Primary Surgery Followed by Selective Chemoradiotherapy Versus Preoperative Chemoradiotherapy Followed by Surgery for Locally Advanced Rectal Cancer: A Randomized Clinical Trial.

PURPOSE: The aim of this work was to determine whether locally advanced rectal cancer (LARC) with negative mesorectal fascia (MRF) predicted by magnetic resonance imaging (MRI) can be excluded from preoperative radiation therapy treatment. METHODS AND MATERIALS: This multicenter, open-label, non-inferiority, randomized clinical trial enrolled patients with LARC within 6 to 12 cm from the anal verge and with negative MRI-predicted MRF. Participants were randomized to the intervention group (primary surgery, in which the patients with positive pathologic [CRM] circumferential margins were subjected to chemoradiotherapy [CRT] and those with negative CRM underwent adjuvant chemotherapy according to pathologic staging) or the control group (preoperative CRT, in which all patients underwent subsequent surgery and adjuvant chemotherapy). The primary endpoint was 3-year disease-free survival (DFS). RESULTS: A total of 275 patients were randomly assigned to the intervention (n = 140) and control (n = 135) groups, in which 33.57% and 28.15% patients were at clinical T4 stage and 85.92% and 80.45% patients were at "bad" or "ugly" risk in the intervention and control groups, respectively. There were 2 patients (1.52%) and 1 patient (0.77%) with positive CRM in the intervention and control groups, respectively (P > .05). The non-adherence rates for the intervention and control groups were 3.6% and 23.7%, respectively. After a median follow-up of 34.6 months (IQR, 18.2-45.7), 43 patients had positive events (28 patients and 15 patients in the intervention and control groups, respectively). There were 6 patients (4.4%) with local recurrence in the intervention group and none in the control group, which led to the termination of the trial. The 3-year DFS rate was 81.82% in the intervention group (95% CI, 78.18%-85.46%) and 85.37% in the control group (95% CI, 81.75%-88.99%), with a difference of -3.55% (95% CI, -3.71% to -3.39%; hazard ratio, 1.76; 95% CI, 0.94-3.30). In the per-protocol data set, the difference between 3-year DFS rates was -5.44% (95% CI, -5.63% to -5.25%; hazard ratio, 2.02; 95% CI, 1.01-4.06). CONCLUSIONS: Based on the outcomes of this trial, in patients with LARC and MRI-negative MRF, primary surgery could negatively influence their DFS rates. Therefore, primary surgery was an inferior strategy compared with preoperative CRT followed by surgery and cannot be recommended for patients with LARC.

Production improvement of FK506 in Streptomyces tsukubaensis by metabolic engineering strategy.

AIMS: Study of the effect of isoleucine on the biosynthesis of FK506 and modification of its producing strain to improve the production of FK506. METHODS AND RESULTS: Metabolomics analysis was conducted to explore key changes in the metabolic processes of Streptomyces tsukubaensis Δ68 in medium with and without isoleucine. In-depth analysis revealed that the shikimate pathway, methylmalonyl-CoA, and pyruvate might be the rate-limiting factors in FK506 biosynthesis. Overexpression of involved gene PCCB1 in S. tsukubaensis Δ68, a high-yielding strain Δ68-PCCB1 was generated. Additionally, the amino acids supplement was further optimized to improve FK506 biosynthesis. Finally, FK506 production was increased to 929.6 mg L-1, which was 56.6% higher than that in the starter strain, when supplemented isoleucine and valine at 9 and 4 g L-1, respectively. CONCLUSIONS: Methylmalonyl-CoA might be the key rate-limiting factors in FK506 biosynthesis and overexpression of the gene PCCB1 and further addition of isoleucine and valine could increase the yield of FK506 by 56.6%.

Improvement of FK506 production via metabolic engineering-guided combinational strategies in Streptomyces tsukubaensis.

