Long-term results and complications of preoperative radiation in the treatment of rectal cancer

A retrospective study of 149 patients with rectal cancer diagnosed between 1972 and 1979 was undertaken to compare survival, disease-free survival, recurrence sites, and long-term complications of 40 patients who received 4000 to 4500 rads of preoperative adjuvant radiotherapy (radiation group) with those of 109 patients treated by resection alone (control group). After a mean follow-up of 84 months and 99 months, respectively, survival of the irradiated patients was significantly better than that of controls (68% versus 52%, p less than 0.05). Disease-free survival of those patients rendered free of disease by treatment was also superior for the irradiated group (84% versus 57%, p less than 0.005). Local recurrence without signs of distant metastases developed only one-third as often in irradiated patients (6% versus 18%). Distant metastases, alone or in combination with local recurrence, were also less common after radiation (12% versus 27%). Second primary tumors developed in 15% and 10% of the respective groups, a difference that was not statistically significant. When we consider the survival benefit of preoperative radiation therapy, long-term complications were relatively mild. Delayed healing of the perineum was noted in two irradiated patients. Persistent diarrhea was severe enough to warrant treatment in only one case, and one patient required a colostomy for intestinal obstruction from pelvic fibrosis.

Impaired polymorphonuclear leukocyte function in chronically hemodialyzed patients with iron overload

Polymorphonuclear (PMN) leukoyte function tests and clinical data analyses were performed in 28 chronic renal failure (CRF) patients receiving regular hemodialysis. We divided them into two groups; 12 patients with normal serum ferritin were classified as group 1 and 16 patients with high serum ferritin as group 2. There was no difference in age, BUN, serum creatinine, complement (C3, C4), peripheral white blood cell count and the duration of dialysis between the two groups, but the serum iron level was higher in group 2 (129.1 ± 46.58 μg/dl) than in group 1 (74.3 ± 20.9 μg/dl) (p<0.001). The total iron binding capacity was lower in group 2 (p<0.05) and the number of transfusions was higher in group 2 (25 ± 16.1) than in group 1 (12 ± 8.7) (p<0.05). The nitroblue-tetrazolium (NBT) test showed no difference among groups 1, 2 and the healthy control group. In chemotaxis to fMLP (N-formylmethionylleucylphenylalanine), the mean number of migrated neutrophils to fMLP (10⁻⁶ M/L) per high power field was significantly decreased in group 2 (99.5 ± 37.6) compared with the healthy control group (140.1 ± 13.4) (p<0.005), but not in group 1 (155.8 ± 79.4). In the phagocytosis test using Staphylococcus aureus, the phagocytic index ratio compared to the healthy control group was significantly decreased in group 2 (0.59 ± 0.14), but not in group 1 (0.97 ± 0.18). These results suggest that iron overload due to multiple transfusions in patients receiving regular long term hemodialysis may play a part in causing susceptibility to infection by impairing PMN leukocyte functions, especially chemotaxis and phagocytosis.

[Determination of the oxidation rate of medium-chain triglycerides in newborn infants with the 13C trioctanoin breath test]

Up to the present time medium chain triglycerides (MCT) have been applied solely for the enteral nutrition of newborn infants. Results of the oxidative utilization of parenterally applicated MCT have not yet been published. We therefore investigated the MCT oxidation with the 13C trioctanoin breath test in neonates. The patients received parenterally 10 mg/kg MCT (1-13C3 trioctanoin) enriched with the stable isotope 13C and emulsified with MCT/LCT 10%. The expired 13CO2 resulting from fat oxidation was determined by a ratio-mass-spectrometer. The 13C content of exhaled air represents the rate of fatty acid oxidation. Within the test period the fatty acid oxidation showed a clear dependency on the simultaneous carbohydrate supply. The oxidation rates of MCT were about twice als high as those of long chain triglycerides (LCT). On account of their high energetic level, MCT-containing emulsions are, in principle, also suitable for the parenteral nutrition of newborn infants.

