Good compliance to enhanced recovery program improves outcome after colorectal surgery.

AIM OF THE STUDY: The fast-track (FT) protocol consists of several measures to optimize physiologic response to the surgical stress and improve postoperative outcome. Our goal was to evaluate the compliance to our protocol and to analyze the effect of compliance to the FT protocol on postoperative outcome and postoperative hospital stay. We also aimed to identify isolated FT measures able to influence outcome. METHODS: This retrospective study involves a cohort of consecutive patients who underwent colorectal surgery within a FT protocol between 2007 and 2013. Beside basic demographics, adherence to protocol, postoperative complications, and postoperative hospital stay (POHS) were recorded. Both univariate and multivariate analyses were performed to determine the predictive value of the FT protocol compliance and of specific FT items on surgical outcome and POHS. RESULTS: There were 284 patients with a mean age of 58 years. Compliance to the FT protocol reached a median of 18 out of 19 items. The median hospital stay was 3 days (2-49). Overall complications rate was 34.9% and 7,4% when Dindo-Clavien classification > 2 was considered. Higher compliance to the FT protocol reduces the complication rate (p = 0.00004), severity of complication (p = 0.002), and POHS (p = < 0.00001). We have not been able to identify any specific isolated FT measure able to influence post-operative outcome. CONCLUSIONS: Greater adherence to the FT protocol decreases postoperative complications and POHS. Our data support a holistic effect of the FT protocol rather than specific isolated measures to improve the patient's postoperative outcome.

Clinical evidence for dorsal root ganglion stimulation in the treatment of chronic neuropathic pain. A review.

Treating chronic neuropathic pain remains a challenge, despite the existing therapies. Recent years have seen the emergence of promising new technologies, such as the neurostimulation of the dorsal root ganglion (DRG). In the present article, we review the clinical evidence for the efficacy and safety of DRG neurostimulation in the treatment of chronic pain. While the results from a number of small observational studies are promising, it is not yet possible to conclude on the long-term effectiveness and safety of DRG stimulation and it is too early to recommend its widespread use outside of a research protocol. To improve the level of proof, larger randomized controlled trials are needed. These should include well-described populations, a sufficiently long follow-up and a detailed description of concurrent treatments (pharmacologic and patient integration in a multidisciplinary approach).

Endovenous Laser Ablation of the Great Saphenous Vein with a 1470 nm Wavelength Laser : Results of a Prospective, Single Centre Cohort Study.

BACKGROUND: Endovenous laser ablation (EVLA) is a widely accepted treatment for venous insufficiency. Our aim was to report the standardised technique used in our centre and to evaluate the anatomic and clinical success rates. METHODS: All details of patients treated with EVLA were prospectively collected in a database. A standardized examination and surgical protocol was used, and every detail in the technique was registered. A follow-up visit was organised after 1 week and after 4-6 weeks with a duplex. RESULTS: A total of 441 limbs were treated in 366 patients using a 1470 nm wavelength laser with bare tip fiber -(Biolitec(®)). At 6 weeks postoperative a total obliteration of the vein was established in 98.62% of the cases with 78.67% of the patients free from complaints. No major complications were reported. Minor complaints were low (10.74% induration, 3.9% paresthesia). 93.11% reported no pain, 5.2% mentioned moderate pain. Mean duration of absence was equal or less than 1 week (65,28%). Satisfaction level was high (92.84%, level 10). CONCLUSIONS: EVLA of the GSV and the Anterior Accessory Vein (AAV) with a 1470 nm wavelength laser with bare tip fiber is a minimally invasive, safe and effective technique. We are convinced that every detail is important : tumescence technique, Trendelenburg position, no external compression, and the position of the vein in the fascial sheath. Further reduction of linear endovenous energy density (LEED) used for EVLA can improve the therapy. This is possible by using a new fiber tip design (radial optical fiber) and needs further investigation.

How to track and register adverse events and incidents related to gastrointestinal endoscopy.

