Time to Flip the Approach: Retroperitoneoscopic Adrenalectomy.

INTRODUCTION: Retroperitoneoscopic adrenalectomy (RPA) has gained increasing popularity with its excellent perioperative outcomes and direct surgical access compared to other adrenalectomy approaches. We review perioperative outcomes of RPA by a specialized endocrine surgeon before and after expert intensive trainings (EITs), and to that of other laparoscopic adrenalectomy approaches at our center over a 9-year period, aiming to ascertain if RPA is worth the steep learning curve. MATERIAL AND METHODS: One hundred twenty one adrenalectomies were performed between January 2014 to June 2022. Patient demographic, tumor characteristics, and perioperative outcomes were retrospectively reviewed. The primary endpoints included procedure duration, complications, and length of stay. Part I of the study examined the effect of EITs on RPA's learning curve, and part II compared these outcomes with that of the alternative approach, transabdominal lateral adrenalectomy (TLA). RESULTS: Both procedure duration and days in hospital markedly decreased after the two EITs for RPA. RPA resulted in a shorter procedure duration and hospital stay compared to TLA, and had lesser and milder intraoperative and postoperative complications compared to TLA. CONCLUSIONS: RPA results in safe and excellent outcomes, and offers additional benefit of direct surgical access, feasibility in patients with previous abdominal surgery, high body mass index, and multiple comorbidities. The steep learning curve can be overcome and shortened by EITs, motivating centers with specialized endocrine surgery to integrate RPA training into its curriculum, given its foreseeable rewarding outcomes.

Isolation and Characterisation of Culturable Thermophilic Cyanobacteria from Perak Hot Springs and their Plant Growth Promoting Properties Effects on Rice Seedlings (Oryza sativa L.).

Malaysia is home to a number of hot springs that are rich in microbial diversity including the photosynthetic cyanobacteria. Although this microbial community has been characterised based on metagenomics approach, the culturable thermophilic isolates have not been isolated and characterised extensively. Compared to the mesophiles, information on plant growth promoting (PGP) properties of these thermophiles remain largely untapped. As the amount of arable land for microbial bioprospecting is decreasing due to extensive human activities, the search for alternative source for microbial strains with PGP properties is important for the development of potential biofertilisers. This study sought to isolate and characterise culturable cyanobacteria strains from two local hot springs - Sungai Klah (SK) and Lubuk Timah (LT) located in Perak using morphological and molecular methods. The IAA production from the axenic cultures were measured. The PGP properties were also measured by priming the rice seeds with cyanobacterial water extracts. A total of six strains were isolated from both hot springs. Strains LTM and LTW from LT were identified as Leptolyngbya sp. whereas strains SEM, SEH, STH and STM were identified as Thermosynechococcus elongatus. All six strains produced IAA ranged from 670.10 pg/µL to 2010 pg/µL. The water extracts were found to increase the seed amylase activity of the rice seeds from 5th day of germination (DAG) to 10th DAG. In general, the IAA production and increased seed amylase activity might have contributed in enhancing the longest root length, shoot length and root-to-shoot (RS) ratio. To conclude, the thermophilic cyanobacteria from hot springs can be further exploited as a novel source of PGP microbes for the development of biofertilsers.

Complications of Central Venous Access Devices Used in Palliative Care Settings for Terminally Ill Cancer Patients: A Systematic Review and Meta-Analysis.

(1) Background: Central venous access devices (CVADs) have been commonly employed during various courses of anticancer treatment. Currently, there are a few types of clinically available CVADs, which are associated with short-term and long-term complications. However, little is known about the complication rates when CVADs are used only in palliative care settings. We therefore performed a systematic review and meta-analysis of all the published literature to evaluate the complication rates of CVADs in this clinical setting. (2) Methods: A systematic review and meta-analysis were conducted to identify publications from PubMed/MEDLINE, Embase (Ovid), Scopus, Cochrane Library, CINAHL, Google Scholar, and trial registries. Publications reporting the complication rates of PICCs, central lines, and PORTs in palliative settings for terminally ill cancer patients were included, while those on the use of systemic anticancer therapy and peripheral venous catheters were excluded. The outcome measures included overall complication rate, rate of catheter-related bloodstream infection (CRBSI), and rate of thromboembolism (TE). This systematic review was registered with PROSPERO (CRD42023404489). (3) Results: Five publications with 327 patients were analyzed, including four studies on PICCs and one study on central lines. No studies on PORTs were eligible for analysis. The overall complication rate for PICCs (pooled estimate 7.02%, 95% CI 0.27-19.10) was higher than that for central lines (1.44%, 95% CI 0.30-4.14, p = 0.002). The risk of CRBSI with PICCs (2.03%, 95% CI 0.00-9.62) was also higher than that with central lines (0.96%, 95% CI 0.12-3.41, p = 0.046). PICCs also had a trend of a higher risk of TE (2.10%, 95% CI 0.00-12.22) compared to central lines (0.48%, 95% CI 0.01-2.64, p = 0.061). (4) Conclusions: PICCs for palliative cancer care were found to have greater complications than central lines. This might aid in the formulation of future recommendation guidelines on the choice of CVAD in this setting.

