A methodological protocol for the development of a national guideline on perioperative management of gastrointestinal tumors in Germany.

BACKGROUND: The success of abdominal cancer surgery depends not only on the surgery itself but is influenced by the overall perioperative management. Given the multitude of perioperative measures and the ever-increasing number of studies on perioperative management, it is difficult to keep track and provide evidence-based perioperative management. The planned guideline on perioperative management will review the existing evidence and derive treatment recommendations. METHODS: The processing of the evidence is carried out by 6 working groups according to an 8-step scheme: after drafting the guideline questions in PICO format (1), a systematic literature search is carried out (2), and the records found are screened by two independent reviewers from the coordination team. Subsequently, the full texts of the potentially relevant articles are made available to the working groups for full text screening (3). All articles to be included are reviewed for methodological quality (4) before summary of findings tables are generated (5). In line with the GRADE approach, confidence in the evidence is assessed (6) before a recommendation is derived from the evidence, using a modified GRADE Evidence to Decision Framework (7). Finally, all recommendations are compiled and agreed within the guideline group (8). DISCUSSION: Guidelines serve as foundation for therapy decisions in everyday clinical practice and should therefore be based on up-to-date research results. However, while primary studies and systematic reviews are critically reviewed for their methodological quality, the process of guideline development is often not comprehensible. A protocol with predefined methodology should therefore create transparency and strengthen confidence in the recommendations. TRIAL REGISTRATION: The guideline is registered in the AWMF (Association of the Scientific Medical Societies) Guideline Register (088-010OL).

[Implementation of fast-track measures in colorectal resections : A survey among members of the DGAI]. / Umsetzung anästhesiologischer Fast-Track-Maßnahmen bei kolorektalen Resektionen : Eine Umfrage unter Mitgliedern der DGAI.

PURPOSE: The fast-track (FT) concept is a multimodal, interdisciplinary approach to perioperative patient care intended to reduce postoperative complications. Despite good evidence implementation seems to need improvement, whereby almost all studies focused on the implementation of surgical modules regardless of the interdisciplinary aspect. Adherence to the anesthesiological measures (prehabilitation, premedication, volume and temperature management, pain therapy), on the other hand, has been insufficiently studied. To assess the status quo a survey on the implementation of anesthesiological FT measures was conducted among members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) to analyze where potential for improvement exists. METHODS: Using the SurveyMonkey® online survey tool, 28 questions regarding perioperative anesthesiological care of colorectal surgery patients were sent to DGAI members in order to analyze adherence to FT measures. RESULTS: While some of the FT measures (temperature management, PONV prophylaxis) are already routinely used, there is a divergence between current recommendations and clinical implementation for other components. In addition to premedication, interdisciplinary measures (prehabilitation) and measures that affect multiple interfaces (operating theatre, recovery room, ward), such as volume management or perioperative pain management, are particularly affected. CONCLUSION: The anesthesiological recommendations of the FT concept are only partially implemented in Germany. This particularly affects the interdisciplinary components as well as measures at the operating theatre, recovery room and ward interfaces. The establishment of an interdisciplinary FT team and interdisciplinary development of SOPs can optimize adherence, which in turn improves the short-term and long-term outcome of patients.

Spatial odor discrimination in the hawkmoth, Manduca sexta (L.).

Flying insects track turbulent odor plumes to find mates, food and egg-laying sites. To maintain contact with the plume, insects are thought to adapt their flight control according to the distribution of odor in the plume using the timing of odor onsets and intervals between odor encounters. Although timing cues are important, few studies have addressed whether insects are capable of deriving spatial information about odor distribution from bilateral comparisons between their antennae in flight. The proboscis extension reflex (PER) associative learning protocol, originally developed to study odor learning in honeybees, was used as a tool to ask if hawkmoths, Manduca sexta, can discriminate between odor stimuli arriving on either antenna. We show moths discriminated the odor arrival side with an accuracy of >70%. Information about spatial distribution of odor stimuli may be available to moths searching for odor sources, opening the possibility that they use both spatial and temporal odor information.This article has an associated First Person interview with the first author of the paper.

