Long term persistence and risk factors for anorectal symptoms following low anterior resection for rectal cancer.

BACKGROUND: Rectal cancer is commonly treated by chemoradiation therapy, followed by the low anterior resection anal sphincter-preserving surgery, with a temporary protecting ileostomy. After reversal of the stoma a condition known as low anterior resection syndrome (LARS) can occur characterized by a combination of symptoms such as urgent bowel movements, lack of control over bowel movements, and difficulty fully emptying the bowels. These symptoms have a significant negative impact on the quality of life for individuals who have survived the cancer. Currently, there is limited available data regarding the presence, risk factors, and effects of treatment for these symptoms during long-term follow-up. AIMS: To evaluate long term outcomes of low anterior resection surgery and its correlation to baseline anorectal manometry (ARM) parameters and physiotherapy with anorectal biofeedback (BF) treatment. METHODS: One hundred fifteen patients (74 males, age 63 ± 11) who underwent low anterior resection surgery for rectal cancer were included in the study. Following surgery, patients were managed by surgical and oncologic team, with more symptomatic LARS patients referred for further evaluation and treatment by gastroenterologists. At follow up, patients were contacted and offered participation in a long term follow up by answering symptom severity and quality of life (QOL) questionnaires. RESULTS: 80 (70%) patients agreed to participate in the long term follow up study (median 4 years from stoma reversal, range 1-8). Mean time from surgery to stoma closure was 6 ± 4 months. At long term follow up, mean LARS score was 30 (SD 11), with 55 (69%) patients classified as major LARS (score > 30). Presence of major LARS was associated with longer time from surgery to stoma reversal (6.8 vs. 4.8 months; p = 0.03) and with adjuvant chemotherapy (38% vs. 8%; p = 0.01). Patients initially referred for ARM and BF were more likely to suffer from major LARS at long term follow up (64% vs. 16%, p < 0.001). In the subgroup of patients who underwent perioperative ARM (n = 36), higher maximal squeeze pressure, higher maximal incremental squeeze pressure and higher rectal pressure on push were all associated with better long-term outcomes of QOL parameters (p < 0.05 for all). 21(54%) of patients referred to ARM were treated with BF, but long term outcomes for these patients were not different from those who did not perform BF. CONCLUSIONS: A significant number of patients continue to experience severe symptoms and a decline in their quality of life even 4 years after undergoing low anterior resection surgery. Prolonged time until stoma reversal and adjuvant chemotherapy emerged as the primary risk factors for a negative prognosis. It is important to note that referring patients for anorectal physiology testing alone tended to predict poorer long-term outcomes, indicating the presence of selection bias. However, certain measurable manometric parameters could potentially aid in identifying patients who are at a higher risk of experiencing unfavorable functional outcomes. There is a critical need to enhance current treatment options for this patient group.

In Vitro and In Vivo Studies of the Trypanocidal Effect of Novel Quinolines.

Therapies for human African trypanosomiasis and Chagas disease, caused by Trypanosoma brucei and Trypanosoma cruzi, respectively, are limited, providing minimal therapeutic options for the millions of individuals living in very poor communities. Here the effects of 10 novel quinolines are evaluated in silico and by phenotypic studies using in vitro and in vivo models. Absorption, distribution, metabolism, excretion, and toxicity (ADMET) properties revealed that most molecules did not infringe on Lipinski's rules, which is a prediction of good oral absorption. These quinolines showed high probabilities of Caco2 permeability and human intestinal absorption and low probabilities of mutagenicity and of hERG1 inhibition. In vitro screens against bloodstream forms of T. cruzi demonstrated that all quinolines were more active than the reference drug (benznidazole [Bz]), except for DB2171 and DB2192, with five (DB2187, DB2131, DB2186, DB2191, and DB2217) displaying 50% effective concentrations (EC50s) of <3 µM (4-fold lower than that of Bz). Nine quinolines were more effective than Bz (2.7 µM) against amastigotes, showing EC50s ranging from 0.6 to 0.1 µM. All quinolines were also highly active in vitro against African trypanosomes, showing EC50s of ≤0.25 µM. The most potent and highly selective candidates for each parasite species were tested in in vivo models. Results for DB2186 were promising in mice with T. cruzi and T. brucei infections, reaching a 70% reduction of the parasitemia load for T. cruzi, and it cured 2 out of 4 mice infected with T. brucei DB2217 was also active in vivo and cured all 4 mice (100% cure rate) with T. brucei infection.

