The learning curve of a bronchus-first method in bi-port video-assisted thoracoscopic surgery for left upper lobe lung cancer.

Video-assisted thoracic surgery (VATS) has been widely used in lung cancer treatment. However, VATS left upper lobectomy (LUL) is complex due to the intricate branching pattern of the left pulmonary artery (PA). Nevertheless, VATS right upper lobectomy can be simplified through a bronchus-first and simultaneous vessel stapling technique. In this study, the learning curve was obtained while ensuring favorable oncological outcomes using bronchus-first method for VATS LUL. First, retrospective data of 148 consecutive patients who underwent VATS LUL (bronchus-first method) for non-small cell lung cancer (NSCLC) from March 2018 to October 2020 were analyzed. The learning curve was then assessed via cumulative sum (CUSUM) analysis. Moreover, data at different stages of the learning curve, including operation time, blood loss, postoperative hospital stay, lymph node harvested, thoracotomy conversion, postoperative complications, endoscopic stapler consumptions, and 3 year overall survival, were recorded. The learning curve was best modeled as the equation: y = - 7.78 + 2.05x-2.23 × 10-2x2 + 6.43 × 10-5x3, with a good-to-fit test R2 = 0.97. The surgeon entered the proficient stage (59th case-148th case) after consecutive operations of 58 cases (learning stage, 1st case-58th case). Notably, more lymph nodes were harvested in the proficient stage than in the learning stage (17.69 ± 1.47 vs. 15.53 ± 1.43, P < 0.01). Compared with the learning stage, the proficient stage was associated with shorter operation time (114.28 ± 8.56 min vs. 126.81 ± 7.30 min, P < 0.01), fewer blood loss (44.22 ± 7.75 mL vs. 57.41 ± 22.98 mL, P < 0.01), shorter postoperative hospital stay (6.02 ± 0.99 d vs. 7.22 ± 1.34 d, P < 0.01), and fewer endoscopic stapler consumptions (5.89 ± 0.64 vs. 6.53 ± 0.50, P < 0.01). However, thoracotomy conversion (4/90 vs. 5/58, P = 0.32), postoperative complications (10/90 vs. 11/58, P = 0.23) and 3 year overall survival (62.2% vs. 50.8%, log-rank test, P = 0.11) showed no significant difference between the two stages. The surgeon with former single-direction VATS lobectomy experience can master bronchus-first VATS LUL after attending to 58 cases.

Rational design of geranylgeranyl diphosphate synthase enhances carotenoid production and improves photosynthetic efficiency in Nicotiana tabacum.

Restricted genetic diversity can supply only a limited number of elite genes for modern plant cultivation and transgenesis. In this study, we demonstrate that rational design enables the engineering of geranylgeranyl diphosphate synthase (NtGGPPS), an enzyme of the methylerythritol phosphate pathway (MEP) in the model plant Nicotiana tabacum. As the crucial bottleneck in carotenoid biosynthesis, NtGGPPS1 interacts with phytoene synthase (NtPSY1) to channel GGPP into the production of carotenoids. Loss of this enzyme in the ntggpps1 mutant leads to decreased carotenoid accumulation. With the aim of enhancing NtGGPPS1 activity, we undertook structure-guided rational redesign of its substrate binding pocket in combination with sequence alignment. The activity of the designed NtGGPPS1 (a pentuple mutant of five sites V154A/I161L/F218Y/I209S/V233E, d-NtGGPPS1) was measured by a high-throughput colorimetric assay. d-NtGGPPS1 exhibited significantly higher conversion of IPP and each co-substrate (DMAPP ~1995.5-fold, GPP ~25.9-fold, and FPP ~16.7-fold) for GGPP synthesis compared with wild-type NtGGPPS1. Importantly, the transient and stable expression of d-NtGGPPS1 in the ntggpps1 mutant increased carotenoid levels in leaves, improved photosynthetic efficiency, and increased biomass relative to NtGGPPS1. These findings provide a firm basis for the engineering of GGPPS and will facilitate the development of quality and yield traits. Our results open the door for the structure-guided rational design of elite genes in higher plants.

Tramadol Use in Perioperative Care and Current Controversies.

