Effects of the short-stitch technique for midline abdominal closure: short-term results from the randomised-controlled ESTOIH trial

Purpose

The short-stitch technique for midline laparotomy closure has been shown to reduce hernia rates, but long stitches remain the standard of care and the effect of the short-stitch technique on short-term results is not well known. The aim of this study was to compare the two techniques, using an ultra-long-term absorbable elastic suture material.

Methods

Following elective midline laparotomy, 425 patients in 9 centres were randomised to receive wound closure using the short-stitch (USP 2-0 single thread, n = 215) or long-stitch (USP 1 double loop, n = 210) technique with a poly-4-hydroxybutyrate-based suture material (Monomax^®). Here, we report short-term surgical outcomes.

Results

At 30 (+10) days postoperatively, 3 (1.40%) of 215 patients in the short-stitch group and 10 (4.76%) of 210 patients in the long-stitch group had developed burst abdomen [OR 0.2830 (0.0768–1.0433), p = 0.0513]. Ruptured suture, seroma and hematoma and other wound healing disorders occurred in small numbers without differences between groups. In a planned Cox proportional hazard model for burst abdomen, the short-stitch group had a significantly lower risk [HR 0.1783 (0.0379–0.6617), p = 0.0115].

Conclusions

Although this trial revealed no significant difference in short-term results between the short-stitch and long-stitch techniques for closure of midline laparotomy, a trend towards a lower rate of burst abdomen in the short-stitch group suggests a possible advantage of the short-stitch technique.

Trial registry

NCT01965249, registered October 18, 2013.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Remote entanglement between a single atom and a Bose-Einstein condensate

Entanglement between stationary systems at remote locations is a key resource for quantum networks. We report on the experimental generation of remote entanglement between a single atom inside an optical cavity and a Bose-Einstein condensate (BEC). To produce this, a single photon is created in the atom-cavity system, thereby generating atom-photon entanglement. The photon is transported to the BEC and converted into a collective excitation in the BEC, thus establishing matter-matter entanglement. After a variable delay, this entanglement is converted into photon-photon entanglement. The matter-matter entanglement lifetime of 100 μs exceeds the photon duration by 2 orders of magnitude. The total fidelity of all concatenated operations is 95%. This hybrid system opens up promising perspectives in the field of quantum information.

Finite-temperature collective dynamics of a Fermi gas in the BEC-BCS crossover

We report on experimental studies on the collective behavior of a strongly interacting Fermi gas with tunable interactions and variable temperature. A scissors mode excitation in an elliptical trap is used to characterize the dynamics of the quantum gas in terms of hydrodynamic or near-collisionless behavior. We obtain a crossover phase diagram for collisional properties, showing a large region where a nonsuperfluid strongly interacting gas shows hydrodynamic behavior. In a narrow interaction regime on the BCS side of the crossover, we find a novel temperature-dependent damping peak, suggesting a relation to the superfluid phase transition.

Precision measurements of collective oscillations in the BEC-BCS crossover

We report on precision measurements of the frequency of the radial compression mode in a strongly interacting, optically trapped Fermi gas of (6)Li atoms. Our results allow for a test of theoretical predictions for the equation of state in the BEC-BCS crossover. We confirm recent quantum Monte Carlo results and rule out simple mean-field BCS theory. Our results show the long-sought beyond-mean-field effects in the strongly interacting Bose-Einstein condensation (BEC) regime.

Tenascin C and annexin II expression in the process of pancreatic carcinogenesis

Tenascin C (TNC) is a component of the provisional extracellular matrix (ECM) that characterizes solid tumours. Cell surface annexin II is a high-affinity receptor for large TNC splice variants. The aim of this study was to analyse whether TNC and annexin II play a role in the development of pancreatic ductal adenocarcinoma (PDAC). PDAC is characterized by a rich ECM populated by pancreatic stellate cells, which play a crucial role in pancreatic desmoplasia. The mRNA and protein levels of TNC and of annexin II were analysed in pancreatic tissues by DNA array, quantitative reverse transcriptase-polymerase chain reaction (QRT-PCR) and immunohistochemistry. TNC large splice variants were detected by RT-PCR. Enzyme linked immunosorbent assay (ELISA) was used to measure TNC levels in serum and culture supernatants. TNC and annexin II mRNA levels were significantly higher in pancreatic cancer tissues than in the normal pancreas. TNC expression was detected with increased frequency in the progression from PanIN-1 lesions to PDAC, and a parallel switch from cytoplasmic to cell surface expression of annexin II was observed. Large TNC transcripts were found in pancreatic cancer and in chronic pancreatitis, but not in the normal pancreas. TNC expression was demonstrated in pancreatic stellate cells, where it could be induced by tumour necrosis factor alpha (TNFalpha), transforming growth factor beta1 (TGF-beta1) and by cancer cell supernatants supplemented with TGF-beta1. In conclusion, the expression of TNC and cell surface annexin II increases in the progression from low-grade PanIN lesions to pancreatic cancer. Pancreatic stellate cells are identified as a source of TNC in pancreatic tissues, possibly under the influence of soluble factors released by the tumour cells.

Mutational spectrum of steroid 21-hydroxylase and the genotype-phenotype association in Middle European patients with congenital adrenal hyperplasia

OBJECTIVE

To analyze the mutational spectrum of steroid 21-hydroxylase (CYP21) and the genotype- phenotype correlation in patients with congenital adrenal hyperplasia (CAH) registered in the Middle European Society for Pediatric Endocrinology CAH database, and to design a reliable and rational approach for CYP21 mutation detection in Middle European populations.

DESIGN AND METHODS

Molecular analysis of the CYP21 gene was performed in 432 CAH patients and 298 family members. Low-resolution genotyping was performed to detect the eight most common point mutations. High-resolution genotyping, including Southern blotting and sequencing was performed to detect CYP21 gene deletions, conversions, point mutations or other sequence changes.

