Is the Use of a Support Bridge Beneficial for Preventing Stomal Retraction After Loop Ileostomy? A Prospective Nonrandomized Study.

PURPOSE: A temporary defunctioning loop ileostomy is frequently created during low colorectal or coloanal anastomosis to prevent peritoneal sepsis associated with anastomotic leakage. We investigated whether routine support bridge placement prevents stoma retraction after the formation of a loop ileostomy. DESIGN: Prospective, nonrandomized trial. SUBJECTS AND SETTING: The study sample comprised 32 consecutive patients who underwent defunctioning loop ileostomy at an academic tertiary care center in Seoul Korea from February to September 2010. METHODS: Patients were nonrandomly allocated to "no bridge," "short-term bridge" (1 week), and "long-term bridge" (3 weeks) groups based on the surgeon's clinical judgment. Group differences in stoma height changes over time were analyzed. RESULTS: Subjects' mean age was 59.5 (range: 43-82) years, and the male-to-female ratio was 2.2:1.0. The mean heights of the stoma on postoperative day 2 and postoperative month 3, respectively, were 1.07 ± 0.16 cm (mean ± SD) and 0.81 ± 0.17 cm in the no-bridge group, 1.70 ± 0.29 cm and 1.21 ± 0.18 cm in the short-term bridge group, and 1.18 ± 0.16 cm and 1.01 ± 0.20 cm in the long-term bridge group. The changes in the stoma height 3 months after the surgery showed no statistically significant differences among the groups (P = .430). Stoma Quality of Life scores at 3 weeks (47.4 vs 46.1; P = .730) were similar for patients with and without bridges. However, a significantly greater number of patients with bridges reported difficulty with pouch changes compared to those without bridges (72.7% vs 14.3%; P = .002). CONCLUSIONS: Routine use of support bridges during loop ileostomy is unnecessary and inconvenient to patients. If a support bridge must be used, it can be removed early.

Wnt5a controls Notch1 signaling through CaMKII-mediated degradation of the SMRT corepressor protein.

Serine-threonine Ca(2+)/calmodulin-dependent protein kinase II (CaMKII) is the key component in noncanonical Wnt5a signaling and has been shown to regulate its signaling. In this study, we found that CaMKII induced by Wnt5a remarkably reduced the protein stability of the silencing mediator of retinoic acid and thyroid hormone receptor (SMRT), a co-repressor of Notch signaling, through proteasomal degradation. Wnt5a was found to enhance Notch1 intracellular domain (Notch1-IC) transcription activity, which could be inhibited by treatment with KN93, a CaMKII inhibitor. The kinase activity of CaMKII was essential for the activation of Notch signaling. We also determined that CaMKII could enhance the association between Notch1-IC and RBP-Jk. Furthermore, the physical association between RBP-Jk and SMRT was substantially suppressed by CaMKII. We demonstrated that CaMKII directly bound and phosphorylated SMRT at Ser-1407, thereby facilitating SMRT translocation from the nucleus to the cytoplasm and proteasome-dependent degradation. These results suggest that CaMKII down-regulated the protein stability of SMRT through proteasomal degradation.

Serum- and glucocorticoid-inducible kinase 1 (SGK1) controls Notch1 signaling by downregulation of protein stability through Fbw7 ubiquitin ligase.

Notch is a transmembrane protein that acts as a transcriptional factor in the Notch signaling pathway for cell survival, cell death and cell differentiation. Notch1 and Fbw7 mutations both lead the activation of the Notch1 pathway and are found in the majority of patients with the leukemia T-ALL. However, little is known about the mechanisms and regulators that are responsible for attenuating the Notch signaling pathway through Fbw7. Here, we report that the serum- and glucocorticoid-inducible protein kinase SGK1 remarkably reduced the protein stability of the active form of Notch1 through Fbw7. The protein level and transcriptional activity of the Notch1 intracellular domain (Notch1-IC) were higher in SGK1-deficient cells than in SGK1 wild-type cells. Notch1-IC was able to form a trimeric complex with Fbw7 and SGK1, thereby SGK1 enhanced the protein degradation of Notch1-IC via a Fbw7-dependent proteasomal pathway. Furthermore, activated SGK1 phosphorylated Fbw7 at serine 227, an effect inducing Notch1-IC protein degradation and ubiquitylation. Moreover, accumulated dexamethasone-induced SGK1 facilitated the degradation of Notch1-IC through phosphorylation of Fbw7. Together our results suggest that SGK1 inhibits the Notch1 signaling pathway via phosphorylation of Fbw7.