PURPOSE OF REVIEW: The aim of this review is to discuss the use of tramadol in the perioperative period. There is no doubt that tramadol has revolutionized pain treatment, making it important to understand the pharmacokinetics and pharmacodynamics in order to provide patients with the safest and most effective analgesia. RECENT FINDINGS: Tramadol is a centrally acting synthetic analgesic with a multimode of action used to help treat moderate to severe pain. Pharmacologically, the unique opioid acts as a serotonin-norepinephrine reuptake inhibitor, while its metabolite, O-desmethyltramadol, acts on the µ-opioid receptor. The analgesic strength of tramadol is about one-tenth that of morphine, making it a relatively safe analgesic. Potential side effects of tramadol include nausea, vomiting, constipation, pruritus, and respiratory depression; however, the severity of these symptoms is minimal compared to traditional opioids. Although some of the perioperative uses of tramadol may be rare, it is a pain management option to consider when alternatives have proved ineffective.

Dual targeting of MEK and PI3K effectively controls the proliferation of human EGFR-TKI resistant non-small cell lung carcinoma cell lines with different genetic backgrounds.

BACKGROUND: Molecular targeted therapy for non-small cell lung carcinoma (NSCLC) is restricted due to resistance to epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs). This study evaluated the effects of dual targeting of MEK and PI3K in human EGFR-TKI resistant NSCLC cell lines. METHODS: EGFR-TKI resistant NSCLC cell lines H1975, H460, and A549, with different mutation and amplification status in EGFR, K-RAS, PIK3CA, and MET genes, were treated with a MEK162 (MEK inhibitor) and BKM120 (PI3K inhibitor) combination or a BIBW2992 (EGFR inhibitor) and ARQ197 (MET inhibitor) combination and assayed for cell proliferation, apoptosis, and cell cycle distribution. RESULTS: Dual targeting of MEK and PI3K efficiently inhibited the cell proliferation, induced apoptosis and the G0/G1 cell cycle, and decreased the phosphorylation of ERK1/2, AKT, S6, and 4E-BP1. H460 cells with K-RAS and PIK3CA mutation were most sensitive to MEK162 and BKM120 combinations. H1975 cells with EGFR and PIK3CA mutation and MET amplification were sensitive to BIBW2992 and ARQ197 combinations. CONCLUSION: Dual targeting regulated the proliferation of EGFR-TKI-resistant NSCLC cells, especially mutants in K-RAS and PIK3CA that are promising for EGFR-TKI-resistant NSCLC therapeutics.

Effectiveness and safety of bovine pericardium patch repair for cervical anastomotic leakage after oesophagectomy for cancer.

BACKGROUND: The objective of this study is to evaluate the effectiveness and safety of bovine pericardium patch (BPP) repair for cervical anastomotic leakage after esophageal squamous cancer. METHODS: Intractable cervical anastomotic leakage developed in 7 patients of esophageal squamous cell carcinoma undergoing cervical anastomosis. These patients received the BPP repair. The necrotic tissue around the cervical anastomosis was removed during the operation, and the defect was repaired with BPP according to the size of the leakage. RESULTS: The operative duration was 60-90 min (median, 75 min). There were no signs of recurrent anastomotic leakage in each patient undergoing BPP repair. Oral intake was initiated 5-8 days (median, 6 days) after the BPP repair operation without any discomfort. CONCLUSIONS: The BPP repair is a safe and effective processing scheme for patients with cervical anastomotic fistula after resection of esophageal squamous cell carcinoma. This method may be recommended for appropriate patients with intractable cervical anastomotic fistula.

Identification of a novel cytochrome P450 enzyme that catalyzes the C-2α hydroxylation of pentacyclic triterpenoids and its application in yeast cell factories.

C-2α hydroxylated triterpenoids are a large class of plant secondary metabolites. These compounds, such as maslinic, corosolic and alphitolic acid, have important biological activities against HIV, cancer and diabetes. However, the biosynthesis pathways of these compounds have not been completely elucidated. Specifically, the cytochrome P450 (CYP) enzyme responsible for C-2α hydroxylation was unknown. In this study, a novel CYP enzyme that catalyzes C-2α hydroxylation was identified in Crataegus pinnatifida (Hawthorn) using a metabolic engineering platform. It is a multifunctional enzyme with C-2α oxidase activity on oleanane-, ursane- and lupane-type pentacyclic triterpenoids. In addition, the complete biosynthesis pathways of these three triterpenoids were reconstituted in yeast, resulting in the production of 384, 141 and 23 mg/L of maslinic, corosolic and alphitolic acid, respectively. This metabolic engineering platform for functional gene identification and strain engineering can serve as the basis for creating alternative pathways for the microbial production of important natural products.