RESULTS

CYP21 gene deletion and In2 and Ile172Asn mutation accounted for 72.7% of the affected alleles in the whole study group. A good genotype-phenotype correlation was observed, with the exception of Ile172Asn and Pro30Leu mutations. In 37% of patients low resolution genotyping could not identify the causative mutation or distinguish homozygosity from hemizygosity. Using high-resolution genotyping, the causative mutations could be identified in 341 out of 348 analyzed patients. A novel mutation Gln315Stop was found in one simple virilising CAH (SV-CAH) patient from Austria. In the remaining seven patients polymorphisms were identified as the leading sequence alteration. The presence of elevated basal and ACTH-stimulated 17-hydroxyprogesterone, premature pubarche, advanced bone age and clitoral hypertrophy directly implicated Asn493Ser polymorphism in the manifestation of nonclassical- (NC) and even SV-CAH.

CONCLUSIONS

By genotyping for the most common point mutations, CYP21 gene deletion/conversion and the 8 bp deletion in exon 3, it should be possible to identify the mutation in 94-99% of the diseased alleles in any investigated Middle European population. In patients with a mild form of the disease and no detectable mutation CYP21 gene polymorphisms should be considered as a plausible disease-causing mutation.

Spontaneous 24-h ghrelin secretion pattern in fasting subjects: maintenance of a meal-related pattern

OBJECTIVE

Ghrelin stimulates GH release and causes weight gain through increased food intake and reduced fat utilization. Ghrelin levels were shown to rise in the preprandial period and decrease shortly after meal consumption, suggesting a role as a possible meal initiator. However, ghrelin secretion in fasting subjects has not yet been studied in detail.

DESIGN

24-h ghrelin profiles were studied in six healthy volunteers (three females; 25.5 years; body mass index 22.8 kg/m(2)) and compared with GH, insulin and glucose levels.

METHODS

Blood samples were taken every 20 min during a 24-h fasting period and total ghrelin levels were measured by RIA using a polyclonal rabbit antibody. The circadian pattern of ghrelin secretion and pulsatility (Cluster analysis) were evaluated.

RESULTS

An increase and spontaneous decrease in ghrelin were seen at the timepoints of customary meals. Ghrelin was secreted in a pulsatile manner with approximately 8 peaks/24 h. An overall decrease in ghrelin levels was observed during the study period. There was no correlation of ghrelin with GH, insulin or blood glucose levels.

CONCLUSIONS

This pilot study indicates that fasting ghrelin profiles display a circadian pattern similar to that described in people eating three times per day. In a fasting condition, GH, insulin and glucose do not appear to be involved in ghrelin regulation. In addition, we found that ghrelin is secreted in a pulsatile pattern. The variation in ghrelin independently of meals in fasting subjects supports previous observations that it is the brain that is primarily involved in the regulation of meal initiation.

Pronounced short stature in a girl with tricho-rhino-phalangeal syndrome II (TRPS II, Langer-Giedion syndrome) and growth hormone deficiency

We report on a 10-year-old girl with tricho-rhino-phalangeal syndrome type II (TRPS II) and pronounced short stature (-4.8 SD). The patient has an interstitial chromosome 8q24.1 deletion of 12-15 Mb. The deletion spans all genes from CSMD3 to at least ANXA13 including the TRPS1 and EXT1 genes, which are responsible for the TRPS II phenotype. In addition to the features of TRPS II, the patient had growth hormone (GH) deficiency with diminished response in three stimulation tests. Therapy with 0.2 mg GH/kg/week led to an increase of growth velocity from 2.5 to 6.6 cm/year. To our knowledge, such a combination of TRPS II and GH deficiency has not yet been described.

[Patient compliance and efficacy of diagnostic procedures in the surveillance of colorectal cancer: experience from a cancer center]

Postoperative surveillance is an important part of the curative therapy of colorectal cancer patients. The effort and effectiveness of these surveillance programs are controversially discussed. We analyzed the practiced follow-up of patients who had undergone a curative resection of colorectal cancer to demonstrate the difficulty to validate the performed surveillance program and to point out possible improvements. For a follow-up period of 37 months (median) we included 530 patients with at least one postoperative examination. 70 patients ended the follow-up prematurely - out of these 56 % quit the surveillance during the first 18 months. Another 68 patients died during the follow-up period. Cancer recurred in 28 % of the patients (n = 109 metastasis, n = 26 local recurrences, 18 patients developed a secondary cancer). 90 % of these recurrences occurred within the first three years. 3525 follow-up examinations took place within 79 months. Patient histories and physical examinations were not helpful for the diagnosis of local recurrences; neither were laboratory routine screenings meaningful. Carcinoembryonic antigen (CEA) and CA 19 - 9 tests, ultrasonographic studies, chest XD-rays and colonoscopic procedures had a higher diagnostic value on the other hand. We demonstrated the problematic nature of the evaluation of different follow-up tests concerning their validity as they were part of a complex postoperative surveillance program. It is also important to point out that the success of the postoperative surveillance depends strongly on the compliance of the patients. To increase this compliance we suggest that the follow-up of patients should be more strongly oriented towards the incidence of recurrences.

Precise determination of 6Li cold collision parameters by radio-frequency spectroscopy on weakly bound molecules

We employ radio-frequency spectroscopy on weakly bound (6)Li(2) molecules to precisely determine the molecular binding energies and the energy splittings between molecular states for different magnetic fields. These measurements allow us to extract the interaction parameters of ultracold (6)Li atoms based on a multichannel quantum scattering model. We determine the singlet and triplet scattering lengths to be a(s) = 45.167(8)a(0) and a(t) = -2140(18)a(0) (1a(0) = 0.052 917 7 nm), and the positions of the broad Feshbach resonances in the energetically lowest three s-wave scattering channels to be 83.41(15), 69.04(5), and 81.12(10) mT.

Observation of the Pairing Gap in a Strongly Interacting Fermi Gas

We studied fermionic pairing in an ultracold two-component gas of 6Li atoms by observing an energy gap in the radio-frequency excitation spectra. With control of the two-body interactions through a Feshbach resonance, we demonstrated the dependence of the pairing gap on coupling strength, temperature, and Fermi energy. The appearance of an energy gap with moderate evaporative cooling suggests that our full evaporation brought the strongly interacting system deep into a superfluid state.

