To close or not to close? Wound management in emergent colorectal surgery, an EAST Multicenter prospective cohort study

BACKGROUND

To determine the clinical impact of wound management technique on surgical site infection (SSI), hospital length of stay (LOS) and mortality in emergent colorectal surgery.

METHODS

A prospective observational study (2021-2023) of urgent or emergent colorectal surgery patients at 15 institutions was conducted. Pediatric patients and traumatic colorectal injuries were excluded. Patients were classified by wound closure technique: skin closed (SC), skin loosely closed (SLC), or skin open (SO). Primary outcomes were SSI, hospital LOS and in-hospital mortality rates. Multivariable regression was used to assess the effect of wound closure on outcomes after controlling for demographics, patient characteristics, ICU admission, vasopressor use, procedure details and wound class. A priori power analysis indicated that 138 patients per group were required to detect a 10% difference in mortality rates.

RESULTS

In total, 557 patients were included (SC n = 262, SLC n = 124, SO n = 171). Statistically significant differences in BMI, race/ethnicity, ASA scores, EBL, ICU admission, vasopressor therapy, procedure details, and wound class were observed across groups (Table 1). Overall, average LOS was 16.9 ± 16.4 days, and rates of in-hospital mortality and SSI were 7.9% and 18.5%, respectively, with the lowest rates observed in the SC group (Table 2). After risk adjustment, SO was associated with increased risk of mortality (OR = 3.003, p = 0.028 in comparison to the SC group. SLC was associated with increased risk of superficial SSI (OR = 3.439, p = 0.014), after risk adjustment.

CONCLUSION

When compared to the SC group, the SO group was associated with mortality, but comparable when considering all other outcomes, while the SLC was associated with increased superficial SSI. Complete skin closure may be a viable wound management technique in emergent colorectal surgery.

STUDY TYPE

Level III Therapeutic/Care Management.

Validation of the American Association for the Surgery of Trauma Emergency General Surgery Grading System for Colorectal Resection: An EAST Multicenter Study

BACKGROUND

The American Association for the Surgery of Trauma (AAST) has developed a grading system for emergency general surgery (EGS) conditions. We sought to validate the AAST EGS grades for patients undergoing urgent/emergent colorectal resection.

METHODS

Patients enrolled in the "Eastern Association for the Surgery of Trauma Multicenter Colorectal Resection in EGS-to anastomose or not to anastomose" study undergoing urgent/emergent surgery for obstruction, ischemia, or diverticulitis were included. Baseline demographics, comorbidity severity as defined by Charlson comorbidity index (CCI), procedure type, and AAST grade were prospectively collected. Outcomes included length of stay (LOS) in-hospital mortality, and surgical complications (superficial/deep/organ-space surgical site infection, anastomotic leak, stoma complication, fascial dehiscence, and need for further intervention). Multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication or mortality.

RESULTS

There were 367 patients, with a mean (± SD) age of 62 ± 15 years. 39% were women. The median interquartile range (IQR) CCI was 4 (2-6). Overall, the pathologies encompassed the following AAST EGS grades: I (17, 5%), II (54, 15%), III (115, 31%), IV (95, 26%), and V (86, 23%). Management included laparoscopic (24, 7%), open (319, 87%), and laparoscopy converted to laparotomy (24, 6%). Higher AAST grade was associated with laparotomy (P = .01). The median LOS was 13 days (8-22). At least 1 surgical complication occurred in 33% of patients and the mortality rate was 14%. Development of at least 1 surgical complication, need for unplanned intervention, mortality, and increased LOS were associated with increasing AAST severity grade. On multivariable analysis, factors predictive of in-hospital mortality included AAST organ grade, CCI, and preoperative vasopressor use (odds ratio (OR) 1.9, 1.6, 3.1, respectively). The American Association for the Surgery of Trauma emergency general surgery grade was also associated with the development of at least 1 surgical complication (OR 2.5), while CCI, preoperative vasopressor use, respiratory failure, and pneumoperitoneum were not.

CONCLUSION

The American Association for the Surgery of Trauma emergency general surgery grading systems display construct validity for mortality and surgical complications after urgent/emergent colorectal resection. These results support incorporation of AAST EGS grades for quality benchmarking and surgical outcomes research.

The physical activity experience of prostate cancer patients: a multicentre peer motivation monitoring feasibility study. The Acti-Pair study

BACKGROUND

Although the benefits of physical activity (PA) on health are recognised, prostate cancer patients do not follow PA recommendations. The barriers to PA, whether physical, environmental or organisational, are known. Furthermore, even when such barriers are overcome, this achievement is not systematically accompanied by a change in lifestyle habits. The proposal of a programme enabling the integration of PA in the patient's everyday life represents a new challenge in the personalized management of cancer patients. Peer-mentoring interventions have demonstrated their effectiveness in increasing adherence to PA by patients. This study aimed (1) to assess the feasibility of a peer-mentoring intervention: the Acti-Pair program in a local context and (2) to assess the effectiveness of the intervention in this context.

METHODS AND ANALYSIS

A pre-post  design pilot study will be used to evaluate feasibility, potential effectiveness and implementation outcomes overs in prostate cancer patients. We performed a mixed quantitative and qualitative prospective study to assess means and process indicators and the implementation of the Acti-Pair program. This study will be performed in cancer centres of Loire district and will be comprised of three successive stages (1) diagnosis of the target population, (2) recruitment and training of peers, and (3) implementation of this intervention in the Loire department.

DISCUSSION

This study will allow us to extend the peer-mentoring intervention to other contexts and assess the effectiveness of this intervention and its generalisability.

Relation between cognitive disorders and type of physical activity: Results of the FréLE cohort

Background

Few previous cohorts have studied the different type of physical activities and the degree of cognitive decline. The objective of this work was to analyze the leisure, domestic and professional activities with mild and moderate cognitive disorders in older people living in community.