Parameters of motion vision in low light in the hawkmoth Manduca sexta.

The hawkmoth Manduca sexta is nocturnally active, beginning its flight activity at sunset, and executing rapid controlled maneuvers to search for food and mates in dim light conditions. The visual system of this moth has been shown to trade off spatial and temporal resolution for increased sensitivity in these conditions. The study presented here uses tethered flying moths to characterize the flight performance envelope of the wide-field-motion-triggered steering response of M. sexta in low light conditions by measuring attempted turning in response to wide-field visual motion. Moths were challenged with a horizontally oscillating sinusoidal grating at a range of luminance, from daylight to starlight conditions. The impact of luminance on response to a range of temporal frequencies and spatial wavelengths was assessed across a range of pattern contrasts. The optomotor response decreased as a function of decreasing luminance, and the lower limit of the moth's contrast sensitivity was found to be between 1 and 5%. The preferred spatial frequency for M. sexta increased from 0.06 to 0.3 cycles deg-1 as the luminance decreased, but the preferred temporal frequency remained stable at 4.5 Hz across all conditions. The relationship between the optomotor response time to the temporal frequency of the pattern movement did not vary significantly with luminance levels. Taken together, these results suggest that the behavioral response to wide-field visual input in M. sexta is adapted to operate during crepuscular to nocturnal luminance levels, and the decreasing light levels experienced during that period changes visual acuity and does not affect their response time significantly.

Implementing a low-starch biscuit-free diet in zoo gorillas: the impact on behavior.

In the wild, western lowland gorillas travel long distances while foraging and consume a diet high in fiber and low in caloric density. In contrast, gorillas in zoos typically consume a diet that is low in fiber and calorically dense. Some items commonly used in captive gorilla diets contain high levels of starch and sugars, which are present at low levels in the natural diet of gorillas. Diet items high in simple carbohydrates are associated with obesity and heart disease in humans. Typical captive gorilla diets may also encourage undesirable behaviors. In response to these issues, we tested the behavioral impact of a diet that was biscuit-free, had low caloric density, and which was higher in volume at five institutions. We hypothesized that this diet change would reduce abnormal behaviors such as regurgitation and reingestion (R/R), decrease time spent inactive, and increase time spent feeding. The biscuit-free diet significantly reduced (and in the case of one zoo eliminated) R/R and may have reduced hair-plucking behavior. However, an increase in coprophagy was observed in many individuals following the diet change. The experimental diet caused a general increase in time the gorillas spent feeding, but this increase did not occur across all institutions and varied by individual. Interestingly, the overall time gorillas spent inactive actually increased with this diet change. Future research will examine these behavioral changes in a greater number of individuals to determine if the results remain consistent with these preliminary findings. Additionally, future research will examine the physiological impact of this diet change.

Implementing a low-starch biscuit-free diet in zoo gorillas: the impact on health.

In the wild, western lowland gorillas consume a diet high in fiber and low in caloric density. In contrast, many gorillas in zoos consume a diet that is high-calorie and low in fiber. Some items commonly used in captive gorilla diets contain high levels of starch and sugars, which are minimal in the natural diet of gorillas. There is a growing concern that captive gorillas may qualify as obese. Furthermore, the leading cause of death for adult male gorillas in zoos is heart disease. In humans, a diet that is high in simple carbohydrates is associated with both obesity and the incidence of heart disease. In response to these issues, we implemented a biscuit-free diet (free of biscuits and low in fruit) and measured serum biomarkers of obesity and insulin resistance pre- and post-diet change at three institutions: North Carolina Zoological Garden, Cleveland Metroparks Zoo, and Columbus Zoo and Aquarium. We also added a resistant starch supplement to gorilla diets at two of the above institutions. We anticipated that these diet changes would positively affect biomarkers of obesity and insulin resistance. Both diet manipulations led to a reduction in insulin. Resistant starch also decreased overall serum cholesterol levels. Future research will examine these health changes in a greater number of individuals to determine if the results remain consistent with these preliminary findings.