Returning to the nest: Emerging adults living with parents during the COVID-19 pandemic.

Changes in the working, study and social lives of emerging adults due to the COVID-19 pandemic have led to greater need for external supports. Many who lived independently may have sought that support by returning to live with parents. This study identifies factors associated with returns made between 2019 and 2020. It describes supports needed and obtained, relationships between parents and their resident emerging adults and identifies correlates of poor coping and high psychological distress. Data from the Longitudinal Surveys of Australian Youth and the Longitudinal Study of Australian Children were used and showed half of the emerging adults who moved did so due to COVID-19 restrictions. Loss of work and increased need for emotional and financial support were key drivers of moves. Nineteen per cent who returned found spending more time with family difficult and over half did not have their support needs fully met, increasing their odds of poor coping at that time (OR = 2.9, 4.3, respectively) and subsequent psychological distress (OR = 6.0). Families were an important source of support but could not necessarily mitigate all challenges; for some emerging adults, returning to live with parents gave rise to additional difficulties which negatively affected mental health.

Psychological well-being and coping strategies of healthcare students during the prolonged COVID-19 pandemic.

Background: This study aimed to investigate the psychological well-being, and stress coping strategies, as well as their relationships, among healthcare students during prolonged COVID-19 pandemic. Methods: An online questionnaire was used to assess psychological well-being (the Ryff Scale) and coping strategies (the brief Coping Orientation to Problems Experienced Inventory [COPE] Scale). COPE scores were categorized to identify the primary coping strategies: "approach" indicates more active coping strategies; "avoidant" indicates more dysfunctional and maladaptive mechanisms. Results: A total of 202 valid questionnaire were collected. Those with lower academic confidence and lower self-rated peer and family relationship scores during the COVID-19 pandemic had lower Ryff scores, indicating poorer psychological well-being. Nursing students reported the lowest psychological well-being and the highest levels of adopting avoidant coping strategies (26.4%). Conclusion: The study's findings may help educators identify the healthcare students most vulnerable to stress and develop interventions to empower students to adopt problem-focused stress coping strategies.

A Consortium of Pseudomonas aeruginosa and Trichoderma harzianum for Improving Growth and Induced Biochemical Changes in Fusarium Wilt Infected Bananas.

Fusarium wilt of banana cannot be effectively controlled by current control strategies. The most virulent form that caused major losses in the banana production is Fusarium oxysporum f. sp. cubense Tropical Race 4 (Foc-TR4). Biocontrol of Foc-TR4 using microbial antagonists offers a sustainable and eco-friendly alternative. A consortium of biocontrol agents (BCAs), Pseudomonas aeruginosa DRB1 and Trichoderma harzianum CBF2 was formulated into pesta granules, talc powder, alginate beads and liquid bioformulations. Previous study indicated bioformulations containing both BCAs successfully reduced the disease severity of Foc-TR4. To date, the biocontrol mechanism and plant growth promoting (PGP) traits of a consortium of BCAs on infected bananas have not been explored. Therefore, the study was undertaken to investigate the effect of a consortium of DRB1 and CBF2 in the growth and biochemical changes of Foc-TR4 infected bananas. Results indicated pesta granules formulation produced bananas with higher biomass (fresh weight: 388.67 g), taller plants (80.95 cm) and larger leaves (length: 39.40 cm, width: 17.70 cm) than other bioformulations. Applying bioformulations generally produced plants with higher chlorophyll (392.59 µg/g FW-699.88 µg/g FW) and carotenoid contents (81.30 µg/g FW-120.01 µg/g FW) compared to pathogen treatment (chlorophyll: 325.96 µg/g FW, carotenoid: 71.98 µg/g FW) which indicated improved vegetative growth. Bioformulation-treated plants showed higher phenolic (49.58-93.85 µg/g FW) and proline contents (54.63 µg/g FW-89.61 µg/g FW) than Foc-TR4 treatment (phenolic: 46.45 µg/g FW, proline: 28.65 µg/g FW). The malondialdehylde (MDA) content was lower in bioformulation treatments (0.49 Nm/g FW-1.19 Nm/g FW) than Foc-TR4 treatment (3.66 Nm/g FW). The biochemical changes revealed that applying bioformulations has induced host defense response by increasing phenolic and proline contents which reduced root damage caused by Foc-TR4 resulting in lower MDA content. In conclusion, applying bioformulations containing microbial consortium is a promising method to improve growth and induce significant biochemical changes in bananas leading to the suppression of Foc-TR4.

