Multicentre prospective observational study on professional wound care using honey (Medihoney™).

In recent years, the treatment of wounds with honey has received an increasing amount of attention from healthcare professionals in Germany and Austria. We conducted a prospective observational multicentre study using Medihoney™ dressings in 10 hospitals - nine in Germany and one in Austria. Wound-associated parameters were monitored systematically at least three times in all patients. Data derived from the treatment of 121 wounds of various aetiologies over a period of 2 years were analysed. Almost half of the patients were younger than 18 years old, and 32% of the study population was oncology patients. Overall, wound size decreased significantly during the study period and many wounds healed after relatively short time periods. Similarly, perceived pain levels decreased significantly, and the wounds showed noticeably less slough/necrosis. In general, our findings show honey to be an effective and feasible treatment option for professional wound care. In addition, our study showed a relationship between pain and slough/necrosis at the time of recruitment and during wound healing. Future comparative trials are still needed to evaluate the extent to which the positive observations made in this and other studies can definitely be attributed to the effects of honey in wound care.

Induction of IL-6 within the rodent intestinal muscularis after intestinal surgical stress.

BACKGROUND: Postoperative ileus is a poorly understood surgical problem characterized by leukocyte extravasation into the intestinal muscularis and suppression in muscle function. The study objective was to delineate a mechanistic inflammatory cascade initiated by intestinal manipulation. METHODS: ACI and Sprague-Dawley rats, and IL-6 +/+ and IL-6 -/- mice were subjected to intestinal manipulation. One group of rats received adhesion molecule-blocking antibodies (1A29 and WT.3) before intestinal manipulation. Interleukin-6 (IL-6) messenger RNA (mRNA) levels and electrophoretic mobility shift assay for signal transducers and activators of transcription (STAT) activation were measured in tissue extracts. IL-6 protein levels were assessed by immunohistochemistry and enzyme-linked immunosorbent assay. RESULTS: IL-6 mRNA from muscularis extracts demonstrated a significant induction after intestinal manipulation. No IL-6 induction was observed in mucosal extracts. Adhesion molecule blockade resulted in a marked decrease of cellular infiltration but did not change IL-6 mRNA expression in muscularis extracts. Resident macrophages in the muscularis stained for IL-6 by immunohistochemistry after intestinal manipulation. The isolated manipulated muscularis demonstrated a significant increase in IL-6 release. Electrophoretic mobility shift assay of manipulated muscularis showed a marked increase in IL-6-dependent Stat3 activation. CONCLUSIONS: This study demonstrates that manipulation of the small bowel during an abdominal operation initiates downstream induction, translation, release, and functional activity of IL-6 within the muscularis.

Protective effects of ex vivo graft radiation and tacrolimus on syngeneic transplanted rat small bowel motility.

BACKGROUND: Intestinal transplantation is unduly complicated by the nontolerogenic properties of the gut-associated lymphoid tissue. Because simultaneous graft irradiation and bone marrow infusion significantly prolong the survival of the small bowel transplanted animal, our objective was to determine the functional motility effects of the immune modulating, graft irradiation procedure in the presence and absence of tacrolimus immunosuppression. METHODS: Four groups of syngeneic orthotopic small bowel transplanted animals were studied 48 hours after operations (untreated, tacrolimus, ex vivo graft irradiation, and tacrolimus + irradiation) and compared with controls. Histologic analysis was performed for mucosal apoptosis and neutrophilic infiltration into the muscularis externa. Gastrointestinal in vivo transit and in vitro circular muscle strip contractions were quantified in response to bethanechol (0.3-300 micromol/L). RESULTS: Graft irradiation ex vivo alone or in the presence of tacrolimus significantly increases (> 10-fold) the number of apoptotic mucosal cells after transplantation. Functional measurements showed that transplantation resulted in a significant delay in gastrointestinal transit and a decrease in muscle strip contractility. Tacrolimus and graft irradiation significantly ameliorated the transplant-induced dysfunction. CONCLUSIONS: Given the endowed propensity of mucosal regeneration, the immunologic and functional benefits of ex vivo graft irradiation appear to outweigh the detrimental effects to the mucosa.

KRAS, NRAS, PIK3CA exon 20, and BRAF genotypes in synchronous and metachronous primary colorectal cancers diagnostic and therapeutic implications.