Quantification of healthy and atretic germ cells and follicles in the developing and post-natal ovary of the South American plains vizcacha, Lagostomus maximus: evidence of continuous rise of the germinal reserve.

The female germ line in mammals is subjected to massive cell death that eliminates 60-85% of the germinal reserve by birth and continues from birth to adulthood until the exhaustion of the germinal pool. Germ cell demise occurs mainly through apoptosis by means of a biased expression in favour of pro-apoptotic members of the BCL2 gene family. By contrast, the South American plains vizcacha, Lagostomus maximus, exhibits sustained expression of the anti-apoptotic BCL2 gene throughout gestation and a low incidence of germ cell apoptosis. This led to the proposal that, in the absence of death mechanisms other than apoptosis, the female germ line should increase continuously from foetal life until after birth. In this study, we quantified all healthy germ cells and follicles in the ovaries of L. maximus from early foetal life to day 60 after birth using unbiased stereological methods and detected apoptosis by labelling with TUNEL assay. The healthy germ cell population increased continuously from early-developing ovary reaching a 50 times higher population number by the end of gestation. TUNEL-positive germ cells were <0.5% of the germ cell number, except at mid-gestation (3.62%). Mitotic proliferation, entrance into prophase I stage and primordial follicle formation occurred as overlapping processes from early pregnancy to birth. Germ cell number remained constant in early post-natal life, but a remnant population of non-follicular VASA- and PCNA-positive germ cells still persisted at post-natal day 60. L. maximus is the first mammal so far described in which female germ line develops in the absence of constitutive massive germ cell elimination.

The ovary of Lagostomus maximus (Mammalia, Rodentia): an analysis by confocal microscopy

Lagostomus maximus is a notable mammalian model for reproductive studies. Females have an extremely high ovulation rate, which is due to down-regulation of the follicular apoptosis pathway, which ensures a large pool of developing follicles. This large pool is supported by the convoluted anatomy of the mature ovary, whose germinal tissue is found in irregularly curved ridges throughout the cortex. Medullary tissue is restricted to a minimum. Lyso Tracker Red reconstruction under confocal laser scanning microscopy was used to recognize and measure all follicular stages from primordial to antral. Unlike most mammals in which early primordial follicles are just found in fetal life, the adult ovary shows regions packed with early primordial follicles. Follicle size ranged from 24 to 316 microm. We discuss the relationships of L. maximus follicles size with regard to other species of mammals and propose that the physiology of the adult viscacha ovary obeys to a neoteny process in the evolution of this species

The ovary of Lagostomus maximus (Mammalia, Rodentia): an analysis by confocal microscopy

Lagostomus maximus is a notable mammalian model for reproductive studies. Females have an extremely high ovulation rate, which is due to down-regulation of the follicular apoptosis pathway, which ensures a large pool of developing follicles. This large pool is supported by the convoluted anatomy of the mature ovary, whose germinal tissue is found in irregularly curved ridges throughout the cortex. Medullary tissue is restricted to a minimum. Lyso Tracker Red reconstruction under confocal laser scanning microscopy was used to recognize and measure all follicular stages from primordial to antral. Unlike most mammals in which early primordial follicles are just found in fetal life, the adult ovary shows regions packed with early primordial follicles. Follicle size ranged from 24 to 316 microm. We discuss the relationships of L. maximus follicles size with regard to other species of mammals and propose that the physiology of the adult viscacha ovary obeys to a neoteny process in the evolution of this species

The developing ovary of the South American plains vizcacha, Lagostomus maximus (Mammalia, Rodentia): massive proliferation with no sign of apoptosis-mediated germ cell attrition.