Methods

The study used data from the longitudinal and observational study, FrèLE (FRagility: Longitudinal Study of Expressions). The collected data included: socio-demographic variables, lifestyle, and health status (frailty, comorbidities, cognitive status, depression). Cognitive decline was assessed by using: MMSE (Mini-Mental State Examination) and MoCA (Montreal Cognitive Assessment). MoCA was used with two cut-offs (26 and 17) so as to define mild and moderate cognitive disorders Physical activity was assessed by the PASE (Physical Activity Scale for the Elderly), structured in three sections: leisure, domestic and professional activities. Spline and proportional hazards regression models (Cox) were used to estimate the risk of cognitive disorders.

Results

At baseline, 1623 participants were included and the prevalence of cognitive disorders was 6.9% (MMSE) and 7.2% (MoCA), mild cognitive disorders was 71.3%. The mean age was 77 years, and 52% of the participants were women. After a 2 years long follow-up, we found 6.9% (MMSE) and 6% (MoCA) cognitive disorders on participants. Analyses showed that domestic activities were associated to cognitive decline (HR = 0.52 [0.28-0.94] for MMSE and HR = 0.48 [0.28-0.80] for MoCA). No association were found with leisure and professional activities, and no spline were significant with mild cognitive disorders.

Conclusions

Analysis showed a relationship between cognitive disorders and type of physical activity, thanks to the use of specific questionnaire of elderly and two global test of cognition. These findings will contribute to the debate on the beneficial effects of physical activity on cognition.

Key messages

This work allowed to compare two test of cognition and their link with physical activity. It contributes to the debate on the beneficial effects of physical activity on cognition. The work allowed us to see the effect of the different types of physical activity and the impact of the statistical method on the results.

Epidemiology of burnout syndrome in four occupational sectors in Cameroon-impact of the practice of physical activities and sport

Background

The purpose of this study was to determine the prevalence of Burnout syndrome (BOS), risk factors and the effect of physical activity in six professions in Cameroon.

Methods

2012 participants completed questionnaires related to socio-demographic conditions and work perception. Appropriate Maslach Burnout Inventory (MBI) psychometers were used for specific professions. Level of physical activity and sports practice was determined using the Ricci and Gagnon scale.

Results

The overall prevalence of burnout was 67.9%; with 5.3% high; 34.3% moderate; and 60.4% low degree. 42.2% of victims of BOS were in high loss of personal achievement, 39.9% in high depersonalization of and 38.2% in high emotional exhaustion. Higher prevalence of BOS was found in Army (85.3%) and educational sectors (78.5% in secondary school teachers (SET) and 68% in university teaching staff (UTS)). BOS was significantly associated (p < 0.05) with distance from home to workplace, number of children per participant, number of hospitals attended, number of guards per month, labour hours per day, conflicts with the hierarchy, conflicts with colleagues, poor working conditions, unsatisfactory salary, part time teaching in private university institutions, job seniority, sedentariness. Apart from UTS, no association was observed between the level of physical activity and occurrence of BOS.

Conclusion

Burnout is a reality in occupational environments in Cameroon.

Dispatch from the field II: the mystery of the red and blue Opadometa male (Araneae, Tetragnathidae, Opadometa sarawakensis)

Background

Males of Opadometa are difficult to associate with conspecific females, and sex-matching errors may persist in the taxonomic literature. Recommended best practices for definitive sex matching in this genus suggest finding a male in the web of a female, or better yet, mating pairs.

New information

A male Opadometa was observed hanging on a frame line of the web of a female Opadometa sarawakensis, a species for which the male was previously undescribed. This occurred during a tropical ecology field course held at the Danau Girang Field Centre in Sabah, Malaysia. A taxonomic description was completed as a course activity.

Practical Considerations on the Use of Extreme Sib-pairs for Obesity

Objectives: The extreme sib-pair approach has been shown to be a powerful strategy to identify susceptibility loci linked to quantitative traits. The body mass index is the usually assessed trait in genetic studies on human obesity. Environmental factors clearly play an important role for this trait. We hypothesized that the low weight of most sibs who were seemingly discordant to the obese index proband was influenced by other environmental and/or genetic factors like restrained eating or psychiatric disorders.

Methods: A screening questionnaire was sent to parents of all consecutively admitted patients three weeks prior to referral of index probands for inpatient treatment of obesity. The first 320 families were further investigated. Twenty-seven seemingly extremely discordant sib-pairs (ED) were identified and examined in detail.

Results: The low weight of most sibs who were seemingly discordant to the obese index proband was influenced by factors like restrained eating or psychiatric disorders. Only 20% of the interviewed ED could be considered as genuine ED.

Conclusion: We conclude that extensive medical evaluation is necessary if the aim is to guarantee genuine ED in family studies for human obesity. Non-paternity deserves specific attention in ED studies.

Abstract P5-13-07: An investigator-initiated registry trial of simple oral therapy for low risk breast cancer

Background: Across multiple studies performed in several countries with widely instituted screening mammography programs at different intervals between exams, up to 19% of breast cancer identified is in patients whose disease would otherwise go undetected and not have caused any ill effect if left untreated. Recent advances in pathologic and multigene assays have demonstrated promise to better identify low risk breast cancer and appropriately tailor treatments. Nonetheless, most women who may have such low-risk, estrogen receptor expressing lesions continue to be offered only an aggressive treatment paradigm. This most commonly includes surgery and lymph node evaluation and, in the case of breast conservation, breast irradiation following surgery, with the option of endocrine therapy for 5-10 years.

Trial design: We propose a multi-center US registry study of post-menopausal, female breast cancer patients age 60 and older who will be managed 5 years with oral endocrine therapy for mammographically screen-detected, node-negative, unifocal invasive disease with low clinical grade, high estrogen/progesterone receptor expression, negative Her2 expression, Ki67 rate &lt;20%, and low-risk multigene expression analysis with Mammaprint Breast Cancer Recurrence Assay. Target lesions will be confirmed with a pre-treatment bilateral breast MRI and imaged routinely with standard mammography or ultrasound at 3-month intervals during months 1-36 and at 6-month intervals during months 37-60 to assess for disease response. Enrolled patients will have an ECOG performance status of 0-2. Medication history will be documented at routine follow-up visits.

