Emergency surgery during the COVID-19 pandemic: what you need to know for practice.

INTRODUCTION: Several articles have been published about the reorganisation of surgical activity during the COVID-19 pandemic but few, if any, have focused on the impact that this has had on emergency and trauma surgery. Our aim was to review the most current data on COVID-19 to provide essential suggestions on how to manage the acute abdomen during the pandemic. METHODS: A systematic review was conducted of the most relevant English language articles on COVID-19 and surgery published between 15 December 2019 and 30 March 2020. FINDINGS: Access to the operating theatre is almost exclusively restricted to emergencies and oncological procedures. The use of laparoscopy in COVID-19 positive patients should be cautiously considered. The main risk lies in the presence of the virus in the pneumoperitoneum: the aerosol released in the operating theatre could contaminate both staff and the environment. CONCLUSIONS: During the COVID-19 pandemic, all efforts should be deployed in order to evaluate the feasibility of postponing surgery until the patient is no longer considered potentially infectious or at risk of perioperative complications. If surgery is deemed necessary, the emergency surgeon must minimise the risk of exposure to the virus by involving a minimal number of healthcare staff and shortening the occupation of the operating theatre. In case of a lack of security measures to enable safe laparoscopy, open surgery should be considered.

The introduction of radioactive seed localisation improves the oncological outcome of image guided breast conservation surgery.

INTRODUCTION: Radioactive seed localisation (RSL) has become increasingly popular for localisation of non-palpable breast tumours. This is largely due to advantages it offers in terms of practicality and convenience when compared to guide wire localisation (WL). This institute switched from using WL to RSL in September 2014. The primary aim was to assess whether this change improved the accuracy of excision with regards to inadequate margin rates and weight of excision specimens. The secondary aim was to establish whether there is a "learning curve" associated with RSL technique. METHODS: Retrospective data collection was performed for 333 consecutive cases of unifocal non-palpable invasive breast cancers undergoing excision with WL or RSL. An inadequate margin was defined as tumour <1 mm from an inked radial margin. Patient demographics, tumour characteristics and clinical outcomes were compared between WL and RSL cases. RESULTS: 100 WL and 233 RSL cases were included. Patient demographics and tumour characteristics were similar for both groups. Inadequate margin rates were 18% with WL and 8.6% with RSL (p = 0.013). Median specimen weights were 33.3 g with WL and 28.7 g with RSL (p = 0.014). Subdividing the RSL group into the first 100 cases performed (RSL1) and the subsequent 133 cases (RSL2), inadequate margin rates were 13.0% and 5.3% respectively (p = 0.037). Mean specimen weights were similar. CONCLUSION: Switching from WL to RSL results in a significant reduction in both inadequate margin rates and specimen weights. A procedure-specific learning curve is present on first implementation of RSL and following this, inadequate margin rates are further reduced.

A systematic review of generic and breast cancer specific life expectancy models in the elderly.

INTRODUCTION: The use of primary endocrine therapy (PET) in managing breast cancer in the elderly has become common practice. Whilst there appears to be no difference in overall survival in comparison with surgery, PET has been found to be inferior in local disease control with a limited duration of efficacy (2-3 years). The International Society of Geriatric Oncology (SIOG) state that PET may be considered in patients with a short life expectancy (<2 years) or considered unfit for surgery. Frequently, decision making for PET allocation is a subjective process by the clinician. METHOD: A systematic literature review was performed to establish what prediction models are available for all-cause mortality in the elderly, and what breast-specific models have been produced. RESULTS: 18 prognostic models were deemed eligible from 15 papers. 1 breast-specific model was found, 2 nursing home related and 15 for community-dwelling elders. Accuracy (as defined by discrimination; c-statistic or AUROC) ranged from 0.69 (moderate) to 0.86 (very good). CONCLUSIONS: This review highlighted a variety of validated prognostic indexes. Several models with very good accuracy were identified but most were validated in US-populations and relied on information from administrative datasets. One breast specific model by Stotter et al. was identified, specifically to aid treatment planning for frail elderly patients but had limited accuracy. The strength of an index will ultimately be on its clinical impact and influence on treatment decisions rather than its accuracy and as of yet no trials exploring this have been carried out.

Genetic factors regulating inflammation and DNA methylation associated with prostate cancer.

BACKGROUND: Prostate cancer (PCa) displays a strong familiarity component and genetic factors; genes regulating inflammation may have a pivotal role in the disease. Epigenetic changes control chromosomal integrity, gene functions and ultimately carcinogenesis. The enzyme glycine-N-methyltransferase (GNMT) contributes to S-adenosylmethionine level regulation and, by affecting DNA methylation, influences gene expression. The genotype and allele distribution of single-nucleotide polymorphisms (SNPs) in the promoter regions of vascular endothelial growth factor (VEGF), interleukin (IL)-10, IL-1ß, alpha-1-antichymotrypsin (ACT) and GNMT genes, the level of global DNA methylation and the influence of GNMT SNP upon DNA methylation in a PCa case-control study have been investigated. METHODS: SNPs of VEGF (rs699947), ACT (rs1884082), IL-1ß (rs16944), IL-10 (rs1800896) and GNMT (rs9462856) genes were assessed by PCR or by real-time PCR methods. DNA methylation was assessed by an ELISA assay. RESULTS: Frequencies of the VEGF AA genotype, the IL-10 A allele and GNMT T allele were higher in PCa. The concomitant presence of the AA genotype of VEGF, the A allele of IL-10 and T allele of GNMT increased the risk of PCa. Total DNA methylation was decreased in PCa; control GNMT T carriers (T+) showed the highest level of DNA methylation. CONCLUSIONS: SNPs in VEGF, IL-10 and GNMT genes might have a synergistic role in the development of PCa. The GNMT T allele may influence PCa risk by affecting DNA methylation and prostate gene expression. Our observations might help implement the screening of unaffected subjects with an increased susceptibility to develop PCa.