Blood group O: A novel risk factor for increased postpartum blood loss?

INTRODUCTION: Blood group O is known to be associated with lower levels of von Willebrand factor (VWF) and with increased bleeding complications. The influence of blood group O on postpartum blood loss was assessed by a few studies, however, without adjustment for important obstetric risk factors for postpartum blood loss. AIM: Aim of this study was to investigate whether women with blood group O exhibit increased blood loss after delivery in consideration of established risk factors for postpartum bleeding. METHODS: A total of 1487 patients were prospectively included into this cohort study. Blood loss was assessed by estimated blood loss (in mL), and drop of haemoglobin (Δ haemoglobin) was calculated. Association of blood loss with risk factors (such as blood group O, cervical tears, morbidly adherent placenta, placenta praevia and uterine atony amongst others) was assessed with appropriate tests. Significant variables were entered into a stepwise multivariate regression analysis. RESULTS: Women with blood group O showed a significantly higher blood loss when compared to women with blood group non-O (529.2 mL ± 380.4 mL and 490.5 mL ± 276.4 mL, respectively, P = .024)). The increased blood loss in women with blood group O remained significant after multivariate regression analysis (difference 47 mL, P = .019). CONCLUSION: This is the first study reporting significantly increased blood loss following delivery in women with blood group O after adjustment for major risk factors for postpartum blood loss. Albeit having a statistically significant, but clinically minor effect on absolute blood loss, blood group O carriers may suffer from aggravated bleeding in the presence of additional obstetric bleeding pathologies.

Adipocyte differentiation: a transcriptional regulatory cascade.

The adipose cell is now known to play a complex role in energy homeostasis, energy storage and signaling to other tissues concerning the state of energy balance. The past few years have seen an explosive increase in our knowledge of the transcriptional basis of adipocyte differentiation. Factors such as peroxisome proliferator-activated receptor gamma, the CCAAT/enhancer binding protein family members, and adipocyte determination- and differentiation-dependent factor 1 play important regulatory roles in this process. Furthermore, these factors provide a focus for beginning to understand how various hormones and metabolites influence the development of adipose tissue in vivo.

Efficacy of the novel diamidine compound 2,5-Bis(4-amidinophenyl)- furan-bis-O-Methlylamidoxime (Pafuramidine, DB289) against Trypanosoma brucei rhodesiense infection in vervet monkeys after oral administration.

Owing to the lack of oral drugs for human African trypanosomiasis, patients have to be hospitalized for 10 to 30 days to facilitate treatment with parenterally administered medicines. The efficacy of a novel orally administered prodrug, 2,5-bis(4-amidinophenyl)-furan-bis-O-methlylamidoxime (pafuramidine, DB289), was tested in the vervet monkey (Chlorocebus [Cercopithecus] aethiops) model of sleeping sickness. Five groups of three animals each were infected intravenously with 10(4) Trypanosoma brucei rhodesiense KETRI 2537 cells. On the seventh day postinfection (p.i.) in an early-stage infection, animals in groups 1, 2, and 3 were treated orally with pafuramidine at dose rates of 1, 3, or 10 mg/kg of body weight, respectively, for five consecutive days. The animals in groups 4 and 5 were treated with 10 mg/kg for 10 consecutive days starting on the 14th day p.i. (group 4) or on the 28th day p.i. (group 5), when these animals were in the late stage of the disease. In the groups treated in the early stage, 10 mg/kg of pafuramidine completely cured all three monkeys, whereas lower doses of 3 mg/kg and 1 mg/kg cured only one of three and zero of three monkeys, respectively. Treatment of late-stage infections resulted in cure rates of one of three (group 4) and zero of three (group 5) monkeys. These studies demonstrated that pafuramidine was orally active in monkeys with early-stage T. brucei rhodesiense infections at dose rates above 3 mg/kg for 5 days. It was also evident that the drug attained only minimal efficacy against late-stage infections, indicating the limited ability of the molecule to cross the blood-brain barrier. This study has shown that oral diamidines have potential for the treatment of early-stage sleeping sickness.