Effect of electronic toilet system (bidet) on anorectal pressure in normal healthy volunteers: influence of different types of water stream and temperature.

Although bidets are widely used in Korea, its effects on anorectal pressures have not been studied in detail in terms of the water settings used. Twenty healthy volunteers were placed on a toilet equipped with a bidet, and anorectal pressures were measured with a manometry catheter inserted into the rectum and anal canal before and after using the bidet at different water forces (40, 80, 160, 200 mN), temperatures (24°C vs 38°C), and water jet widths (narrow vs wide). The pressure at anal high pressure zone decreased from 96.1 ± 22.5 to 81.9 ± 23.3 mmHg at water jet pressure of 40 mN and 38°C wide water jet (P < 0.001), from 94.3 ± 22.4 to 80.0 ± 24.1 mmHg at water jet pressure of 80 mN and 38°C narrow water jet (P < 0.001), and from 92.3 ± 22.4 to 79.6 ± 24.7 mmHg at a water jet pressure of 80 mN and 38°C wide water jet (P < 0.001). At other settings, no significant changes were observed. Our results indicate that, in addition to cleansing effect, bidet could be used to reduce anal resting pressure in the same manner as the traditional warm sitz bath under the conditions of low or medium water jet pressure, a warm water temperature, and a wide type water jet.

DJ-1 modulates the p38 mitogen-activated protein kinase pathway through physical interaction with apoptosis signal-regulating kinase 1.

DJ-1 has been reported as a gene linked to early onset familial Parkinson's disease, and is functionally involved in transcriptional regulation and oxidative stress-induced cell death. To understand the role of DJ-1 in cellular stress, this study investigated DJ-1's effect on stress-activated protein kinase signaling and H(2)O(2)-induced activation of apoptosis signal-regulating kinase 1 (ASK1). According to the results, the overexpression of DJ-1 inhibited H(2)O(2)-induced activation of ASK1 as well as the activation of downstream kinases in the p38 mitogen-activated protein kinase (MAPK) signaling cascade. The results of both in vivo binding and kinase studies have revealed that ASK1 is the direct target of DJ-1, whereas it has shown no effect on either MKK3 or p38. DJ-1 blocked both the homo-oligomerization of ASK1 and inhibited ASK1 activity. Taken together, our data strongly suggest that DJ-1, by directly inhibiting ASK1, may act as a negative regulator in ASK1 signaling cascades.

Tip60 histone acetyltransferase acts as a negative regulator of Notch1 signaling by means of acetylation.

The Notch signaling pathway appears to perform an important function in a wide variety of organisms and cell types. In our present study, we provide evidence that UV irradiation-induced Tip60 proteins reduced Notch1 activity to a marked degree. Accumulated UV irradiation-induced Tip60 suppresses Notch1 transcriptional activity via the dissociation of the Notch1-IC-CSL complex. The binding between endogenous Tip60 and Notch1-IC in UV radiation-exposed cells was verified in this study by coimmunoprecipitation. Interestingly, the physical interaction of Tip60 with Notch1-IC occurs to a more profound degree in the presence of CSL but does not exist in a trimeric complex. Using Notch1-IC and Tip60 deletion mutants, we also determined that the N terminus, which harbors the RAM domain and seven ankyrin repeats of Notch1-IC, interacts with the zinc finger and acetyl coenzyme A domains of Tip60. Furthermore, here we report that Notch1-IC is a direct target of the acetyltransferase activity of Tip60. Collectively, our data suggest that Tip60 is an inhibitor of the Notch1 signaling pathway and that Tip60-dependent acetylation of Notch1-IC may be relevant to the mechanism by which Tip60 suppresses Notch1 signaling.

Integrin-linked kinase controls Notch1 signaling by down-regulation of protein stability through Fbw7 ubiquitin ligase.

Integrin-linked kinase (ILK) is a scaffold and protein kinase that acts as a pivotal effector in integrin signaling for various cellular functions. In this study, we found that ILK remarkably reduced the protein stability of Notch1 through Fbw7. The kinase activity of ILK was essential for the inhibition of Notch1 signaling. Notably, the protein level and transcriptional activity of the endogenous Notch1 intracellular domain (Notch1-IC) were higher in ILK-null cells than in ILK wild-type cells, and the level of endogenous Notch1-IC was increased by the blocking of the proteasome, suggesting that ILK enhances the proteasomal degradation of Notch1-IC. ILK directly bound and phosphorylated Notch1-IC, thereby facilitating proteasomal protein degradation through Fbw7. Furthermore, we found down-regulation of Notch1-IC and up-regulation of ILK in basal cell carcinoma and melanoma patients but not in squamous cell carcinoma patients. These results suggest that ILK down-regulated the protein stability of Notch1-IC through the ubiquitin-proteasome pathway by means of Fbw7.

