Inflammation and altered metabolism impede efficacy of functional electrical stimulation in critically ill patients.

BACKGROUND: Critically ill patients suffer from acute muscle wasting, which is associated with significant physical functional impairment. We describe data from nested muscle biopsy studies from two trials of functional electrical stimulation (FES) that did not shown improvements in physical function. METHODS: Primary cohort: single-centre randomized controlled trial. Additional healthy volunteer data from patients undergoing elective hip arthroplasty. Validation cohort: Four-centre randomized controlled trial. INTERVENTION: FES cycling for 60-90min/day. ANALYSES: Skeletal muscle mRNA expression of 223 genes underwent hierarchal clustering for targeted analysis and validation. RESULTS: Positively enriched pathways between healthy volunteers and ICU participants were "stress response", "response to stimuli" and "protein metabolism", in keeping with published data. Positively enriched pathways between admission and day 7 ICU participants were "FOXO-mediated transcription" (admission = 0.48 ± 0.94, day 7 = - 0.47 ± 1.04 mean log2 fold change; P = 0.042), "Fatty acid metabolism" (admission = 0.50 ± 0.67, day 7 = 0.07 ± 1.65 mean log2 fold change; P = 0.042) and "Interleukin-1 processing" (admission = 0.88 ± 0.50, day 7 = 0.97 ± 0.76 mean log2 fold change; P = 0.054). Muscle mRNA expression of UCP3 (P = 0.030) and DGKD (P = 0.040) decreased in both cohorts with no between group differences. Changes in IL-18 were not observed in the validation cohort (P = 0.268). Targeted analyses related to intramuscular mitochondrial substrate oxidation, fatty acid oxidation and intramuscular inflammation showed PPARγ-C1α; (P < 0.001), SLC25A20 (P = 0.017) and UCP3 (P < 0.001) decreased between admission and day 7 in both arms. LPIN-1 (P < 0.001) and SPT1 (P = 0.044) decreased between admission and day 7. IL-18 (P = 0.011) and TNFRSF12A (P = 0.009) increased in both arms between admission and day 7. IL-1ß (P = 0.007), its receptor IL-1R1 (P = 0.005) and IL-6R (P = 0.001) decreased in both arms between admission and day 7. No between group differences were seen in any of these (all p > 0.05). CONCLUSIONS: Intramuscular inflammation and altered substrate utilization are persistent in skeletal muscle during first week of critical illness and are not improved by the application of Functional Electrical Stimulation-assisted exercise. Future trials of exercise to prevent muscle wasting and physical impairment are unlikely to be successful unless these processes are addressed by other means than exercise alone.

Detection and characterization of viruses of the genus Megalocytivirus in ornamental fish imported into an Australian border quarantine premises: an emerging risk to national biosecurity.

This report documents an emerging trend of identification of Megalocytivirus-like inclusions in a range of ornamental fish species intercepted during quarantine detention at the Australian border. From September 2012 to February 2013, 5 species of fish that had suffered mortality levels in excess of 25% whilst in the post-entry quarantine and had Megalocytivirus-like inclusion bodies in histological sections were examined by PCR. The fish had been imported from Singapore, Malaysia and Sri Lanka. Ninety-seven of 111 individual fish from affected tanks of fish tested were positive for the presence of Megalocytivirus by PCR. Sequence analysis of representative PCR products revealed an identical sequence of 621 bp in all cases which was identical to a previously characterized Megalocytivirus (Sabah/RAA1/2012 strain BMGIV48). Phylogenetic analysis of available Megalocytivirus major capsid protein (MCP) sequences confirmed the existence of 3 major clades of Megalocytivirus. The virus detected in this study was identified as a member of Genotype II. The broad host range and pathogenicity of megalocytiviruses, coupled to the documented spread of ornamental fish into the environment, render this a significant and emerging biosecurity threat to Australia.

Effect of whey protein- and carbohydrate-enriched diet on glycogen resynthesis during the first 48 h after a soccer game.

