The relationship between mesorectal grading and oncological outcome in rectal adenocarcinoma

AIM

The prognostic association between mesorectal grading and oncological outcome in patients undergoing resection for rectal adenocarcinoma is controversial. The aim of this retrospective chart review was to determine the individual impact of mesorectal grading on rectal cancer outcomes.

METHOD

We compared oncological outcomes in patients with complete, near-complete and incomplete mesorectum who underwent rectal excision with curative intent from 2009 to 2014 for Stage cI-III rectal adenocarcinoma. We also assessed the independent association of mesorectal grading and oncological outcome using multivariate models including other relevant variables.

RESULTS

Out of 505 patients (339 men, median age of 60 years), 347 (69%) underwent a restorative procedure. There were 452 (89.5%), 33 (6.5%) and 20 (4%) patients with a complete, near-complete and incomplete mesorectum, respectively. Local recurrence was seen in 2.4% (n = 12) patients after a mean follow-up of 3.1 ± 1.7 years. Unadjusted 3-year Kaplan-Meier analysis by mesorectal grade showed decreased rates of overall, disease-free and cancer-specific survival and increased rates of overall and distant recurrence with a near-complete mesorectum, while local recurrence was increased in cases of an incomplete mesorectum (all P < 0.05). On multivariate analyses, a near-complete mesorectum was independently associated with decreased cancer-specific survival (hazard ratio 0.26, 95% CI 0.1-0.7; P = 0.007). There were no associations between mesorectal grading and overall survival, disease-free survival, overall recurrence or distant recurrence (all P > 0.05).

CONCLUSION

Mesorectal grading is independently associated with oncological outcome. It provides unique information for optimizing surgical quality in rectal cancer.

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018

BACKGROUND

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol.

METHODS

A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly.

CONCLUSIONS

The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Mobilum-a new mobile app to engage visuospatial processing for the reduction of intrusive visual memories

Intrusive memories are a key symptom of posttraumatic stress disorder (PTSD), a prevalent condition causing considerable personal suffering, and entailing large direct and indirect societal costs. While effective treatment options for PTSD exist, on a global scale they are not readily available to many patients in need. In the last years, several studies have shown that the computer game Tetris can reduce the frequency of intrusive memories in healthy subjects (after a trauma analogue), in populations at high risk of developing PTSD, as well as in patients already suffering from PTSD. The presumed mechanism behind this effect is that both Tetris and intrusions require-and therefore compete for-limited visuospatial working memory resources. In search for a new alternative tool that can engage visuospatial processing as effectively as Tetris, we developed a game named Mobilum. This is an app for Android devices, in which users have to rotate in an imaginative way around a translucent virtual cube in order to decide from which perspective a complex three-dimensional figure inside the cube is seen. Mobilum was developed to investigate whether the intrusion-reducing effect is exclusively inherent to Tetris, or if it can be achieved with another task engaging users in visuospatial processing. Also, unlike available versions of Tetris, Mobilum offers full control over key game parameters (e.g., difficulty, game duration), and is free of copyright and commercial issues. In this method paper, we describe the new Mobilum app, its theoretical background and development. Additionally, the first data on usability and feasibility are reported, as rated by N=16 inpatients. Finally, we will provide an outlook on the next steps necessary to investigate Mobilum's potential as a therapeutic tool.

Investigating the effect of proactive interference control training on intrusive memories

Intrusive re-experiencing is a hallmark symptom of Posttraumatic Stress Disorder (PTSD). According to prominent models of intrusive phenomena, intrusive memories may result from impairments in the efficiency of working memory capacity (WMC), more specifically proactive interference control. Yet, experimental research is scarce. Therefore, the present study aimed to investigate experimentally the role of proactive interference control in intrusive memories. We randomly assigned 57 healthy participants to either receive a high interference control training or a low interference control training. Participants were then exposed to highly distressing film clips. WMC was assessed before and after the training. Intrusion symptoms were assessed directly post-training and after one week using an Intrusion Provocation Task (IPT), a one-week intrusions diary, and the retrospective intrusion subscale of the Impact of Event Sale - Revised (IES-R). Results indicated that both groups reported improvements in WMC and fewer intrusions on the second IPT post-training, with no differences between groups. Similarly, no group differences on intrusions were found at one-week follow-up (i.e., intrusion diary and IES-R). To conclude, these data are not consistent with the hypothesis that WMC plays a role in intrusive re-experiencing. Implications for future research are discussed.

Control of stem cell response and bone growth on biomaterials by fully non-peptidic integrin selective ligands

Integrin selective peptidomimetics tune stem cell behavior in vitro and improve bone formation in rat calvarial defects.