Our primary objective will be to determine the frequency of conversion from a low-toxicity approach with oral endocrine therapy to conventional care with surgery +/- radiation therapy as a result of progression of disease or patient/provider choice. Progression of disease will be quantified objectively as &gt;20% growth of the target lesion as compared to baseline in imaging measurements. After 5 years of endocrine therapy sans disease progression, patients may elect to continue or stop treatment or convert to standard care.

Statistical methods: We will determine the conversion rate from oral therapy for any cause to conventional management (compliance). Compared to the most pessimistic assumed true-rate for compliance of 0.5, we predict &gt;90% power to detect a decrease of 0.1 in outcomes with an alpha of 5% (corresponds to a 95% Confidence Interval). Using descriptive statistics, we will also quantify for disease responses and progression-free survival. Our sample size will be ample for multiple sub-analyses including measurement of differences emanating from tertiary care versus local oncologic management, advanced imaging outcomes (if performed on any subset of patients), effect of type of endocrine therapy type (SERM vs AI), and effect of age and/or comorbidity severity interaction.

Accrual: Clinic sites with large patient cohorts are now being selected nationwide to enroll and manage patients' disease with endocrine treatment only. We will select up to 20 sites and enroll 300 patients with low-risk disease.

Citation Format: Gadi VK, Preusse C, Calhoun KE, Kim J, Linden HM, Rendi M, Etzioni RB, Gooley T, Lyman G, Stork L, van der Baan B, Barth N, Rahbar H. An investigator-initiated registry trial of simple oral therapy for low risk breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-13-07.

[The Motivation for Physicians in Training as Specialists in General Medicine to Open their Own Surgery]

Our mixed methods (narrative interviews; group discussions; quantitative online survey) study examines the motivation of physicians in training as specialists in general practice to open their own practice. In addition, we wondered how motivations change during the vocational training. In a synchronic perspective motivations are highly differentiated on the one hand, on the other hand they are clearly gender-specific. In a diachronic perspective, the decision for or against their own GP surgery is uncertain for a long time during vocational training.

Influence of pyrogenic particles on the micromechanical behavior of thin sol-gel layers

Coatings based on sol-gel technology with different types of nanoparticles embedded into the sol-gel matrix were fabricated, and the resulting properties were investigated. Pyrogenic silica nanoparticles were added to the sol before coating. The silica particles varied in primary particle size and agglomerate size, and in their surface modification. The particles were wetted in ethanol and dispersed to certain finenesses. The difference in agglomerate size was partly caused by varying particle types, but also by the dispersing processes that were applied to the particles. The resulting coatings were examined by visual appearance and SEM microscopy. Furthermore, their micromechanical properties were determined by nanoindentation. The results show an important influence from the added nanoparticles and their properties on the visual appearance as well as the micromechanical behavior of the sol-gel coatings. It is shown that, in fact, the particle size distribution can have a major impact on the coating properties as well as the surface modification.

Bid-induced release of AIF from mitochondria causes immediate neuronal cell death

Mitochondrial dysfunction and release of pro-apoptotic factors such as cytochrome c or apoptosis-inducing factor (AIF) from mitochondria are key features of neuronal cell death. The precise mechanisms of how these proteins are released from mitochondria and their particular role in neuronal cell death signaling are however largely unknown. Here, we demonstrate by fluorescence video microscopy that 8-10 h after induction of glutamate toxicity, AIF rapidly translocates from mitochondria to the nucleus and induces nuclear fragmentation and cell death within only a few minutes. This markedly fast translocation of AIF to the nucleus is preceded by increasing translocation of the pro-apoptotic bcl-2 family member Bid (BH3-interacting domain death agonist) to mitochondria, perinuclear accumulation of Bid-loaded mitochondria, and loss of mitochondrial membrane integrity. A small molecule Bid inhibitor preserved mitochondrial membrane potential, prevented nuclear translocation of AIF, and abrogated glutamate-induced neuronal cell death, as shown by experiments using Bid small interfering RNA (siRNA). Cell death induced by truncated Bid was inhibited by AIF siRNA, indicating that caspase-independent AIF signaling is the main pathway through which Bid mediates cell death. This was further supported by experiments showing that although caspase-3 was activated, specific caspase-3 inhibition did not protect neuronal cells against glutamate toxicity. In conclusion, Bid-mediated mitochondrial release of AIF followed by rapid nuclear translocation is a major mechanism of glutamate-induced neuronal death.

Role of Smac in cephalostatin-induced cell death

Cephalostatin 1 is a natural compound isolated from a marine worm that induces apoptosis in tumor cells via an apoptosome-independent but caspase-9-dependent pathway and through an endoplasmic reticulum stress response that is accompanied by caspase-4 activation. Here, we show that cephalostatin evokes mitochondrial Smac (second mitochondria-derived activator of caspases) but not cytochrome c release in various carcinoma cell lines. We also show that Smac is critically involved in caspase-9 activation as evidenced by gene silencing experiments. Remarkably, caspase-2 appears to be a major target for cephalostatin-induced cytosolic Smac. Using biochemical and genetic inhibition experiments, we demonstrate that caspase-2 participates in the apoptotic machinery induced by cephalostatin. Cephalostatin-activated caspase-2 appears to act as initiator caspase and is not involved in the activation of caspase-9. Importantly, experiments immunoprecipitating PIDD (p53-induced protein with a DD), RAIDD (RIP-associated ICH-1/CED-3-homologous protein with DD) and caspase-2 identify cephalostatin as an experimental drug that induces the formation of the PIDDosome. The bis-steroid cephalostatin proves to be both a helpful tool to investigate apoptotic signaling and a promising chemotherapeutic agent.