The effect of a whey protein- and carbohydrate (CHO)-enriched diet on the rate of muscle glycogen resynthesis after a soccer match was examined. Sixteen elite soccer players were randomly assigned to a group ingesting a diet rich in carbohydrates and whey protein [CHO, protein, and fat content was 71, 21, and 8E%, respectively; high content of carbohydrates and whey protein (HCP), n = 9] or a group ingesting a normal diet (55, 18, and 26E%; control [CON], n = 7) during a 48-h recovery period after a soccer match. CON and three additional players carried out a 90- and 60-min simulated match without body contacts (SIM90 and SIM60). Muscle glycogen was lowered (P < 0.05) by 54, 48, 53, and 38% after the matches in CON, HCP, SIM90, and SIM60, respectively. Glycogen resynthesis during the first 48 h after the match was not different between CON and HCP, whereas glycogen resynthesis was slower (P < 0.05) during the first 24 h after SIM60 than SIM90 (2.88 ± 0.84 vs 4.32 ± 0.54 mmol/kg dw/h). In HCP, glycogen content in type II muscle fibers was still lowered 48 h after the match. In conclusion, glycogen resynthesis 48 h after a soccer match is not elevated by ingestion of a HCP diet. Furthermore, glycogen resynthesis does not appear to be impaired by body contacts during a match.

Basal and insulin-stimulated pyruvate dehydrogenase complex activation, glycogen synthesis and metabolic gene expression in human skeletal muscle the day after a single bout of exercise.

The role of pyruvate dehydrogenase complex (PDC) in insulin-stimulated glycogen replenishment the day after exercise, and its molecular control, has not been examined. This study investigated the effect of acute exercise on basal and insulin-stimulated PDC activity (the rate-limiting step in glucose oxidation), glycogen synthesis and the expression of metabolic genes and transcription factors associated with changes in PDC activation and glucose metabolism. Eight healthy men (age 24 +/- 2 years, body mass 79 +/- 4 kg) underwent a euglycaemic, hyperinsulinaemic clamp 22 h after 90 min of one-legged cycling at 60% maximal oxygen consumption. Skeletal muscle glycogen content was similar in the exercised (EX) and non-exercised leg (CON) preclamp (471 +/- 30 versus 463 +/- 50 mmol (kg dry matter)(1), respectively) but increased during the clamp in EX to 527 +/- 20 mmol (kg dry matter)(1), such that it was 17% greater than in CON (449 +/- 35 mmol (kg dry matter)(1), P < 0.05). This increase in insulin-mediated glycogen storage was independent of insulin-stimulated Akt serine(473) phosphorylation and activation of PDC. Prior exercise did not modulate the mRNA expression and protein content of pyruvate dehydrogenase kinase 4 (PDK4) in skeletal muscle, but was associated with increased hexokinase II mRNA expression and protein content and upregulation of peroxisome proliferator-activated receptor (PPAR)-gamma coactivator 1alpha (PGC1alpha) and PPARdelta gene expression. Collectively, these findings suggest that prior exercise does not alter basal and insulin-stimulated PDC activation and the protein content of PDK4 the following day, but is associated with increased capacity (through upregulation of hexokinase II content) of muscle to phosphorylate and divert glucose towards glycogen storage.

Histopathology of oedema in pearl oysters Pinctada maxima.

In October 2006, severe mortalities (80 to 100%) were reported in pearl oyster Pinctada maxima production farms from Exmouth Gulf, Western Australia. Only P. maxima were affected; other bivalves including black pearl oysters P. margaratifera remained healthy. Initial investigations indicated that the mortality was due to an infectious process, although no disease agent has yet been identified. Gross appearance of affected oysters showed mild oedema, retraction of the mantle, weakness and death. Histology revealed no inflammatory response, but we did observe a subtle lesion involving tissue oedema and oedematous separation of epithelial tissues from underlying stroma. Oedema or a watery appearance is commonly reported in published descriptions of diseased molluscs, yet in many cases the terminology has been poorly characterised. The potential causes of oedema are reviewed; however, the question remains as to what might be the cause of oedema in molluscs that are normally iso-osmotic with seawater and have no power of anisosmotic extracellular osmotic regulation.

Unidentified microsporidian in western pygmy perch Edelia vittata (Nannopercidae) from Australia.

Specimens of western pygmy perch, Edelia vittata Castelnau 1873, were submitted for examination because of the presence of black masses in the body wall in the abdominal area. The owner reported that approximately 10% of mature fish in one dam were affected. The masses had no apparent effect on the health of affected fish, but they were unsuitable for sale for aesthetic reasons. After necropsy and histological examination, the masses were found to be microsporidial xenomas within the abdominal cavity. Transmission electron microscopy results suggest that this microsporidian is a previously unreported species, because the melanised xenoma wall and internal structure of the spores differ from previously described species. The epidemiology of the parasite remains largely unknown and highlights the need for further surveys of the disease status and parasites of Australian native fish, especially those of interest to aquaculturists.