Collective excitations of a degenerate gas at the BEC-BCS crossover

We study collective excitation modes of a fermionic gas of (6)Li atoms in the BEC-BCS crossover regime. While measurements of the axial compression mode in the cigar-shaped trap close to a Feshbach resonance confirm theoretical expectations, the radial compression mode shows surprising features. In the strongly interacting molecular BEC regime, we observe a negative frequency shift with increasing coupling strength. In the regime of a strongly interacting Fermi gas, an abrupt change in the collective excitation frequency occurs, which may be a signature for a transition from a superfluid to a collisionless phase.

Crossover from a molecular Bose-Einstein condensate to a degenerate Fermi gas

We demonstrate a reversible conversion of a 6Li2 molecular Bose-Einstein condensate to a degenerate Fermi gas of atoms by adiabatically crossing a Feshbach resonance. By optical in situ imaging, we observe a smooth change of the cloud size in the crossover regime. On the Feshbach resonance, the ensemble is strongly interacting and the measured cloud size is 75(7)% of the one of a noninteracting zero-temperature Fermi gas. The high condensate fraction of more than 90% and the adiabatic crossover suggest our Fermi gas to be cold enough to form a superfluid.

Bose-Einstein Condensation of Molecules

We report on the Bose-Einstein condensation of more than 10(5) Li2 molecules in an optical trap starting from a spin mixture of fermionic lithium atoms. During forced evaporative cooling, the molecules are formed by three-body recombination near a Feshbach resonance and finally condense in a long-lived thermal equilibrium state. We measured the characteristic frequency of a collective excitation mode and demonstrated the magnetic field-dependent mean field by controlled condensate spilling.

Validation of a mathematical model predicting the response to growth hormone treatment in prepubertal children with idiopathic growth hormone deficiency

OBJECTIVE

To validate a mathematical model developed by Ranke et al. (J Clin Endocrinol Metab 1999;84:1174-7783) to predict the GH response during the first years of GH replacement therapy.

PATIENTS AND METHODS

38 children with idiopathic GH deficiency (GHD) met all inclusion criteria for the prediction model, but the group differed in some characteristics from the cohort from which the model was derived.

RESULTS

Using the model for the 1st year including maximum GH after stimulation and the equation for the 6th year, the predicted value corresponded well with actual height gain. Differences were found when the growth response of the 1st year excluding maximum GH and that of the 2nd-5th year were calculated, resulting in a significant underestimation of actual height gain (-0.63 to -1.07 cm/year).

CONCLUSION

The mathematical prediction model tended to underpredict the growth response to GH treatment in our patients with pronounced GHD. The severity of GHD seems to be an important parameter for the 1st year prediction.

Modernes Operationsmanagement im Workflow Operation. Aufgabenspektrum und Herausforderungen der Zukunft

The operating unit is one of the cost-intensive facilities in a surgical clinic with a pacemaking function for most of the internal procedures. The power of performance of the operating unit is based on the cooperation of all disciplines and professions involved. The key to management of the operating unit is not only to coordinate the daily procedures, but also to interact with support personnel. To ensure successful OR management, the internal structure of the OR must fit the clinical tasks and the available quantity of personnel in each profession must be coordinated. Sufficient utilization of resources and equipment must be guaranteed without cost-intensive over-capacities and patient flow must be orientated to OR capacities. The development of such a business structure requires the management to clearly define the goal, to know the actual on-site data in detail with regard to the idiosyncratic workings of each specialty and to clearly assign the competence of each member of the team working in the OR. Coordination of the operating unit is the main task of OR management, which must ensure the following: transparent and coordinated schedule management in the various operative specialties, goal-directed changes of the schedule with incorporation of emergencies, as well as effective organization of staff. In order to realize these tasks, it is reasonable to implement interdisciplinary rules of procedures. In addition, the assignment of a neutral decision-making body within the OR and the creation of an information center for all OR personnel. The challenge of OR organization in the future is to implement more effective documentation systems and active controlling within the OR. One can ensure adequate utilization of resources in the OR with prospectively oriented planning. Better transparency of operations in the OR contributes to increased efficiency. Implementation of quality management is the foundation for a successfully operating surgical hospital. Not only the productivity of individual members of the staff, but also the precise documentation of the quality of results will become important parameters in a successful surgical hospital, whose nucleus is the OR.

[Suture of fresh Achilles tendon rupture. Comparison of open with percutaneous suture technique]

INTRODUCTION

The open repair of the acute Achilles' tendon rupture reduces the incidence of rerupture compared with nonsurgical treatment; however, it yields more surgical complications. Early mobilization of the patients improves the postoperative outcome. Percutaneous suture techniques have a low incidence of rerupture and improve the conditions for early mobilization.

METHODS

This study includes all patients (n = 97) with acute subcutaneous rupture of the Achilles' tendon with surgical treatment at the University of Heidelberg from 1992 to 1999. Open surgical repair and postoperative immobilization has been compared with a percutaneous suture technique and postoperative early mobilization. Altogether, 77 patients (80%) have been interviewed and 62 patients (65%) have undergone a clinical examination.

RESULTS

There were local complications in 18% of the patients after open repair (n = 49) compared with 6% of the patients after percutaneous suture. In both groups there were two patients (4%) who sustained a rerupture. In the control group there were two patients with deep vein thrombosis (4%) and 1 lung embolism (2%). The clinical examination revealed no difference between open and percutaneous repair except for some disturbances in sensitivity of the sural nerve after percutaneous repair. The lower expenditure of therapy in percutaneous versus open sutures show the comparison of the hospitalization rates (29% versus 88%) and the rates of endotracheal anesthesia (53% versus 90%).

CONCLUSION

Percutaneous suture technique for the repair of the Achilles' tendon is a simple and safe surgical procedure which allows early mobilization with a low rerupture rate. Thus this method should be performed as standard procedure for acute subcutaneous rupture of the Achilles' tendon.