Spongistatin 1: a new chemosensitizing marine compound that degrades XIAP

Spongistatin 1 is a new experimental chemotherapeutic agent isolated from marine sponges. Here we show that spongistatin 1 potently induces cell death in patient primary acute leukemic cells with higher efficiency than 8/10 clinically used cytotoxic drugs and prevents long-term survival of leukemic cell lines. Spongistatin 1 triggers caspase-dependent apoptosis in Jurkat T cells by the release of cytochrome c, Smac/DIABLO and Omi/HtrA2. As caspase-9 acts as an initiator caspase and Bcl-2 and Bcl-xL overexpression suppress spongistatin 1-induced apoptosis, cell death is mediated through the mitochondrial apoptosis pathway. Importantly, spongistatin 1 leads to the degradation of the antiapoptotic X-linked inhibitor of apoptosis protein. In apoptosis-resistant leukemic tumor cells overexpressing XIAP, spongistatin 1 effectively causes cell death and potentiates cell death induction by other apoptosis-promoting factors that might be caused by spongistatin 1-mediated degradation of XIAP. Our data show that spongistatin 1 represents a promising novel therapeutic agent for the treatment of leukemic tumor cells especially in the clinically highly relevant situation of chemoresistance due to overexpression of XIAP.

[Consequences of physical maltreatment, deprivation and sexual abuse in children]

Physical maltreatment, neglect and sexual abuse have manifold consequences for the young victims. Depending on subsequent life circumstances, they may develop not only physical problems, but also anxiety disorders, depression, personality disorders, eating disorders, and other problems. A lack of self-esteem, exaggerated aggressiveness and bonding problems can result in long-term psychosocial consequences that may persist into adulthood.

Practical considerations on the use of extreme sib-pairs for obesity

OBJECTIVES

The extreme sib-pair approach has been shown to be a powerful strategy to identify susceptibility loci linked to quantitative traits. The body mass index is the usually assessed trait in genetic studies on human obesity. Environmental factors clearly play an important role for this trait. We hypothesized that the low weight of most sibs who were seemingly discordant to the obese index proband was influenced by other environmental and/or genetic factors like restrained eating or psychiatric disorders.

METHODS

A screening questionnaire was sent to parents of all consecutively admitted patients three weeks prior to referral of index probands for inpatient treatment of obesity. The first 320 families were further investigated. Twenty-seven seemingly extremely discordant sib-pairs (ED) were identified and examined in detail.

RESULTS

The low weight of most sibs who were seemingly discordant to the obese index proband was influenced by factors like restrained eating or psychiatric disorders. Only 20% of the interviewed ED could be considered as genuine ED.

CONCLUSION

We conclude that extensive medical evaluation is necessary if the aim is to guarantee genuine ED in family studies for human obesity. Non-paternity deserves specific attention in ED studies.

Transmission disequilibrium studies in children and adolescents with obsessive-compulsive disorders pertaining to polymorphisms of genes of the serotonergic pathway

Pharmacological and challenge study data showed an involvement of the serotonergic system in the development of obsessive-compulsive disorder (OCD). We studied transmission disequilibrium of polymorphisms in three candidate genes of the serotonergic pathway in 64 trios comprising patients with early onset OCD and both of their parents. Polymorphisms of the following genes were studied: tryptophan hydroxylase 1 (rs1800532), serotonin transporter (polymorphism in the promoter region; 5-HTTLPR) and the serotonin 1 B receptor (rs6296). This is, to our knowledge, one of the first family based association studies pertaining to children and adolescents with OCD. We did not detect transmission disequilibrium of the investigated polymorphisms in OCD. Hence, these polymorphisms do not play a major role in the genetic predisposition to early onset OCD.

(r)-, but not (s)-alpha lipoic acid stimulates deficient brain pyruvate dehydrogenase complex in vascular dementia, but not in Alzheimer dementia

In dementia of Alzheimer type (DAT), cerebral glucose metabolism is reduced in vivo, and enzymes involved in glucose breakdown are impaired in post-mortem brain tissue. Pyruvate dehydrogenase complex activity (PDHc) is one of the enzymes known to be reduced, while succinate dehydrogenase activity (SDH), another enzyme of oxidative glucose metabolism is unchanged. In dementia of vascular type (DVT), variable changes in glucose metabolism have been demonstrated in vivo, while changes of enzyme activities in post-mortem brain tissue are unknown. Here, PDHc and SDH activity were stimulated with each of the two stereoisomers of alpha lipoic acid in post-mortem parietal brain cortex of patients with DAT, DVT, and one case of Pick's disease and compared to stimulation effects in a control group, matched for age, sex, post-mortem delay, and storage time of brain tissue. PDHc in DAT and DVT, but not in Pick's disease was reduced. PDHc activity could be slightly stimulated by 10 micro M of the physiological stereoisomer (r)-alpha-lipoic acid, in controls and DVT (possibly also in Pick's disease), but not in DAT. In all groups investigated SDH was activated by 100 micro M and 1 mM of both isomers of alpha-lipoic acid, whereas 10 mM of both stereoisomers of alpha-lipoic acid caused an inhibition of both, PDHc and SDH activity. The loss of basal and of (r)-alpha-lipoic acid stimulated PDHc activity indicate that a functional or structural impairment of PDHc may exist in DAT and DVT which is not merely attributable to loss of mitochondria since basal and stimulated SDH activities are similar in controls, DVT and DAT, thus indicating selective vulnerability of PDHc.

Identification of regulatory elements in the human adipose most abundant gene transcript-1 ( apM-1) promoter: role of SP1/SP3 and TNF-alpha as regulatory pathways

AIMS/HYPOTHESIS

The human adipocyte-specific apM-1 (adipose most abundant gene transcript-1) gene encodes for a secretory protein of the adipose tissue that seems to play a role in the pathogenesis of obesity-related insulin resistance and its expression is inhibited by TNF-alpha. Our aim was to characterize the tissue-specific regulation of the recently cloned apM-1 promoter and the mechanisms of TNF-alpha-induced downregulation of the apM-1 gene.

METHODS

We characterised the apM-1 gene by electrophoretic mobility shift assays (EMSA) and luciferase reporter gene assays (LRA).

RESULTS

Although several putative binding sites for transcription factors known to be involved in adipogenesis such as C/EBP and PPARgamma are present in the promoter, we could not detect any binding of these nuclear proteins from differentiated adipocytes. However, a proximal SP1 binding site specifically binds both, recombinant SP1 protein and SP1 derived from adipocyte nuclear extracts. Since the expression of SP1 during adipocyte differentiation has not yet been analysed, we could show by using EMSA, that binding activity of SP1 is increased during adipocyte differentiation. The stimulatory activity of SP1 was confirmed in LRA by cotransfection experiments in S2 Schneider cells lacking endogenous SP factors. An inhibitory activity of SP3 on the stimulatory effect of SP1 could be confirmed in LRA by contransfection experiments in adipocytes. Nuclear extracts from adipocytes incubated with TNF-alpha showed a reduced binding activity of SP1.

