Medical student education in sleep and its disorders is still meagre 20 years on: A cross-sectional survey of UK undergraduate medical education.

Sleep is a pillar of health, alongside adequate nutrition and exercise. Problems with sleep are common and often treatable. Twenty years ago, UK medical school education on sleep disorders had a median teaching time of 15 min; we investigate whether education on sleep disorders has improved. This is a cross-sectional survey, including time spent on teaching sleep medicine, subtopics covered and forms of assessment. Thirty-four medical degree courses in the UK were investigated via a questionnaire. We excluded responses not concerned with general undergraduate education (i.e. optional modules). Twenty-five (74%) medical schools responded. Time spent teaching undergraduates sleep medicine was: median, 1.5 hr; mode, <1 hr; mean, 3.2 hr (SD = 2.6). Only two schools had a syllabus or core module (8%) and five (22%) were involved in sleep disorders research. Despite the above, half of the respondents thought provision was sufficient. Free-text comments had recurring themes: sleep medicine is subsumed into other specialties, obstructive sleep apnea dominates teaching, knowledge of sleep disorders is optional, and there is inertia regarding change. A substantial minority of respondents were enthusiastic about improving provision. In conclusion, little has changed over 20 years: sleep medicine is neglected despite agreement on its importance for general health. Sleep research is the exception rather than the rule. Obstacles to change include views that "sleep is not a core topic" or "the curriculum is too crowded". However, there is enthusiasm for improvement. We recommend establishment of a sleep medicine curriculum. Without better teaching, doctors will remain ill-equipped to recognize and treat these common conditions.

Ten golden rules for a safe MIS inguinal hernia repair using a new anatomical concept as a guide.

BACKGROUND: Although laparoscopic inguinal hernia repair was described about 30 years ago and advantages of the technique have been demonstrated, the utilization of this approach has not been what we would expect. Some reasons may be the need for surgeons to understand the posterior anatomy of the groin from a new vantage point, as well as to acquire advanced laparoscopic skills. Recently, however, the introduction of a robotic approach has dramatically increased the adoption of minimally invasive techniques for inguinal hernia repair. METHODS: Important recent contributions to this evolution have been the establishment of a new concept known as the critical view of the Myopectineal Orifice (MPO) and the description of a new way of understanding the posterior view of the antomy of the groin (inverted Y and the five triangles). In this paper, we describe 10 rules for a safe MIS inguinal hernia repair (TAPP, TEP, ETEP, RTAPP) that combines these two new concepts in a unique way. CONCLUSIONS: As the critical view of safety has made laparoscopic cholecystectomy safer, we feel that following our ten rules based on understanding the anatomy of the posterior groin as defined by zones and essential triangles and the technical steps to achieve the critical view of the MPO will foster the goal of safe MIS hernia repair, no matter which minimally invasive technique is employed.

Anticancer activity of fish oils against human lung cancer is associated with changes in formation of PGE2 and PGE3 and alteration of Akt phosphorylation.

The beneficial effects of omega-3 fatty acids are believed to be due in part to selective alteration of arachidonate metabolism that involves cyclooxygenase (COX) enzymes. Here we investigated the effect of eicosapentaenoic acid (EPA) on the proliferation of human non-small cell lung cancer A549 (COX-2 over-expressing) and H1299 (COX-2 null) cells as well as their xenograft models. While EPA inhibited 50% of proliferation of A549 cells at 6.05 µM, almost 80 µM of EPA was needed to reach similar levels of inhibition of H1299 cells. The formation of prostaglandin (PG)E3 in A549 cells was almost threefold higher than that of H1299 cells when these cells were treated with EPA (25 µM). Intriguingly, when COX-2 expression was reduced by siRNA or shRNA in A549 cells, the antiproliferative activity of EPA was reduced substantially compared to that of control siRNA or shRNA transfected A549 cells. In line with this, dietary menhaden oil significantly inhibited the growth of A549 tumors by reducing tumor weight by 58.8 ± 7.4%. In contrast, a similar diet did not suppress the development of H1299 xenograft. Interestingly, the ratio of PGE3 to PGE2 in A549 was about 0.16 versus only 0.06 in H1299 xenograft tissues. Furthermore, PGE2 up-regulated expression of pAkt, whereas PGE3 downregulated expression of pAkt in A549 cells. Taken together, the results of our study suggest that the ability of EPA to generate PGE3 through the COX-2 enzyme might be critical for EPA-mediated tumor growth inhibition which is at least partly due to down-regulation of Akt phosphorylation by PGE3.