Mutant isolation and molecular cloning of mre genes, which determine cell shape, sensitivity to mecillinam, and amount of penicillin-binding proteins in Escherichia coli

A chromosomal region of Escherichia coli contiguous to the fabE gene at 71 min on the chromosomal map contains multiple genes that are responsible for determination of the rod shape and sensitivity to the amidinopenicillin mecillinam. The so-called mre region was cloned and analyzed by complementation of two closely related but distinct E. coli mutants characterized, respectively, by the mutations mre-129 and mre-678, that showed a rounded to irregular cell shape and altered sensitivities to mecillinam; the mre-129 mutant was supersensitive to mecillinam at 30 degrees C, but the mre-678 mutant was resistant. The mre-678 mutation also caused simultaneous overproduction of penicillin-binding proteins 1Bs and 3. A chromosomal region of the wild-type DNA containing the total mre region and the fabE gene was first cloned on a lambda phage; a 7-kilobase (kb) fragment containing the whole mre region, but not the fabE gene, was then recloned on a mini F plasmid, pLG339; and finally, a 2.8-kb fragment complementing only mre-129 was also cloned on this low-copy-number plasmid. The whole 7-kb fragment was required for complementing the mre-678 mutant phenotypes. Fragments containing fabE but not the mre-129 region could be cloned on a high-copy-number plasmid. Southern blot hybridization indicated that the mre-678 mutant had a large deletion of 5.25 kb in its DNA, covering at least part of the mre-129 gene.

Osteomalacia of the mother--rickets of the newborn

During the last 4 years we observed four cases of neonatal rickets. The mothers of the infants suffered from osteomalacia for 1-3 years prior to its diagnosis shortly after the birth of their children. All four infants were born with craniotabes, and one infant had, in addition, a radial fracture. The diagnoses were confirmed by radiological and laboratory tests which revealed a rarefied bone structure, decreased serum 25-hydroxy-vitamin D and increased alkaline phosphatase levels in all patients. The disorder regressed under low-dose vitamin D3 therapy. As osteomalacia seems to be predominant in oriental women living in Berlin, it is necessary to consider vitamin D deficiency when clinical symptoms of this disease arise and to treat these women at least during pregnancy.

[Effect of carbohydrate administration on leucine oxidation in newborn infants. Studies using the 13C leucine breath test]

The branched-chain amino acid leucine plays an important role in the protein metabolism of human beings. It not only inhibits protein degradation but also stimulates protein synthesis. The oxidation rate of leucine and the influence which nutritional conditions have on this amino acid can be measured with the intravenous 13C-leucine breath test. In order the apply the breath test on newborn infants, the required dosage of L-(1-13C)-leucine and the reproducibility of the test had, firstly, to be determined. Following this, the extent to which the leucine oxidation rate was influenced by a simultaneous carbohydrate intake was investigated. An evident discrimination between the 13CO2-exhalation and the 13CO2-baseline exhalation is demonstrated after a bolus injection of 1 mg L-(1-13C)-leucine/kg B.W. We were able to measure reproducible values of the leucine oxidation rate in newborn infants with a tracer dosage of 4 mg L-(1-13C)-leucine/kg B.W. We found that a higher intake of carbohydrate given at the same time produced a lower rate of leucine oxidation, which indicates increased utilization of leucine for the benefit of protein synthesis.

Intestinal anastomosis after preoperative radiation therapy for carcinoma of the rectum

A retrospective review was conducted on 133 patients who underwent anterior resection and primary intestinal anastomosis for adenocarcinoma of the rectum from 1973 to 1983 at the Baystate Medical Center. Forty patients received a moderate dose, 4,500 rads, of radiation therapy preoperatively. Twenty-six of these patients (65 per cent) underwent protective colostomy at operation. An additional 93 patients underwent an operation without radiation and 38 of these (42 per cent) had a colostomy. We found no significant difference between patients who did or did not undergo radiation therapy in the over-all rate of complications (25 per cent for those who underwent radiation and 29 per cent for those who did not). Furthermore, there was no significant difference in anastomotic leak rates between the two groups (10 and 7 per cent respectively), even after controlling for the presence of a protective colostomy. We did find that leak rates for both groups were markedly higher for patients with a colostomy (14 per cent) than for patients without (1 per cent) (p less than 0.005). We conclude that a moderate dose of radiation therapy preoperatively does not increase the risk of anastomotic leakage or other operative complications with anterior resection. Colorectal intestinal anastomosis may be safely performed without routine colostomy after planned preoperative adjuvant radiation therapy if the anastomosis is technically satisfactory.

