morbidity in the overall study collective. After ext-LND, 55.4% of the patients experienced one of the investigated complications compared to 46.2% in the limited LND group (p = .2113). There was no difference in the occurrence of lymphatic fistula, wound infection, severe bleeding or neurological complications. In addition, patients with positive lymph node status showed improved regional recurrence-free survival following ext-LND (p = .0425).

CONCLUSION

Ext-LND can be considered a quality marker of LND in melanoma patients.

Impact of adjuvant chemotherapy after neoadjuvant radio- or radiochemotherapy for patients with locally advanced rectal cancer

BACKGROUND

Due to its primarily extraperitoneal location, potential affection of the anorectal continence and different metastatic behavior the rectal carcinoma (RC) is classified and treated as an independent disease. Over the past few decades various trials have led to improved multimodal therapies (including radiation, chemotherapy and surgery) for locally advanced rectal cancer and significant changes in the management of this disease whereas the benefit of adjuvant chemotherapy remains unclear.

METHODS

Based on a prospective tumor register of the University Hospital of Wuerzburg data of 263 patients having undergone neoadjuvant therapy and surgical resection for locally advanced rectal cancer were retrieved from the Wuerzburg International database (WID) between October 1992 and September 2013 analyzing the overall survival according to the application of an adjuvant therapy.

RESULTS

The cohort consisted of 263 patients with a median age of 65 years (27-89 years), mostly male gender (n = 191; 72.6%) and an ASA performance score of II or III. 143 patients (54.3%) received an adjuvant therapy. Those patients have been significant younger (median 10 years; p < 0.05) and in a better general condition (ASA-score; p < 0.05). The tumor specific overall survival of adjuvant treated patients was significant better (5-years overall-survival 87.4%; p = 0.025) than the surveillance group. In the performed subgroup analysis no significant differences in overall survival according to the kind of neoadjuvant therapy (radiation vs. radiochemotherapy) have been found whereas patients in lower UICC-stages (ypUICC 0 + I) had a significant benefit by receiving a postoperative chemotherapy (p = 0.035).

CONCLUSION

We considered patients with locally advanced rectal cancer have a significant benefit in overall survival by receiving an adjuvant chemotherapy especially in lower pathological tumor stage (ypUICC 0 + I). Especially because of the heterogeneity of our study population prospective randomized trials are necessary to determine the impact of adjuvant chemotherapy for locally advanced rectal cancer.

Morbidity and oncologic outcome after saphenous vein-sparing inguinal lymphadenectomy in melanoma patients

BACKGROUND

Inguinal lymph node dissection (LND) is a surgical procedure with a high morbidity rate. Variations in surgical procedure, such as sparing of the saphenous vein, have been proposed to reduce surgical morbidity. While sparing of the saphenous vein has shown promising results in earlier studies, data for this procedure in melanoma patients are rare. In this retrospective study, we report 10-year findings on the effects of saphenous vein-sparing LND on surgical morbidity and oncologic outcomes in melanoma patients.

METHODS

A retrospective analysis of melanoma patients receiving inguinal LND in our facility between 2003 and 2013 was performed. Patients were divided into two groups: the saphenous vein resection group and the vein sparing group. Surgical morbidity, including wound infection, lymphatic fistula, severe bleeding, neurological complications, and chronic lymphedema, as well as regional recurrence-free survival were investigated.

RESULTS

A total of 106 patients were included in this study; of these, the saphenous vein was spared in 41 patients (38.7%). The rate of lymphatic fistula was 51.6 vs. 48.8%, wound infection occurred in 31.3 vs. 24.4%, and patients suffered from chronic lymphedema in 30.0 vs. 26.5% in V. saphena magna resection vs. sparing group. Differences observed, however, were not significant. No difference in regional recurrence-free survival between the two study groups was detected.

CONCLUSIONS

The results of our retrospective analysis could not confirm the promising results reported in earlier studies. Thus, sparing of the saphenous vein appears to be optional.