Infection with Photobacterium damselae subspecies damselae and Vibrio harveyi in snapper, Pagrus auratus with bloat.

OBJECTIVE: To diagnose the cause of chronic, low mortality associated with bloat in tanks of snapper at an aquaculture facility. DESIGN: A clinical, pathological and microbiological investigation into the cause of a low number of ongoing mortalities associated with bloat in snapper at an aquaculture facility is outlined. Necropsy, histology, microbiology and a comparison of haematology and water analysis from affected and unaffected fish and holding tanks, respectively were conducted. RESULTS: Affected moribund fish were found in lateral or dorsal recumbency floating on the water surface within 24 hours of death. Photobacterium damselae subspecies damselae was isolated from intestinal contents and Vibrio harveyi from the blood of affected fish and both were isolated from culture water. Both V harveyi and P damselae subspecies damselae isolates were sensitive to tetracycline, ciprofloxacin and sulphamethoxazole plus trimethoprim. Environmental parameters such as pH and dissolved oxygen were similar in tanks of affected and unaffected fish. Affected fish had gas distended swimbladders, anaemia, and the intestines were diffusely distended with a clear, pale yellowish fluid. Livers were mottled tan and green in a zonal pattern. Histologically the intestines of fish from tanks suffering mortality had a moderate granulocytic enteritis with oedema and infiltrations with eosinophilic granule cells that were also present as an infiltrate in the gills. There were elevated numbers of melanomacrophage centres and haemosiderin deposits in the spleen, kidney and liver of affected fish. CONCLUSION: Vibrio harveyi and Photobacterium damselae subspecies damselae infection should be recognised as potential pathogens of snapper held in water of less than optimal quality.

Surgical removal of an ovarian tumour in a koi carp (Cyprinus carpio).

Ultrasonography, radiography and exploratory coeliotomy were used to diagnose and treat a large intracoelomic neoplasm from a female koi carp (Cyprinus carpio) presented for abdominal enlargement of several months duration. Feed was withheld for 1 week immediately prior to surgery and the fish was sedated with isoeugenol (AQUI-S) at a dose rate of 10 mL/L to facilitate diagnostic imaging techniques. Surgical anaesthesia was induced by adding tricaine (MS-222) 50 mg/L to the water and an exploratory coeliotomy and tumour removal was performed. The fish was allowed to recover in fresh water at 18 degrees C and salt was added slowly to the water over a period of 1 hour to a concentration of 5 g/L This concentration was maintained in a recovery pond for 1 week postoperatively. Enrofloxacin was administered intramuscularly (10 mg/kg) immediately, 3 days and 1 week postoperatively. A diagnosis of undifferentiated ovarian carcinoma was made on the basis of the histological appearance of the neoplasm and immunohistochemical staining.

Cell cycle homogeneity in bone marrow samples from different sites: flow cytometric evaluation of multiple samples from sheep.

The distributions of cells in each of the phases of the cell cycle, determined by flow cytometry (FCM), were compared in multiple marrow trephine biopsy samples from 3 sites (both iliac bones and sternum) in 5 sheep. Within any one animal no significant differences could be found between the proportions of cells in the G0/G1, S or G2 + M phases of the cycle from different sites. Differences between animals were detected and these were consistent for any of the sites sampled. We conclude that the proliferative characteristics of marrow cells as determined by FCM in any one animal at one time are comparable at anatomically distinct marrow sites, and that a sample from one site is representative of the whole.

Comparison of intra-arterial versus intravenous 5-fluorouracil administration on epidermal squamous cell carcinoma in sheep.

Clinical evidence that intra-arterial chemotherapy is more effective in regressing head and neck cancers than equivalent intravenous doses is lacking. Intra-arterial versus intravenous 5-fluorouracil infusion was compared in a naturally occurring, auricular epidermal squamous cell cancer in sheep. Of 18 lesions infused intra-arterially and of 18 infused intravenously with the same dose, 39 and 11%, respectively responded objectively (over 50% regression); mean (S.E.) tumour volume reduction was 37(23) and 18(22)%, respectively. There was a statistically significant difference in the mean tumour response and in numbers of tumours regressing by at least 40% of tumour volume (50% of intra-arterial treated tumours compared with 11% of intravenous treated lesions) after the 16 day total infusion time in favour of intra-arterial treatment. Technically, the intra-arterial route in this model was an improvement on previous small animal models. These findings lend support to the need for continuing clinical study of intra-arterial infusion.