BACKGROUND: FK506, a macrolide mainly with immunosuppressive activity, can be produced by various Streptomyces strains. However, one of the major challenges in the fermentation of FK506 is its insufficient production, resulting in high fermentation costs and environmental burdens. Herein, we tried to improve its production via metabolic engineering-guided combinational strategies in Streptomyces tsukubaensis. RESULTS: First, basing on the genome sequencing and analysis, putative competitive pathways were deleted. A better parental strain L19-2 with increased FK506 production from 140.3 to 170.3 mg/L and a cleaner metabolic background was constructed. Subsequently, the FK506 biosynthetic gene cluster was refactored by in-situ promoter-substitution strategy basing on the regulatory circuits. This strategy enhanced transcription levels of the entire FK506 biosynthetic gene cluster in a fine-tuning manner and dramatically increased the FK506 production to 410.3 mg/mL, 1.41-fold higher than the parental strain L19-2 (170.3 mg/L). Finally, the FK506 production was further increased from 410.3 to 603 mg/L in shake-flask culture by adding L-isoleucine at a final concentration of 6 g/L. Moreover, the potential of FK506 production capacity was also evaluated in a 15-L fermenter, resulting in the FK506 production of 830.3 mg/L. CONCLUSION: From the aspects of competitive pathways, refactoring of the FK506 biosynthetic gene cluster and nutrients-addition, a strategy for hyper-production and potentially industrial application of FK506 was developed and a hyper-production strain L19-9 was constructed. The strategy presented here can be generally applicable to other Streptomyces for improvement of FK506 production and streamline hyper-production of other valuable secondary metabolites.

Activation and discovery of tsukubarubicin from Streptomyces tsukubaensis through overexpressing SARPs.

Genome sequencing has revealed that each Streptomyces contains a wide range of biosynthetic gene clusters (BGCs) and has the capability to produce more novel natural products than what is expected. However, most gene clusters for secondary metabolite biosynthesis are cryptic under normal growth conditions. In Streptomyces tsukubaensis, combining overexpression of the putative SARPs (Streptomyces antibiotic regulatory proteins) and bioactivity-guided screening, the silent gene cluster (tsu) was successfully activated and a novel bioactive anthracycline tsukubarubicin was further isolated and identified. Biological activity assays demonstrated that tsukubarubicin possessed much better antitumor bioactivities against various human cancer cell lines (especially the breast cancer cell lines) than clinically used doxorubicin. Moreover, the previously unreported gene cluster (tsu) for biosynthesis of tsukubarubicin was first characterized and detailed annotations of this gene cluster were also conducted. Our strategy presented in this work is broadly applicable in other Streptomyces and will assist in enriching the natural products for potential drug leads. KEY POINTS: • Generally scalable strategy to activate silent gene clusters by manipulating SARPs. • The novel anthracycline tsukubarubicin with potent antitumor bioactivities. • Identification and annotation of the previously uncharacterized tsu gene cluster.

A meta-analysis of dietary carbohydrate intake and inflammatory bowel disease risk: evidence from 15 epidemiology studies.

BACKGROUND AND PURPOSE: epidemiological studies that assess the association of dietary total carbohydrate intake and inflammatory bowel disease risk (IBD) have yielded controversial results. Therefore, this study of various epidemiological studies was conducted in order to explore this relationship. METHODS: a systematic literature search of the PubMed, Embase, Web of Science and Medline databases was performed up to September 2017. Cohort, case-control or cross-sectional design studies were included that reported the association of dietary carbohydrate intake and IBD risk. Summary odds ratio (OR) and the corresponding 95% CI were calculated using the random effects model. RESULTS: a total of eight articles with 15 individual studies that included 1,361 cases were eligible according to the inclusion criteria. Dietary carbohydrate intake had a non-significant relationship with the risk of IBD (OR = 1.091, 95% CI = 0.817-1.455, I2 = 31.6%, pfor heterogeneity = 0.116). The pooled OR and 95% CI for ulcerative colitis (UC) and Crohn's disease (CD) with regard to dietary carbohydrate intake was 1.167 (0.777-1.752) and 1.010 (0.630-1.618), respectively. These associations were also non-significant in both European and Asia populations. CONCLUSIONS: a higher dietary total carbohydrate intake had a non-significant relationship with IBD risk. Further studies with large populations are needed to verify this relationship.

Laparoscopic-Assisted Transhiatal Esophagogastrectomy Without Thoracic or Cervical Access: A Series of One Hundred Three Consecutive Cases.