[Modern operations management in workflow operation. Spectrum of responsibilities and challenges for the future]

The operating unit is one of the cost-intensive facilities in a surgical clinic with a pacemaking function for most of the internal procedures. The power of performance of the operating unit is based on the co-operation of all disciplines and professions involved. The key to management of the operating unit is not only to co-ordinate the daily procedures, but also to interact with support personnel. To ensure successful OR management, the internal structure of the OR must fit the clinical tasks and the available quantity of personnel in each profession must be co-ordinated. Sufficient utilization of resources and equipment must be guaranteed without cost-intensive over-capacities and patient flow must be orientated to OR capacities. The development of such a business structure requires the management to clearly define the goal, to know the actual on-site data in detail with regard to the idiosyncratic workings of each speciality and to clearly assign the competence of each member of the team working in the OR. Co-ordination of the operating unit is the main task of OR management, which must ensure the following: transparent and co-ordinated schedule management in the various operative specialities, goal-directed changes of the schedule with incorporation of emergencies, as well as effective organization of staff. In order to realize these tasks, it is reasonable to implement interdisciplinary rules of procedures. In addition, the assignment of a neutral decision-making body within the OR and the creation of an information center for all OR personnel. The challenge of OR organization in the future is to implement more effective documentation systems and active controlling within the OR. One can ensure adequate utilization of resources in the OR with prospectively oriented planning. Better transparence of operations in the OR contributes to increased efficiency. Implementation of quality management is the foundation for a successfully operating surgical hospital. Not only the productivity of individual members of the staff, but also the precise documentation of the quality of results will become important parameters in a successful surgical hospital, whose nucleus is the OR.

[Influence of the space layout of a surgical department on use efficiency]

There is a growing gap between the rapidly increasing diagnostic and therapeutic opportunities and the patient demands on one side and the continuously declining hospital budgets on the other side. This gap forces hospitals to search for rationalization potentials and ways to increase their efficiency. It is well known that the operating theatre unit is one of the most important internal cost factors. Many reorganization projects therefore focus on operating theatres. In Germany, several alternative operating room layouts have been developed in order to reduce running und building costs and to reach a high degree of flexibility in their everyday use by means of an improved design. This article analyses and compares the classic operating room and four alternative layouts intended to make them suitable for reaching the promised objectives and, especially, achieving an economically run business management. Furthermore, preferred layouts for certain types of operations are recommended.

[Microbiological and clinical effects of selective bowel decontamination in transthoracic resection of carcinoma of the esophagus and cardia]

INTRODUCTION

Surgical therapy of carcinoma of the esophagus or cardia by transthoracic esophageal resection is associated with a high morbidity in which nosocomial infections have a great importance. This study investigates the influence of prophylactic selective bowel decontamination on the course and results of transthoracic resection of the esophagus.

METHODS

Seventy patients with carcinoma of the esophagus and cardia were included in this prospective and partially randomized study at the University of Heidelberg. Twenty-five patients received prophylactically selective bowel decontamination with tobramycin, polymyxin B and amphotericin B. The treatment course was documented uniformly. In addition, microbiological screening was performed by swab examinations of nose, throat and anus, by urine and blood cultures, and the documentation of results of additional microbiological diagnostic studies.

RESULTS

Bacteriological screening confirmed a reduction in infectious agents and a change of their spectrum in the respiratory and digestive tract without an increase in multiresistant bacteria. Patients who received selective bowel decontamination had a lower infection rate, a shorter artificial respiration period and a shorter intensive care stay without statistically significant differences. The mortality rate was 4% vs 9% in the control group (95% confidence interval -0.172-0.116).

CONCLUSION

This study confirms the feasibility and microbiological effectiveness of selective bowel decontamination in the context of surgical therapy which is associated with a high nosocomial infection rate. The result of the clinical treatment seems slightly more favorable in the treatment group. Decisive are complications caused by surgery which fundamentally determine the clinical course and frequently cause infectious complications. The prophylactic use of selective bowel decontamination may be useful in patients with an increased risk of prolonged ventilation support or colon interposition but it is not to be generally recommended.

Serum tenascin-C is an indicator of inflammatory bowel disease activity

Tenascin-C is a multifunctional matrix protein that is induced in inflammation and neoplasia. In the colonic mucosa of ulcerative colitis patients tenascin-C indicates tissue repair, and mucosal concentrations are correlated with local disease activity. We prospectively examined the relationship between serum concentrations of tenascin-C parameters of disease activity in surgically treated patients with ulcerative colitis and patients with inflammatory bowel disease (IBD). Perioperative serum concentrations were quantified by ELISA in 58 patients admitted for restorative proctocolectomy; controls were 37 patients with familial adenomatous polyposis receiving the same treatment. We also measured tenascin-C serum levels in 47 patients with ulcerative colitis and Crohn's disease who were receiving nonsurgical treatment. Preoperative serum tenascin-C levels were significantly higher in ulcerative colitis patients than in controls (17.2 +/- 14.6 microg/ml vs. 3.2 +/- 1.7 microg/ml) and were significantly correlated with clinical and histological parameters of disease activity; levels decreased significantly after restorative proctocolectomy. Serum tenascin-C levels were also correlated with the course of disease activity in conservatively treated IBD patients. Tenascin-C is thus not disease-specific. However, it does indicate the activity of IBD and may reflect the degree of tissue remodeling. The tenascin-C levels therefore offers a novel serum parameter for assessing disease activity and monitoring therapy in patients with IBD.

Inhibition of distant caspase homologues by natural caspase inhibitors

Caspases play an important role in the ability of animal cells to kill themselves by apoptosis. Caspase activity is regulated in vivo by members of three distinct protease inhibitor families, two of which, baculovirus p35 and members of the inhibitor of apoptosis (IAP) family, are thought to be caspase specific. However, caspases are members of the clan of cysteine proteases designated CD, which also includes animal and plant legumains, and the bacterial proteases clostripain, gingipain-R and gingipain-K. Since these proteases have been proposed to have a common mechanism and evolutionary origin, we hypothesized that the caspase inhibitors may also regulate these other proteases. We tested this hypothesis by examining the effect of the natural caspase inhibitors on other members of protease clan CD. The IAP family proteins were found to have only a slight inhibitory effect on gingipain-R. The cowpox viral cytokine-response modifier A (CrmA) serpin had no effect on any of the proteases tested but a single point mutation of CrmA (Asp-->Lys) resulted in strong inhibition of gingipain-K. More substantial, with respect to the hypothesis, was the strong inhibition of gingipain-K by wild-type p35. The site in p35, required for inhibition of gingipain-K, was mapped to Lys94, seven residues C-terminal to the caspase inhibitory site. Our data indicate that the virally encoded caspase inhibitors have adopted a mechanism that allows them to regulate disparate members of clan CD proteases.