SPECT evaluation of arterial perfusion in regional chemotherapy.

Simultaneous emission and transmission tomography was performed after the injection of [99mTc]MAA in 30 patients undergoing intra-arterial chemotherapy to nonhepatic sites to determine the accuracy of catheter placement. The transmission and emission data were reconstructed in transverse, and optionally, coronal and sagittal planes. The correlation of the emission scan with the reconstructed transmission data allowed accurate anatomical localization of the infusate distribution. In seven patients, catheter placement resulted in perfusion to nontumor sites, and hence required repositioning. MAA accumulation was seen in the lungs of all patients, regardless of tumor site, indicating arterio-venous shunting of the MAA. The degree of uptake in the lungs was quantified from planar anterior/posterior thorax images in terms of injected dose in ten patients, with values of 5-50% of injected dose present in the lungs. The technique provides a noninvasive means of accurately determining regional perfusion of chemotherapeutic agents delivered intra-arterially.

A report on the comparative response of sheep epidermal squamous-cell carcinoma to intraarterial versus intravenous Cisplatin infusion.

There is an apparent lack of randomised clinical trials demonstrating a therapeutic advantage for intra-arterial, versus systemic, cisplatin administration as cancer treatment. A spontaneous, head and neck epidermal squamous cell carcinoma in sheep was used to compare intra-arterial and equivalent dose intravenous cisplatin infusion. The objective response rate for intra-arterially infused lesions was 73%, with a mean tumour regression for all carcinomas of 70% +/- 6 (sem). In comparison, 27% of intravenously treated carcinomas showed an objective response, the mean volume reduction being 42% +/- 6 (sem). Statistical comparison of the number of objective response lesions was significantly in favour of intra-arterial cisplatin therapy (p<0.05), as was the difference in the mean tumour response for both groups (p<0.005). The experimental data suggest that further study of the clinical application of intra-arterial induction cisplatin therapy is warranted.

Pharmacokinetics of intra-arterial chemotherapy.

Advanced or aggressive, but localised, malignancies can often be reduced to more curable proportions by the use of "basal chemotherapy", that is, using chemotherapy as the first mode of treatment, prior to definitive radiotherapy and/or surgical excision. In using anticancer agents, drug combinations, timing and methods of administration are employed which exploit differences between cancer cells and normal tissues and cells. One exploitable difference which is often overlooked is the fact that localised tumour is often supplied with blood by one artery; this can be cannulated so that the agents used can be delivered selectively in high concentration to the region containing the tumour. The advantage in delivering drugs regionally by intra-arterial infusion depends upon the size of the artery infused, the rate of excretion or detoxification of the agents used, the amount of the agent infused entering the tissues - especially from the first circulation, and especially the amount of agent entering the tissues which is biologically active against tumour cells. Taking all these factors into account, mathematical calculations indicated that under the worst possible circumstances infusion of anticancer agents intra-arterially should be at least 1.8 times more effective regionally than intravenous administration. In most situations and with most agents used the advantage would be significantly greater than this. These calculations are supported by evidence in the literature and by observations of a greater regional effect, albeit toxic, of intra-arterial administration of the agents. These effects include more pronounced loss of hair in the region of distribution of the artery infused, and increased skin and mucosal ulceration in the distribution of the artery infused. The disadvantage of using intra-arterial infusion delivery is the need for hospitalisation. Therefore, properly controlled, randomised clinical trials should be conducted to compare clinical results of intra-arterial and intravenous chemotherapy administration.

Intra-arterial induction chemotherapy.

When effective anti-cancer drugs first became available to clinicians they were commonly used by surgeons by intra-arterial infusion to treat difficult regional cancer problems. Because they were most often used to treat poorly vascularised recurrent cancers results were, in general, unsatisfactory. The intra-arterial approach fell into disrepute and continued use of these techniques has often been criticised and results achieved treated with scepticism. Reasons for the original poor results are now well understood and techniques for effective and safe regional chemotherapy have been developed. These techniques of regional chemotherapy, when appropriately used especially as induction treatment, have an important role to play in a comprehensive oncology therapeutic service. However the criticisms and reluctance to accept the use of chemotherapy on a regional basis remain widespread. Some of the objections and difficulties expressed are valid but some are quite invalid and indicate reluctance to review the situation in spite of valuable progress and understanding and in spite of important clinical applications. Outlined in this review are valid objections, including increased facilities and skills needed and their cost, as well as invalid objections based on misconceptions, inexperience and reluctance to review or accept need for change of familiar practices.