CONCLUSION/INTERPRETATION

SP1 is expressed and its binding activity is enhanced during adipocyte differentiation. SP1 has stimulatory effects, SP3 has inhibitory effects on apM-1 promoter activity, mediated by a proximal SP1 binding site. The mechanism of TNF-alpha-induced inhibition of apM-1 gene expression is, at least in part, due to a decrease of transcriptional SP1 binding activity caused by TNF-alpha and thus provides a new mechanism of TNF-alpha-dependent signalling.

Pro12Ala polymorphism in the peroxisome proliferator-activated receptor-gamma2 (PPARgamma2) is associated with higher levels of total cholesterol and LDL-cholesterol in male caucasian type 2 diabetes patients

The peroxisome proliferator-activated receptor-gamma2 (PPAR(gamma2)) represents the transcriptional master regulator of adipocyte differentiation and therefore has been suggested as candidate gene for the pathogenesis of obesity, type 2 diabetes and related metabolic disorders. Aim of our study was to determine the frequency of a missense point mutation within exon 2 of PPAR(gamma2), Pro12Ala, and its possible association with metabolic parameters as well as diabetic retinopathy (in a population-based sample of 560 (318 male ad 242 female) type 2 diabetic patients. Subsequent to genomic PCR amplification, the Hpa-II RFLP analysis was used for genotyping.

RESULTS

436 (77.9%) subjects were homozygous for the wildtype allele (Pro/Pro), 118 (21.1%) were heterozygous (Pro/Ala) and 6 (1.1%) were homozygous for the mutated allele (Ala/Ala). Genotype frequency was calculated to be 0.81 for the wildtype and 0.19 for the mutated allele. These frequencies did not differ from non-diabetic cohorts examined earlier. In contrast to females, total cholesterol and LDL-cholesterol were significantly higher in males (Total cholesterol: 281.8 +/- 51.3 vs 253.1 +/- 49.8 mg/dl, p < 0.0001; LDL-cholesterol: 182.0 +/- 49.2 vs 155.6 +/- 42.0 mg/d, p < 0.0001) in the presence of the mutated allele as compared to the wildtype subgroup. No differences were found with respect to BMI, HbA1c, blood pressure and serum levels of leptin nor to prevalence of retinopathy. Pro12Ala polymorphism of PPAR(gamma2) gene is not associated with diabetic retinopathy but is associated with dyslipidemia in male type 2 diabetic patients.

Haemolytic anaemia in a patient with anorexia nervosa

We report on a 17-year-old female patient with severe anorexia nervosa (AN) (body mass index of 9.8 kg/m(2)) who developed hypophosphataemia (serum phosphate 0.4 nmol/l) and subsequent haemolytic anaemia during oral refeeding. Hypophosphataemia due to an increased phosphate uptake may lead to a reduction of erythrocyte adenosine triphosphate. This mechanism is important for the differential diagnosis of haemolytic anaemia in patients with AN. To prevent this complication, phosphate supplementation should be considered in the refeeding of severely malnourished patients.

Gly15Gly polymorphism within the human adipocyte-specific apM-1gene but not Tyr111His polymorphism is associated with higher levels of cholesterol and LDL-cholesterol in caucasian patients with type 2 diabetes

The recently described mutations within the human adipocyte-specific apM-1 gene might play a role in the pathogenesis of obesity, type 2 diabetes and related metabolic disorders.

DESIGN

Frequency of apM-1 gene polymorphisms and their association with metabolic parameters was evaluated in a population-based sample of 556 type 2 (316 males / 240 females) diabetic patients. PCR-based RFLP analysis was performed in blood samples. The T --> G transition at nucleotide +45 within exon-2 [Gly15Gly] was detected with an allelic frequency of 0.91 for the wildtype allele and 0.09 for the mutated allele. The missense point mutation (TAC --> CAC) at nucleotide +331 within exon 3 [Tyr111His] was detected with an allelic frequency of 0.97 and 0.03, respectively. These frequencies did not differ from a non-diabetic cohort examined earlier. Concerning the Gly15Gly polymorphism, the TT-genotype was found in 457 (82.2%) and the TG-genotype in 99 (17.8%), concerning the Tyr111His polymorphism, TT-genotype was found in 525 (94.4) and TC-genotype in 31 (5.6%) of type 2 diabetic patients. In TG-genotype as compared to TT-genotype significantly more patients had LDL-serum levels in high LDL-classes (<150 mg/dl: 24.4% (TG) vs. 41.4% (TT), 150mg/dl to 190mg/dl: 40.0% (TG) vs. 33.9% (TT), >190 mg/l: 35.6% (TG) vs. 25.0% (TT); p = 0.010). No differences in serum levels of lipids were found in genotype-subgroups of the Tyr111His polymorphism. Thus, Gly15Gly polymorphism of apM-1 gene might play a role in dyslipidaemia in type 2 diabetic patients.