Einfiuß der Kohlenhydratzufuhr auf die Leuzinoxydation bei Neugeborenen

Die verzweígtkettige essentielle Aminosäure Leuzin nimmt eine Schlüsselstellung im Proteinmetabolismus des Menschen ein. Ihr wird ein hemmender Einfiuß auf Proteinabbau und ein stimulierender Effekt auf den Proteinaufbau zugeschrieben. Mit dem íntravenösen ¹³C-Leuzin-Atemtest kann die Oxydationsrate dieser Aminosäure und ihre Beeinflussung durch unterschiedliche Ernährungsbedingungen bestimmt werden. Um den Atemtest im Neugeborenenalter anwen-den zu können, wurden zunächst die erforderliche Dosis und die Reproduzierbarkeit des Tests bestimmt. Anschließend untersuchten wir die Abhängigkeit der Leuzinoxydation von einer gleichzeitigen Kohlenhydratzufuhr. Bereits nach intravenöser Bolusgabe von 1 mg L- (1-¹³C)-Leuzin/kg KG ist eine deutliche Diskriminierung der ¹³CO,-Exhalation von der ¹³CO₂-Basisausscheidung nachzuweisen. Mit der Tracermenge von 4 mg ¹³C-Leuzin/kg KG werden beim Neugeborenen reproduzierbare Ergebnisse der Leuzinoxydationsrate gemessen. Die gleichzeitige Kohlenhydratgabe beeinflußt die Leuzinoxydation. Bei einer höheren Kohlenhydratzufuhr wird eine niedrigere Leuzinoxydation als Hin-weis auf eine vermehrte Nutzung des Leuzins für die Proteinsynthese gefunden.

Impaired fat utilization in parenterally fed low-birth-weight infants suffering from sepsis

Lipid infusion in low-birth-weight infants suffering from sepsis is still controversial. Consequently, we investigated the fat tolerance in six low-birth-weight infants with sepsis and 15 low-birth-weight infants without sepsis. For measurement of fat clearance, we assayed the serum concentrations of triglycerides enzymatically, and of the free fatty acids by colorimetric micromethod. The fatty acid oxidation was analyzed with the [13C]triolein breath test by means of ratio-mass spectrometry. The infants were maintained on continuous parenteral nutrition with various amounts of soybean oil emulsion (1 g, 2 g, and 3 g fat/kg body weight per day). Comparing the lipid infusion of 1 and 2 g fat/kg body weight per day between the two groups, we found triglyceride and free fatty acid values in both groups to be in the normal range. At a dose of 3 g of fat/kg body weight per day, septic low-birth-weight infants showed a significantly higher concentration of triglycerides (2.02 +/- 0.46 mmol/liter) and of free fatty acids (2.06 +/- 0.45 mmol/liter) than the nonseptic low-birth-weight infants (triglycerides: 1.09 +/- 0.43 mmol/liter; free fatty acids: 1.05 +/- 0.41 mmol/liter). The low-birth-weight infants with sepsis showed a reduced fat oxidation rate of 16.0 +/- 1.5% in contrast to that of the low-birth-weight infants without sepsis, whose rate was 38.4 +/- 1.8%. Accordingly, we apply dosages not exceeding 2 g of fat/kg body weight per day to septic low-birth-weight infants.