Background and study aims: Gastrointestinal endoscopic procedures have evolved significantly in the last sixty years revolutionising the approach to the diagnostic and therapeutic spheres of medicine. Despite the advantages of using natural orifices to the bowel, adverse events (AE) may occur following endoscopy. Systematic AE registration is an objective in every realm of quality medicine. Despite the obvious advantage as a quality indicator, tracking endoscopy-related AE is not evident. The current study aimed at tracking all AE of all endoscopic procedures during a 3-month period. The three methods used were voluntary reporting by the endoscopist and by the patient in parallel with retrospective data analysis of patients' electronic medical records to allow capture of all AE and comparison of the three methods. Patients and methods: During a 3-month period endoscopists and patients were requested to report any possible AE. At the end of the period, a systematic review of all patient files was performed to track all AE related to the endoscopic procedure or the endoscopyrelated anaesthesia. In total 2668 endoscopic procedures were reviewed. Results: The total AE rate was 1.95%. Only half (51.9%) of all AE were voluntarily reported by endoscopists, the other half were extracted from the electronic medical record. There were no patient-reported AE. Although the majority (66.7%) of unreported AE were mild, these findings illustrate that voluntary AE reporting is unreliable. However, the retrospective tracking process proved to be difficult and time-consuming. Conclusions: The current study highlighted that systematic registration of all endoscopy-related AE is feasible, but challenging because of multiple hurdles. More practical methods are warranted to obtain reliable and long-term data as part of endoscopy quality measures.

Action of spontaneously produced beta interferon in differentiation of embryonal carcinoma cells through an autoinduction mechanism.

In the current study, we have addressed the role of interferons (IFNs) in controlling the differentiation of pluripotent P19 embryonal carcinoma (EC) cells. Blocking IFN activity in the culture medium of differentiating cells with antibodies leads to a strong decrease in the degree of differentiation. The antibodies are active for a relatively short time. During this time, IFN-beta mRNA can be detected in the differentiating cells, as can increases of IFN stimulation response element-binding activity and NF-KB. The timing of IFN action also coincides with the accumulation of cytoplasmic double-stranded RNA (dsRNA) and with a drop in dsRNA unwindase-modificase activity. A model for the involvement of autoinduction of IFN by intracellular dsRNA in the control of differentiation in this system is presented.

A multifactorial injury prevention intervention reduces injury incidence in Physical Education Teacher Education students.

Physical Education Teacher Education (PETE) students are at considerable risk for non-contact sports injuries of the lower extremities. Multifactorial injury prevention interventions including exercises have been successful in sports populations, but no such study has ever been performed in PETE students. This study investigated the efficacy of a multifactorial injury prevention intervention on injury incidence reduction in PETE students. PETE students in the intervention group (n = 154) and in the control group (n = 189) registered sports injuries prospectively. The intervention lasted one academic year and consisted of an injury awareness programme and preventive strategies, implemented by the PETE sports lecturers. Differences in injury incidence between the intervention and control group were tested by Poisson regression Wald tests. There was a trend towards significantly lower incidence rate (2.18 vs. 2.73; p = 0.061) in the intervention group compared with the control group. Students in the intervention group had significantly less acute, first-time and extracurricular injuries. The largest reduction was observed for injuries during unsupervised practice sessions. A multifactorial injury prevention intervention embedded into a regular PETE programme is a promising and feasible strategy to prevent injuries in PETE students. Further research is needed to investigate whether the results may be generalised to other PETE programmes.

Bax-alpha promotes apoptosis induced by cancer chemotherapy and accelerates the activation of caspase 3-like cysteine proteases in p53 double mutant B lymphoma Namalwa cells.

Stable transfected human p53 (mt/mt) B lymphoma Namalwa variant lines showing differential expression of the Bax-alpha protein were derived under hygromycin selection. Overexpression of Bax-alpha in these variant cells accelerates cell death induced by short or continuous treatments with various concentrations of camptothecin, etoposide, vinblastine and shows no accelerating cell death activity in cis-platinum and paclitaxel-treated cells. Activation of apoptosis and oligonucleosome-sized DNA fragmentation was observed in the variant lines with more pronounced effect in cells containing high level of Bax-alpha protein. These results suggest that increased cell death mediated by anticancer drugs correlates with Bax-alpha level of expression and that Bax-alpha sensitizes Namalwa cells treated at low drug concentrations. The extent of DNA synthesis inhibition following DNA topoisomerase inhibitor treatments was similar in control and all transfected Namalwa cells suggesting that Bax-alpha acts downstream of DNA topoisomerase-mediated DNA strand breaks. To define further the relation between Bax-alpha expression and apoptosis activation, kinetics of caspase activation was measured in drug-treated cells. Caspase activities were measured using specific fluorogenic peptide derivatives DABCYL-YVADAPV-EDANS and Ac-DEVD-AMC, substrates of the caspase 1-like and caspase 3-like families, respectively. In control and Bax-alpha transfected Namalwa cells no increase in caspase 1-like activity was detected following camptothecin and etoposide treatments. In contrast, a significant difference in Ac-DEVD-AMC hydrolysis activity was observed in Bax-alpha transfected Namalwa cells compared to that of control Namalwa cells after camptothecin and etoposide treatment. Increased caspase 3-like activity correlated also with poly(ADPribosyl) polymerase cleavage. Taken together, these results suggest that Bax-alpha sensitize B lymphoma cells to series of anticancer drugs and accelerates the activation of apoptotic protease cascade.