Chronic stress promotes tumor growth and angiogenesis in a mouse model of ovarian carcinoma.

Stress can alter immunological, neurochemical and endocrinological functions, but its role in cancer progression is not well understood. Here, we show that chronic behavioral stress results in higher levels of tissue catecholamines, greater tumor burden and more invasive growth of ovarian carcinoma cells in an orthotopic mouse model. These effects are mediated primarily through activation of the tumor cell cyclic AMP (cAMP)-protein kinase A (PKA) signaling pathway by the beta(2) adrenergic receptor (encoded by ADRB2). Tumors in stressed animals showed markedly increased vascularization and enhanced expression of VEGF, MMP2 and MMP9, and we found that angiogenic processes mediated the effects of stress on tumor growth in vivo. These data identify beta-adrenergic activation of the cAMP-PKA signaling pathway as a major mechanism by which behavioral stress can enhance tumor angiogenesis in vivo and thereby promote malignant cell growth. These data also suggest that blocking ADRB-mediated angiogenesis could have therapeutic implications for the management of ovarian cancer.

CHALLENGES TO THE 10 GOLDEN RULES FOR A SAFE MINIMALLY INVASIVE SURGERY (MIS) INGUINAL HERNIA REPAIR: CAN WE IMPROVE?

BACKGROUND: Since publication of our paper "Ten Golden Rules for a Safe MIS Inguinal Hernia Repair" we have received many questions. As the authors, we feel it is important to address these topics as a follow-up to our paper. AIM: To discuss in more details the main points of controversy, review the rules and update de recommendations. METHOD: The questions and discussions came mainly over five rules, numbered 3, 5, 6, 7, 10. We analyzed all the comments about recommendations and update some technical principles. RESULTS: Rule 3 - Removing normal fat plugs from the obturator canal is unnecessary and therefore is not recommended; Rule 5 - transection of the uterine round ligament (1 cm proximal to the deep ring) facilitates adequate dissection. When performed in this way it does not appear to be associated with complications; Rule 6 - transection of huge sacs are safer than over-dissection of the cord structures. Whether dissecting completely the sac or abandon the distal part it results in less postoperative seromas is an ongoing debate; Rule 7 - any retroperitoneal structure traversing the internal ring is or play a role like a hernia. Failing to identify and remove the lipoma will ultimately result in the patient experiencing a recurrence; Rule 10 - in TAPP peritoneum should preferably be closed with suture than tackes. CONCLUSION: 10 Golden Rules emphasize the most important surgical tips and technical steps that allow the safe performance of MIS repairs of inguinal hernias, regardless the technique.

Disruption of the gene for CYP1A2, which is expressed primarily in liver, leads to differential regulation of hepatic and pulmonary mouse CYP1A1 expression and augmented human CYP1A1 transcriptional activation in response to 3-methylcholanthrene in vivo.