Biosynthesis of dendroketose from different carbon sources using in vitro and in vivo metabolic engineering strategies.

BACKGROUND: Asymmetric aldol-type C-C bond formation with ketones used as electrophilic receptor remains a challenging reaction for aldolases as biocatalysts. To date, only one kind of dihydroxyacetone phosphate (DHAP)-dependent aldolases has been discovered and applied to synthesize branched-chain sugars directly using DHAP and dihydroxyacetone (DHA) as substrate. However, the unstable and high-cost properties of DHAP limit large-scale application. Therefore, biosynthesis of branched-chain sugar from low-cost and abundant carbon sources is essential. RESULTS: The detailed catalytic property of l-rhamnulose-1-phosphate aldolase (RhaD) and l-fuculose-1-phosphate aldolase (FucA) from Escherichia coli in catalyzing the aldol reactions with DHA as electrophilic receptors was characterized. Furthermore, we calculated the Bürgi-Dunitz trajectory using molecular dynamics simulations, thereby revealing the original sources of the catalytic efficiency of RhaD and FucA. A multi-enzyme reaction system composed of formolase, DHA kinase, RhaD, fructose-1-phosphatase, and polyphosphate kinase was constructed to in vitro produce dendroketose, a branched-chain sugar, from one-carbon formaldehyde. The conversion rate reached 86% through employing a one-pot, two-stage reaction process. Moreover, we constructed two artificial pathways in Corynebacterium glutamicum to obtain this product in vivo starting from glucose or glycerol. Fermentation with glycerol as feedstock produced 6.4 g/L dendroketose with a yield of 0.45 mol/mol glycerol, representing 90% of the maximum theoretical value. Additionally, the dendroketose production reached 36.3 g/L with a yield of 0.46 mol/mol glucose when glucose served as the sole carbon resource. CONCLUSIONS: The detailed enzyme kinetics data of the two DHAP-dependent aldolases with DHA as electrophilic receptors were presented in this study. In addition, insights into this catalytic property were given via in silico simulations. Moreover, the cost-effective synthesis of dendroketose starting from one-, three-, and six-carbon resources was achieved through in vivo and in vitro metabolic engineering strategies. This rare branched-chain ketohexose may serve as precursor to prepare 4-hydroxymethylfurfural and branched-chain alkanes using chemical method.

[Clinical characteristics and risk factors affecting outcomes of elderly patients with non-small cell lung cancer complicated by chronic obstructive pulmonary disease].

OBJECTIVE: To investigate the clinical features, treatment strategy and risk factors affecting the prognosis of elderly patients with non-small cell lung cancer (NSCLC) complicated by chronic obstructive pulmonary disease (COPD). METHODS: We retrospectively analyzed the data of elderly patietns (>60 years) with newly diagnosed NSCLC complicated by COPD at the Geriatric Institution of General Hospital of PLA between January, 2000 and June, 2015. The clinical data collected included history of smoking, pulmonary function test results, initial treatments, TNM stage, chief complaints, comorbidities and laboratory tests. The Cox proportional hazards regression model was used to explore the prognostic factors in these patients. RESULTS: A total of 200 NSCLC patients were reviewed, of which 107 (53.5%) patients had the co-morbidity of COPD as confirmed by spirometry using bronchodilator test. The median survival of the patients with NSCLC complicated by COPD was 45.8 months with 1-, 3-, 5-, and 10-year survival rates of 80.4%, 55.4%, 41.0% and 20.0%, respectively. Stratification analysis showed that patients with COPD Gold grades 1 and 2 had a significant longer median overall survival (51.7 and 43.1 months, respectively) than those with grade 3/4 (16.9 months; P=0.020 and 0.043, respectively). Univariate and multivariate analyses using Cox proportional hazards regression model showed that an older age, a higher Gold grade, advanced disease stage (stages III and IV), squamous cell carcinoma, nonsurgical initial treatment, coughing and an elevated serum CEA level were independent risk factors for shorter survival of the patients. CONCLUSION: Multiple prognostic factors can affect the outcomes of elderly patients with NSCLC complicated by COPD, and a higher COPD Gold grade that fails to respond to treatment within 3 months is the independent risk factor for survival of the patients.