Survival of Trypanosoma brucei in the tsetse fly is enhanced by the expression of specific forms of procyclin.

African trypanosomes are not passively transmitted, but they undergo several rounds of differentiation and proliferation within their intermediate host, the tsetse fly. At each stage, the survival and successful replication of the parasites improve their chances of continuing the life cycle, but little is known about specific molecules that contribute to these processes. Procyclins are the major surface glycoproteins of the insect forms of Trypanosoma brucei. Six genes encode proteins with extensive glutamic acid-proline dipeptide repeats (EP in the single-letter amino acid code), and two genes encode proteins with an internal pentapeptide repeat (GPEET). To study the function of procyclins, we have generated mutants that have no EP genes and only one copy of GPEET. This last gene could not be replaced by EP procyclins, and could only be deleted once a second GPEET copy was introduced into another locus. The EP knockouts are morphologically indistinguishable from the parental strain, but their ability to establish a heavy infection in the insect midgut is severely compromised; this phenotype can be reversed by the reintroduction of a single, highly expressed EP gene. These results suggest that the two types of procyclin have different roles, and that the EP form, while not required in culture, is important for survival in the fly.

Lymphocytes of the toad Xenopus laevis have the gene set for promoting tadpole development.

Nuclear transplantation experiments show that differentiated cells, such as lymphocytes, from the adult frog can express the genes necessary for tadpole development. The transplanted cells were proven to be lymphocytes by immunological methods. The origin of the tadpoles that developed after lymphocyte nuclei injections was ascertained by a karyotypic marker.

Plasmodium berghei ANKA: selection of resistance to piperaquine and lumefantrine in a mouse model.

We have selected piperaquine (PQ) and lumefantrine (LM) resistant Plasmodium berghei ANKA parasite lines in mice by drug pressure. Effective doses that reduce parasitaemia by 90% (ED(90)) of PQ and LM against the parent line were 3.52 and 3.93 mg/kg, respectively. After drug pressure (more than 27 passages), the selected parasite lines had PQ and LM resistance indexes (I(90)) [ED(90) of resistant line/ED(90) of parent line] of 68.86 and 63.55, respectively. After growing them in the absence of drug for 10 passages and cryo-preserving them at -80 degrees C for at least 2 months, the resistance phenotypes remained stable. Cross-resistance studies showed that the PQ-resistant line was highly resistant to LM, while the LM-resistant line remained sensitive to PQ. Thus, if the mechanism of resistance is similar in P. berghei and Plasmodium falciparum, the use of LM (as part of Coartem) should not select for PQ resistance.

Lymphoepithelioma-like carcinoma of the urinary bladder in a cow associated with bovine papillomavirus type-2.

Lymphoepithelioma-like carcinoma (LELCA) of the urinary bladder is reported in a 7-year-old cow that had grazed pasture rich in bracken fern and had suffered from severe intermittent haematuria from 3 to 4 years of age. On necropsy examination there were multiple haemorrhagic foci scattered over the mucosal surface of the urinary bladder. Microscopically there were nests, cords and sheets of neoplastic cells infiltrating the lamina propria and muscularis propria. These had a syncytial appearance with ill-defined cytoplasmic borders, large nuclei and prominent nucleoli. There was a prominent associated inflammatory infiltrate comprising lymphocytes and plasma cells with sparse histiocytes and granulocytes. Immunohistochemically, LELCA cells expressed cytokeratin but not vimentin. The LELCA was focally admixed with a concomitant papillary high-grade carcinoma that also infiltrated the lamina propria. A diffuse carcinoma in situ was also present. Bovine papillomavirus type-2 (BPV-2) DNA was amplified from frozen neoplastic tissue and from selected areas of formalin-fixed, paraffin wax-embedded tissue obtained by laser capture microdissection. Microbiological culture of a urine sample resulted in isolation of Weeksella virosa, Rhizobium radiobacter and Staphylococcus warneri. Flow cytometric analysis performed on blood mononuclear cells revealed down-regulation of a panel of markers including CD3, CD4, CD8alpha, CD45, MHC class I and MHC class II (HLA-DRalpha, HLA-DQ, HLA-DP). This report extends the spectrum of neoplastic urothelial lesions described in cattle and provides further evidence that some features of these tumours are similar to human counterparts.