A Preclinical Animal Model for the Study of Scaffold-Guided Breast Tissue Engineering.

Scaffold-guided breast tissue engineering (SGBTE) has the potential to transform reconstructive breast surgery. Currently, there is a deficiency in clinically relevant animal models suitable for studying novel breast tissue engineering concepts. To date, only a small number of large animal studies have been conducted and characterization of these large animal models is poorly described in the literature. Addressing this gap in the literature, this publication comprehensively describes our original porcine model based on the current published literature and the experience gained from previous animal studies conducted by our research group. In a long-term experiment using our model, we investigated our SGBTE approach by implanting 60 additively manufactured bioresorbable scaffolds under the panniculus carnosus muscle along the flanks of 12 pigs over 12 months. Our model has the flexibility to compare multiple treatment modalities where we successfully investigated scaffolds filled with various treatments of immediate and delayed fat graft and augmentation with platelet rich plasma. No wound complications were observed using our animal model. We were able to grow clinically relevant volumes of soft tissue, which validates our model. Our preclinical large animal model is ideally suited to assess different scaffold or hydrogel-driven soft tissue regeneration strategies. Impact statement The ability to regenerate soft tissue through scaffold-guided tissue engineering concepts can transform breast reconstructive surgery. We describe an original preclinical large animal model to study controlled and reproducible scaffold-guided breast tissue engineering (SGBTE) concepts. This model features the flexibility to investigate multiple treatment conditions per animal, making it an efficient model. We have validated our model with a long-term experiment over 12 months, which exceeds other shorter published studies. Our SGBTE concept provides a more clinically relevant approach in terms of breast reconstruction. Future studies using this model will support the translation of SGBTE into clinical practice.

Programmed Cell Death Ligand Expression Drives Immune Tolerogenesis across the Diverse Subtypes of Neuroendocrine Tumours.

INTRODUCTION: A comprehensive characterization of the tumour microenvironment is lacking in neuroendocrine tumours (NETs), where programmed cell death-1 receptor-ligand (PD-1/PD-L1) inhibitors are undergoing efficacy testing. OBJECTIVE: We investigated drivers of cancer-related immunosuppression across NETs of various sites and grades using multi-parameter immunohistochemistry and targeted transcriptomic profiling. METHODS: Tissue microarrays (n = 102) were stained for PD-L1 and 2 and indoleamine deoxygenase-1 (IDO-1) and evaluated in relationship to functional characteristics of tumour-infiltrating T-lymphocytes (TILs) and biomarkers of hypoxia/angiogenesis. PD-L1 expression was tested in circulating tumour cells (CTCs, n = 12) to evaluate its relationship with metastatic dissemination. RESULTS: PD-L1 expression was highest in lung NETs (n = 30, p = 0.007), whereas PD-L2 was highest in pancreatic NETs (n = 53, p < 0.001) with no correlation with grade or hypoxia/angiogenesis. PD-L1+ NETs (n = 26, 25%) had greater CD4+/FOXP3+ and CD8+/PD1+ TILs (p < 0.001) and necrosis (p = 0.02). CD4+/FOXP3+ infiltrate had the highest PD-L1/IDO-1 co-expressing tumours (p = 0.006). Grade 3 well-differentiated NETs had lower CD4+/FOXP3+ and CD8+/PD1+ TIL density (p < 0.001), and NanoString immune profiling revealed enrichment of macrophage-related transcripts in cases with poorer prognosis. We identified PD-L1(+) CTC subpopulations in 75% of evaluated patients (n = 12). CONCLUSIONS: PD-L1 expression correlates with T-cell exhaustion independent of tumour hypoxia and is enhanced in a subpopulation of CTCs, suggesting its relevance to the progression of NETs. These findings support a potential therapeutic role for PD-L1 inhibitors in a subset of NETs.