Targeted therapy of advanced colorectal carcinoma (CRC) necessitates KRAS genotyping. Because we were interested in diagnostic and therapeutic consequences, we studied the KRAS, NRAS, PIK3CA exon 20, and BRAF genotypes in synchronous and metachronous primary CRCs; in addition, we studied their available metastases. We studied 21 patients with 43 synchronous and 2 metachronous adenocarcinomas of the colorectum (n = 20) and stomach (n = 1). Five patients had liver metastases and one had a distant lymph node metastasis. Genomic DNA was extracted from microdissected tumor tissue. The DNA was analyzed by Sanger sequencing and pyrosequencing. Fifty-seven different neoplastic lesions were genotyped, showing 18 (31.6%) KRAS, 2 (3.5%) NRAS, and 7 (12.3%) BRAF mutations, distributed among 10 (47.6%), 1 (4.8%), and 5 (23.8%) of the patients. An identical genotype of all synchronous primary CRCs was found only in 7 (35%) of the patients; the remainder had dissimilar genotypes in various combinations. Interestingly, a single patient had an unknown KRAS genotype (c.37_39dupGGC). Six patients with 13 primary carcinomas had distant metastases. In three of these patients, the metastasis shared the genotype only with one of the primary tumors, because the other primary tumors had another genotype. Synchronous and metachronous primary CRCs of the same patient have variable KRAS, NRAS, and BRAF genotypes. When metastases occur in these patients, the genotype has diagnostic and therapeutic implications and should be determined from the simultaneous or metachronous distant metastases.

Cohort study based on the seventh edition of the TNM classification for gastric cancer: proposal of a new staging system.

PURPOSE: We investigated the effect of the new TNM classification on gastric cancer staging. PATIENTS AND METHODS: From hospital records, information from patients with gastric cancer, who had undergone either total or partial gastrectomy for adenocarcinomas of the stomach or esophagogastric junction, was retrieved. The pathologic TNM stage was determined according to the sixth and seventh editions of the International Union Against Cancer guidelines and was based on surgical pathologic examination. RESULTS: Five hundred fifty-four patients (338 men and 216 women; median age, 68 years) had undergone partial or complete gastrectomy for intestinal (n = 209) or diffuse (n = 249) adenocarcinoma of the esophagogastric junction and stomach. Survival data and date of death were available for all patients. Patient death correlated significantly with age at diagnosis, tumor type, histologic grade, local tumor growth (T category), number of metastatic lymph nodes, lymph node ratio, lymph node status (N category), and tumor stage. No major difference was noted between the sixth and seventh editions of the TNM classification. On the basis of survival data, we revised the stage grouping system; stage I and II tumors were confined to nonmetastatic tumors, and stage III and IV tumors were confined to metastatic tumors. The Kaplan-Meier plots of this modified stage grouping showed statistically significant differences between individual stage subgroups without crossing curves and demonstrated improved survival of patients with stage II disease. CONCLUSION: The seventh edition of the TNM classification is associated with a stage migration in 60% of patients with esophagogastric and stomach cancer. This change did not improve the assessment of patient prognosis, and therefore, a revised staging system is proposed.

Bacterial toxin N-formyl-methionyl-leucyl-phenylalanine acutely contracts human and rabbit detrusor through the release of eicosanoids.

PURPOSE: Uropathogenic bacteria that secrete N-formylmethionyl oligopeptides such as N-formyl-methionyl-leucyl-phenylalanine (f-MLP) are a common cause of urinary tract infections. We determined the in vitro effects of f-MLP on human and rabbit detrusor as well as its mechanism and site of action. MATERIALS AND METHODS: Reverse transcriptase-polymerase chain reaction was used to investigate cyclooxygenase-2 messenger RNA within the rabbit detrusor. Standard mechanical organ bath recording techniques were used to measure contractile activity from rabbit and human detrusor muscle strips. Immunohistochemistry was performed using macrophage specific antibodies (human BerMAC3 and rabbit RAM11) on detrusor whole mount specimens. RESULTS: Muscle activity recorded from human and rabbit detrusor showed that f-MLP caused contracture of the detrusor, which was completely blocked by indomethacin and partially blocked by individual cyclooxygenase-1 and cyclooxygenase-2 selective inhibitors. Exposure of the detrusor to exogenous prostaglandins indicated that f-MLP released an effective concentration of more than 1 microM. from an endogenous source. Immunohistochemical staining of the human (BerMAC3) and rabbit (RAM11) bladder demonstrated a dense network of resident macrophages lying within the detrusor muscle bundles, which are known to secrete prostaglandins during the activation of specific f-MLP receptors. CONCLUSIONS: Bacterial derived f-MLP contracts the detrusor through the release of eicosanoids from resident macrophages. These data suggest that bacterial activation of the resident macrophage network could participate in causing the symptoms of bacterial cystitis.

Ileus in critical illness: mechanisms and management.