The rising incidence of breast cancer in women and prostate cancer in men. Dietary influences: a possible preventive role for nature's sex hormone modifiers - the phytoestrogens (review).

The rise in breast cancer in women and prostate cancer in men in Western societies this century, stimulated a search for any possibly reversible aetiological associations common to both. Apart from more citizens living to an older age the most significant associated factor in common is the dietary practices of communities most at risk, particularly a decreasing Western dependence on plant foods with increasing dietary animal fats. Plant foods, especially legumes like soy, contain phytoestrogens (plant oestrogens). They are natural hormone modifying agents and give balance to levels of circulating hormones in both sexes. Animal fats hinder hormone modulation. They retain and slowly release unwanted stored hormones. To reverse this situation Western communities could revert to Asian type diets with high soy content but a more practical approach might be to add concentrated soy or other phytoestrogen product to a fat reduced Western diet.

Induction chemotherapy: to downgrade aggressive cancers to improve curability by surgery and/or radiotherapy.

Induction chemotherapy can be effective in reducing locally advanced or aggressive cancers to improve their prospects of cure by planned follow-up surgery and/or radiotherapy. Systemic (intravenous) delivery is the simplest and most readily available method of administering induction chemotherapy. In some situations, a greater chemotherapy impact can be achieved by delivering a more concentrated dose of effective anti-cancer agents into the arterial blood supply of the cancer. Intra-arterial (i.a.) chemotherapy may or may not be advantageous. To achieve an advantage, the tumour must be fully contained in tissue supplied by one or more arteries that can be effectively cannulated and infused. The cancer must also be one known to respond better to concentrated chemotherapy and the agents used must be effective in the state in which they are delivered. The advantages must outweigh the likely increased risks of regional toxicity and experienced personnel and appropriate specialized equipment must be available to reduce any risk of mistakes made by the more exacting techniques of delivery. In general, systemic chemotherapy is most appropriate in treating tumours without a single artery of supply; when certain agents that are inactive until modified in body tissues (such as cyclophosphamide or DTIC) are to be used; when satisfactory responses can be achieved safely and more easily by systemic delivery; when technical skills and facilities for regional delivery are not available; or when the patient's general health, poor co-operation or long-term prognosis precludes the additional complexity of regional delivery. Intra-arterial infusion may have advantages in treating some locally advanced malignancies in the head and neck, a limb, some invasive stomach cancers and some breast cancers. Primary and some metastatic liver cancers, some pelvic cancers and possibly pancreatic malignancies may also respond well to initial direct chemotherapy infusion and are the subject of several studies. Closed circuit perfusion (Creech-Krementz), chemofiltration infusion and "stop-flow" perfusion (Aigner) and regional limb infusion (Thompson) are more complex techniques aimed at even greater localized initial tissue chemotherapy concentrations over a short time span. These are the subject of ongoing studies in highly specialized units. Their use is designed to achieve tumour responses in treating such malignancies as melanoma, some sarcomas or pancreatic cancer that usually show a poor response to standard systemic chemotherapy.

The role of regional chemotherapy in gastric cancer.

Pre-operative intra-arterial chemotherapy has given impressive response rates in gastric cancer patients, and high survival rates longer term. The technique is demanding in skills and resources, but further studies using more effective drugs and less demanding regimens are in progress.

Induction chemotherapy via hepatic artery for gallbladder carcinoma.

The prognosis after surgery for carcinoma of the gallbladder remains poor. Treatment failure is frequently due to loco-regional recurrence in the adjacent liver and regional lymph nodes. We report a case of gallbladder carcinoma with proven involvement of the cystic duct node (Nevin stage IV). Pre-operative intra-arterial induction chemotherapy using two cycles of cisplatin, 5-fluorouracil, doxorubicin and mitomycin C was administered via the common hepatic artery. A radical cholecystectomy was performed 4 weeks later, and histological examination of the resected specimen showed a near total response, with no residual nodal disease. The patient remains well and free of disease 3 years later. Intra-arterial induction chemotherapy warrants further evaluation.