A propensity-matched analysis of surgery and stereotactic body radiotherapy for early stage non-small cell lung cancer in the elderly.

Elderly patients with early stage non-small cell lung cancer (NSCLC) who undergo surgical resection are at a high risk of treatment-related complications. Stereotactic body radiation therapy (SBRT) is considered an alternative treatment option with a favorable safety profile. Given that prospective comparative data on SBRT and surgical treatments are limited, we compared the 2 treatments for early stage NSCLC in the elderly.We retrospectively collected information from the database at our geriatric institution on patients with clinical stage IA/B NSCLC who were treated with surgery or SBRT. The patients were matched using a propensity score based on gender, age, T stage, tumor location, pulmonary function (forced expiratory volume in 1 second [FEV1]% and FEV1), Charlson comorbidity score, and World Health Organization performance score. We compared locoregional control rate, recurrence-free survival (RFS), overall survival (OS), and cancer-specific survival (CSS) between the 2 treatment cohorts before and after propensity score matching.A total of 106 patients underwent surgery, and 74 received SBRT. Surgical patients were significantly younger (72.6 ±â€Š7.9 vs 82.6 ±â€Š4.1 years, P = 0.000), with a significantly higher rate of adenocarcinoma (P = 0.000), better Eastern Cooperative Oncology Group performance scores (P = 0.039), and better pulmonary function test results (P = 0.034 for predicted FEV1 and P = 0.032 for FEV1). In an unmatched comparison, there were significant differences in locoregional control (P = 0.0012) and RFS (P < 0.001). The 5-year OS was 69% in patients who underwent surgery and 44.6% in patients who underwent SBRT (P = 0.0007). The 5-year CSS was 73.9% in the surgery group and 57.5% in the SBRT group (P = 0.0029). Thirty-five inoperable or marginally operable surgical patients and 35 patients who underwent SBRT were matched to their outcomes in a blinded manner (1:1 ratio, caliper distance = 0.25). In this matched comparison, the follow-up period of this subgroup ranged from 4.2 to 138.1 months, with a median of 58.7 months. Surgery was associated with significantly better locoregional control (P = 0.0191) and RFS (P = 0.0178), whereas no significant differences were found in OS (5-year OS, 67.8% for surgery vs 47.4% for SBRT, P = 0.07) or CSS (67.8% for surgery vs 58.2% for SBRT, P = 0.1816).This retrospective analysis found superior locoregional control rates and RFS after surgery compared with SBRT, but there were no differences in OS or CSS. SBRT is an alternative treatment option to surgery in elderly NSCLC patients who cannot tolerate surgical resection because of medical comorbidities. Our findings support the need to compare the 2 treatments in randomized controlled trials.

Ultrasound-guided Transversus Abdominis Plane Block Improves Postoperative Analgesia and Early Recovery in Patients Undergoing Retroperitoneoscopic Urologic Surgeries: A Randomized Controlled Double-blinded Trial.