Small bowel fed response as measured by wireless motility capsule: Comparative analysis in healthy, gastroparetic, and constipated subjects.

BACKGROUND: Small bowel fed response is an increased contractile activity pattern following the ingestion of a meal. Postprandial motility is traditionally evaluated using small bowel manometry. Wireless motility capsule (WMC) is an ingestible wireless capsule that measures pH, temperature, and intraluminal pressure. The primary aim of the study was to assess small bowel fed response captured with the non-invasive WMC. The secondary aim was to compare the fed response patterns between healthy subjects and patients with motility disorders of gastroparesis and constipation. METHODS: All subjects had 250 cc Ensure® meal 6 hours after WMC ingestion. Frequency of contractions (Ct), area under the curve (AUC), and motility index (MI) were analyzed during 30 minutes of pre-prandial baseline and 60 minutes postprandially in 20-minute windows. KEY RESULTS: One hundred and eighty-eight subjects (107 healthy, 23 gastroparetics, 58 constipated) were analyzed. Healthy: Ct, AUC, and MI all increased significantly immediately after meal ingestion (P < .01). Motility parameters peak at 20-40 minutes postmeal. The motor activity decreased at the end of postprandial hour, but was still significantly higher than the fasting baseline (P < .01). Gastroparetics: All motility parameters failed to increase significantly compared to the baseline throughout the entire postprandial hour. Constipated: The fed response was similar to healthy subjects. CONCLUSIONS AND INFERENCES: The small bowel fed response was readily observed in healthy and chronic constipation subjects with WMC but is blunted in gastroparetics. A blunted small bowel fed response suggests neuropathic changes outside the stomach and may contribute to postprandial symptoms.

Isothermal microcalorimetry - A quantitative method to monitor Trypanosoma congolense growth and growth inhibition by trypanocidal drugs in real time.

Trypanosoma congolense is a protozoan parasite that is transmitted by tsetse flies, causing African Animal Trypanosomiasis, also known as Nagana, in sub-Saharan Africa. Nagana is a fatal disease of livestock that causes severe economic losses. Two drugs are available, diminazene and isometamidium, yet successful treatment is jeopardized by drug resistant T. congolense. Isothermal microcalorimetry is a highly sensitive tool that can be used to study growth of the extracellular T. congolense parasites or to study parasite growth inhibition after the addition of antitrypanosomal drugs. Time of drug action and time to kill can be quantified in a simple way by real time heat flow measurements. We established a robust protocol for the microcalorimetric studies of T. congolense and developed mathematical computations in R to calculate different parameters related to growth and the kinetics of drug action. We demonstrate the feasibility and benefit of the method exemplary with the two standard drugs, diminazene aceturate and isometamidium chloride. The method and the mathematical approach can be translated to study other pathogenic or non-pathogenic cells if they are metabolically active and grow under axenic conditions.

Human African trypanosomiasis: pharmacological re-engagement with a neglected disease.