Impact of flavophospholipol and vancomycin on conjugational transfer of vancomycin resistance plasmids

The influence of vancomycin and flavophospholipol (FPL) on the transfer rate of conjugative plasmids harboring the vancomycin resistance operon vanA was determined in several clinical and animal isolates of Enterococcus faecium. FPL significantly inhibited the frequency of transfer of conjugative VanA plasmids up to 70-fold. Vancomycin had no significant effect on the transfer rate of VanA plasmids.

Long-term treatment in children with hypopituitarism: pubertal development and final height

Auxological data, pubertal development and final height were analyzed in 25 patients with growth hormone (GH) deficiency who were treated only with pituitary GH in 3 doses/week. 15 patients had a spontaneous onset of puberty and in 10 puberty was induced. The duration of therapy was 7.5 years, the dosage was about 11 U/m2/week and was not changed during puberty. 80% of the patients with induced puberty, but only 33% of the children with spontaneous puberty reached final heights within the 2 SD range. Final height was correlated with height at the start of treatment only in patients with spontaneous puberty, which shows the necessity of early treatment initiation in this group. The lack of this correlation in patients with induced puberty might be attributed to gonadotropin deficiency. Height at the onset of puberty was related to final height only in the group with gonadotropin deficiency. A prediction model for calculation of the first year height velocity which was derived from present treatment procedures showed a too favorable prediction for our patients. The reasons for the insufficient final results may be due to impure GH preparations, suboptimal dosage, low frequency of injections and late onset of therapy.

Posterior pituitary ectopy in children with idiopathic growth hormone deficiency

AIMS

To evaluate the underlying pathogenesis in children with pituitary hormone deficiency by means of high resolution MRI of the brain.

PATIENTS/METHODS

Thirty-seven children with short stature and isolated GH deficiency (IGHD, n = 17) or multiple pituitary hormone deficiency (MPHD, n = 20) were subjected to an MRI of the brain at the age of 1.0-17.3 years. The anatomic condition of the hypothalamo-pituitary area was analyzed and the height of the pituitary gland was measured and compared to the data of age-matched healthy subjects.

RESULTS

Seventy percent of the patients had a characteristic anomaly: the adenohypophysis was hypoplastic, the infundibulum was absent and the posterior pituitary lobe was ectopic at the bottom of the median eminence. The height of the anterior pituitary was significantly reduced in these patients (1.9 +/- 0.1 mm; mean +/- SD) when compared to age-matched healthy controls (4.1 +/- 0.8 mm, p<0.001) or hypopituitary patients with a normal MRI (4.3 +/- 0.8 mm). MPHD was found in 62% of patients with the pituitary anomaly whereas only 27% of children with a normal MRI had MPHD (p<0.05).

CONCLUSIONS

The pathogenesis of the pituitary anomaly is unknown; a disorder during embryonal development or perinatal events have been discussed as causal factors. MRI should have a prominent position in the work-up of hypopituitary children. When an anatomical malformation is visualized by MRI, the diagnostic terminology should be adapted accordingly.

The German experience: the surgeon as a prognostic factor in colon and rectal cancer surgery

The data of the German prospective multicenter study of the Study Group for Colo-Rectal Carcinoma (SGCRC) were analyzed by uni- and multivariate methods with regard to surgeon-related prognostic factors. The parameters were frequency of intraoperative local tumor spillage, surgical volume, and department and surgical quality group. The results obtained from the data of the SGCRC implicate consequences for analyses and comparisons of therapy results and studies on adjuvant therapy in colon and rectal cancer. All identified prognostic factors must be regarded and respectively considered in study designs. Colon and rectal cancer patients must also be distinguished and separate analyses are necessary for these.

Genetic rearrangements of the regions adjacent to genes encoding heat-labile enterotoxins (eltAB) of enterotoxigenic Escherichia coli strains

One of the most common bacterially mediated diarrheal infections is caused by enterotoxigenic Escherichia coli (ETEC) strains. ETEC-derived plasmids are responsible for the distribution of the genes encoding the main toxins, namely, the heat-labile and heat-stable enterotoxins. The origins and transfer modes (intra- or interplasmid) of the toxin-encoding genes have not been characterized in detail. In this study, we investigated the DNA regions located near the heat-labile enterotoxin-encoding genes (eltAB) of several clinical isolates. It was found that the eltAB region is flanked by conserved 236- and 280-bp regions, followed by highly variable DNA sequences which consist mainly of partial insertion sequence (IS) elements. Furthermore, we demonstrated that rearrangements of the eltAB region of one particular isolate, which harbors an IS91R sequence next to eltAB, could be produced by a recA-independent but IS91 sequence-dependent mechanism. Possible mechanisms of dissemination of IS element-associated enterotoxin-encoding genes are discussed.

Hearing loss and tinnitus in acute acoustic trauma

Despite extensive educational and protective measures, acute acoustic trauma continues to be a major problem in young military recruits. This retrospective study concern conscripts from eastern Austria who were referred to the Central Military Hospital for acute acoustic trauma (AAT) during the last 18 months. The study was designed to provide information on the profile of hearing loss and the presence of tinnitus after AAT. At the time when AAT occurred, hearing protection was not used in the majority of cases. In more than 75% of the ears hearing loss was registered in the high-frequency region (above 2 kHz). In the remaining 25% the speech frequency range under 2 kHz was also affected. Interestingly, the degree of hearing loss was independent of the type of firearm used, the number of shots and the use of hearing protection (ear plugs). Hearing loss occurred asymmetrically due to one-sided noise, whereas the distribution of tinnitus was symmetrical. The majority of patients experienced both, tinnitus and hearing loss as a consequence of AAT. Yet, in 6.2% of the subjects tinnitus was the only symptom. These results strongly suggest that tinnitus is as important a symptom of AAT as is hearing loss. Therefore, we believe that a tinnitus match should be performed in every patient with suspected AAT.