Frequency and significance of Pro12Ala and Pro115Gln polymorphism in gene for peroxisome proliferation-activated receptor-gamma regarding metabolic parameters in a Caucasian cohort

Peroxisome proliferation-activated receptor-gamma2 (PPARgamma2) is exclusively expressed in adipose tissue and belongs to the transcriptional regulators of adipocyte differentiation. Recently, two missense single-point mutations have been described in the PPARgamma2 gene: Pro12Ala and Pro115Gln. It was our aim to determine the frequency of these polymorphisms in a Caucasian cohort and to investigate their possible role in the pathogenesis of obesity, type 2 diabetes, and related metabolic disorders. The genotypes of 359 subjects (149 males, 210 females) with varying degrees of obesity and with or without type 2 diabetes were determined. Subsequent to genomic polymerase chain reaction amplification, the HpaII restriction fragment length polymorphism (RFLP) analysis and the HindII RFLP analysis were used for genotyping the Pro12Ala and Pro115Gln polymorphism, respectively. For the Pro115Gln polymorphism, all 359 subjects showed wild-type sequence, emphasizing the very rare occurrence of the mutated allele. For the Pro12Ala polymorphism, 276 subjects (76.9%) were homozygous for the wild-type allele, 80 (22.3%) were heterozygous, and only 3 (0.8%) were homozygous for the mutated allele. Genotype frequency was calculated to be 0.88 for the wild-type allele and 0.012 for the mutated allele. No significant differences were found in age; gender; body mass index; total cholesterol; low-density, high-density, and very low density lipoproteins; triglycerides; Lp(a); uric acid; and diabetes manifestation by comparing the different genotypes. Therefore, a major role of these polymorphisms in the pathogenesis of obesity and diabetes can be excluded.

Mutation analysis of the human adipocyte-specific apM-1 gene

BACKGROUND

The aim of this study was to analyse the human adipocyte-specific apM-1 gene for sequence variations.

METHODS

Sequence analysis was performed in 344 randomly chosen blood samples using a capillary sequencer.

RESULTS

Whereas no mutations were detected in intronic regions and in 2.7 kb of the promoter, two sequence variations were found within the coding sequence of apM-1. For both mutations, a polymerase chain reaction-(PCR) based restriction fragment length polymorphism (RFLP) analysis was developed, which provided a rapid screening method. A conservative T --> G transition at nucleotide + 45 within exon-2 [Gly15Gly] was detected with an allelic frequency of 0.9 for the wild-type allele and 0.1 for the mutated allele. In addition, a missense point mutation at nucleotide + 331 within exon-3 [Tyr111His] was detected with an allelic frequency of 0.97 for the wild-type allele and 0.03 for the mutated allele. This mutation replaces a tyrosine by an histidine within the carboxyterminal globular domain of apM-1. Concerning the Gly15Gly polymorphism, the TT genotype was found in 275 subjects (79.9%), the TG genotype in 67 subjects (19.5%) and the GG genotype in 2 subjects (0.6%): one with maturity onset diabetes of young age (MODY-diabetes) and one with Lipoatrophic Diabetes Syndrome (LPDS). Concerning the Tyr111His polymorphism, the TT genotype was found in 328 subjects (95.4%), the TC genotype in 15 subjects (4.3%) and the CC genotype in 1 subject (0.3%).

CONCLUSION

The existence of two yet unknown mutations within the apM-1 gene was demonstrated and RFLP analysis was established for rapid screening. Well defined cohorts of patients are necessary to determine the putative role of apM-1 gene mutations in the pathogenesis of metabolic disorders.

Identification of a new missense mutation (Gly95Glu) in a highly conserved codon within the high-mobility group box of the sex-determining region Y gene: report on a 46,XY female with gonadal dysgenesis and yolk-sac tumor

Leydig cells and Sertoli cells of the testes produce hormones that cause male differentiation, if receptors are present. The Y chromosomal SRY gene (sex determining Region Y gene) acts as TDF and is required for regular male sex determination. SRY represents a transcription factor belonging to the superfamily of genes sharing the HMG-box motif(high-mobility group-box), which acts as DNA binding region. Here, we describe a nonmosaic XY sex-reversed female with pure gonadal dysgenesis (46,XY karyotype, completely female external genitalia, normal Müllerian ducts, absence of Wolffian ducts, streak gonads) who harbored a yolk-sac tumor and was referred for the assessment of primary amenorrhea. Using genomic PCR analysis, a 423-bp PCR product, encompassing the HMG-box of the SRY gene, was amplified from the proposita, her father, and her three brothers, whereas no band was visible in the patient's mother and her three sisters. The PCR products were sequenced for mutations subsequently. A new de novo missense mutation within the HMG-box of the SRY gene was discovered in the proposita. A G is replaced by an A in codon 95 at position +284, resulting in the replacement of the nonpolar aminoacid glycine by the polar amino acid glutamate. The glycine at codon 95 is highly conserved between the family of HMG-box proteins and between species. This point mutation has not been described earlier and brings the total number of SRY mutations described so far to 36, each mutation being unique. This mutation was not detected in the patient's father and her male siblings. The present data provide further evidence to support the functional importance of the putative DNA binding activity of the SRY HMG-box domain.

Das “zyklische Erbrechen” im Kindes- und Jugendalter

Zusammenfassung: Anhand eines Fallbeispiels eines 5,5 Jahre alten Kindes wird das Krankheitsbild des “zyklischen Erbrechens” vorgestellt. Kernsymptom dieser rezidivierenden Störung ist ein aus völligem Wohlbefinden heraus schwer zu beeinflussendes Erbrechen, welches in regelmäßigen Zyklen auftritt. Die Symptomatik, die Differentialdiagnose und die Therapie dieser hauptsächlich im Kindesalter auftretenden Erkrankung wird dargestellt. Ätiologisch wird die enge Verwandtschaft zur kindlichen Migräne diskutiert. Wir diskutieren kritisch die Diagnose “psychogenes Erbrechen”, die in Deutschland häufig für Störungsbilder herangezogen wird, die dem zyklischen Erbrechen ähnlich sind.

["Cyclic vomiting" in childhood and adolescence]

The clinical picture of the "cyclical vomiting syndrome" is discussed in the case of a 5 1/2-year-old child. The core symptom of this recurrent disorder is vomiting that occurs in regular cycles and while the patient is in a state of complete well-being, and which is hard to influence. The symptoms, the differential diagnosis, and the therapy of this disorder, which occurs primarily in childhood, are discussed along with the close etiological relationship to infantile migraine. The diagnosis of "psychogenic vomiting" is addressed critically, since it is frequently applied in Germany to disorder pictures that are similar to cyclical vomiting.

Epidemic obesity: are genetic factors involved via increased rates of assortative mating?