The impact of pulmonary metastasectomy in patients with previously resected colorectal cancer liver metastases

Background

40–50% of patients with colorectal cancer (CRC) will develop liver metastases (CRLM) during the course of the disease. One third of these patients will additionally develop pulmonary metastases.

Methods

137 consecutive patients with CRLM, were analyzed regarding survival data, clinical, histological data and treatment. Results were stratified according to the occurrence of pulmonary metastases and metastases resection.

Results

39% of all patients with liver resection due to CRLM developed additional lung metastases. 44% of these patients underwent subsequent pulmonary resection. Patients undergoing pulmonary metastasectomy showed a significantly better five-year survival compared to patients not qualified for curative resection (5-year survival 71.2% vs. 28.0%; p = 0.001). Interestingly, the 5-year survival of these patients was even superior to all patients with CRLM, who did not develop pulmonary metastases (77.5% vs. 63.5%; p = 0.015). Patients, whose pulmonary metastases were not resected, were more likely to redevelop liver metastases (50.0% vs 78.6%; p = 0.034). However, the rate of distant metastases did not differ between both groups (54.5 vs.53.6; p = 0.945).

Conclusion

The occurrence of colorectal lung metastases after curative liver resection does not impact patient survival if pulmonary metastasectomy is feasible. Those patients clearly benefit from repeated resections of the liver and the lung metastases.

Transarterial chemoembolization with drug-eluting beads versus conventional transarterial chemoembolization in locally advanced hepatocellular carcinoma

Purpose

In hepatocellular carcinoma patients with large or multinodal tumors, where curative treatment options are not feasible, transarterial therapies play a major role. Transarterial chemoembolization (TACE) with drug-eluting beads (DEB-TACE) is a promising new approach due to higher intratumoral and lower systemic concentration of the chemotherapeutic agent compared to conventional TACE (cTACE).

Patients and methods

In a retrospective analysis, 32 patients with hepatocellular carcinoma who received either DEB or a cTACE were compared regarding survival time, disease recurrence, and side effects such as pain and fever.

Results

No significant differences could be detected between the cTACE and DEB-TACE groups with regard to mean hospital stay, appearance of postinterventional fever, or 30-day mortality. However, the application of intravenous analgesics as postinterventional pain medication was needed more often in patients treated with DEB-TACE (57.1% vs 12.5%, P=0.0281). The overall median survival after the initial procedure was 10.8 months in the cTACE group and 9.2 months in the DEB-TACE group, showing no significant difference.

Conclusion

No survival benefit for patients treated with either DEB-TACE or cTACE was observed. Surprisingly, a higher rate of postinterventional pain could be detected after DEB-TACE.

A case report of a solitary pancreatic metastasis of an adrenocortical carcinoma

Background

Solitary metastases to the pancreas are rare. Therefore the value of resection in curative intention remains unclear. In the literature there are several promising reports about resection of solitary metastasis to the pancreas mainly of renal origin.

Case presentation

Here we report for the first time on the surgical therapy of a 1.5 cm solitary pancreatic metastasis of an adrenocortical carcinoma. The metastasis occurred almost 6 years after resection of the primary tumor. A partial pancreatoduodenectomy was performed and postoperatively adjuvant mitotane treatment was initiated. During the follow-up of 3 years after surgery no evidence of tumor recurrence occurred.

Conclusion

Resection of pancreatic tumors should be considered, even if the mass is suspicious for metastatic disease including recurrence of adrenocortical cancer.

The MARK-AGE extended database: data integration and pre-processing

MARK-AGE is a recently completed European population study, where bioanalytical and anthropometric data were collected from human subjects at a large scale. To facilitate data analysis and mathematical modelling, an extended database had to be constructed, integrating the data sources that were part of the project. This step involved checking, transformation and documentation of data. The success of downstream analysis mainly depends on the preparation and quality of the integrated data. Here, we present the pre-processing steps applied to the MARK-AGE data to ensure high quality and reliability in the MARK-AGE Extended Database. Various kinds of obstacles that arose during the project are highlighted and solutions are presented.