Peptidoglycan synthetic activities in membranes of Escherichia coli caused by overproduction of penicillin-binding protein 2 and rodA protein

Penicillin-binding protein (PBP)-2 and the RodA protein are known to function in determining the rod shape of Escherichia coli cells. Peptidoglycan biosynthetic reactions that required these two proteins were demonstrated in the membrane fraction prepared from an E. coli strain that overproduced both of these two proteins and which lacked PBP-1B activity (the major peptidoglycan synthetase activity in the normal E. coli membranes). The cross-linked peptidoglycan was synthesized from UDP-N-acetylmuramylpentapeptide and UDP-N-acetylglucosamine in the presence of a high concentration of cefmetazole that inhibited all of PBPs except PBP-2. The peptidoglycan was synthesized via a lipid intermediate and showed up to 30% cross-linking. The cross-linking reaction was strongly inhibited by the amidinopenicillin, mecillinam, and by other beta-lactam antibiotics that have a high affinity for PBP-2, but not by beta-lactams that had very low affinity for PBP-2. The formation of peptidoglycan required the presence of high levels of both PBP-2 and the RodA protein in the membranes, but it is unclear which of the two proteins was primarily responsible for the extension of the glycan chains (transglycosylation). However, the sensitivity of the cross-linking reaction to specific beta-lactam antibiotics strongly suggested that it was catalyzed by PBP-2. The transglycosylase activity of the membranes was sensitive to enramycin and vancomycin and was unusual in being stimulated greatly by a high concentration of a chelating agent.

Purification and sequencing of the active site tryptic peptide from penicillin-binding protein 5 from the dacA mutant strain of Escherichia coli (TMRL 1222)

The localization of the active site of penicillin-binding protein 5 from the dacA mutant of Escherichia coli strain TMRL 1222 has been determined. The protein was purified to homogeneity and labeled with [14C] penicillin G. The labeled protein was digested with trypsin, and the active site tryptic peptide was purified by a combination of gel filtration and high-pressure liquid chromatography. Sequencing of the purified [14C]penicilloyl peptide yielded the sequence Arg-Asp-Pro-Ala-Ser-Leu-Thr-Lys, which corresponds to residues 40-47 of the gene sequence (Broome-Smith, J., Edelman, A., and Spratt, B. G. (1983) in The Target of Penicillin (Hakenbeck, R., Holtje, J.-V., and Labischinski, H., eds) pp. 403-408, Walter de Gruyter, Berlin). The catalytic amino acid residue that forms a covalent bond with penicillin was identified by treating the purified [14C]penicilloyl peptide with a mixture of proteases and then separating the radioactive products using high-pressure liquid chromatography. Analysis of the radioactive peaks by amino acid analysis confirmed that it is the serine residue that reacts with the beta-lactam ring of penicillin.

[Fat utilization in newborn infants with and without heparin administration. Comparative study with the 13C-triolein breath test]

The elimination of parenterally administered lipids from the bloodstream of premature infants can be accelerated by activation of the lipoprotein-lipase using heparin. We have no evidence that the free fatty acids increasing under enhanced lipolytical activity are utilized for energy production. For this reason, the oxidation rates of intravenously administered lipids in premature infants are examined both with and without heparin. Triolein marked with 13C and processed in soybean oil is administered intravenously at a dosage of 10 mg/kg. 13CO2 results from fatty acid oxidation and is exhaled through the lungs, whereafter it is collected in separate breath samples over a period of 6 hours and determined by mass spectrometry. The examination was performed in 5 premature infants, first without heparin, then after heparin injection (10 U/kg). The extent of 13CO2 exhalation was not significantly influenced by heparin. Without heparin supply we measured a fatty acid oxidation of 32.0 +/- 2.57% which was the same (31.6 +/- 2.34%) after heparin injection. Single intravenous administration of 10 U heparin/kg does not cause increased fatty acid oxidation in premature infants.