OBJECTIVE

Prevalence rates of obesity have been increasing in several countries over the past two decades. Mainly secular changes in energy intake and expenditure have been invoked to underly the increasing rates; genetic factors have not been considered because of the very recency of this phenomenon. We hypothesize that genetic factors might very well be involved via an increased rate of assortative mating between obese individuals. We speculate that the recent upsurge in social stigmatization of obese individuals underlies the hypothesized increase in assortative mating.

DESIGN

To accumulate evidence for our hypothesis we analysed deduced rates of assortative mating among parents of extremely obese children and adolescents, who belonged to two different large study groups (n = 201 and n = 270). For this purpose we calculated parental body mass indices (BMIs) based on (a) measured current heights and weights, (b) self-reported current heights and weights, and finally (c) measured current heights and recalled weights at ages 20 and 30, respectively. BMI centiles were determined which in turn were attributed to the respective BMI decile. Deduced rates of assortative mating were evaluated in bivariate histograms of the paternal and maternal BMI deciles.

RESULTS

High rates of assortative mating were observed as deduced from the bivariate histograms, which revealed a fairly consistent pattern. Thus, in the first study group almost 35% of the parental pairs had a BMI in the tenth decile; over 50% of the mothers and fathers had a BMI in this top decile. Recalled parental BMIs at ages 20 and 30 also clustered in the upper decile. These results were basically replicated in the second study group. In addition, parental loading on the tenth decile was shown to be higher for the subgroup of children and adolescents who had a BMI equal to or exceeding the highest BMI of the population-based age and gender matched control group.

CONCLUSIONS

Our results indicate that assortative mating is common among parents of extremely obese children and adolescents, ascertained between 1995 and 1997. In addition, the parental loading on the tenth decile is most prominent for the most obese children. Whereas we are unable to document an increased rate of assortative mating, we interpret our results as being consistent with the hypothesis that an increased rate of assortative mating has contributed to the recent rise in obesity rates in several countries. Thus, assortative mating warrants further studies to assess its impact on obesity prevalence rates through both genetic and non-genetic mechanisms. Our results suggest that assortative mating might especially increase the rates for extreme obesity.

Screening for mutations in the neuropeptide Y Y5 receptor gene in cohorts belonging to different weight extremes

OBJECTIVE

The neuropeptide Y (NPY) Y5 receptor is presumed to be involved in the regulation of food intake.

DESIGN

To investigate the possible role of this receptor in weight regulation, the whole coding region of the NPY Y5 receptor gene was screened for mutations using temperature gradient gel electrophoresis (TGGE). Detected mutations were screened in extended cohorts. STUDY COHORTS AND METHODS: Cohorts of 87 extremely obese children and adolescents, 15 underweight subjects and 25 patients with anorexia nervosa (AN) were initially screened by TGGE. Extended samples of these cohorts (160 obese children and adolescents; mean body mass index (BMI) 33.5 +/- 6.4 kg/m2, 128 underweight subjects; mean BMI 18.4 +/- 1.0 kg/m2 and 58 patients with AN; mean BMI 14.6 +/- 1.7 kg/m2) were screened to determine the frequencies of a detected mutation and a detected polymorphism in the NPY Y5 receptor gene. In addition, a previously described polymorphism in the first intron of the NPY Y1 receptor gene was analysed.

RESULTS

The coding region of the NPY Y5 receptor gene encompasses one exon. A single mutation, which results in a non-conservative amino acid substitution in the first extracellular domain of the receptor (Glu-4-Ala), and one silent polymorphism (Gly-426-Gly-Gly) at nucleotide position 1278 (G-->A) were detected by TGGE. Both tests for association and linkage to the NPY Y1 and NPY Y5 receptor polymorphisms were negative among all cohorts. The Glu-4-Ala mutation was found only in a single patient with AN and her mother.

CONCLUSION

The results do not support a major role of the NPY Y5 receptor gene in the variability of body weight in children and adolescents.

Further support for linkage of extreme obesity to the obese gene in a study group of obese children and adolescents

The role of the obese gene in human obesity is presently unclear. Evidence for linkage of markers flanking the gene to obesity has been found in some but not all studies. We investigated transmission disequilibrium between two highly polymorphic microsatellite markers (D7S504 and D7S1875) flanking the human obese gene (OB) and extreme obesity in a study group of German children and adolescents. Due to the early onset and severity of obesity in the ob/ob mouse we hypothesized that especially children and adolescents with extreme obesity are enriched for possible mutations in the human OB. The analysis of 88 trios (index probands and both parents) for transmission disequilibrium of a haplotype which has previously been determined to be linked to extreme obesity (Reed et al., 1996) revealed a one-sided transmission disequilibrium test (TDT) p-value of 0.039. Post hoc analyses revealed one-sided TDT p-values of 0.015 for the 214 bp allele of D7S1875 (corrected p-value = 0.03) and 0.215 for the 145 bp allele of D7S504 (corrected p-value = 0.43). These findings substantiate the evidence for linkage of extreme obesity to OB.

Serotonin transporter gene-linked polymorphic region: allele distributions in relationship to body weight and in anorexia nervosa

Several lines of evidence implicate a role for the serotonergic system in body weight regulation and eating disorders. The magnitude and duration of postsynaptic responses to serotonin (5-HT) is directed by the transport into and release from the presynaptic neuron. Recently, a common polymorphism of a repetitive element in the region of the serotonin transporter (5-HTT) gene-linked polymorphic region (5-HTTLPR) was identified that results in a system of two common alleles. The activity of the 5-HTT, as measured in in vitro assays and in human lymphoblastoid cell lines, is dependent on the respective genotype. We thus hypothesized that this polymorphism is relevant for weight regulation in general and is possibly involved in the etiology of anorexia nervosa (AN). Allele frequencies and genotypes were determined in a total of 385 unrelated obese children, adolescents and adults, 112 underweight subjects and 96 patients with AN. Furthermore, both parents of 98 obese children and adolescents and of 55 patients with AN, respectively, were genotyped, thus allowing to test for both association and linkage. The comparison of allele frequencies between obese and underweight probands provided no evidence for a major role of the 5-HTTLPR in weight regulation. Patients with AN had allele frequencies not significantly different to those observed for obese and underweight individuals.