AIM: To evaluate short-term and long-term outcomes of laparoscopic-assisted transhiatal esophagogastrectomy (LTEG) for treatment of adenocarcinoma of the esophagogastric junction (AEG). METHODS: Patients with AEG who underwent laparoscopic or open surgery at our department from October 2008 to December 2012 were enrolled in this retrospective study. Patients' demographics, perioperative outcomes, and survival data were collected. RESULTS: A total of 136 patients with AEG were enrolled (103 patients underwent laparoscopic surgery and 33 patients underwent open surgery). Patient characteristics were comparable between two groups in terms of age, gender, tumor-node-metastasis stage, tumor size, preoperative complications, and type of surgery. The median operative time was longer in laparoscopic group (240 versus 210 minutes, P = .048). However, the estimated blood loss was less, and the rate of pleural rupture was lower in laparoscopic group (20 versus 70 mL, P < .001 and 18.4% versus 36.4%, P = .033, respectively). The rate of patients with pleural rupture requiring prolonged use of mechanical ventilation longer than 12 hours (6/31, 19.4%) was higher than that of patients without pleural rupture (6/105, 5.7%) (P = .019). The incidence of reflux symptoms at postoperative month six was similar in two groups (18.4% in laparoscopic group versus 24.2% in open group, P = .468), as well as the use of proton pump inhibitors (12.6% versus 15.2%, P = .709). Furthermore, the number of lymph nodes harvested (22 versus 25), 2-year cumulative overall survival rates (80.4% versus 57.5%), and the median survival times (51.52 months versus 24.24 months) were similar between two groups (P > .05). CONCLUSION: LTEG is a safe, feasible, and oncologically effective procedure for AEG when performed by an experienced surgeon. Laparoscopic surgery is associated with a lower risk of pleural rupture, but pleural rupture in laparoscopic surgery may cause an adverse effect on the recovery of pulmonary function presumably due to tension pneumothorax.

Short-Term and Long-Term Outcomes of Laparoscopic Versus Open Surgery for Low Rectal Cancer.

AIM: To compare the short-term and long-term outcomes of laparoscopic versus open surgery for low rectal cancer. METHODS: Patients with low rectal cancer who underwent laparoscopic or open surgery at our department from January 2009 to December 2013 were enrolled in this retrospective study. The primary end points were 3-year local recurrence and overall and disease-free survival (DFS) rates. Secondary end points were intraoperative and postoperative outcomes. RESULTS: Laparoscopic group had longer operative time (165.0 versus 140.0, P < .001), less blood loss (20.0 versus 40.0, P < .001), shorter length of incision (5.0 versus 18.0, P < .001), and more lymph node harvested (11.0 versus 9.0, P = .002). However, time to first flatus (P = .941), postoperative hospital stay (P = .095), postoperative complications (P = .155), and 30-day mortality (P = .683) was similar between two groups. With the median follow-up period of 65 months, the 3-year local recurrence rate was 4.3% in laparoscopic group and 7.5% in open group (P = .077); the 3-year overall and DFS rates were similar in two groups (85.9% versus 88.8%, P = .229 and 76.9% versus 79.2%, P = .448, respectively); and the overall and DFS curves were comparable between two groups (hazard ratio [HR] = 0.858, 95% confidence intervals [CI] 0.709-1.037, P = .112 and HR = 1.076, 95% CI 0.834-1.389, P = .275, respectively). CONCLUSIONS: Laparoscopic surgery is safe and has equivalent long-term oncologic outcomes for low rectal cancer when compared to open surgery. Furthermore, large-scale, prospective randomized clinical trials are needed to confirm the present findings.

Hand-assisted laparoscopic right hemicolectomy with complete mesocolic excision and central vascular ligation: a novel technique for right colon cancer.

BACKGROUND: It can be difficult to locate the superior mesenteric vein and dissect around middle colic vessels during laparoscopic right hemicolectomy with complete mesocolon excision due to a high rate of vascular variations in the superior mesenteric vessels. Therefore, we report a modified technique for hand-assisted laparoscopic right hemicolectomy with complete mesocolic excision and central vascular ligation, which addresses these two problems. METHODS: Thirty-one consecutive patients with right colon cancer underwent this procedure from March 2014 to August 2015. Extracorporeally, the transverse colon and distal ileum were excised with a transumbilical hand-port incision, and the distal part of the superior mesenteric vein was identified. Intracorporeally, with the assistance of the surgeon's left hand inserted through the incision, D3-lymphadenectomy with central vascular ligation was performed, and the colon with the tumor, which had no blood supply, was removed. Patients' demographic data and intraoperative, postoperative and pathological characteristics were examined. RESULTS: The median operative time was 130.0 (range 115-180) minutes. The median blood loss was 45.0 (range 20-300) milliliters. The median length of the hand-port incision was 7.3 (range 6.0-8.2) centimeters. The median numbers of lymph nodes and central lymph nodes was 34.0 (range 18-91) and 13.0 (range 3-28), respectively. Five (16.1%) of 31 patients had positive central lymph nodes. Specimen morphometric quantitation was as follows: the median distances from the tumor and nearest bowel wall to the high tie were 10.5 (range 5.0-15.0) and 8.0 (range 6.0-12.0) centimeters, respectively; the median resected area of the mesentery was 200.0 (range 96.0-300.0) square centimeters; the median width of the chain of lymph-adipose tissue at the central lymph nodes area was 2.0 (range 0.8-8.0) centimeters; and the median length of the central lymph-adipose chain was 19.0 (range 3.0-26.0) centimeters. CONCLUSIONS: Our procedure confers technical advantages and is feasible for treatment of right colon cancer.