Survival following moderate-dose preoperative radiation therapy for carcinoma of the rectum

We performed a retrospective study of patients with carcinoma of the rectum or rectosigmoid undergoing surgical resection. Forty-two patients received adjuvant preoperative radiation therapy (4000-4500 rad). One hundred twenty patients underwent surgical resection alone. Survival of radiation patients was significantly improved over that of Surgery Only patients, even after adjusting for nontreatment factors using Cox regression. Crude 5-year survival was 63% for radiation patients (74% adjusted) compared to 46% for surgery-only patients (48% adjusted) (P less than 0.025). Radiation patients also had longer disease-free survival than surgery-only patients (P less than 0.05) and fewer recurrences (14% versus 37%; P less than 0.025). Fewer radiation patients had lymph nodes involved with tumor than surgery-only patients (20% versus 35%; P = 0.07). Although 71% of radiation patients experienced radiation reactions, these were primarily mild and transitory. We believe that preoperative radiation is an effective and safe adjunct to surgery in the treatment of rectal cancer and that its use can lead to improved survival rates.

The affinity of imipenem (N-formimidoylthienamycin) for the penicillin-binding proteins of Staphylococcus aureus--binding and release

Penicillin-binding proteins 1, 2 and 3 in Staphylococcus aureus were found to possess common properties. All have very strong affinities for both benzylpenicillin and imipenem (N-formimidoylthienamycin), and all have an activity which releases bound imipenem, but not bound benzylpenicillin. Lower molecular weight penicillin-binding protein 4, which has a rather weak affinity for benzylpenicillin and also weak penicillinase activity showed an extraordinarily high affinity for imipenem but no antibiotic-releasing activity.

Measurement of fatty acid oxidation in premature newborn infants with the 13C-triolein breath test

The 13C-triolein breath test is a method giving evidence of extent and rate of fatty acid oxidation in newborn infants on parenteral nutrition. The test has the special advantage of being non-invasive. Triolein labeled with the stable carbon isotope 13C and emulsified in soybean-oil is used as a tracer. 10 mg of 13C triolein per kg body weight are administered intravenously. The 13CO2 resulting from the fatty acid oxidation is analysed in expired breath by ratio-mass-spectrometry. The calculated 13C elimination is representative of the rate of fatty acid oxidation during the examination period. First studies on 15 premature infants have shown that an average of 27.0 +/- 1.8% of the dose administered is oxidized within 4 h. The present results suggest that the oxidation rate may be related to the maturity of the prematurely born infants.

Lipid infusion in premature infants suffering from sepsis

In as much as possible side effects attributing to insufficient fat clearance with hyperlipemia, parenteral lipid administration to septic premature infants is controversial. In this study serum triglyceride and free fatty acid concentrations of nine low birth weight infants with septicemia and 21 low birth weight infants without septicemia were measured. Acidosis, hypoxia, hyperglycemia, and cardiovascular insufficiency were treated before parenteral lipid infusion was started. There was no occurrence of septic shock. In the course of fat infusion with 3 g/kg body weight per day in low birth weight infants without systemic infection we only found triglyceride concentrations of 1.15 mmol/liter and free fatty acid levels of 1.05 mmol/liter. Premature infants with septicemia showed, under fat application of 2 g/kg body weight per day, mean triglyceride levels of 1.67 mmol/liter and free fatty acid values of 1.94 mmol/liter. The highest concentrations occurred at 3 g fat/kg body weight per day with triglycerides of 2.02 mmol/liter and free fatty acids of 2.06 mmol/liter. They indicate a reduced clearance and support earlier findings of reduced utilization of infused fat in premature infants with septicemia. Triglyceride concentrations more than 1.7 mmol/liter probably induce an increase of phagocytosis of the fat particles with the effect of a partial block of the reticuloendothelial system and an impairment of pulmonary diffusion capacity. Therefore, we suggest dosages no higher than 2 g fat/kg body weight per day to low birth weight infants and we advise to check the triglycerides daily. Hypertriglyceridemia implicates an immediate reduction or total interruption of the lipid infusion until normal triglyceride values are regained.