The cytochrome P4501A (CYP1A) enzymes play important roles in the metabolic activation and detoxification of numerous environmental carcinogens, including polycyclic aromatic hydrocarbons (PAHs). In this study, we tested the hypothesis that hepatic CYP1A2 differentially regulates mouse hepatic and pulmonary CYP1A1 expression and suppresses transcriptional activation of human CYP1A1 (hCYP1A1) promoter in response to 3-methylcholanthrene (MC) in vivo. Administration of wild-type (WT) (C57BL/6J) or Cyp1a2-null mice with a single dose of MC (100 µmol/kg i.p.) caused significant increases in hepatic CYP1A1/1A2 activities, apoprotein content, and mRNA levels 1 day after carcinogen withdrawal compared with vehicle-treated controls. The induction persisted in the WT, but not Cyp1a2-null, animals, for up to 15 days. In the lung, MC caused persistent CYP1A1 induction for up to 8 days in both genotypes, with Cyp1a2-null mice displaying a greater extent of CYP1A1 expression. It is noteworthy that MC caused significant augmentation of human CYP1A1 promoter activation in transgenic mice expressing the hCYP1A1 and the reporter luciferase gene on a Cyp1a2-null background, compared with transgenic mice on the WT background. In contrast, the mouse endogenous hepatic, but not pulmonary, persistent CYP1A1 expression was repressed by MC in the hCYP1A1-Cyp1a2-null mice. Liquid chromatography-mass spectrometry experiments showed that CYP1A2 catalyzed the formation of 1-hydroxy-3-MC and/or 2-hydroxy-3-MC, a metabolite that may contribute to the regulation of CYP1A1 expression. In conclusion, the results suggest that CYP1A2 plays a pivotal role in the regulation of hepatic and pulmonary CYP1A1 by PAHs, a phenomenon that potentially has important implications for PAH-mediated carcinogenesis.

Persistent induction of cytochrome P4501A1 in human hepatoma cells by 3-methylcholanthrene: evidence for sustained transcriptional activation of the CYP1A1 promoter.

Cytochrome P450 (P450)1A1 plays a critical role in the metabolic activation and detoxification of polycyclic aromatic hydrocarbons (PAHs), many of which are potent human carcinogens. In this investigation, we tested the hypothesis that MC elicits persistent induction of CYP1A1 expression in human hepatoma cells (HepG2) and that this phenomenon is mediated by sustained transcriptional activation of the CYP1A1 promoter. Treatment of HepG2 cells with MC resulted in marked induction (8-20-fold) of ethoxyresorufin O-de-ethylase activities, CYP1A1 apoprotein contents, and mRNA levels, which persisted for up to 96 h. MC also caused sustained transcriptional activation of the human CYP1A1 promoter for up to 96 h, as inferred from transient transfection experiments. Experiments with deletion constructs indicated that Ah response elements located at -886, -974, and -1047, but not -491, nucleotides from the start site, contributed to the sustained transcriptional activation of the CYP1A1 promoter. Electrophoretic mobility-shift and chromatin immunoprecipitation assays suggested that prolonged CYP1A1 induction was mediated by Ah receptor (AHR)-independent mechanisms. Experiments with [3H]MC and liquid chromatography-tandem mass spectrometry demonstrated rapid elimination of MC and its metabolites from the cells by 12 to 24 h, suggesting that these compounds did not elicit sustained CYP1A1 induction via the classical AHR-mediated pathway. In conclusion, the results of this study support the hypothesis that MC causes persistent induction of CYP1A1 in human hepatoma cells by mechanisms entailing sustained transcriptional activation of the CYP1A1 promoter via AHR-independent mechanisms. These observations have important implications for human carcinogenesis mediated by PAHs.

Bile reflux after Roux-en-Y gastric bypass: an unrecognized cause of postoperative pain.