TGF-β1 as possible link between loss of bone mineral density and chronic inflammation

Background

The TGF family plays a key role in bone homeostasis. Systemic or topic application of proteins of this family apparently positively affects bone healing in vivo. However, patients with chronic inflammation, having increased TGF-β₁ serum-levels, often show reduced bone mineral content and disturbed bone healing. Therefore, we wanted to identify intracellular mechanisms induced by chronic presence of TGF-β₁ and their possible role in bone homeostasis in primary human osteoblasts.

Methodology/Principal Findings

Osteoblasts were isolated from femur heads of patients undergoing total hip replacement. Adenoviral reporter assays showed that in primary human osteoblasts TGF-β₁ mediates its signal via Smad2/3 and not Smad1/5/8. It induces proliferation as an intermediate response but decreases AP-activity and inorganic matrix production as a late response. In addition, expression levels of osteoblastic markers were strongly regulated (AP↓; Osteocalcin↓; Osteopontin↑; MGP↓; BMP 2↓; BSP2↓; OSF2↓; Osteoprotegerin↓; RANKL↑) towards an osteoclast recruiting phenotype. All effects were blocked by inhibition of Smad2/3 signaling with the Alk5-Inhibitor (SB431542). Interestingly, a rescue experiment showed that reduced AP-activities did not recover to base line levels, even 8 days after stopping the TGF-β₁ application.

Conclusions/Significance

In spite of the initial positive effects on cell proliferation, it is questionable if continuous Smad2/3 phosphorylation is beneficial for bone healing, because decreased AP-activity and BMP2 levels indicate a loss of function of the osteoblasts. Thus, inhibition of Smad2/3 phosphorylation might positively influence functional activity of osteoblasts in patients with chronically elevated TGF-β₁ levels and thus, could lead to an improved bone healing in vivo.

Functional requirement of p23 and Hsp90 in telomerase complexes

Most normal human diploid cells have no detectable telomerase; however, expression of the catalytic subunit of telomerase is sufficient to induce telomerase activity and, in many cases, will bypass normal senescence. We and others have previously demonstrated in vitro assembly of active telomerase by combining the purified RNA component with the reverse transcriptase catalytic component synthesized in rabbit reticulocyte extract. Here we show that assembly of active telomerase from in vitro-synthesized components requires the contribution of proteins present in reticulocyte extracts. We have identified the molecular chaperones p23 and Hsp90 as proteins that bind to the catalytic subunit of telomerase. Blockade of this interaction inhibits assembly of active telomerase in vitro. Also, a significant fraction of active telomerase from cell extracts is associated with p23 and Hsp90. Consistent with in vitro results, inhibition of Hsp90 function in cells blocks assembly of active telomerase. To our knowledge, p23 and Hsp90 are the first telomerase-associated proteins demonstrated to contribute to telomerase activity.

Posttransfusion purpura. A survey of 13 cases

Thirteen cases of posttransfusion purpura (PTP) which were diagnosed in Germany and Austria from 1977-1985 are described. All patients were women with a mean age of 58.6 years (range, 36-77 years). All but one had been pregnant and received blood transfusions 2 to 12 days prior to the onset of PTP. The thrombocytopenic purpura was always severe with a nadir of platelet counts below 10 X 10(9)/l and lasted between 3 and 60 days. All patients recovered from PTP. Optimal therapy consisted of administration of high-dose IgG. Twelve of the 13 patients had developed platelet-specific Zwa antibodies (eight of them together with HLA antibodies), in one Zwa positive individual only HLA antibodies were detectable. Five of six HLA-DR typed patients carried DR3 which is considered an immunogenetic risk factor in PTP. Clinical awareness of this rare, but serious iatrogenic transfusion complication is prerequisite for prompt diagnosis and improved therapy.