This review discusses the challenges of chemotherapy for human African trypanosomiasis (HAT). The few drugs registered for use against the disease are unsatisfactory for a number of reasons. HAT has two stages. In stage 1 the parasites proliferate in the haemolymphatic system. In stage 2 they invade the central nervous system and brain provoking progressive neurological dysfunction leading to symptoms that include the disrupted sleep wake patterns that give HAT its more common name of sleeping sickness. Targeting drugs to the central nervous system offers many challenges. However, it is the cost of drug development for diseases like HAT, that afflict exclusively people of the world's poorest populations, that has been the principal barrier to new drug development and has led to them becoming neglected. Here we review drugs currently registered for HAT, and also discuss the few compounds progressing through clinical trials. Finally we report on new initiatives that might allow progress to be made in developing new and satisfactory drugs for this terrible disease.

Factor C*, the specific initiation component of the mouse RNA polymerase I holoenzyme, is inactivated early in the transcription process.

Factor C* is the component of the RNA polymerase I holoenzyme (factor C) that allows specific transcriptional initiation on a factor D (SL1)- and UBF-activated rRNA gene promoter. The in vitro transcriptional capacity of a preincubated rDNA promoter complex becomes exhausted very rapidly upon initiation of transcription. This is due to the rapid depletion of C* activity. In contrast, C* activity is not unstable in the absence of transcription, even in the presence of nucleoside triphosphates (NTPs). By using 3'dNTPs to specifically halt elongation, C* is seen to remain active through transcription complex assembly, initiation, and the first approximately 37 nucleotides of elongation, but it is inactivated before synthesis proceeds beyond approximately 40 nucleotides. When elongation is halted before this critical distance, the C* remains active and on that template complex, greatly extending the kinetics of transcription and generating manyfold more transcripts than would have been synthesized if elongation had proceeded past the critical distance where C* is inactivated. In complementary in vivo analysis under conditions where C* activity is not replenished, C* activity becomes depleted from cells, but this also occurs only when there is ongoing rDNA transcription. Thus, both in vitro and in vivo, the specific initiation-conferring component of the RNA polymerase I holoenzyme is used stoichiometrically in the transcription process.

Establishment of a panel of reference Trypanosoma evansi and Trypanosoma equiperdum strains for drug screening.

The animal pathogenic protozoan, Trypanosoma evansi, leads to a wasting disease in equines, cattle and camels, commonly known as Surra. It is extensively distributed geographically with a wide range of mammalian hosts and causes great economical loss. Trypanosoma equiperdum causes a venereal disease called Dourine in horses and donkeys. Chemotherapy appears to be the most effective form of control for T. evansi, whereas infections caused by T. equiperdum are considered incurable. Due to emerging drug resistance, efficient control of T. evansi is severely threatened, emphasising the urgent need to find new alternative drugs. A drug profile for a panel of T. evansi and T. equiperdum strains has been established for the four standard drugs currently used in treatment. The (3)H-hypoxanthine incorporation assay was used to obtain 50% inhibitory concentration (IC(50)) values for each standard drug against the various strains. The results indicate the presence (and in some cases, the emergence) of drug resistance in several strains. This panel of characterised strains with known drug sensitivities and resistances will be of great value for the screening of new active compounds, in comparison with the four standard drugs currently available.

In vitro and in vivo evaluation of the antitrypanosomal activity of fractions of Holarrhena africana.

The aqueous extract of young leaves of Holarrhena africana, a plant used in the Nigerian traditional medicine, exhibited good activity against Trypanosoma brucei spp. The extract was fractionated and eight fractions were obtained. One fraction designated as HaF(5) showed in vitro activity against Trypanosoma brucei rhodesiense with an IC(50) value of 0.785 microg/mg and no overt cytotoxicity against L-6 cells. Fraction HaF(5) was tested in vivo at two doses and found to exhibit in vivo efficacy in Trypanosoma brucei brucei infected mice leading to a complete disappearance of parasitaemia followed by a relapse.

Comparison of the in vitro drug sensitivity of Trypanosoma brucei gambiense strains from West and Central Africa isolated in the periods 1960-1995 and 1999-2004.