BACKGROUND: To determine, in a private practice, whether symptomatic bile reflux can occur after Roux-en-Y gastric bypass (RYGB) for morbid obesity and the outcome after laparoscopic alimentary (Roux) limb lengthening. Bile reflux as a cause of pain after laparoscopic RYGB has not been previously described. We report on a series of patients with chronic pain after RYGB as a result of bile reflux owing an abnormally short alimentary limb. METHODS: A prospective database of patients who underwent revisional surgery to treat symptomatic bile reflux at our center was retrospectively reviewed and analyzed for the onset of symptoms, interval to revision, length of alimentary limb, and outcome after revision. RESULTS: A total of 16 patients were diagnosed with bile reflux and underwent revisional surgery. The onset of symptoms occurred at 58.3 +/- 22.2 months after RYGB. All patients complained of pain, 13 (81.3%) had vomiting, and 7 (43.8%) had dysphagia. Endoscopy was performed in all patients and confirmed the presence of bile in all patients and detected marginal ulceration in 5 (31.3%) and gastritis in 8 (50.0%). At revisional surgery, the mean alimentary limb length was 37.7 +/- 12.4 cm (range 20-62 cm). At a mean follow-up of 14.9 months after revision, all patients had reported resolution of their symptoms. CONCLUSION: Although previously unreported after RYGB, bile reflux can be an important possible cause of chronic pain. Bile reflux, however, responds favorably to alimentary limb lengthening to 100 cm and was not been seen in patients with an alimentary limb length >62 cm.

Acquired resistance to erlotinib in A-431 epidermoid cancer cells requires down-regulation of MMAC1/PTEN and up-regulation of phosphorylated Akt.

Erlotinib (Tarceva), an epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor, has clinical activity in advanced lung cancer, but disease that initially responds to erlotinib eventually progresses. The mechanism of this acquired resistance is unclear. We established two erlotinib-resistant pools of A-431 cells, a well-characterized epidermoid cancer cell line that constitutively overexpresses EGFR and is sensitive to erlotinib, by continuous exposure to erlotinib over a 6-month period. The extent of EGFR gene amplification or mutation of the EGFR tyrosine kinase domain was not altered in the resistant cells. Intracellular erlotinib concentrations, determined by liquid chromatography-tandem mass spectrometry, were almost the same in all three cell lines. Immunoprecipitation with EGFR antibody followed by detection with phosphotyrosine antibody revealed that erlotinib effectively reduced EGFR phosphorylation in both parental cells and resistant cells. Erlotinib induced mutated in multiple advanced cancers 1/phosphatase and tensin homologue (MMAC1/PTEN) and suppressed phosphorylated Akt (Ser(473)) but not in the erlotinib-resistant cells. Overexpression of MMAC1/PTEN by transfection with Ad.MMAC1/PTEN or by pharmacologic suppression of Akt activity restored erlotinib sensitivity in both resistant pools. Further, transfection of parental A-431 cells with constitutively active Akt was sufficient to cause resistance to erlotinib. We propose that acquired erlotinib resistance associated with MMAC1/PTEN down-regulation and Akt activation could be overcome by inhibitors of signaling through the phosphatidylinositol 3-kinase pathway.

Determinants of human and mouse melanoma cell sensitivities to oleandrin.

Oleandrin, a cardiac glycoside component of Nerium oleander, has been shown to induce apoptosis in malignant cells. While human tumor cells are very sensitive to growth inhibition by oleandrin, murine tumor cells are extremely resistant. Using human BRO and mouse B16 melanoma cell lines, we explored several possible determinants of cell sensitivity to oleandrin and compared with ouabain. The studies include Na+, K(+)-ATPase activity and its isoforms as well as the cellular uptake of these cardiac glycosides. Oleandrin and ouabain induced apoptosis was detected in BRO cells while no evidence of cell death was observed in B16 cells even at concentrations 1000-fold higher than that used for BRO cells. Cellular uptake of oleandrin and ouabain was 3-4 fold greater in human BRO tumor cells than murine tumor cells. Partially purified Na+, K(+)-ATPase from human BRO cells was inhibited at a concentration that was 1000-fold less than that was required to inhibit mouse B16 enzyme to the same extent. Using Western blot analyses, human BRO cells were found to express both the sensitive alpha3 isoform and the less sensitive alpha1 isoform of Na+, K(+)-ATPase while mouse B16 cells expressed only the alpha1 isoform. These data suggest that differential expressions of Na+, K(+)-ATPase activities and its isoforms in BRO and B16 cells as well as cellular drug uptake may be important determinants of tumor cell sensitivity to cardiac glycosides.