Apoptosis-dependent massive germ cell death is considered a constitutive trait of the developing mammalian ovary that eliminates 65-85% of the germinal tissue depending on the species. After birth and during adult lifetime, apoptotic activity moves from the germ cell proper to the somatic compartment, decimating germ cells through follicular atresia until the oocyte reserve is exhausted. In contrast, the South American rodent Lagostomus maximus shows suppressed apoptosis-dependent follicular atresia in the adult ovary, with continuous folliculogenesis and massive polyovulation, which finally exhausts the oocyte pool. The absence of follicular atresia in adult L. maximus might arise from a failure to move apoptosis from the germinal stratum to the somatic compartment after birth or being a constitutive trait of the ovarian tissue with no massive germ cell degeneration in the developing ovary. We tested these possibilities by analysing oogenesis, expression of germ cell-specific VASA protein, apoptotic proteins BCL2 and BAX, and DNA fragmentation by TUNEL assay in the developing ovary of L. maximus. Immunolabelling for VASA revealed a massive and widespread colonisation of the ovary and proliferation of germ cells organised in nests that disappeared at late development when folliculogenesis began. No sign of germ cell attrition was found at any time point. BCL2 remained positive throughout oogenesis, whereas BAX was slightly detected in early development. TUNEL assay was conspicuously negative throughout the development. These results advocate for an unrestricted proliferation of germ cells, without apoptosis-driven elimination, as a constitutive trait of L. maximus ovary as opposed to what is normally found in the developing mammalian ovary.

Odor-modulated orientation in walking male cockroaches Periplaneta americana, and the effects of odor plumes of different structure.

The location of distant resources using odor information usually also requires information on the flow of air (or water) through the environment together with the expression of internally programmed steering responses. The orientation responses of virgin male Periplaneta americana L. to wind and the female sex-pheromone component (-)-periplanone-B were video-recorded in a laboratory wind tunnel and quantified. P. americana males showed no preferred walking orientation when released in zero wind in the absence of pheromone. When introduced into 25 cm s(-1) wind in the absence of pheromone, 79% of males walked downwind. Upon introduction to a plume of (-)-periplanone-B in wind, 100% of males walked upwind in the pheromone plume to the source. Males were then challenged with wind-borne plumes of (-)-periplanone-B of four different temporal/spatial structures. In nearly all cases, the only statistically significant changes in behavioral parameters measured from their walking tracks were observed from males tracking the treatment consisting of the most turbulent plume. The plume-tracking performances of males challenged with the other three less turbulent plumes were visually and quantitatively similar, regardless of the width. Males tracking all four plumes showed evidence of turns resulting from multiple mechanisms. Some of the observed maneuvers were temporally regular counterturns, suggesting steering according to an ongoing internal program, while others could have been triggered by encountering the change in odor concentration between pheromone and clean air at the lateral boundary of the plume or chemotactically upon the detection of changes in odor concentration.

Dramatic structural and thermodynamic consequences of repacking a protein's hydrophobic core.

BACKGROUND: Rop is an RNA binding, dimeric, four-helix bundle protein with a well-defined, regular hydrophobic core ideally suited for redesign studies. A family of Rop variants in which the hydrophobic core was systematically redesigned has previously been created and characterized. RESULTS: We present a structural and thermodynamic analysis of Ala2Ile2-6, a variant of Rop with an extensively redesigned hydrophobic core. The structure of Ala2Ile2-6 reveals a completely new fold formed by a conformational "flip" of the two protomers around the dimeric interface. The free-energy profile of Ala2Ile2-6 is also very different from that of wild-type Rop. Ala2Ile2-6 has a higher melting temperature than Rop, but undergoes a slightly smaller free-energy change on unfolding. CONCLUSIONS: The structure of Ala2Ile2-6, along with molecular modeling results, demonstrate the importance of tight packing of core residues and the adoption of favorable core side chain rotamer values in determining helix-helix interactions in the four-helix bundle fold. Structural disorder at the N and C termini of Ala2Ile2-6 provides a basis for the large differences in the enthalpy and entropy of Ala2Ile2-6 folding compared with wildtype Rop.

Variability in odor-modulated flight by moths.