Interaction between acylphosphatase and SERCA in SH-SY5Y cells.

Ca2+ transport by sarco/endoplasmic reticulum, tightly coupled with the enzymatic activity of Ca2+ -dependent ATPase, controls the cell cycle through the regulation of genes operating in the critical G, to S checkpoint. Experimental studies demonstrated that acylphosphatase actively hydrolyses the phosphorylated intermediate of sarco/endoplasmic reticulum calcium ATPase (SERCA) and therefore enhances the activity of Ca2+ pump. In this study we found that SH-SY5Y neuroblastoma cell division was blocked by entry into a quiescent G0-like state by thapsigargin, a high specific SERCA inhibitor, highlighting the regulatory role of SERCA in cell cycle progression. Addition of physiological amounts of acylphosphatase to SY5Y membranes resulted in a significant increase in the rate of ATP hydrolysis of SERCA. In synchronized cells a concomitant variation of the level of acylphosphatase isoenzymes opposite to that of intracellular free calcium during the G1 and S phases occurs. Particularly, during G1 phase progression the isoenzymes content declined steadily and hit the lowest level after 6 h from G0 to G1 transition with a concomitant significant increase of calcium levels. No changes in free calcium and acylphosphatase levels upon thapsigargin inhibition were observed. Moreover, a specific binding between acylphosphatase and SERCA was demonstrated. No significant change in SERCA-2 expression was found. These findings suggest that the hydrolytic activity of acylphosphatase increase the turnover of the phosphoenzyme intermediate with the consequences of an enhanced efficiency of calcium transport across endoplasmic reticulum and a subsequent decrease in cytoplasmic calcium levels. A hypothesis about the modulation of SERCA activity by acylphosphatase during cell cycle in SY5Y cells in discussed.

Alteration of intracellular free calcium and acylphosphatase levels in differentiating SH-SY5Y neuroblastoma cells.

Levels of acylphosphatase isoenzymes and free intracellular calcium have been investigated in cultured SH-SY5Y human neuroblastoma cells under stimulation with all-trans retinoic acid and phorbol-12-myristate-13-acetate. Under these conditions morphological and functional characteristics demonstrated the differentiation of SH-SY5Y cells towards neuronal phenotype. Retinoic acid treatment caused a progressive and synchronous increase of the organ common-type acylphosphatase and of free intracellular calcium but not of the muscle-type acylphosphatase. Phorbol-12-myristate-13-acetate treatment gave rise to a peak of the muscle-type acylphosphatase levels during the early differentiation stage whereas organ common-type isoenzyme and free calcium levels show a pattern similar to that observed in retinoic acid-treated cells. These evidences indicate that the two acylphosphatase isoenzymes play different roles in SH-SY5Y differentiation and that during this process the expression of organ common-type acylphosphatase increases in a synchronous way with intracellular free calcium concentration.

Alteration of acylphosphatase levels in familial Alzheimer's disease fibroblasts with presenilin gene mutations.

Acylphosphatase (AcPase), an enzyme that modulates the activity of Ca(2+)-ATPase by hydrolysing its phosphorylated moiety, has been found to be significantly higher in cultured skin fibroblasts from donors affected by early onset familial Alzheimer's disease (EOFAD) with PS-1 and PS-2 gene mutations. Of the two known isoenzymes of acylphosphatase, only the erythrocyte one accounts for the total increase in activity. No relevant alteration was observed in phosphotyrosine phosphatase activity (PTPase), in Ca(2+)-ATPase and Na+, K(+)-ATPase activities of the same cells as compared to age-matched controls. This finding could suggest a possible explanation for the calcium-dependent biochemical alterations previously described in Alzheimer's disease fibroblasts.

Expression of human acylphosphatase in Escherichia coli affects intracellular calcium levels.

In vitro experiments demonstrated the ability of acylphosphatase to hydrolyze the phosphorylated intermediate that is formed during the activity of Na+, K(+)- and Ca(2+)-ATPases of mammalian cells membranes. In order to investigate the effect of this enzyme on intracellular cation levels, a synthetic gene for human muscle acylphosphatase has been expressed in E. coli strains BL21 and JM101. Intracellular total steady-state calcium concentration, as measured by isotopic exchange, was significantly higher in transformed cells as compared to controls and the rising was dependent on the level of acylphosphatase expression. Accordingly also free intracellular calcium concentration, as measured by Fura-2 fluorescence, increased in transformed cells. On the other hand, phosphate levels were not affected by the expression of acylphosphatase, while sodium and rubidium levels increase in transformed cells. Intracellular pH resulted to be slightly affected by the expression of acylphosphatase, cytoplasm of transformed JM101 bacteria being more alkaline (pH 7.45) as compared to control cells (pH 7.40). On the basis of these results, it can be suggested that acylphosphatase acts in vivo by regulating the cation transport in E. coli.