Breast Augmentation and Reconstruction from a Regenerative Medicine Point of View: State of the Art and Future Perspectives.

Breast reconstruction and augmentation are very common procedures, yet the prevailing current methods utilize silicone implants that may have significant local complications requiring reoperation. Lipofillling is increasingly used to contour and is considered safe, however, its utility is limited by significant volume loss. A new approach could offer an alternative and increase the scope of patient choice. A small number of teams around the world are investigating a breast tissue engineering (TE) paradigm. Conventional breast TE concepts are based on seeding a scaffold with the patients' own stem cells. However, the clinical viability of many of these approaches is limited by their costs in relevant volumes. In this article the state of the art of tissue-engineered breast reconstruction is reviewed and future perspectives are presented and discussed.

Conserved pharmacological rescue of hereditary spastic paraplegia-related phenotypes across model organisms.

Hereditary spastic paraplegias (HSPs) are a group of neurodegenerative diseases causing progressive gait dysfunction. Over 50 genes have now been associated with HSP. Despite the recent explosion in genetic knowledge, HSP remains without pharmacological treatment. Loss-of-function mutation of the SPAST gene, also known as SPG4, is the most common cause of HSP in patients. SPAST is conserved across animal species and regulates microtubule dynamics. Recent studies have shown that it also modulates endoplasmic reticulum (ER) stress. Here, utilizing null SPAST homologues in C. elegans, Drosophila and zebrafish, we tested FDA-approved compounds known to modulate ER stress in order to ameliorate locomotor phenotypes associated with HSP. We found that locomotor defects found in all of our spastin models could be partially rescued by phenazine, methylene blue, N-acetyl-cysteine, guanabenz and salubrinal. In addition, we show that established biomarkers of ER stress levels correlated with improved locomotor activity upon treatment across model organisms. Our results provide insights into biomarkers and novel therapeutic avenues for HSP.

An update on irreversible electroporation of liver tumours.

OBJECTIVE. To investigate the clinical efficacy and safety of irreversible electroporation for ablation of liver tumour in humans. DATA SOURCES. The PubMed and MEDLINE databases were systematically searched. STUDY SELECTION. Clinical research published in English in the last 10 years until October 2013 that address clinical issues related to irreversible electroporation of human liver tumours were selected. "Liver tumor", "local ablative therapy", and "irreversible electroporation" were used as the search terms. DATA EXTRACTION AND SYNTHESIS. The data extracted for this review was analysed by the authors, with a focus on the clinical efficacy and the safety of irreversible electroporation. The complete response rates look promising, ranging from 72% to 100%, except in one study in a subgroup of liver tumours in which the complete response rate was only 50% that was likely due to the inclusion of larger-size tumours. In one study, the local recurrence rate at 12 months was approximately 40%. As for the safety of irreversible electroporation, there were only a few reported complications (cardiac arrhythmia, pneumothorax, and electrolyte disturbance) that were mostly transient and not serious. There was no reported mortality related to the use of irreversible electroporation. CONCLUSION. Irreversible electroporation is a potentially effective liver tumour ablative therapy that gives rise to only mild and transient side-effects. Further studies with better patient selection criteria and longer follow-up are needed to clarify its role as a first-line liver tumour treatment modality.

Intracoronary upregulation of platelet extracellular matrix metalloproteinase inducer (CD147) in coronary disease.