Based on previous studies of odor-modulated flight where track parameter data was lumped and averaged, the speed and orientation of the moths' movement along their flight tracks have been said to be controlled to maintain certain "preferred" values. The results from our fine-scaled analysis of this behavior show that none of the track parameters typically measured are held constant. The moths' speed along the flight track is modulated substantially and predictably: fastest along the straight legs and slowest around the turns. In addition, about half of the individuals studied progressively reduced the peak speed along the straight legs as they approached the pheromone source. While most of the track legs between the turns were directed upwind, their orientations were widely distributed, indicating no preferred direction. Small fluctuations of orientation along some straight legs suggest corrective maneuvers to stabilize flight direction about an internal set point. The visual inputs hypothesized to control steering and speed, transverse and longitudinal image flow, changed continuously during upwind flight in pheromone, but no regular relationship between them was observed. We found that the orientation of the longitudinal body axis and the direction of thrust (course angle) were only rarely coincident during upwind flight to the odor source, suggesting that moths receive sensory input which differs quantitatively from that calculated by conventional methods. Our results strongly suggest that the long-accepted hypothetical mechanisms of control for this behavior do not operate in the manner in which they have been proposed.

Normal glomerular organization of the antennal lobes is not necessary for odor-modulated flight in female moths.

A prominent hypothesis for the function of the glomerular structures in the primary olfactory neuropil of many groups of vertebrate and invertebrate animals is that they enable the processing and coding of information about the chemical compounds that compose complex odors. Previous studies have indicated that various degrees of glomerulus formation in the antennal lobes of the brain of the moth Manduca sexta can be effected by reducing the number of olfactory sensory axons that grow from the antenna into the antennal lobe during metamorphosis. To test the hypothesis that the presence of glomerular structure is necessary to process and identify odors, we substantially reduced, by surgery, the number of antennal segments in developing moths and upon metamorphosis we observed and quantified behavioral responses known to be elicited by odors. Intact and lesioned adult female moths were challenged to fly upwind to the source of an attractive host-plant odor in a wind tunnel. Some of the moths that had developed with reduced olfactory input flew upwind to the odor source. The flight behavior of these individuals was similar to the odor-mediated flight typically observed in moths that had developed normally. Histological analysis of the moths' antennal lobes revealed that the lobes of more than half of the respondents that had been lesioned during development lacked normal glomerular organization. The neuropil of these abnormally developed antennal lobes was mostly aglomerular, but with a few isolated, clearly abnormal glomerulus-like structures. This suggests either that even a few abnormal glomeruli are sufficient to mediate this specific behavior or that "canonical" glomerular organization per se is not necessary for this odor-mediated behavior.

In search of the real respiratory neurons: culture of medullary fetal cells sensitive to CO2 and low pH.

Although extensively pursued, the real respiratory neurons have remained elusive. We departed from the more conventional physiologic and morphologic methods of system and tissue examination and cultured dissociated fetal rat cells from the areas of the nucleus ambiguus and the nucleus tractus solitarius located within the 2 mm rostral to the obex. Pacemaker-like cells, with a regular single or bursting activity, studied at 3-5 weeks of age, responded to very small pulses of CO2 (50 ms) and low pH with an increase in spike frequency and a decrease in amplitude. Other irregularly beating or silent cells did not respond or else required very large pulses (> 200 ms) to do so. The pacemaker cells also responded to hypoxia induced by administration of sodium hydrosulfite with an increase in spike frequency and amplitude; high oxygen (> 600 Torr) and adenosine produced a decrease in electrical activity. Most of these cells were multipolar after staining with antibodies to neuron-specific enolase and fragment C of tetanus toxin. They did not stain for choline acetyltransferase. The results suggest that these cultured cells, expressing a phenotype inherently responsive to CO2 and low pH, have the characteristics of central respiratory chemoreceptors, and may be involved in the generation of the respiratory rhythm.

In search of the central respiratory neurons: I. Dissociated cell cultures of respiratory areas from the upper medulla.