Objective To evaluate the effects of ultrasound-guided transversus abdominis plane (TAP) block on postoperative analgesia and early recovery in patients undergoing retroperitoneoscopic urologic surgeries. Methods This was a randomized, controlled, double-blinded trial. Eligible patients scheduled for retroperitoneoscopic urologic surgeries were randomly assigned to two groups. Group TAP received ultrasound-guided TAP block with 0.5% ropivacaine 20 ml at 30 minutes before surgery, and Group C received TAP sham block with normal saline. All patients received retroperitoneoscopic urologic surgeries under general anesthesia. The primary outcome was the severity of pain after surgery. Secondary outcomes included opioids consumption, analgesics, postoperative nausea and vomiting, time to Foley catheter removal and to passage of flatus, length of post-anesthesia care unit stay and hospital stay. Results Eighty patients completed the study, forty cases in each group. Compared to the Group C, the Group TAP had lower visual analogue scale pain scores within two postoperative days (all P<0.05). They also had less consumption of intraoperative fentanyl (2.0±0.5 vs. 3.8±0.7 µg/kg, P<0.05), reduced incidence of postoperative rescue analgesic usage (12.5% vs. 45.0%, P<0.05), and lower incidence of postoperative nausea and vomiting within postoperative 48 hours (12.5% vs. 25.0%, P<0.05) when compared to the Group C. In addition, Group TAP had a shortened post-anesthesia care unit stay (25±8 vs. 49±12 minutes, P<0.05), and a greater proportion of patients discharged within postoperative three days (57.5% vs. 35.0%, P<0.05). Conclusion Preoperative ultrasound-guided TAP block is an effective technique to improve postoperative analgesia and early recovery in patients undergoing retroperitoneoscopic urologic surgeries.

[A retrospective study on the diagnosis and treatment of vocal folds white lesions].

OBJECTIVE: To analyze the pathogenesis and clinical features of the vocal fold white lesions, and to investigate the principles of the diagnosis and treatment. METHODS: One hundred and fifty-six cases of vocal fold white lesions encountered between January 2006 and December 2013 were analyzed. All patients had bilateral-vocal folds whitening under laryngoscopic examination, and all the patients had been observed over three months. There were 135 males and 21 females in the study, the age ranged from 18 to 60 years, with the mean age of (38.8±8.1) years old. All patients had a history of vocal abuse, with moderate-severe degree of voice disorder. RESULTS: After a month of voice rest and suitable treatment, the result of reexamination showed that the symptoms faded away in 81 cases (51.9%), with the voice recuperated; the range of white lesion was reduced with the voice improving in 71 cases (45.4%); the range of white lesion was not obviously changed in 4 cases (2.6%), the pathological examination in these 4 cases showed moderate-severe dysplasia in two cases, and the surgical treatment was applied for them. Two months later, the reexamination showed 26 male cases still had vocal fold white lesion with various degree; and three months later, only 7 male cases retained mild vocal fold white lesion. CONCLUSION: Histopathologically, not all vocal fold white lesions were laryngeal precancerous lesions, and not all of these patients should be treated surgically.

Lipase member H is a novel secreted protein associated with a poor prognosis for breast cancer patients.

The objective of this study is to identify the expression status and clinical implications of lipase member H (LIPH) in breast cancer in order to develop strategies for breast cancer management. LIPH expression status was detected in 346 breast cancer specimens by immunohistochemistry. The relationship between LIPH expression, clinico-pathological parameters, and prognosis of breast cancer was determined. LIPH expression was higher in breast cancer specimens than in paracarcinoma tissues (P=0.01). In total, 64.74% (224/346) of breast cancer samples had high expression of the LIPH protein. LIPH was related to tumor size, histological grade, lymph node metastasis, and distant metastasis (P=0.073, 0.001, 0.001, and 0.001, respectively). Furthermore, individuals with high LIPH expression had a significantly higher rate of distant metastasis and poorer disease-specific survival than those with no or low LIPH expression (P=0.01). A Cox regression test indicated that the LIPH protein was an independent prognostic factor (P=0.001). LIPH was differentially expressed in breast cancer individuals and is an independent prognostic factor for breast cancer as well as a potential target for its management.

Arsenic trioxide inhibits the growth of human lung cancer cell lines via cell cycle arrest and induction of apoptosis at both normoxia and hypoxia.