Nonobstructive ileus, signifying the impairment of coordinated propulsive intestinal motility, remains a frequently documented and almost inevitable consequence of open abdominal surgery and sepsis. Despite the frequency and major impact of ileus on morbidity and mortality, the exact underlying molecular and cellular mechanisms of this important clinical conundrum are still ill defined. Animal models suggest that both neuronal and local inflammatory responses within the intestinal muscularis mechanistically contribute to intestinal ileus. The neuronal mechanism appears to involve the enhanced release of nitric oxide from inhibitory motor neurons. Likewise, nitric oxide and prostaglandins are released from inflammatory cells (macrophages and monocytes) via the induction of nitric oxide synthase (iNOS) and cyclooxygenase-2. Recently, preliminary data have confirmed the existence of an intraoperative local muscularis inflammatory response during surgery in human patients.

MCP-1 causes leukocyte recruitment and subsequently endotoxemic ileus in rat.

Endotoxemia causes an inflammatory response within the intestinal muscularis and gastrointestinal dysmotility. We hypothesize that the resident macrophage-derived chemokine monocyte chemoattractant protein-1 (MCP-1) plays a significant role in the recruitment of leukocytes into the lipopolysaccharide (LPS)-stimulated rat intestinal muscularis. MCP-1 mRNA expression was investigated by RT-PCR. Leukocyte extravasation and MCP-1 protein localization were determined by immunohistochemistry. Contractile activity was assessed by using a standard organ bath in rats that were treated with saline, recombinant MCP-1, LPS, LPS + nonspecific antibody, or LPS + MCP-1 antibody. Endotoxemia caused a significant 280-fold increase in MCP-1 mRNA expression in the muscularis, peaking at 3 h. MCP-1 protein was immunohistochemically located to muscularis macrophages. LPS application caused significant leukocyte recruitment into the muscularis and a 51% decrease in muscle contractility. MCP-1 antibody treatment significantly averted leukocyte recruitment and significantly prevented muscle dysfunction. These parameters were not significantly altered by the nonspecific antibody. Results show that resident muscularis macrophage-derived MCP-1 plays a major role in the recruitment of monocytes during endotoxemia, which then subsequently secrete kinetically active substances that cause ileus.

Pathogenesis of paralytic ileus: intestinal manipulation opens a transient pathway between the intestinal lumen and the leukocytic infiltrate of the jejunal muscularis.

OBJECTIVE: To investigate the existence of a pathway between intraluminal products and the muscularis leukocytic infiltrate. SUMMARY BACKGROUND DATA: Mild intestinal manipulation or lipopolysaccharide initiates an intense inflammatory response within the intestinal muscularis, resulting in paralytic ileus. A major potential morbidity factor in ileus is luminal bacterial overgrowth. METHODS: ACI rats were subjected to small bowel manipulation, after which fluorescent carboxylated or paramagnetic microspheres were administered into the gut lumen. Animals were killed between 0 and 24 hours; unoperated rats served as controls. RESULTS: Intestinal manipulation led to an early transient transference of microspheres from the intestinal lumen into mesenteric lymph that was not observed in unmanipulated controls. A time- dependent, significant increase in microsphere-laden phagocytes was observed within the intestinal muscularis. Immunohistochemistry and electron microscopy of the intestinal muscularis identified the phagocytes as extravasating ED1+ monocytes. Interruption of the lymphatics abolished the accumulation of microsphere-laden monocytes within the muscularis, although a significant monocytic recruitment could still be observed within the intestinal muscularis. CONCLUSIONS: These data show that intestinal manipulation leads to a transient increase in mucosal permeability and that the extraintestinal endocytotic uptake of transferred particles by circulating monocytes precedes their infiltration into the gut wall. The transference of luminal bacterial products may follow a similar route and time course as the microspheres. The authors hypothesize that endogenous bacterial products act synergistically with the inflammatory response within the postsurgical intestinal muscularis, leading to an exacerbation of postoperative ileus.

Lipopolysaccharide preconditioning and cross-tolerance: the induction of protective mechanisms for rat intestinal ileus.

BACKGROUND & AIMS: Endotoxin elicits an inflammatory response within the intestinal muscularis and causes intestinal muscle dysfunction. Our aims were to investigate intestinal muscle recovery after a single or repeated lipopolysaccharide (LPS) injections. We also investigated the ability of LPS to induce cross-tolerance to postoperative ileus. METHODS: Motility was measured in vivo and in vitro by transit and organ-bath techniques. Nuclear factor kappa-B, nuclear factor interleukin 6, and signal transducer and activator of transcription were quantified by using electrophoretic mobility shift assay, and tumor necrosis factor alpha, interleukin 6, inducible nitric oxide synthase, and cyclooxygenase 2 were measured with reverse-transcription polymerase chain reaction. Myeloperoxidase histochemistry for neutrophils was performed in jejunal muscularis whole mounts. RESULTS: Endotoxin-induced suppression of in vitro muscle contractility temporally recovered over 7 days with a similar profile whether after a single dose or during the continuous daily injection of LPS. Functional adaptation to continuous LPS was reflected in a significant blunting of transcription factor activation and cytokine messenger RNA up-regulation compared with the naive LPS-stimulated muscularis. Preconditioning of the muscularis showed significant cross-tolerance to the functional, molecular, and leukocytic sequelae of intestinal manipulation. CONCLUSIONS: The muscularis externa recovered and developed tolerance to endotoxin over 7 days, which conferred cross-tolerance to intestinal manipulation. Thus, preconditioning induces protective mechanisms to a subsequent insult within the muscularis externa.