Dissociated cells from the areas of the nucleus ambiguus and the nucleus tractus solitarius obtained by tissue punch or block dissection from coronal slices of the medulla at the level of the obex were cultured from fetal rats at 18 to 21 days gestation. The dissociated neurons were plated either directly in vitrogen-coated 35 mm tissue culture dishes or in such dishes which had been seeded with subcultures of cortex- or medulla-derived astrocytes. After the astrocytes reached confluency and were treated with an antimitotic agent, dissociated nucleus ambiguus or nucleus tractus solitarius was plated at 0.5-1.0 x 10(6) cells per dish. Neurons grew well on monolayers of medullary or cortical astrocytes, but survived poorly on vitrogen-coated dishes without a cellular substrate. Rat medulla was preferred as the source of astrocytes. Tissue dissociation with papain rather than trypsin produced less cellular debris, and the neuronal yield from the tissue was higher. The neuronal population was heterogenous in morphology including small and large bipolar, pyramidal, and multipolar cells. Neurons sensitive to CO2 and/or low pH (Rigatto et al., J Neurosci Res 33:590-597, 1992) did not appear to have any definitive morphologic characteristics, but most were multipolar. These neurons stained well with antibodies to neuron-specific enolase and Fragment C of tetanus toxin, but not to choline acetyltransferase (ChAT). These findings suggest that neurons possibly responsible for the central regulation of respiration can be maintained for several weeks in dissociated cell culture, providing a system for neurotransmitter, electrophysiological, and morphological studies.

In search of the central respiratory neurons: II. Electrophysiologic studies of medullary fetal cells inherently sensitive to CO2 and low pH.

Although extensively pursued, the central respiratory neurons have remained elusive. We departed from the more conventional physiologic and morphologic methods of system and tissue examination and cultured dissociated fetal rat cells (Fitzgerald et al., J Neurosci Res 33:579-589, 1992) from the area of the nucleus ambiguus and the nucleus tractus solitarius located within the 2 mm rostral to the obex. Pacemaker-like cells, with a regular single or bursting activity, studied at 3-5 weeks of age, responded to very small pulses of CO2 (50 ms) and low pH with an increase in spike frequency and a decrease in spike amplitude. Other irregularly beating or silent cells did not respond or else required very large pulses (> 200 ms) to do so. The pacemaker cells also responded to hypoxia induced by administration of sodium hydrosulfite with an increase in spike frequency and amplitude; high oxygen (> 600 torr) and adenosine produced a decrease in electrical activity. Most of these cells were multipolar after staining with antibodies to neuron-specific enolase (NSE) and Fragment C of tetanus toxin. They did not stain for choline acetyltransferase (ChAT). The results suggest that these cultured cells, expressing a phenotype inherently responsive to CO2 and low pH, have the characteristics of central respiratory chemoreceptors, and may be involved in the generation of the respiratory rhythm.

Odor-modulated upwind flight of the sphinx moth, Manduca sexta L.

1. Male and female Manduca sexta flew upwind in response to the odor of female sex-pheromone gland extract or fresh tobacco leaf respectively, and generated very similar zigzagging tracks along the odor plume. 2. After loss of odor during flight, males and females alike: (1) first flew slower and steered their flight more across the wind, then (2) stopped moving upwind, and finally (3) regressed downwind. 3. Males flying upwind in a pheromone plume in wind of different velocities maintained their ground speed near a relatively constant 'preferred' value by increasing their air speed as the velocity of the wind increased, and also maintained the average angle of their resultant flight tracks with respect to the wind at a preferred value by steering a course more precisely due upwind. 4. The inter-turn duration and turn rate, two measures of the temporal aspects of the flight track, were maintained, on average, with remarkable consistency across all wind velocities and in both sexes. The inter-turn durations also decreased significantly as moths approached the odor source, suggesting modulation of the temporal pattern of turning by some feature of the odor plume. This temporal regularity of turning appears to be one of the most stereotyped features of odor-modulated flight in M. sexta.