Detection of tenascin-C isoforms in colorectal mucosa, ulcerative colitis, carcinomas and liver metastases

The glycoprotein tenascin-C is up-regulated in inflammatory and neoplastic diseases. Most available data on tissue tenascin-C content do not distinguish its various isoforms. We have quantified tissue tenascin-C signals in colorectal mucosa, ulcerative colitis, colorectal carcinomas and liver metastases using 5 monoclonal antibodies (MAbs) with different binding sites. Tenascin-C of tissue extracts was analyzed by a standardized Western blot technique and densitometry. As a reference MAb, K8 displayed tenascin-C tissue concentrations of 4.1 +/- 2.3 microgram/mg total protein in normal mucosa, 13.8 +/- 4.7 microgram/mg in ulcerative colitis, 28.8 +/- 14.5 microgram/mg in colorectal carcinomas and 25.6 +/- 8.9 microgram/mg in liver metastases. The optical density values per microgram protein tissue extract of the 5 MAbs reflect the levels of the corresponding tenascin-C epitopes. Various signal intensities indicate a distinct diagnostic usefulness of the MAbs in detecting colorectal carcinomas. The binding characteristics of MAb J1/tn2 point to an under-representation of the TNfnD domain in metastasizing colorectal carcinomas, while MAb 19H12 showed an increased binding rate on the TNfnA1,2,4 region. Our comparative study of tenascin-C in inflammatory and neoplastic diseases of the colon mucosa substantiates the occurrence of large differences in the diagnostic value of tenascin-C MAbs. The detected alterations of tenascin-C in metastasizing colorectal carcinomas might indicate a prognostic value of specific tenascin-C isoforms.

Detection of tenascin-C isoforms in colorectal mucosa, ulcerative colitis, carcinomas and liver metastases

The glycoprotein tenascin-C is up-regulated in inflammatory and neoplastic diseases. Most available data on tissue tenascin-C content do not distinguish its various isoforms. We have quantified tissue tenascin-C signals in colorectal mucosa, ulcerative colitis, colorectal carcinomas and liver metastases using 5 monoclonal antibodies (MAbs) with different binding sites. Tenascin-C of tissue extracts was analyzed by a standardized Western blot technique and densitometry. As a reference MAb, K8 displayed tenascin-C tissue concentrations of 4.1 +/- 2.3 microgram/mg total protein in normal mucosa, 13.8 +/- 4.7 microgram/mg in ulcerative colitis, 28.8 +/- 14.5 microgram/mg in colorectal carcinomas and 25.6 +/- 8.9 microgram/mg in liver metastases. The optical density values per microgram protein tissue extract of the 5 MAbs reflect the levels of the corresponding tenascin-C epitopes. Various signal intensities indicate a distinct diagnostic usefulness of the MAbs in detecting colorectal carcinomas. The binding characteristics of MAb J1/tn2 point to an under-representation of the TNfnD domain in metastasizing colorectal carcinomas, while MAb 19H12 showed an increased binding rate on the TNfnA1,2,4 region. Our comparative study of tenascin-C in inflammatory and neoplastic diseases of the colon mucosa substantiates the occurrence of large differences in the diagnostic value of tenascin-C MAbs. The detected alterations of tenascin-C in metastasizing colorectal carcinomas might indicate a prognostic value of specific tenascin-C isoforms.

Impairment of peroxisomal biogenesis in human colon carcinoma

Peroxisomes and the activities of their enzymes have been reported to be significantly reduced in various types of tumors including the colon carcinoma. Therefore, the present study was designed to investigate the gene expression of several peroxisomal proteins in human colon carcinoma and additionally those of the peroxisome proliferator activated receptor alpha (PPARalpha) and PEX5, a receptor protein involved in the import of most peroxisomal matrix proteins. Samples from adenocarcinomas and adjacent normal colon were analyzed by immunohistochemistry and western blotting. The mRNA content was assessed by a novel sensitive dot blot RNase protection assay and northern blotting. By immunohistochemistry, peroxisomes were distinctly visualized in normal colonocytes but were not detected in colon carcinoma cells. The protein levels of catalase (CAT), acyl-CoA oxidase as well as the 22 and 70 kDa peroxisomal membrane proteins (PMP22 and PMP70) were all significantly decreased in carcinomas. The corresponding mRNAs for CAT and PMP70, however, were unchanged. In contrast, the mRNA of PEX5 was significantly increased. The expression of PPARalpha was not altered in tumors, neither at protein nor mRNA levels. These observations show that the reduction of peroxisomes and their proteins in colon carcinoma is not due to a generalized reduction of transcription of their genes. It seems more likely that this phenomenon is regulated at a post-transcriptional or translational level. Alternatively, and more likely, an impairment of the biogenesis of the organelle could account for the paucity of peroxisomes in colon carcinoma.

[Comparative study of oncological outcome quality in colorectal carcinoma--ranking by surrogate endpoint?]

The data of the German Prospective Multicenter Study of the Study Group Colorectal Carcinoma (SGCRC) were analyzed with regard to interinstitutional differences in 5-year survival by statistical methods adequate for ranking and observing anonymity. Furthermore, possible so-called surrogate endpoints that allow an assessment of definite outcome after surgical treatment earlier than after 5 years were also analyzed. This requires a separate analysis for rectal and colon carcinoma patients. For rectal carcinoma, the combination of the frequency of local tumor cell spillage during tumor resection (iatrogenous tumor perforation and/or incision into or through tumor tissue) and the rate of locoregional recurrences (within 2 years after surgery) could be demonstrated as reliable surrogate endpoint. For colon carcinoma, no reliable surrogate endpoint could be found. Surgical morbidity is not an indicator of definite outcome. A very low rate of surgical mortality does not ensure satisfactory long-term results in colorectal cancer surgery.

Lymphocyte subsets in renal transplant recipients during growth hormone therapy

OBJECTIVE

To evaluate the effect of growth hormone treatment on growth, levels of insulin-like growth factor I (IGF-I) and lymphocyte subsets in immunosuppressed renal allograft recipients.