Staphylococcus aureus and Micrococcus luteus peptidoglycan transglycosylases that are not penicillin-binding proteins

Major peptidoglycan transglycosylase activities, which synthesize uncross-linked peptidoglycan from lipid-linked precursors, were solubilized from the membranes of Staphylococcus aureus and Micrococcus luteus and were partially purified. The transglycosylase activities were separated from penicillin-binding proteins by solubilization and by purification steps. Therefore, we concluded that these activities were not activities of the penicillin-binding proteins, which are the presumptive peptidoglycan transpeptidases in these gram-positive cocci. Unlike Escherichia coli, in which the network structure of peptidoglycan is synthesized by multiple two-headed penicillin-binding proteins with both transpeptidase and transglycosylase activities, these gram-positive cocci have cell wall peptidoglycan which seems to be synthesized by penicillin-binding protein transpeptidases and a separate transglycosylase.

A computer-assisted radiologic reporting system

The patient registration and interpretation/reporting modules of a computer-assisted radiologic reporting system are described. Entries may be made at several levels of complexity, using bar codes or keyboard input. Several functions allow convenient access to the database. Output may be reformatted without programmer intervention via a maintenance file. The system allowed improved turnaround time, reduced costs, and better understanding of work patterns.

Adducted thumb syndrome. Report of a new case and a diagnostic approach

We report on a female newborn baby with a "myopathic" stiff face, open mouth, high-arched palate, microgenia, generalized muscular hypotonia, limited extension of elbows, wrists and knees, flexed adducted thumbs, velopharyngeal insufficiency, and hypertrichosis. Death occurred at 3 months due to respiratory insufficiency. Muscular biopsy revealed myopathic abnormalities.

Fat elimination in parenterally fed low birth weight infants during the first two weeks of life

Eighteen low birth weight infants (27-34 wk gestation) were given supplementary parenteral nutrition via peripheral veins of a maximal dose of 8.5 g glucose, 2.5 g amino acids (Aminovenös päd 10%) and 2 g soybean oil egg lecithin emulsion (Intralipid 10%) kg body weight/24 hr. The fat emulsion was infused continuously at a rate of 0.084 g/kg body weight/hr. The elimination of Intralipid from the blood stream was controlled by enzymatic determination of serum triglyceride concentrations, and the fatty acid pattern of the serum lipids was determined by gas chromatography. The serum triglyceride concentrations were 0.60 +/- 0.16 mmol/liter on the 1st day, increased to 0.96 +/- 0.29 mmol/liter up to the 5th day, and approached a level around 0.90 mmol/liter in the further course. No hypertriglyceridemia was noted. The fatty acid pattern of the serum lipids showed a linoleic acid fraction of 8.1 +/- 4.0% in the beginning, which was followed by a continuous increase up to 27.8 +/- 4.8% on the 7th day. No significant changes were noticed thereafter. The levels were within the normal limits as found in 2-wk-old enterally fed preterm infants of comparative maturity (25.6 +/- 3.4%). We conclude that the preterm infants can eliminate Intralipid from the blood stream if maximal dosage and infusion rate, as described above, are applied.

[Current status of parenteral feeding with fat infusions. Clinical experiences with premature and newborn infants]

By administration of fat emulsion a well-balanced parenteral nutrition concerning calories is possible in newborn infants. Investigations with great amounts of fat during and after a short-time infusion have shown that the maximal fat clearance of very-low-birth-weight and small-for-gestational-age newborn infants is limited. Heparin can improve the lipid clearance and reduce hyperlipaemia occurring under lipid application. The fat oxidation is not affected by heparinization. Extent and velocity of the fatty acid utilization can be judged by the 13C-triolein breath test. Under the clinical conditions of a continuous long-term infusion with 2 g fat/kg BW/day a complete fat clearance is observed in low-birth-weight infants with respiratory distress syndrome and septicaemia and small-for-gestational-age newborn infants. The determination of serum triglycerides is considered to be a sufficient control of fat clearance in respect to clinical concerns. The fat emulsion is continuously applied for 24 h and is being increased stepwise up to a dosage of 2-3 g/kg BW/day. Before starting parenteral nutrition, acidosis, hypoxaemia, hyperglycaemia and insufficient circulation must have been treated. Contraindications to this are shock, disturbances of blood coagulation and of fat metabolism. Complications are avoided by using an adapted and standardized nutritional programme under sufficient clinical and laboratory control.