Prognostic role of the lymphocyte-to-monocyte ratio in patients undergoing resection for nonmetastatic rectal cancer.

Lymphocyte-to-monocyte ratio (LMR) was associated with survival benefit in some types of cancer. The relationship between LMR and rectal cancer has not been investigated. We conducted a retrospective cohort study to assess the prognostic significance of LMR in patients with nonmetastatic rectal cancer. Patients with rectal cancer who underwent potentially curative resection between January 2009 and December 2013 were enrolled. The LMR was calculated from preoperative blood test by dividing the absolute lymphocyte counts by the absolute monocyte counts. The optimal cut-off value for LMR was calculated as the median value. On the basis of the cut-off value, patients were divided into 2 groups: low group and high group. A total of 543 patients with rectal cancer were eligible for this study. The median follow-up time for all patients was 55 months (range 6-85 months). The cut-off value of LMR was 5.13 and patients were divided into 2 groups: low group (LMR < 5.13) and high group (LMR ≥ 5.13). In the univariate and multivariate analysis, the LMR was not significantly associated with overall survival (OS) [hazard ratio (HR): 1.034, 95% confidence intervals (CIs): 0.682-1.566, P = 0.876]. When disease-free survival (DFS) was compared, univariate and multivariate analysis also indicated that the LMR was not significantly associated with DFS (HR: 0.988, 95% CI: 0.671-1.453, P = 0.950). In addition, in the subgroup analysis by tumor-node-metastasis stage, there existed no significance between LMR and OS and DFS. Although as an easy access and highly efficient laboratorial inflammatory marker, LMR cannot predict the prognosis of nonmetastatic rectal cancer patients.

Molecular epidemiology of genogroup II norovirus infection among hospitalized children with acute gastroenteritis in Suzhou (Jiangsu, China) from 2010 to 2013.

Noroviruses (NoVs) are the most common cause of acute gastroenteritis in both sporadic and outbreak cases. Genotyping and recombination analyses were performed in order to help getting more knowledge of the distribution and genetic diversity of NoVs in Suzhou, located in Jiangsu province of China. All stool samples were collected from hospitalized children younger than 5 years old with acute gastroenteritis. For genotyping, the open reading frame (ORF) 1 and ORF2 were partially amplified and sequenced. 26.9% of stool samples were positive for genogroup II NoVs. The most common genotype was GII.4 and its variants included Den Haag-2006b, New Orleans-2009, and Sydney-2012. The Den Haag-2006b variants predominated during 2010-2012. In 2013, it was replaced by the Sydney-2012 variant. The second most common genotype was GII.12/GII.3. NoVs could be detected throughout the year, with GII.4 and GII.12/GII.3 coexisting during the cold months, and GII.4 was the main genotype during the warm months. The highest prevalence of NoV was detected in young children aged <24 months. Patients infected with GII.4 had a higher chance of getting moderate fever than other NoV-positive patients, while those infected with GII.12/GII.3 tended to have a mild degree of fever. NoV is an important pathogen responsible for viral gastroenteritis among children in Suzhou. Analyses of NoV circulating between 2010 and 2013 revealed a change of predominant variant of NoV GII.4 in each epidemic season and intergenotype recombinant strains represented an important part.

Novel triterpenoid saponins from the seeds of Celosia argentea L.

Two new triterpenoid saponins celosin I (1) and celosin II (2) were isolated from the seeds of Celosia argentea L. (Amaranthaceae). The structures of the two new compounds were elucidated based on chemical analysis and spectral methods (IR, 1-D and 2-D NMR, ESI-MS, HR-ESI-MS). They exhibited significant hepatoprotective effect on carbon tetrachloride-induced and N,N-dimethylformamide-induced hepatotoxicity in mice.

A novel hepatoprotective saponin from Celosia cristata L.

A new saponin, cristatain (1), together with four other saponins, celosin A (2), celosin B (3), celosin C (4) and celosin D (5) were isolated from the seeds of Celosia cristata L. (Amaranthaceae). Their structures were established by chemical and spectroscopic analyses. For the first time, the saponins were found in C. cristata L. In addition, compound 1 exhibited significant hepatoprotective effect on carbon tetrachloride (CCl(4))- and N,N-dimethylformamide (DMF)-induced hepatotoxicity in mice, which were evidenced by significant decreases in the values of asparate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (ALP) of serum and histopathological examinations compared to controls.