Arsenic trioxide (As(2)O(3)) has been established to be an effective agent for treating acute promyleocytic leukemia. Laboratory data suggest that As(2)O(3) induces apoptosis of several solid tumor cells including lung cancer cells. Regions of tissue hypoxia often arise in aggressive solid tumors, and hypoxic tumors exhibit augmented invasiveness and metastatic ability in several malignancies. Furthermore, hypoxia may impair the treatment efficiency; therefore, we studied the cytotoxic effect of As(2)O(3) on human lung adenocarcinoma cell lines A549 and A549/R (resistant to vincristine, adriamycin and mitomycin etc.) grown under normoxic and hypoxic (1% oxygen) conditions. At both normoxia and hypoxia, 5, 10 and 15 microM As(2)O(3) induced evident growth inhibition and apoptosis in A549 cells as well as A549/R cells after 48 hours of exposure. In contrast, the conventional chemotherapeutic drug vincristine showed lowered efficiency in hypoxic A549 cells. As(2)O(3) induced G(2)/M cell cycle arrest in both normoxic and hypoxic A549 cells. As(2)O(3) significantly decreased the messenger RNA (mRNA) levels of Cyclin B(1) and survivin and the protein levels of Cyclin B(1), phospho-CDC(2) (Thr 161) and survivin in both normoxic and hypoxic A549 cells. Together, our findings indicated that As(2)O(3) significantly inhibited the proliferation of lung cancer cells via G(2)/M cell cycle arrest and induction of apoptosis at both normoxia and hypoxia, and the induction of apoptosis was associated with down regulation of survivin.

tRNA-dependent cysteine biosynthetic pathway represents a strategy to increase cysteine contents by preventing it from thermal degradation: thermal adaptation of methanogenic archaea ancestor.

Although cysteine (Cys) is beneficial to stabilize protein structures, it is not prevalent in thermophiles. For instance, the Cys contents in most thermophilic archaea are only around 0.7%. However, methanogenic archaea, no matter thermophilic or not, contain relatively abundant Cys, which remains elusive for a long time. Recently, Klipcan et al. correlated this intriguing property of methanogenic archaea with their unique tRNA-dependent Cys biosynthetic pathway. But, the deep reasons underlying the correlation are ambiguous. Considering the facts that free Cys is thermally labile and the tRNA-dependent Cys biosynthesis avoids the use of free Cys, we speculate that the unique Cys biosynthetic pathway represents a strategy to increase Cys contents by preventing it from thermal degradation, which may be relevant to the thermal adaptation of methanogenic archaea ancestor.

[Effects of arsenic trioxide on apoptosis and proliferation of human lung cancer cells under hypoxia].

OBJECTIVE: To observe the effects of different concentrations of arsenic trioxide (As(2)O(3)) on apoptosis and proliferation of human lung cancer cell line A549 in vitro under hypoxia and normoxia. METHODS: A549 cells were treated with 0, 1, 2, 4 micromol/L As2O3 for 12, 24 and 48 h under hypoxia (5% O(2)) and normoxia (21% O(2)). The proliferative inhibition rate of A549 cells was measured with methyl thiazolyl tetrazolium assay, and the apoptotic rate of A549 cells was detected by Annexin V/propidium iodide (PI) double staining. RESULTS: Under normoxia and hypoxia, 1, 2, 4 micromol/L As(2)O(3) could significantly inhibit the proliferation of A549 cells and induce the apoptosis of A549 cells. The results depended on the drug concentration and action time. And the hypoxia couldn't influence the effects of As(2)O(3). CONCLUSION: As(2)O(3) can inhibit the proliferation and induce the apoptosis of A549 cells under hypoxia and normoxia.

New furostanol glycosides from the rhizomes of Dioscorea futschauensis R. Kunth.

Two new furostanol glycosides, 26-O-beta-D-glucopyranosyl-3beta,26-dihydroxy-23(S)-methoxyl-25(R)-furosta-5,20(22)-dien-3-O-alpha-L-rhamnopyranosyl(1 --> 2)-[beta-D-glucopyranosyl(1 --> 3)]-beta-D-glucopyranoside (dioscoreside E, 1) and 26-O-beta-D-glucopyranosyl-3beta,26-dihydroxy-25(R)-furosta-5,20(22)-dien-3-O-alpha-Lrhamnopyranosyl(1 --> 2)-[beta-D-glucopyranosyl (1 --> 3)]-beta-D-glucopyranoside (prtotogracillin, 2), together with 11 known furostanol glycosides were isolated from the rhizomes of Dioscorea futshauensis R. Kunth. Their structures were elucidated on the basis of spectroscopic analysis (NMR and FABMS). Their anti-fungal activity against the plant pathogenic fungus Pyricularia oryzae and cytotoxic activity on K562 cancer cell line were evaluated in vitro.