Basal expression of the gene (TIMP) encoding the murine tissue inhibitor of metalloproteinases is mediated through AP1- and CCAAT-binding factors.

In cultured murine fibroblasts, the TIMP gene (encoding tissue inhibitor of metalloproteinases) is transcribed constitutively, although at low levels. We have used a cell-free system in which nuclear extracts prepared from murine L cells support transcription from TIMP DNA templates in vitro. This system was used to study the role of cis-acting DNA sequences in the constitutive expression of TIMP. Sequences important for expression are located both 5' and 3' (in intron 1) to the major transcription start point and are required to obtain detectable levels of transcription. These regions are specifically recognized by murine nuclear factors and contain DNA motifs whose sequences closely resemble binding sites for known transcriptional activators. In particular, the data strongly suggest a role for CCAAT-binding factor(s) and AP1-binding factors in the basal transcription of TIMP.

Purification and polypeptide composition of corpora amylacea from aged human brain.

Corpora amylacea (CA) accumulation in the brain is a normal correlate of ageing. The presence of a small amount of protein in these polyglucosan bodies is a consistent finding, although the nature of this protein material remains unknown. Using sucrose gradient fractionation and density centrifugation on Percoll, a method was developed to obtain highly pure preparations of CA from human brain. The protein content of isolated CA was estimated to be approx. 4% of the total fraction by weight. SDS-PAGE analysis of CA fractions showed several polypeptide bands with molecular weights ranging from 24 to 133 kDa. Four of these bands with molecular weights of 133, 94, 42 and 24 kDa are more abundant. Thus, pure preparations of CA can be obtained that are suitable for protein analysis.

Structure of the gene coding for the mouse TRiC-P5 subunit of the cytosolic chaperonin TRiC.

TRiC is a cytoplasmic chaperonin involved in actin and tubulin folding. It is formed by six to nine different but related proteins of 52 to 65 kDa arranged in two hetero-oligomeric rings. We have cloned the gene coding for the mouse TRiC-P5 subunit (also called CCT gamma) using a XbaI-DraIII fragment of the mTRiC5 cDNA. The mouse genome contains one TRiC5 gene and one TRiC5 pseudogene located on chromosomes 3F and 5B, respectively. The 2-kb transcript of TRiC5 is encoded by 14 exons distributed within 25 kb of genomic DNA. The largest exon is 312 bp and the smallest exon is 51 bp. We have used primer extension to demonstrate multiple transcription start points for the TRiC5 gene. This is consistent with the lack of any obvious TATA box upstream of the transcription start points.

Bcl-xL modulates apoptosis induced by anticancer drugs and delays DEVDase and DNA fragmentation-promoting activities.

Using an episomal eucaryotic expression vector, we derived three stable transfected human leukemic U-937 variant lines showing differential expression of the Bcl-xL protein. Preventive effect of Bcl-xL on cell death induced by various concentrations of camptothecin (DNA topoisomerase I inhibitor; CPT) was observed in the three lines with most pronounced effect in cells containing the highest level of Bcl-xL expression. These results show that increased cell death protection by Bcl-xL is correlated with its level of expression. The extent of DNA strand break formation and DNA synthesis inhibition following CPT treatments was similar in control and transfected U-937 cells, suggesting that Bcl-xL acts downstream of CPT-DNA topoisomerase I-mediated DNA strand breaks. Modulation of cell death by Bcl-xL was also observed in cells treated with etoposide, vinblastine, paclitaxel, and cisplatinum (II) diammine dichloride. To define whether Bcl-xL functions downstream or upstream of apoptogenic proteolytic cascade activation, we compared kinetics of DNA fragmentation in treated cells with kinetics of caspase 1-like, caspase 3-like, and N-tosyl-L-phenylalanylchloromethyl ketone (TPCK)-sensitive activities. In CPT-treated U-937 cells, caspase 3-like and TPCK-sensitive activities promoting DNA fragmentation in a cell-free system were detected much more rapidly in extracts obtained from CPT-treated U-937 cells compared to those obtained from CPT-treated U-937-Bcl-xL variant cells. These results suggest that Bcl-xL delays their activation that correlates with the occurrence of DNA fragmentation. Addition of recombinant Bcl-xL in extracts containing DEVDase and TPCK-sensitive activities did not inhibit these activities, suggesting that Bcl-xL acts primarily upstream of their activation in the apoptotic process. Taken together, these results suggest that Bcl-xL is a primary checkpoint that can block or delay transmission of cell death signals emerging from DNA damage and prevents activation of an apoptogenic proteolytic cascade.