Leptin levels in patients with anorexia nervosa are reduced in the acute stage and elevated upon short-term weight restoration

Circulating leptin concentrations are known to be low in acute anorexia nervosa (AN), which is characterized by low weight, amenorrhea and specific psychopathological features. In this study plasma leptin concentrations were determined during inpatient treatment of 23 adolescent females with AN using a sensitive radioimmunoassay (RIA) and set into relationship to leptin levels of females matched for age, body mass index (BMI; kg m-2) and/or percent body fat. At referral patients had leptin concentrations well below the female controls. Weight gains led to steep increases of leptin levels which peaked at values well in excess of those observed in controls matched for BMI. In patients who reached the final treatment stage and who were followed-up after discharge, levels subsequently fluctuated and finally dropped into or below the control range. The low leptin levels at referral are likely to be involved in the pathogenesis of amenorrhea and the reduced metabolic state of acutely ill patients. Peak leptin levels reached after weight gain are possibly the cause of increased energy expenditure during this stage of the disorder.

Beta 3-adrenergic-receptor allele distributions in children, adolescents and young adults with obesity, underweight or anorexia nervosa

OBJECTIVE

The missense mutation (64Trp to 64Arg) in the beta 3-adrenergic-receptor has previously been described to confer a genetic predisposition to the development of obesity.

DESIGN

To test the hypothesis we evaluated allele frequencies in children, adolescents and young adults who belonged to different weight groups that were delineated with percentiles for the body mass index (BMI; kg/m2).

SUBJECTS

99 underweight probands (BMI < or = 15th percentile). 80 normal weight probands (BMI: 5th-85th percentile). 238 obese children and adolescents (BMI > or = 97th percentile). 84 patients with anorexia nervosa (AN).

MEASUREMENTS

The cohorts were screened by polymerase chain reaction with subsequent restriction fragment length polymorphism (PCR-RFLP) analysis. Data were statistically analysed for association. In addition to these case control studies, the transmission disequilibrium test (TDT) was applied to 80 families of obese probands and to 52 families of patients with AN.

RESULTS

Both the tests for association and linkage were negative. The Trp64Arg allele frequencies in the three weight groups (obesity: 0.071; normal weight: 0.081; underweight: 0.056) and the AN patients (0.054) were similar. Extremely obese individuals showed no excess of the Trp64Arg allele. No homozygotes for the Trp64Arg allele were detected.

CONCLUSION

Heterozygosity for the Trp64Arg allele is not of major importance in regulation of body weight in individuals younger than 35 y. Additionally, the extreme obese subgroup is not enriched for the polymorphism.

Significant weight gains in a clinical sample of obese children and adolescents between 1985 and 1995

OBJECTIVE

Within the past decades prevalence rates for obesity among children and adolescents have increased in different populations. The hypothesis of this study is that the degree of adiposity in clinical study cohorts of extremely obese children and adolescents increased within the past decade.

DESIGN

In six different study cohorts of the time period from 1985-1995 body mass indices (BMIs) of obese children and adolescents who were treated as inpatients at a specialized children's hospital were evaluated. For this purpose body heights, body weights, ages and sex of all inpatients of three referring agencies were retrospectively assessed biannually.

RESULTS

In these six cohorts a significant BMI-increase from 1985-1995 of 1.9 kg/m2 (P < 0.0001) for constant sex, age and referring agencies was found: Comparisons of the quartiles and the ninth decline in both sexes did not show any systematic increase at the first quartile. In contrast, BMI-increases at the ninth decile were approximately 5 kg/m2 for males and 2.5 kg/m2 for females.

CONCLUSION

Within the decade studied a significant BMI-increase was detectable in this clinical population. This effect is especially discernible in the most extreme weight groups and in males.

Evaluation of a Cys23Ser mutation within the human 5-HT2C receptor gene: no evidence for an association of the mutant allele with obesity or underweight in children, adolescents and young adults

Serotonin is a neurotransmitter involved in a large number of psychophysiological processes including the regulation of mood, arousal, aggression, sleep, learning, nociceptions, nerve growth and importantly, appetitive functions. Alterations of 5-HT receptor activity have been shown to occur in many psychiatric diseases including depression, anxiety, eating disorders, schizophrenia etc. Hence, genetic variation in genes coding for serotonin receptor proteins might well be involved in the genetic predisposition to these diseases and therefore are of great pharmacogenetic relevance. Knockout mice deficient of a functional 5-HT2C receptor have implicated a potential role of this receptor subtype in the serotonergic control of appetite. A Cys23Ser mutation in the human 5-HT2C receptor gene discovered recently prompted us to investigate this mutation with regard to the development of human obesity. We have evaluated this mutation in 241 obese children and adolescents (mean BMI > or = 97th percentile), 80 normal weight children (BMI 5th-85th percentile) and 92 underweight probands (BMI < or = 15th percentile) for a possible association with obesity. The frequencies of the mutant allele in all three weight groups (obese subjects: 0.1597; normal weight: 0.168; underweight: 0.1575) were very similar. Association as well as linkage studies were negative. Therefore it is unlikely that this receptor mutation plays a direct role in the development of human obesity.

Two-fold interindividual variation in plasma protein binding of phenytoin in patients with epilepsy

Plasma protein binding of phenytoin (diphenylhydantoin) in 63 epileptic patients was investigated with an ultrafiltration technique at room temperature using 14C-labelled phenytoin. A strong correlation was found between the total and the unbound drug concentration (r = 0.97, p less than 0.001). The unbound phenytoin fraction was 7.1 +/- 1.0% with a range of 4.9 to 10.2%. This variation is considerably less than that reported recently by different authors. Individual phenytoin binding was reproducible when the determination was repeated several weeks later. Salivary phenytoin concentrations in 33 epileptic patients were significantly correlated to the unbound (r = 0.83) and total concentrations (r = 0.82) of phenytoin in plasma. This study confirms that the clinical practice of monitoring total phenytoin plasma concentrations is sufficient, since the unbound phenytoin fraction has only a 2-fold interindividual variation in epileptic patients, provided that they do not suffer from renal or hepatic disease.