BACKGROUND: CD147, also known as extracellular matrix metalloproteinase inducer, is present on circulating platelets and leukocytes in patients with coronary disease and is implicated in atherogenesis, and plaque rupture. We investigated whether CD147 (platelet, leukocyte and soluble) is upregulated within the coronary circulation in patients with stable coronary disease, and whether CD147 levels are associated with coronary shear stress levels. METHODS: A total of 25 patients undergoing intervention of a single coronary lesion had blood sampled within the coronary (n=15) and peripheral circulation (n=10). Platelet and leukocyte CD147 expression was measured by flow cytometry. Soluble CD147 was measured by enzyme-linked immunosorbent assays. Shear stress was calculated using computational fluid dynamics analysis. The effect of shear on platelet CD147 expression in vitro was investigated using a cone-plate viscometer. RESULTS: Platelet CD147 was higher in the coronary sinus (CS) compared to femoral vein (mean ± SD fluorescence intensity: 3.1 ± 0.7 vs. 2.2 ± 0.5, p=0.01). There was a significant linear trend for increased platelet CD147 expression from the proximal artery to the distal artery, and subsequently to the CS (p=0.01), indicating trans-lesion and transmyocardial upregulation. There were no differences between the various sites for monocyte, granulocyte or soluble CD147 levels (all p=ns). Trans-lesion gradients of CD147 did not correlate with shear stress (all p=ns). Blood subjected to shear in vitro had higher levels of platelet P-selectin (p=0.04) but similar levels of platelet CD147 (p=0.46) compared to rested blood. CONCLUSION: Platelet CD147 expression is upregulated in the coronary circulation in patients with stable coronary disease, but its upregulation is independent of shear stress.

Release of tissue-specific proteins into coronary perfusate as a model for biomarker discovery in myocardial ischemia/reperfusion injury.

Diagnosis of acute coronary syndromes is based on protein biomarkers, such as the cardiac troponins (cTnI/cTnT) and creatine kinase (CK-MB) that are released into the circulation. Biomarker discovery is focused on identifying very low abundance tissue-derived analytes from within albumin-rich plasma, in which the wide dynamic range of the native protein complement hinders classical proteomic investigations. We employed an ex vivo rabbit model of myocardial ischemia/reperfusion (I/R) injury using Langendorff buffer perfusion. Nonrecirculating perfusate was collected over a temporal profile of 60 min reperfusion following brief, reversible ischemia (15 min; 15I/60R) for comparison with irreversible I/R (60I/60R). Perfusate proteins were separated using two-dimensional gel electrophoresis (2-DE) and identified by mass spectrometry (MS), revealing 26 tissue-specific proteins released during reperfusion post-15I. Proteins released during irreversible I/R (60I/60R) were profiled using gel-based (2-DE and one-dimensional gel electrophoresis coupled to liquid chromatography and tandem mass spectrometry; geLC-MS) and gel-free (LC-MS/MS) methods. A total of 192 tissue-specific proteins were identified during reperfusion post-60I. Identified proteins included those previously associated with I/R (myoglobin, CK-MB, cTnI, and cTnT), in addition to examples currently under investigation in large cohort studies (heart-type fatty acid binding protein; FABPH). The postischemic release profile of a novel cardiac-specific protein, cysteine and glycine-rich protein 3 (Csrp3; cardiac LIM domain protein) was validated by Western blot analysis. We also identified Csrp3 in serum from 6 of 8 patients postreperfusion following acute myocardial infarction. These studies indicate that animal modeling of biomarker release using ex vivo buffer perfused tissue to limit the presence of obfuscating plasma proteins may identify candidates for further study in humans.

Imaging multiple intermediates of single-virus membrane fusion mediated by distinct fusion proteins.

Membrane fusion plays an essential role in the entry of enveloped viruses into target cells. The merging of viral and target cell membranes is catalyzed by viral fusion proteins, which involves multiple sequential steps in the fusion process. However, the fusion mechanisms mediated by different fusion proteins involve multiple transient intermediates that have not been well characterized. Here, we report a synthetic virus platform that allows us to better understand the different fusion mechanisms driven by the diverse types fusion proteins. The platform consists of lentiviral particles coenveloped with a surface antibody, which serves as the binding protein, along with a fusion protein derived from either influenza virus (HAmu) or Sindbis virus (SINmu). By using a single virus tracking technique, we demonstrated that both HAmu- and SINmu-bearing viruses enter cells through clathrin-dependent endocytosis, but they required different endosomal trafficking routes to initiate viral fusion. Direct observation of single viral fusion events clearly showed that hemifusion mediated by SINmu upon exposure to low pH occurs faster than that mediated by HAmu. Monitoring sequential fusion processes by dual labeling the outer and inner leaflets of viral membranes also revealed that the SINmu-mediated hemifusion intermediate is relatively long-lived as compared with that mediated by HAmu. Taken together, we have demonstrated that the combination of this versatile viral platform with the techniques of single virus tracking can be a powerful tool for revealing molecular details of fusion mediated by various fusion proteins.