Measurement of glucuronometabolites of 17 beta-estradiol and progesterone in early morning urine samples: a promising new method for the evaluation of hormonal responses of Buserelin-hMG treatment in an IVF program.

The success of IVF is related to the number and quality of embryos transferred. In our IVF program we have used two different protocols for superovulation induction. In this study a group of 35 patients was randomized into two groups; the first group (15 patients) was treated with pure FSH and hMG, in the other (20 patients) the normal pituitary function was inhibited with Buserelin before the stimulation with hMG. Ovarian stimulation was monitored by ultrasound examination and endocrine parameters. The RIA determination of 17-beta estradiol (17-E2) plasmatic levels is one of the most widely used techniques in IVF cycle monitoring; however many serious disadvantages are connected with the use of RIA (short half-life of the reagents; hazard of handling radioactive materials; frequent venipunctures for the patients). For these reasons, we propose a chemiluminescence immuno assay (LIA) method for the measurement of glucuronometabolites of 17-E2 and progesterone in early morning urine samples: this technique allows to follow hormonal levels for all the cycle, avoiding patient discomfort. We have found a highly significant correlation between serum and urinary hormonal values. We noted a marked variability in the individual estrogenic response and a significant difference in the response of the two groups. The mean peak on hCG administration day was 6.4 +/- 3.5 micrograms/h for urinary E1-3G and 1270 +/- 678 pg/ml for 17-E2 in Buserelin-hMG group: these hormonal levels appear lower than without ovarian desensitization; (in FSH-hMG group we have, on the same day, 9.7 +/- 3.2 micrograms/h for E1-3G and 1630 +/- 730 pg/ml for serum 17-E2).(ABSTRACT TRUNCATED AT 250 WORDS)

Complete androgen blockade as treatment for advanced prostate cancer: clinical response and side-effects.

Treatment of advanced prostatic cancer is currently based on hormonal manipulation. In 1982 Labrié supported a new concept of hormonal treatment based on complete androgen blockade. The objective of this study was to evaluate the effects of total androgen suppression, achieved by the combination of a LHRH agonist (buserelin) plus a pure anti-androgen (flutamide) in the long-term treatment of advanced prostate cancer. Forty-seven untreated consenting patients with advanced prostatic cancer entered in the study, and 41 of these proved evaluable for response and toxicity. Buserelin and Flutamide were administered three times daily, intranasally and orally respectively, at a dose of 1.2 mg and 750 mg for twelve months. Circulating testosterone levels, regularly measured during the study, were reduced by the treatment to castrated levels. Clinical results are encouraging for the high rate of objective and clinical responses PR + SD = 37 (90%), for its duration (12 months), for the significant improvement of urological symptoms and for the decrease of cancer-related pain, even in cases with detectable bone metastases. Compliance was excellent in all the subjects and no patient was forced to interrupt treatment because of cardiovascular toxicity or severe side-effects, which were limited to occasional loss of libido and potency, hot-flashes, mild diarrhea and nausea.

Phosphohexose isomerase activity as a tumor marker in hepatoma bearing rats (Yoshida A.H. 130).

The object of this study was to examine if there exists, analogously to what happens in human cancer patients, elevation of phosphohexose isomerase activity (PHI, EC 5.3.1.9) in the serum of animals bearing an experimental tumor and, if so, whether such increases were related to the progress of the tumor, as in humans. The behavior of the same enzyme activity within the tumor itself was also studied. Significant correlations were found between serum elevations of PHI and hepatoma growth. These correlations, moreover, emerge at a very early stage. On the other hand, no relation appears to exist between phosphohexose isomerase activity in the tumor and that in the blood. The two divisions, furthermore, do not seem to interact. These results may prove interesting prospectives for the monitoring of human cancer.

Toward a medical prolepsis by chronobiology.

Medicine today strongly aims at prevention and optimization of diagnosis and therapy Studies tried staging and standardization of clinical trials in diseases and made search of markers for early diagnosis, prognosis and therapy. Moreover, risk factors and other variables such as predictors are now investigated more often in groups or populations of apparently healthy subjects, especially for such diseases as atherosclerosis and neoplasia. This new aspect of increasing interest may be defined as medical prolepsis (from the Greek pi rho ómicron lambda eta psi iota zeta = anticipated idea). It includes early signals of disease (protopathology) as well as other signals the host shows as defence or alarm reaction. Hence, we suggest a chronobiological approach in this field, which allows to quantify health and reveals more subtle differences in many physiological variables. According to these views, we reported studies concerning humoral markers and other parameters considered as risk factors both in atherosclerosis and in some endocrine tumors.