METHODS

18 children (aged 8.0-16.6 years) received growth hormone 1 IU/Kg/week daily for two years. Height, IGF-I levels and in 11/18 patients, lymphocyte subsets were evaluated serially.

RESULTS

Standardized growth velocity increased from -1.0+1.5 to +1.2+2.2 and standardized IGF-I levels from +0.8+1.5 to +3.1+1.1 (1 year) and to +1.4+1.7 (2 years). The total lymphocyte count and the number of T lymphocytes (CD3+) decreased. The decrease was more marked in CD8+ (from 1.5+0.3 x10(9)/L to 0.9+0.3 x10(9)/L, 1 year and to 0.8+0.1 x10(9)/L, 2 years) compared to CD4+ (from 1.5+0.3 x10(9)/L to 1.0+0.2 x10(9)/L, 1 year and to 1.3+0.2 x10(9)/L, 2 years), resulting in an increment of the CD4+/CD8+ index.

CONCLUSIONS

The differential effect of growth hormone treatment on CD4+ and CD8+ lymphocytes might be explained by different expression of the IGF-I receptor in these distinct subsets.

Improved extraction procedure and RIA for determination of arginine8-vasopressin in plasma: role of premeasurement sample treatment and reference values in children

We optimized an RIA for measurement of arginine8-vasopressin (AVP) in plasma by use of 100-mg Isolute C18 columns for extraction, addition of a preincubation step, and use of maximal dilution of a commercially available antiserum. The detection limit was 0.06 ng/L when 0.5 mL of acidified plasma was extracted. The within- and between-run CVs (n = 16) at physiological concentrations were 5.8-10. 2% and 6.5-11.7%, respectively. Prolonged storage of blood at 25 degreesC, but not at 4 degreesC, led to a significant increase in measured plasma AVP concentrations. When plasma samples were prepared at several centrifugation speeds, plasma AVP was significantly correlated with the platelet count (r = 0.899; P <0. 001). This emphasizes the need for careful sample preparation to avoid contamination of plasma with platelet-bound AVP. Basal plasma AVP in 203 children and adolescents (105 males and 98 females; ages, 1 day to 18 years) averaged 1.1 +/- 0.6 ng/L. There was no significant difference between males and females and no correlation with age. In 16 healthy adult controls, plasma AVP averaged 1.0 +/- 0.5 ng/L.

Treatment of peripubertal children after renal transplantation (RTX) with recombinant human growth hormone: auxological data and effects on insulin-like growth factor-I (IGF-I) and IGF-binding protein-3 (IGFBP-3) during 24 months

OBJECTIVE

To evaluate growth and endocrine parameters in RTX children with GH treatment during 24 months.

SUBJECTS

18 children (13 boys), age 13.1 yr (8.0-16.6), bone age 10.1 yr (5.4-15.3). Patients were 2.8 yr (0.5-7.5) after RTX and had immunosuppressive therapy, prednisone 0.16 mg/kg/d (0.08-0.68).

METHODS

GH (4 IU/m2/day s.c.) was given and patients were seen every 3 months for evaluation of height, height velocity, bone age, and hormone parameters. Serum IGF-I was determined by RIA, IGFBP-3 by RIA and Western ligand blotting (WLB). Renal function and adverse effects (GFR, glucose tolerance, rejection episodes) were monitored.

RESULTS

Height (+1 SDS) and height velocity (+2.2 SDS) increased significantly during 24 months GH treatment, but delta BA/delta CA was 1.7 and 1.5 during the first and second treatment year, respectively, and all patients entered puberty during the treatment period. GFR decreased slightly during 2 yr (p = 0.048), two patients had chronic rejection and GH therapy was terminated in one patient because of glucose intolerance. The ratio IGF-I/IGFBP-3 rose during the first year (p = 0.002) indicating more bioavailable IGF-I. IGFBP-3 determined by WLB was decreased, but IGFBP-1, -2 and -4 were elevated as compared to a standard.

CONCLUSIONS

GH treatment increased height and growth rate in children after RTX. This may be due to significant changes in IGF-I and IGFBP-3 relationship. However, bone maturation was also accelerated thus diminishing height potential. From month 12 to 24 a continuous decrease of IGF-I was observed. There was a slight but significant deterioration of graft function. Adverse events that led to termination of GH therapy were observed in 3 of 18 patients.

[3-dimensional ultrasound in clinical diagnosis of meniscus lesions]

AIM

To compare the significance of the two-dimensional and three-dimensional sonography in the diagnosis of meniscal tears under clinical conditions.

METHODS

Sixty menisci of knees with clinical symptoms (44 medial and 16 lateral menisci) were examined by an identical transducer in a two- and three-dimensional sonography technique. The findings were compared with the diagnosis made with subsequent arthroscopy.

RESULTS

In the diagnosis of meniscal lesions the two- and three-dimensional sonography reached a sensitivity of 92% and 100% and a specificity of 83% and 88%, respectively. The positive predictive value of these methods was 58% and 67%. The negative predictive value was 98% and 100%. Because of the good results with the two-dimensional sonography, there were no statistically significant differences between both methods. The three-dimensional sonography, however, proved to be superior, to the two-dimensional sonography in the analysis of subgroups (medial and lateral menisci, menisci with and without clinical symptoms). The negative predictive value of the three-dimensional sonography was 100% for all of these subgroups.

CONCLUSION

Although this study shows no significant difference in the results of two- and three-dimensional sonography, the analysis of subgroups displays a slightly improved significance for diagnosis of meniscal tears by three-dimensional sonography. The high negative predictive value shows that three-dimensional sonography, performed by an experienced examiner, may be useful to exclude meniscal tears. This result may help focus further cost-intensive or invasive examinations.

Mucosal tenascin C content in inflammatory and neoplastic diseases of the large bowel

PURPOSE

Tenascin C is a glycoprotein of the extracellular matrix. It is upregulated during embryologic development, wound healing, and under conditions of normal and neoplastic growth. Most available data on tenascin C expression in tissues is based on immunohistologic studies. The present study was designed to quantify tissue concentrations in patients with inflammatory and neoplastic diseases of the large bowel.