Selective jejunal manipulation causes postoperative pan-enteric inflammation and dysmotility.

BACKGROUND AND AIMS: Small bowel manipulation initiates an intense molecular and cellular inflammatory response within the jejunal muscularis, which causes ileus. The current objective was to investigate pan-enteric inflammatory molecular and functional motility alterations of the muscularis from the unmanipulated stomach and colon initiated by selective jejunal manipulation. METHODS: Rat jejunum was manipulated, and animals sacrificed between 0-24 hours. In vivo gastric emptying, gastrointestinal transit, and in vitro colonic circular muscle recordings were measured. Reverse-transcriptase polymerase chain reaction (RT-PCR) and electromobility shift assay (EMSA) of gastric, jejunal, and colonic muscularis extracts were performed. Whole mounts were histochemically stained for myeloperoxidase leukocytes. RESULTS: Surgical manipulation suppressed jejunal contractions that were significantly prevented by dexamethasone pretreatment. Selective jejunal manipulation also suppressed in vivo gastric emptying, gastrointestinal transit, and in vitro colonic circular muscle contractility. Nuclear factor interleukin-6 (NF-IL-6) was activated within the gastric and colonic muscularis. RT-PCR showed a 14.9-, 8.1-, and 11.4-fold up-regulation of IL-6 messenger RNA within the jejunal, gastric, and colonic muscularis, respectively. EMSA showed a 30.6-, 14.2-, and 20.8-fold increased activation of signal transducer and activator of transcription (STAT) proteins in jejunal, gastric, and colonic muscularis extracts, respectively. Tumor necrosis factor-alpha, cyclooxygenase-2, and inducible nitric oxide synthase showed a significant up-regulation in the manipulated jejunum, as well as the unmanipulated gastric and colonic muscularis. Neutrophils were significantly recruited into all gastrointestinal regions. CONCLUSION: Selective small bowel manipulation leads to a molecular, cellular, and functional pan-enteric "field effect" phenomenon in the unmanipulated gastric and colonic muscularis.

Intra-abdominal activation of a local inflammatory response within the human muscularis externa during laparotomy.

OBJECTIVE: To investigate the initiation of a complex inflammatory response within the human intestinal muscularis intraoperatively so as to determine the clinical applicability of the inflammatory hypothesis of postoperative ileus. SUMMARY BACKGROUND DATA: Mild intestinal manipulation in rodents initiates the activation of transcription factors, upregulates proinflammatory cytokines, and increases the release of kinetically active mediators (nitric oxide and prostaglandins), all of which results in the recruitment of leukocytes and a suppression in motility (i.e., postoperative ileus). METHODS: Human small bowel specimens were harvested during abdominal procedures at various times after laparotomy. Histochemical and immunohistochemical techniques were applied to intestinal muscularis whole-mounts. Reverse transcriptase-polymerase chain reaction (RT-PCR) was performed for interleukin (IL)-6, IL-1beta, tumor necrosis factor (TNF)-alpha, inducible nitric oxide synthase (iNOS), and cyclooxygenase-2 (COX-2). Signal transducers and activators of transcription (STAT) protein phosphorylation was determined by electromobility shift assay. Organ bath experiments were performed on jejunal circular smooth muscle strips. GW274150C and DFU were used in vitro as iNOS and COX-2 inhibitors. RESULTS: Normal human muscularis externa contained numerous macrophages that expressed increased lymphocyte function associated antigen-1 (LFA-1) immunoreactivity as a function of intraoperative time. RT-PCR demonstrated a time-dependent induction of IL-6, IL-1beta, TNF-alpha, iNOS, and COX-2 mRNAs within muscularis extracts after incision. Mediators were localized to macrophages with STAT protein activation in protein extracts demonstrating local IL-6 functional activity. DFU alone or in combination with GW274150C increased circular muscle contractility. Specimens harvested after reoperation developed leukocytic infiltrates and displayed diminished in vitro muscle contractility. CONCLUSIONS: These human data demonstrate that surgical trauma is followed by resident muscularis macrophage activation and the upregulation, release, and functional activity of proinflammatory cytokines and kinetically active mediators.