The situation of human African trypanosomiasis remains serious with one of the main threats being the increasing number of relapses or treatment failures after melarsoprol treatment. In order to investigate and to compare drug sensitivities of trypanosomes isolated at different time periods and in different locations, two sets of Trypanosoma brucei gambiense strains were used. One set was isolated in the time period 1960-1981 and the other one in 1995-2004 from different locations of West and Central Africa. These isolates were not selected based on the treatment outcome but on availability. The drug sensitivity profile for all available drugs in use and the diamidine compound DB75 was established. IC(50) values were not significantly different between the "old" and "new" stocks. No indications for emerging drug resistance to any drug could be observed. The results indicate a relative stability of in vitro sensitivity of T. b. gambiense to trypanocidal drugs in space (West and Central Africa) and time (1960-2004).

Synthesis of new esters and oximes with 4-aminobicyclo[2.2.2]octane structure and evaluation of their antitrypanosomal and antiplasmodial activities.

New 4-amino-6,7-diphenylbicyclo[2.2.2]octane derivatives, esters of bicyclo[2.2.2]octan-2-ols and O-methyl oximes of bicyclo[2.2.2]octan-2-ones were synthesised. Their activities against Trypanosoma brucei rhodesiense (STIB 900) and their activity against the K1 strain of Plasmodium falciparum (resistant to chloroquine and pyrimethamine) were determined by use of microplate assays. The cytotoxicity was assessed using L6 cells. The antiprotozoal activities of the new compounds are compared with those of former prepared derivatives and drugs in use. Structure-activity relationships are discussed.

Clinical and serologic responses to human 'apathogenic' trypanosomes.

We describe a female patient suffering from a benign self-healing febrile disease with strongly positive serology for Trypanosoma brucei. The patient showed a clinical picture with similarities to that of human African trypanosomiasis (HAT). HAT due to T. b. gambiense and T. b. rhodesiense were ruled out. We performed serologic tests because the patient was worried about HAT after receiving tsetse bites. The possibilities of an infection with human 'apathogenic' trypanosomes such as T. b. brucei, T. congolense or T. vivax are discussed.

PPAR gamma and the control of adipogenesis.

We recently cloned PPAR gamma as a factor that binds to an enhancer which has specificity for adipose cells. When expressed ectopically, PPAR gamma converts fibroblasts into bona fide preadipose cells. Upon application of activators or PPAR gamma ligands, these cells differentiate into fat cells. Most recently, we have been trying to understand the nature of natural ligands that activate PPAR gamma and the protein domains that control adipogenesis. With regards to ligands, we have shown that an unusual prostanoid, 15-deoxy delta 12,14PG J2, can bind to PPAR gamma and activate it. A second transcription factor that is induced early in differentiation, ADD1/SREBP1, appears to promote the formation of PPAR gamma ligands. Transfection of this molecule, a member of the bHLH family, causes the secretion of molecules that can serve as ligands for PPAR gamma. This ligand-like activity is specific for the gamma isoform of PPAR. Current studies are attempting to identify these potentially novel ligands. With regard to structure-function of PPAR gamma, we first analyzed the adipogenic activity of the three isoforms of PPAR: alpha, gamma and delta. Using appropriate activators of each it is clear that PPAR gamma has the most adipogenic action. PPAR alpha can be adipogenic with high levels of the strongest activators and PPAR delta does not stimulate fat cell differentiation. To identify the domain(s) of PPAR gamma responsible for differentiation, chimeras between PPAR gamma and PPAR delta were created and transfected into fibroblasts. This has allowed the isolation of relatively small regions of this molecule that are responsible for differentiation.

Pyrazolopyrimidine metabolism in African trypanosomes: metabolic similarities to Trypanosoma cruzi and Leishmania spp.

Growth inhibition and radioisotope incorporation studies with allopurinol (4-hydroxypyrazolo(3,4-d)pyrimidine) have shown that the African trypanosomes are biologically and biochemically similar to Leishmania spp. and Trypanosoma cruzi with respect to their response to this compound. These organisms, as a group, share the unique ability to convert allopurinol sequentially to its ribonucleoside monophosphate and 4-aminopyrazolo(3,4-d)pyrimidine ribonucleoside mono-, di- and triphosphates.