Targeting lentiviral vector to specific cell types through surface displayed single chain antibody and fusogenic molecule.

BACKGROUND: Viral delivery remains one of the most commonly used techniques today in the field of gene therapy. However, one of the remaining hurdles is the off-targeting effect of viral delivery. To overcome this obstacle, we recently developed a method to incorporate an antibody and a fusogenic molecule (FM) as two distinct molecules into the lentiviral surface. In this report, we expand this strategy to utilize a single chain antibody (SCAb) for targeted transduction. RESULTS: Two versions of the SCAb were generated to pair with our various engineered FMs by linking the heavy chain and the light chain variable domains of the anti-CD20 antibody (alphaCD20) via a GS linker and fusing them to the hinge-CH2-CH3 region of human IgG. The resulting protein was fused to either a HLA-A2 transmembrane domain or a VSVG transmembrane domain for anchoring purpose. Lentiviral vectors generated with either version of the SCAb and a selected FM were then characterized for binding and fusion activities in CD20-expressing cells. CONCLUSION: Certain combinations of the SCAb with various FMs could result in an increase in viral transduction. This two-molecule lentiviral vector system design allows for parallel optimization of the SCAb and FMs to improve targeted gene delivery.

Maternal periodontal disease and perinatal mortality.

BACKGROUND: Periodontal disease has been associated with increased perinatal mortality. AIMS: To examine the association between maternal periodontal disease and perinatal mortality. METHODS: We performed a retrospective and prospective matched case-control study of women with unexplained perinatal mortality at more than 20 weeks gestational age. Women were matched for socioeconomic status, smoking status and time since delivery. All women underwent a detailed periodontal examination and completed a questionnaire describing oral health symptoms. No intervention took place. RESULTS: Fifty-three women who had experienced a perinatal death and 111 controls completed the study. Thirty-two women were recruited retrospectively and 21 women were recruited prospectively. Twenty-three (43.4%) women who had experienced a perinatal death and 27 (24.3%) controls had periodontal disease. There were no differences in oral health behaviours or symptoms between cases and controls. Perinatal death was associated with periodontal disease (odds ratio (OR) 2.34, 95% confidence interval (CI) 1.05, 5.47). Periodontal disease was more strongly associated with perinatal mortality due to extreme prematurity (OR 3.60, 95% CI 1.20, 12.04). Multivariate analysis showed this relationship to be consistent after inclusion of higher parity, country of birth, advanced maternal age and maternal obesity in the model (OR 4.56, 95% CI 1.25, 21.27). CONCLUSIONS: Maternal periodontal disease may contribute to perinatal mortality, especially that caused by extreme prematurity.

Two-stage management of sternal wound infection using bilateral pectoralis major advancement flap.

OBJECTIVE: To report our experience using two staged bilateral pectoralis major flap as the sole treatment modality for sternal wound infection. METHODS: A retrospective study of 9417 open-heart surgery cases performed between 1998 and 2003 at The Prince Charles Hospital. Sixty-eight patients were referred to the plastic surgical team for consideration of bilateral pectoralis major flap as the sole treatment modality for sternal wound infection. RESULTS: There was a trend for early referral for flap operation (median 10 days) (p=0.49). The median postoperative ventilation time and ICU stay were 1 and 2 days, respectively. The median hospital stay after flap operation was 15.5 days. One-year overall survival was 91%. Ninety-five per cent healed stable sternum was achieved with 100% failure in patients with chronically unstable sternum. Early referral appears to be an important factor in preventing osteomyelitis formation (p=0.05) with the longest recurrence at 10 months postoperatively. CONCLUSIONS: The key to the successful management of deep sternal wound infection is early referral for pectoralis major flap operation. Our approach is safe with good long-term outcomes. We recommend this approach in all severe deep sternal wound infection but not in patients with chronic unstable sternum.