Indirubin-3'-monoxime, a derivative of a Chinese anti-leukemia medicine, inhibits Notch1 signaling.

Notch proteins perform a critical function in cell-fate decisions and in differentiation. In this study, we determined that indirubin-3'-monoxime reduced Notch1 signaling to a remarkable extent. Indirubin-3'-monoxime has been shown to inhibit both constitutive active mutants of Notch1 and Notch1-IC-mediated transactivation activity. However, in such cases, neither the Notch cleavage pattern nor the protein stability of Notch1-IC was determined to have been significantly altered. Indirubin-3'-monoxime suppresses Notch1 transcriptional activity via the dissociation of the Notch1-IC-RBP-Jk complex. Notably, the transcriptional activity of Notch1-IC was not suppressed significantly in the GSK-3beta null cells by indirubin-3'-monoxime as compared to what was observed with GSK-3beta wild-type cells. In the previous study, we synthesized a series of indirubin derivatives. Interestingly, some of these indirubin derivatives were characterized as potent inhibitors of Notch1 signaling. Taken together, the results of this study indicate that indirubin-3'-monoxime downregulated Notch1 signaling in a GSK-3beta-dependent and proteosomal degradation-independent manner.

Zinc-induced downregulation of Notch signaling is associated with cytoplasmic retention of Notch1-IC and RBP-Jk via PI3k-Akt signaling pathway.

The Notch signaling pathway appears to perform an important function in the determination of cell fate and in differentiation, in a wide variety of organisms and cell types. In this study, we provide evidence that the inactivation of Notch signaling by zinc is achieved via a PI3K-Akt-dependent, cytoplasmic retention of Notch1-IC and RBP-Jk. Extracellular zinc has been determined to inhibit constitutive active mutants of both Notch1 (DeltaEN1) and Notch1-IC-mediated transcription. However, in such cases, neither the cleavage pattern of Notch nor the protein stability of Notch1-IC and RBP-Jk was found to have significantly changed. With regard to the modulation of Notch signaling, zinc appears to exert a significant negative influence on the binding occurring between Notch1 and RBP-Jk, both in vivo and in vitro. The zinc-induced inhibition of Notch signaling can be rescued via pretreatment with wortmannin or LY294002, both of which are specific PI3K signaling pathway inhibitors. Furthermore, we ascertained that zinc triggers the cytoplasmic retention of Notch1-IC and RBP-Jk, and that cytoplasmic retention could be rescued via treatment with wortmannin. Overall, we have determined that an important relationship exists between zinc and the Notch1 signaling pathway, and that this relationship is intimately involved with the cytoplasmic retention of Notch and RBP-Jk.

Erratum: Biofeedback Therapy Before Ileostomy Closure in Patients Undergoing Sphincter-Saving Surgery for Rectal Cancer: A Pilot Study.

[This corrects the article on p. 138 in vol. 31, PMID: 26361615.].

Biofeedback Therapy Before Ileostomy Closure in Patients Undergoing Sphincter-Saving Surgery for Rectal Cancer: A Pilot Study.

PURPOSE: This study prospectively investigated the effects of biofeedback therapy on objective anorectal function and subjective bowel function in patients after sphincter-saving surgery for rectal cancer. METHODS: Sixteen patients who underwent an ileostomy were randomized into two groups, one receiving conservative management with the Kegel maneuver and the other receiving active biofeedback before ileostomy closure. Among them, 12 patients (mean age, 57.5 years; range, 38 to 69 years; 6 patients in each group) completed the study. Conservative management included lifestyle modifications, Kegel exercises, and medication. Patients were evaluated at baseline and at 1, 3, 6, and 12 months after ileostomy closure by using anal manometry, modified Wexner Incontinence Scores (WISs), and fecal incontinence quality of life (FI-QoL) scores. RESULTS: Before the ileostomy closure, the groups did not differ in baseline clinical characteristics or resting manometric parameters. After 12 months of follow-up, the biofeedback group demonstrated a statistically significant improvement in the mean maximum squeezing pressure (from 146.3 to 178.9, P = 0.002). However, no beneficial effect on the WIS was noted for biofeedback compared to conservative management alone. Overall, the FI-QoL scores were increased significantly in both groups after ileostomy closure (P = 0.006), but did not differ significantly between the two groups. CONCLUSION: Although the biofeedback therapy group demonstrated a statistically significant improvement in the maximum squeezing pressure, significant improvements in the WISs and the FI-QoL scores over time were noted in both groups. The study was terminated early because no therapeutic benefit of biofeedback had been demonstrated.