METHODS

Fifty patients with ulcerative colitis, 19 patients suffering from familiar adenomatous polyposis without malignant transformation, and 69 patients with colorectal carcinoma were investigated. Tenascin C concentrations in tissue extracts were determined by semiquantitative Western blotting.

RESULTS

The tenascin C tissue concentration of normal mucosa was 2.6 +/- 3.4 microg/mg (n = 55), 2.9 +/- 2.1 microg/mg in colorectal adenomas (n = 19), 7.5 +/- 4.7 microg/mg in ulcerative colitis (n = 50), and 18 +/- 15 microg/mg in colorectal carcinomas (n = 69; mean +/- standard deviation). In ulcerative colitis, the mucosal tenascin C content correlated with histopathologic disease activity. No differences were found between subgroups of adenomas or carcinomas.

CONCLUSIONS

Tenascin C tissue concentrations were not altered in adenomas, slightly elevated in ulcerative colitis, and substantially increased in colorectal carcinomas. Although less useful as a diagnostic parameter, tenascin C tissue levels serve as an instrument for assessing the activity of stromal remodeling in large-bowel diseases generally. Specifically, they may reflect disease activity in ulcerative colitis.

[3-dimensional sonography in the diagnosis of meniscal lesions. An experimental and clinical study]

There is no consensus regarding the clinical significance of conventional two-dimensional ultrasound in the diagnosis of meniscal tears of the knee. Three-dimensional ultrasound spatially reconstructs a transparent image of subsequent ultrasound scans. In an experimental study of 96 menisci, radial and oblique tears were detected more often by three-dimensional ultrasound. In a clinical study of 60 menisci the two- and three-dimensional ultrasound reached a sensitivity of 92% and 100%, a specificity of 83% and 88%, a positive predictive value of 58% and 67%, and a negative predictive value of 98% and 100%, respectively. Altogether, there was no statistically significant difference between both methods. The high negative predictive value, however, shows that the three-dimensional ultrasound may be a clinically relevant examination for special questions in the diagnostics of meniscal tears.

CD95 (APO-1/Fas)-mediated apoptosis in colon epithelial cells: a possible role in ulcerative colitis

BACKGROUND & AIMS

Ligation of CD95 (APO-1/Fas) by antibody or CD95 ligand (CD95L) induces apoptosis and, in some cell lines, growth. Normal colonic epithelial cells constitutively express CD95. The function of CD95 on colonocytes is unknown. The aim of this study was to elucidate the role of epithelial CD95 in the normal colon and in ulcerative colitis.

METHODS

Intact colonic crypts were isolated, and the effects of CD95 ligation in vitro were studied. CD95L-expressing cells and apoptotic cells were detected in situ by RNA hybridization, immunohistochemistry, and DNA nick end labeling.

RESULTS

On CD95 ligation, isolated colonic crypt cells underwent apoptosis within 4 hours. No growth-promoting effect was observed. In normal colon, CD95L expression was restricted to few mononuclear cells randomly scattered within the lamina propria. Therefore, the CD95-CD95L system is very unlikely to operate in the regeneration of the colonic epithelium. However, in ulcerative colitis, the number of interstitial CD95L+ cells and the frequency of apoptosis in both lamina propria and epithelium were increased considerably. Further, a focal association of subepithelial CD95L+ mononuclear cells and epithelial apoptosis was observed.

CONCLUSIONS

In ulcerative colitis, soluble CD95L-mediated epithelial apoptosis may lead to a breakdown of the epithelial barrier function facilitating the invasion of pathogenic microorganisms.

Tenascin-C tissue concentration in inflammatory and neoplastic diseases of the colon mucosa

BACKGROUND

Tenascin-C is a gycoprotein of the extracellular matrix with predominantly antiadhesive qualities. In the colon mucosa tenascin-C has been found to be induced in inflammatory and neoplastic diseases by immunohistology. This study aimed at quantitating mucosal tenascin-C induction.

MATERIALS AND METHODS

Mucosal tenascin-C concentration was determined by Western blotting quantified by densitometry in fresh frozen specimens of the colon from patients with ulcerative colitis, familial polyposis, and colorectal carcinomas.

RESULTS

The tenascin-C concentration in normal mucosa was 2.6 micrograms/mg protein (SD +/- 3.4 micrograms/mg). Colorectal adenomas displayed an equal tissue concentration of 2.8 micrograms/mg protein (SD +/- 2.0 micrograms/mg). In ulcerative colitis statistically significant elevated tissue content of 7.5 micrograms/mg protein (SD +/- 4.7 micrograms/mg) was found. Colorectal carcinomas had a tissue tenascin-C level of 18.0 micrograms/mg protein (SD +/- 14.6 micrograms/mg), which was significantly different from the other groups.

CONCLUSIONS

Tenascin-C concentration is elevated in inflammatory and neoplastic diseases of the colorectal mucosa. The distinct increase in the tenascin-C content in colorectal carcinomas in contrast to normal levels in colorectal adenomas reflects an association of tenascin-C induction with malignant disease.

Pituitary hyperplasia in a girl with gonadal dysgenesis and primary hypothyroidism

A 16-year-old Brazilian girl presented with severe growth retardation (-6.3 SDS), obesity, delayed pubertal development, facial dysmorphia, dry skin, and borderline low intelligence (IQ 89). Endocrinological evaluation showed primary hypothyroidism (no uptake of iodine-131 of the right thyroid lobe). Basal and stimulated gonadotropins were increased and ultrasonography revealed hypoplastic ovaries. The karyotype of peripheral lymphocytes was 46,X,i(Xq). The GH response in euthyroid condition after stimulation with GHRH and insulin was diminished. MRI of the pituitary region showed a suprasellar mass (12 x 15 mm) which was removed by transsphenoidal surgery because of extension to the optic chiasm. Histological examinations revealed regular pituitary tissue with hyperplasia of TSH- and FSH-producing cells. Thyroxine treatment was adjusted and GH was given. We conclude that the suprasellar mass was the consequence of long-lasting hypothalamic overstimulation with TRH and LHRH, due to gonadal and thyroid insufficiency.