Perforated marginal ulcers after laparoscopic gastric bypass.

BACKGROUND: Perforated marginal ulcer (PMU) after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a serious complication, but its incidence and etiology have rarely been investigated. Therefore, a retrospective review of all patients undergoing LRYGB at the authors' center was conducted to determine the incidence of PMU and whether any causative factors were present. METHODS: A prospectively kept database of all patients at the authors' bariatric center was retrospectively reviewed. The complete records of patients with a PMU were examined individually for accuracy and analyzed for treatment, outcome, and possible underlying causes of the marginal perforation. RESULTS: Between April 1999 and August 2007, 1% of the patients (35/3,430) undergoing laparoscopic gastric bypass experienced one or more perforated marginal ulcers 3 to 70 months (median, 18 months) after LRYGB. The patients with and without perforation were not significantly different in terms of mean age (37 vs 41 years), weight (286 vs 287 lb), body mass index (BMI) (46 vs 47), or female gender (89% vs 83%). Of the patients with perforations, 2 (6%) were taking steroids, 10 (29%) were receiving nonsteroidal antiinflammatory drugs (NSAIDs) at the time of the perforation, 18 (51%) were actively smoking, and 6 of the smokers also were taking NSAIDs. Eleven of the patients (31%) who perforated did not have at least one of these possible risk factors, but 4 (36%) of the 11 patients in this group had been treated after bypass for a marginal ulcer. Only 7 (20%) of the 35 patients who had laparoscopic bypass, or 7 (0.2%) in the entire group of 3,430 patients, perforated without any warning. There were no deaths, but three patients reperforated. CONCLUSIONS: The incidence of a marginal ulcer perforating after LRYGB was significant (>1%) and appeared to be related to smoking or the use of NSAIDs or steroids. Because only 0.2% of all patients acutely perforated without some risk factor or warning, long-term ulcer prophylaxis or treatment may be necessary for only a select group of high-risk patients.

Reactive Oxygen Species Generation in Human Cells by a Novel Magnetic Resonance Imaging Contrast Agent.

The novel positive-contrast magnetic resonance imaging (MRI) marker C4 consists of an aqueous solution of cobalt chloride (CoCl2) complexed with the chelator N-acetylcysteine (NAC). We evaluated whether the presence of C4 or its components would produce reactive oxygen species (ROS, including hydroxyl, peroxyl, or other reactive oxygen species) in cultured cells. Human cancer or normal cells were incubated with 1% (w/v) CoCl2·6H2O or 2% NAC or a combination of both (1% CoCl2·6H2O : 2% NAC in an aqueous solution, abbreviated as Co : NAC) in the presence or absence of H2O2. Intracellular ROS levels were measured and quantified by change in relative fluorescence units. Student's t-tests were used. In all cell lines exposed to 1000 µM H2O2, the Co : NAC led to ≥94.7% suppression of ROS at 5 minutes and completely suppressed ROS at 60 and 90 minutes; NAC suppressed ROS by ≥76.6% at 5 minutes and by ≥94.5% at 90 minutes; and CoCl2·6H2O suppressed ROS by ≥37.2% at 30 minutes and by ≥48.6% at 90 minutes. These results demonstrate that neither Co : NAC nor its components generated ROS; rather, they suppressed ROS production in cultured cells, suggesting that C4 would not enhance ROS production in clinical use.

Liquid chromatography mass spectrometry for quantifying plasma lysophospholipids: potential biomarkers for cancer diagnosis.