Affinity Maturation of an Epidermal Growth Factor Receptor Targeting Human Monoclonal Antibody ER414 by CDR Mutation.

It is well established that blocking the interaction of EGFR with growth factors leads to the arrest of tumor growth, resulting in tumor cell death. ER414 is a human monoclonal antibody (mAb) derived by guided selection of the mouse mAb A13. The ER414 exhibited a ~17-fold lower affinity and, as a result, lower efficacy of inhibition of the EGF-mediated tyrosine phosphorylation of EGFR when compared with mAb A13 and cetuximab. We performed a stepwise in vitro affinity maturation to improve the affinity of ER414. We obtained a 3D model of ER414 to identify the amino acids in the CDRs that needed to be mutated. Clones were selected from the phage library with randomized amino acids in the CDRs and substitution of amino acids in the HCDR3 and LCDR1 of ER414 led to improved affinity. A clone, H3-14, with a ~20-fold increased affinity, was selected from the HCDR3 randomized library. Then three clones, ER2, ER78 and ER79, were selected from the LCDR1 randomized library based on the H3-14 but did not show further increased affinities compared to that of H3-14. Of the three, ER2 was chosen for further characterization due to its better expression than others. We successfully performed affinity maturation of ER414 and obtained antibodies with a similar affinity as cetuximab. And antibody from an affinity maturation inhibits the EGF-mediated tyrosine phosphorylation of EGFR in a manner similar to cetuximab.

Surgical treatment of a parastomal hernia.

PURPOSE: Parastomal hernia is a major complication of an intestinal stoma. This study was performed to compare the results of various operative methods to treat parastomal hernias. METHODS: Results of surgical treatment for parastomal hernias (postoperative recurrence, complications and postoperative hospital stays) were surveyed in 39 patients over an 11-year period. The patients enrolled in this study underwent surgery by a single surgeon to exclude surgeon bias. RESULTS: Seventeen patients were male, and twenty-two patients were female. The mean age was 65.9 years (range, 36 to 86 years). The stomas were 35 sigmoid-end-colostomies (90%), 2 loop-colostomies (5%), and 2 double-barrel-colostomies. Over half of the hernias developed within two years after initial formation. Stoma relocation was performed in 8 patients, suture repair in 14 patients and mesh repair in 17 patients. Seven patients had recurrence of the hernia, and ten patients suffered from complications. Postoperative complications and recurrence were more frequent in stoma relocation than in suture repair and mesh repair. Emergency operations were performed in four patients (10.3%) with higher incidence of complications but not with increased risk of recurrence. Excluding emergency operations, complications of relocations were not higher than those of mesh repairs. Postoperative hospital stays were shortest in mesh repair patients. CONCLUSION: In this study, mesh repair showed low recurrence and a low complication rate with shorter hospital stay than relocation methods, though these differences were not statistically significant. Further studies, including randomized trials, are necessary if more reliable data on the surgical treatment of parastomal hernias are to be obtained.

Inhibition of Notch1 signaling by Runx2 during osteoblast differentiation.

Notch1 genes encode receptors for a signaling pathway that regulates cell growth and differentiation in various contexts, but the role of Notch1 signaling in osteogenesis is not well defined. Notch1 controls osteoblast differentiation by affecting Runx2, but the question arises whether normal osteoblastic differentiation can occur regardless of the presence of Notch1. In this study, we observed the downregulation of Notch1 signaling during osteoblastic differentiation. BMPR-IB/Alk6-induced Runx2 proteins reduced Notch1 activity to a marked degree. Accumulated Runx2 suppressed Notch1 transcriptional activity by dissociating the Notch1-IC-RBP-Jk complex. Using deletion mutants, we also determined that the N-terminal domain of Runx2 was crucial to the binding and inhibition of the N-terminus of the Notch1 intracellular domain. Notably, upregulation of the Runx2 protein level paralleled reduced expression of Hes1, which is a downstream target of Notch1, during osteoblast differentiation. Collectively, our data suggest that Runx2 is an inhibitor of the Notch1 signaling pathway during normal osteoblast differentiation.