The Bcl-xL and Bax-alpha control points: modulation of apoptosis induced by cancer chemotherapy and relation to TPCK-sensitive protease and caspase activation.

Defective control of apoptosis appears to play a central role in the pathogenesis of human diseases including neoplasic, autoimmune, and neurodegenerative diseases. Conversely, cancer chemotherapy and ionizing radiation can induce cancer cell death by apoptosis, and deregulated apoptosis following cancer chemotherapy could define a new category of drug resistance mechanism. By understanding the role that some major regulators of apoptosis play either at the commitment or execution phases of cell death in a given tissue and pathology, we will be in a better position to design and explore new therapeutic modalities. The Ced-9 - Bcl-like and Ced-3 - Ice-like gene family products are intrinsic proteins regulating the decision of a cell to survive or die and executing part of the cell death process itself, respectively. Among the various Bcl-like proteins, the effects and functions of the Bcl-x and Bax proteins in controlling apoptosis induced by cancer chemotherapy have been studied recently. In human cancer variant cell lines showing differential expression of the Bcl-xL protein, a preventive effect of Bcl-xL on cell death induced by various cytotoxic drugs is observed, with greater effects in cells containing the highest level of Bcl-xL expression. Similarly, overexpression of Bax-alpha in cancer cell lines sensitizes these cells to some cancer chemotherapy compounds. Modulation of apoptosis either negatively by Bcl-xL or positively by Bax-alpha resides downstream of the primary mechanism of action of anticancer drugs, suggesting that they act primarily as intrinsic control points following cytotoxic drug injuries. An emerging family of Ced-3 - Ice like cysteine proteases (caspases) has been also identified and several studies have revealed their importance in executing the process of cell death. More recently, activation of a N-tosyl-L-phenylalanylchloromethyl ketone (TPCK)-sensitive pathway was also suggested to play an important role in apoptosis induction following cancer chemotherapy. Evidence obtained using a combination of assays including cell-free systems and enzyme activity assays now suggests that Bcl-xL and Bax-alpha control points function upstream of TPCK-sensitive protease and caspase activation. Bcl-xL delays and prevents activation of apoptotic protease cascades whereas Bax-alpha shows the opposite effect, accelerating their activation.

The CrmA- and TPCK-sensitive pathways that trigger oligonucleosome-sized DNA fragmentation in camptothecin-induced apoptosis: relation to caspase activation and high molecular weight DNA fragmentation.

Abstract: In human B lymphoma Namalwa variant cells expressing the serpin-like CrmA protein, the kinetics of oligonucleosome-sized DNA fragmentation was retarded compared with that of control Namalwa cells following camptothecin treatment. However, no difference in the kinetics of high molecular weight DNA fragmentation was observed between the two lines after camptothecin treatment. Similar delay and inhibition of the oligonucleosome-sized DNA fragmentation was observed in human B lymphoma Namalwa and monocytic-like leukemia U-937 cells coincubated in the presence of various concentrations of N-tosyl-L-phenylalanyl chloromethylketone and camptothecin. The effect of N-tosyl-L-phenylalanyl chloromethylketone was similar to that of CrmA and did not prevent the appearance of high molecular weight DNA fragments. Similar suppression of camptothecin-induced internucleosomal DNA fragmentation was also observed in a cell-free system when cytosolic extracts obtained from camptothecin-treated Namalwa and U-937 cells were coincubated with untreated nuclei in the presence of N-tosyl-L-phenylalanyl chloromethylketone. Furthermore, N-tosyl-L-phenylalanyl chloromethylketone had no significant effects on caspase-3-like activities in camptothecin-treated Namalwa and U-937 cells. Hydrolysis of Ac-Asp-Glu-Val-Asp-amino-4-methylcoumarin, a fluorogenic substrate with caspase-3-like activities, was detected in extracts prepared from camptothecin-treated Namalwa and U-937 cells with no apparent difference in the time courses of caspase-3-like activation in the absence or presence of N-tosyl-L-phenylalanyl chloromethylketone. Similarly, N-tosyl-L-phenylalanyl chloromethylketone was a weak inhibitor of caspase-3-like activities in vitro. Taken together, these observations suggest that the pathway sensitive to N-tosyl-L-phenylalanyl chloromethylketone is involved in camptothecin-induced oligonucleosome-sized DNA fragmentation. Furthermore, inhibition of this pathway had no effect on caspase-3-like activation and on the occurrence of high molecular weight DNA fragmentation.