Cancer is a complex disease with many genetic and epigenetic aberrations that result in development of tumorigenic phenotypes. While many factors contribute to the etiology of cancer, emerging data implicate lysophospholipids acting through specific cell-surface, and potentially intracellular, receptors in acquiring the transformed phenotype propagated during disease. Lysophospholipids bind to and activate specific cell-surface G protein-coupled receptors (GPCRs) that initiate cell growth, proliferation, and survival pathways, and show altered expression in cancer cells. In addition, a number of enzymes that increase lysophospholipid production are elevated in particular cell lineages and cancer patients' cells, whereas in a subset of patients, the enzymes degrading lysophospholipids are decreased. Thus, ideal conditions are established to increase lysophospholipids in the tumor microenvironment. Indeed, ascites from ovarian cancer patients, which reflects both the tumor environment and a tumor-conditioned media, exhibits markedly elevated levels of specific lysophospholipids as well as one of the enzymes involved in production of lysophospholipids: autotaxin (ATX). The potential sources of lysophospholipids in the tumor microenvironment include tumor cells and stroma, such as mesothelial cells, as well as inflammatory cells and platelets activated by the proinflammatory tumor environment. If lysophospholipids diffuse from the tumor microenvironment into the bloodstream and persist, they have the potential to serve as early diagnostic markers as well as potential monitors of tumor response to therapy. Many scientific and technical challenges need to be resolved to determine whether lysophospholipids or the enzymes producing lysophospholipids alone or in combination with other markers have the potential to contribute to early diagnosis. Breast cancer is the most frequently diagnosed cancer among women. Mammography is associated with morbidity and has a high false positive and false negative rate. Thus, there is a critical need for biomarkers that can contribute to reduced false positive and false negative diagnoses, and to identify, stage, and/or predict prognosis of this disease to improve patient management. Here we describe a technical approach that can be applied to human blood plasma to measure the concentration of growth factor-like lysophospholipids contained in circulation. Using liquid chromatography mass spectrometry (LC/MS/MS), we quantified the amount of lysophosphatidic acid (16:0, 18:0, 18:1, 18:2, and 20:4), lysophosphatidylinositol (18:0), lysophosphatidylserine (18:1), lysophosphatidylcholine (16:0, 18:0, 18:1, 18:2, and 20:4), sphingosine-1-phosphate, and sphingosylphosphorylcholine species from human female plasma samples with malignant, benign, or no breast tumor present. Other methods described here include handling patient blood samples, lipid extraction, and factors that affect lysophospholipid production and loss during sample handling.

Determination of endogenous tissue inflammation profiles by LC/MS/MS: COX- and LOX-derived bioactive lipids.

Cyclooxygenase and lipoxygenase arachidonate products, including prostaglandins (PGs), leukotrienes (LTs), and hydroxyeicosatetraenoic acids (HETEs), are known to modulate inflammation within tissues and can serve as important etiologic factors in carcinogenesis. Eicosanoid content in tissues is typically determined either as a single molecular species through antibody-based assays or by high-performance liquid chromatography after addition of an exogenous substrate such as arachidonic acid. Unfortunately, the methods currently in use are either time-consuming or complicated. Here we report a method for simultaneously identifying eicosanoids appearing as endogenous bioactive lipids in in vivo settings using LC/MS/MS. The analyses indicate marked differences in endogenous eicosanoid content between malignant tissue types suggesting a need for selective therapeutic approaches. As a demonstration of the utility of the method, we present data to show that the technique can be used to distinguish eicosapentaenoic acid-derived formation of PGE(3) from PGE(2) in murine prostate tissue. The method has also been applied to an examination of endogenous eicosanoid metabolism in 7,12-dimethylbenz[a]anthracene (DMBA)-induced oral cancer in hamsters demonstrating the inflammatory nature of this type of cancer with elevated levels of both PGE(2) and LTB(4). In addition, the concentration of the eicosanoid 13-hydroxyoctadecadienoic acid was 67.6% lower in DMBA treated specimens than in control specimens. Thus, our method provides a powerful tool for measuring modulation of eicosanoid metabolites in various preclinical and clinical tissues and may be useful in studies of the endogenous changes in eicosanoid metabolism at various stages of cancer development.

Oleandrin-mediated oxidative stress in human melanoma cells.