Hospital-Based Surveillance of Rotavirus Diarrhea in the People's Republic of China, August 2003-July 2007.

Rotaviruses cause acute diarrhea worldwide. Previous studies of rotavirus diarrhea in China found that rotavirus infection is the most common cause of severe diarrhea in young children. In the present study, surveillance of rotavirus diarrhea was conducted involving 9549 children aged <5 years who were admitted for treatment of diarrhea at 11 sentinel hospitals in China from August 2003 through July 2007. Group A rotavirus was detected in 3749 (47.8%) of the 7846 fecal specimens by using enzyme-linked immunosorbent assay. Rotavirus isolates were characterized by reverse-transcriptase polymerase chain reaction to determine G and P genotypes. All the strains that are common worldwide were detected; G3P[8] was the most common. An unusual G5 strain was detected in 2 specimens. Of all episodes of rotavirus diarrhea, 94% occurred during the first 2 years of life, peaking at 6-23 months of age. Our findings indicate that globally common rotavirus strains continue to be a major cause of severe childhood diarrhea in China. Introduction of routine immunization with effective rotavirus vaccines would substantially reduce this burden.

[Distribution signature analysis between intussusception and rotavirus diarrhea in young children].

OBJECTIVE: To investigate the annual incidence rate of intussusception over a 5-year period in Suzhou and to determine whether there was a potential link between intussusception rotavirus diarrhea. METHODS: Outpatient and inpatient data from 1999 through 2003 retrospectively were reviewed for young children (< 2 year old) whose diagnosis was confirmed by ultrasonography or radiography and patients were reduced by air enema or surgery. From September 2001, to August 2003, inpatients with diarrhea (< 2 year old) were detected rotavirus antigen in the stool by ELISA technology. RESULTS: From 1999 through 2003, 1101 cases were reported in children below 2 years old. The incidence rate of intussusception under 1 year age each year was 275.3, 338.2, 547.0, 515.3, and 425.4 per 100,000 child years respectively (the average annual incidence was 418.1 per 100,000 child years), and the incidence of intussusception increased over time from 1999 to 2003. A peak age distribution of intussusception was infants 4 to 10 months old (692/1101, 62.85%) and mean age was 9.62 +/- 5.65 months, which were greatly different from those of patients with rotavirus diarrhea, whose peak age distribution was 5 to 16 months old (252/331, 76.13%), and mean age was 11.42 +/- 5.14 months (Z = 6.90, P < 0.01). The peak month distribution of intussusception was from April to August (595/1101, 54.04%), which was distinct from that of patient with rotavirus diarrhea, whose peak month distribution was between October and January (232/331, 70.09%). Test: chi2 = 226.06, P < 0.001. CONCLUSION: The annual incidence rate of intussusception for < 1 year of age was 418.1 per 100,000 child years in Suzhou. We found no epidemiologic evidence for an association between intussusception and rotavirus diarrhea.

[Epidemiological study on rotavirus-borne diarrhea in infants and children in different areas].

OBJECTIVE: To analyze and compare the epidemiological features of rotavirus diarrhea among infants in the different areas so as to provide data for rotavirus vaccine research. METHODS: From Sep. 2001 through Sep. 2003, sentinel sites were set up in Suzhou Children's Hospital and Maanshan Hospital. Fecal samples from children (< 5 years) with acute diarrheal were collected and enzyme linked immunosorbent assay was used to detect rotavirus antigen. Reverse transcription-polymerase chain reaction was used to determine the G serotypes and P genotypes of rotavirus strains. The features of strains in the two places and other areas of China were analyzed and compared. RESULTS: (1) Rotavirus infection appeared in autumn and winter, but the peaks varied. In Suzhou the peaks were from December to next February in 2001, and November to next January in 2002. But in Maanshan, it was November to next January for both two years. (2) Rate of rotavirus infection in Suzhou was much higher than that in Maanshan, infective rates of Inpatient Department and Outpatient Department are 47.28%, 28.39% and 30.38%, 14.77% respectively in the two hospitals. (3) Rates of infection in two hospitals showed age difference but the highest group was in 6 - 35 month-olds. No gender difference was found. (4) Secular distribution of G-typing and P-typing of rotavirus strain was different in Suzhou and Maanshan. G3 was mainly found in Suzhou and G1 in Maanshan. From 2002-2003 on, G3 became dominant in Maanshan. CONCLUSION: Rotavirus caused diarrhea among infant and children were different in terms of areas, period and types, suggesting that the introduction of rotavirus vaccine should be adjusted according to different strains with specific types and optimal timeline.