While certain cardiac glycoside compounds such as oleandrin, bufalin and digitoxin are known to be associated with potent cytotoxicity to human tumor cells, the mechanisms by which this effect is produced are not clear. We now demonstrate that incubation of human malignant melanoma BRO cells with oleandrin results in a time-dependent formation of reactive oxygen species (ROS). Use of Mito-SOX and dihydroethidine dyes revealed the presence of oleandrin-mediated superoxide anions. Formation of superoxide anions correlated with a loss in cellular viability, proliferation and cellular defense mechanisms such as GSH content. Oleandrin also resulted in an unusual time-dependent mitochondrial condensation in BRO cells that could be blocked with use of N-acetyl cysteine (NAC). NAC was also shown to block ROS formation and partially prevent oleandrin-mediated loss of cellular GSH. Taken as a whole, the data suggest that exposure of human tumor cells such as BRO to oleandrin results in the formation of superoxide anion radicals that mediate mitochondrial injury and loss of cellular GSH pools. These mechanisms play a role in cardiac glycoside mediated tumor cell injury. Conversely, incubation of NAC, a precursor to GSH, largely prevents oleandrin-mediated inhibition of proliferation and mitochondria structural changes.

Anastomotic stenosis after Roux-en-Y gastric bypass: A rational approach to treatment.

BACKGROUND: Anastomotic stenosis, a common sequela to Roux-en-Y gastric bypass, has a reported incidence of 1.6-27% and recurs in 17-33%. No universal guidelines for optimal treatment exist. The aim of this study was to develop guidelines to treat stenosis that achieve the lowest rate of recurrence while avoiding the complications of excessive dilation. METHODS: This prospective 2-part study enlisted consecutive patients undergoing Roux-en-Y gastric bypass who developed an anastomotic stenosis. In the first part, all patients, regardless of the grade of stenosis, underwent dilation to 12 mm and were followed up for recurrence. In the second part, patients underwent dilation according to the grade of stenosis (12 mm for low, 13.5 mm for medium, 15 mm for high) and were followed up for recurrence. RESULTS: Among 1345 consecutive Roux-en-Y gastric bypass patients, 204 developed an anastomotic stenosis (15.2%). No differences were found in gender, mean age, preoperative body mass index, or weight loss at 1 year. In part 1, the recurrence rate for low-, medium-, and high-grade stenosis was 2.6%, 34.4%, and 35.9%. In part 2, the corresponding rates were 9.7%, 26.3%, and 43.6%. The corresponding mean number of additional dilations per patient with recurrence in part 1 was 1.0, 1.5, and 2.1 and, in part 2, were 1.0, 1.0 and 1.2. CONCLUSION: The results of this study have shown that the stenosis grade can predict the risk of recurrence and determine the optimal balloon size. Definitive treatment was achieved in >90% of patients with low-grade stenosis dilated to 12 mm. Medium- and high-grade stenosis predicted > or =25% recurrence, but increasing the balloon size reduced the number of additional dilations required for patients with recurrence.

The human lipid phosphate phosphatase-3 decreases the growth, survival, and tumorigenesis of ovarian cancer cells: validation of the lysophosphatidic acid signaling cascade as a target for therapy in ovarian cancer.

Lysophosphatidic acid (LPA) is present at elevated concentrations in the ascites and plasma of ovarian cancer patients. Ovarian cancer cells produce and release LPA both constitutively and after stimulation. LPA can induce proliferation, survival, invasiveness, and resistance to chemotherapy of ovarian cancer cells. This suggests that LPA may be critically important for the development or progression of ovarian cancer and is thus a potential target for therapy. In this study, we demonstrate that introduction of the integral membrane protein, human lipid phosphate phosphohydrolase-3 (hLPP-3) enzyme, which hydrolyzes phosphatidic acid, LPA, sphingosine, and ceramide phosphate in vitro with selectivity for LPA, into SKOV3 and OVCAR-3 ovarian cancer cells decreases colony-forming activity, increases apoptosis, and decreases tumor growth in vitro and in vivo. Strikingly, coculture of hLPP-3-expressing cells with nontransfected parental cells decreased the colony-forming activity of the parental cells, compatible with hLPP-3 decreasing levels of an extracellular mediator, likely LPA. Compatible with this contention, the expression of hLPP-3 was associated with increased rates of extracellular LPA hydrolysis. The effects of hLPP-3 on colony-forming activity were substantially reversed by the LPP-resistant LPA analogue, O-methylphosphothionate. The ability of O-methylphosphothionate to ameliorate the effects of hLPP-3, combined with the inability of an enzymatically inactive hLPP-3 to alter cellular function, suggests that the major effect of hLPP-3 was to increase the hydrolysis of extracellular LPA. Thus genetic or pharmacological manipulation of LPA metabolism, receptor activation, or downstream signaling is an attractive approach for therapy of ovarian cancer.

Challenges to the 10 golden rules for a safe minimally invasive surgery (mis) inguinal hernia repair: can we improve? / Desafios para as 10 regras de ouro para o reparo minimamente invasivo seguro das hérnias inguinais: podemos melhorar?

ABSTRACT Background: Since publication of our paper "Ten Golden Rules for a Safe MIS Inguinal Hernia Repair" we have received many questions. As the authors, we feel it is important to address these topics as a follow-up to our paper. Aim: To discuss in more details the main points of controversy, review the rules and update de recommendations. Method: The questions and discussions came mainly over five rules, numbered 3, 5, 6, 7, 10. We analyzed all the comments about recommendations and update some technical principles. Results: Rule 3 - Removing normal fat plugs from the obturator canal is unnecessary and therefore is not recommended; Rule 5 - transection of the uterine round ligament (1 cm proximal to the deep ring) facilitates adequate dissection. When performed in this way it does not appear to be associated with complications; Rule 6 - transection of huge sacs are safer than over-dissection of the cord structures. Whether dissecting completely the sac or abandon the distal part it results in less postoperative seromas is an ongoing debate; Rule 7 - any retroperitoneal structure traversing the internal ring is or play a role like a hernia. Failing to identify and remove the lipoma will ultimately result in the patient experiencing a recurrence; Rule 10 - in TAPP peritoneum should preferably be closed with suture than tackes. Conclusion: 10 Golden Rules emphasize the most important surgical tips and technical steps that allow the safe performance of MIS repairs of inguinal hernias, regardless the technique.

RESUMO Racional: Desde a publicação de nosso artigo "Dez Regras de Ouro para o Reparo Seguro de Hérnia Inguinal MIS", recebemos muitos questionamentos. Como autores, sentimos que é importante abordar esses tópicos como seguimento do artigo Objetivo: Discutir com mais detalhes os principais pontos de controvérsia, revisar as regras e atualizar as recomendações. Método: As dúvidas e discussões surgiram principalmente sobre cinco regras, numeradas 3, 5, 6, 7, 10. Analisamos todos os comentários sobre as recomendações e atualizamos alguns dos princípios técnicos. Resultados: Regra 3 - remoção dos plugs de gordura normais do canal obturador é desnecessária e, portanto, não é recomendada; Regra 5 - transecção do ligamento redondo do útero (1 cm proximal ao anel profundo) facilita a dissecção adequada e quando realizado dessa forma, não parece estar associada com complicações; Regra 6 - transecção de grandes sacos herniários é mais segura do que a dissecção excessiva das estruturas do cordão espermático e, se dissecar completamente o saco ou abandonar a parte distal, resulta em menos seromas pós-operatórios ainda é motivo de debate; Regra 7 - qualquer estrutura retroperitoneal que atravessa o anel interno é ou desempenha o papel como uma hérnia e deixar de identificar e remover o lipoma acabará resultando em recorrência; Regra 10 - na TAPP o peritônio deve ser fechado preferencialmente com sutura do que com tacks. Conclusão: As 10 Regras de Ouro enfatizam as dicas cirúrgicas e etapas técnicas mais importantes que permitem a realização segura de reparos MIS de hérnias inguinais, independentemente da técnica.