Fluorescence imaging of invasive head and neck carcinoma cells with integrin αvβ6-targeting RGD-peptides: an approach to a fluorescence-assisted intraoperative cytological assessment of bony resection margins

We assessed the use of peptides containing arginylglycylaspartic acid (RGD) that target integrin αvβ6 as a potential approach for a fluorescence-assisted intraoperative cytological assessment of bony resection margins (F-AICAB) in patients who had bone-infiltrating squamous cell carcinoma (SCC) of the head and neck. This was assessed to demarcate invasive carcinoma cells that stained for αvβ6. Specimens from bony resection margins (n=362) were defined as either malignant or benign according to the results of cytological and histological examinations. Integrin αvβ6-targeting fluorescence-labelled RGD peptides were added to the cytological samples and the accuracy of the resulting signal assessed by comparing it with the cytological findings. The value of F-AICAB was evaluated to find out if it could help to improve future diagnoses, tests, and treatments. Integrin αvβ6 was strongly expressed in invasive SCC cells and qualified as a marker for bone-infiltrating carcinoma cells. It showed a high affinity to bind to invasive SCC cells and enabled swift and specific demarcation of αvβ6-stained carcinoma cells. It was also diagnostic, with a sensitivity of 100% (95% CI 81.3% to 99.3%), specificity of 98.3% (95% CI 94.4% to 99.0%), positive predictive value of 92% (95% CI 70.2% to 94.3%), and negative predictive value of 100% (95% CI 96.9% to 99.9%), compared with the cytological findings. The targeting of specific integrin subtypes with selective, synthetic ligands, adapted for multimodal imaging, is a promising new approach to diagnosis. Further studies are necessary to provide more evidence for successful clinical translation and to establish the impact on clinical procedures.

Putative Markers of Repression in Patients Suffering From Mental Disorders

Background: The concept of psychodynamic conflict is essential to psychodynamic theory and therapy. In classical psychodynamic therapy, unconscious conflict themes need to be identified by the therapist and brought to the patient's awareness, in order to work through and ultimately solve them. According to theory, touching upon conflict-related topics leads to arousal, followed by activation of defense mechanisms such as repression. Starting with C.G. Jung's association studies more than 100 years ago, various proposals have been made to investigate psychodynamic conflicts based on free association and psychophysiological measures. This study presents an attempt to identify and differentiate between psychodynamic conflict themes in patients, using an adopted version of Jung's paradigm that had in previous studies been applied to healthy subjects. Method: Seventeen patients suffering from depression and other mental disorders associated freely to different cue sentences. Prior to the experimental procedure, patients' individual psychodynamic conflict types were assessed through clinical interviews. Sentences were either neutral, negative (but not conflict-related), or related to specific types of psychodynamic conflicts. Memory for the first three associations was later tested in an unexpected recall task. Skin conductance response (SCR) was recorded and analyzed together with reaction times (RTs) and self-ratings of emotional valence, arousal, and agreement with cue sentences. Results: Patients showed reduced memory performance for associations to conflict-related sentences in general, compared with negative and neutral sentences. Agreement with conflict-related sentences was lower compared to neutral but not negative sentences. Memory was negatively correlated with RTs and SCR. RTs were longer for conflict types that had been rated as relevant in clinical interviews prior to the association task, compared to the other, non-relevant conflict types. Conclusion: Our study shows that some putative markers of repression of psychodynamic conflicts previously established in healthy participants also occur in patients. Moreover, it provides evidence that general conflict effects differ from specific effects of personally relevant conflicts.

Augmenting inpatient treatment for post-traumatic stress disorder with a computerised cognitive bias modification procedure targeting appraisals (CBM-App): protocol for a randomised controlled trial

INTRODUCTION

Influential theories of post-traumatic stress disorder (PTSD) suggest that dysfunctional appraisals of trauma play a key role in the maintenance of symptoms, and this suggestion is increasingly supported by research. Experimental studies have indicated that a simple computerised cognitive training procedure, here termed cognitive bias modification-appraisals (CBM-App), can modify trauma-relevant appraisals and reduce analogue trauma symptoms among healthy volunteers. This suggests the possibility that CBM-App could improve outcomes in PTSD via targeting the key process of dysfunctional appraisals, for example, if applied as an adjunct to treatment.

METHODS AND ANALYSIS

The study is a randomised controlled trial with two parallel arms. It is planned to randomise 80 patients admitted for treatment for PTSD to an inpatient treatment clinic to complete either sessions of CBM-App or a sham-training control condition, the peripheral vision task. Both interventions comprise eight sessions scheduled over a 2-week period and are completed in addition to the standard treatment programme in the clinic. Outcome assessment occurs pretraining, after 1 week of training, post-training, at discharge from the inpatient clinic and 6 weeks and 3 months postdischarge. The primary outcome is dysfunctional trauma-relevant appraisals at post-training, measured using a scenario completion task. Secondary outcomes include symptom measures and hair cortisol. Outcome analyses will be primarily via mixed linear models and conducted with both intention to treat and per protocol samples.

ETHICS AND DISSEMINATION

The trial has been approved by the Ethics Committee for the Faculty of Psychology, Ruhr-Universität Bochum (approval no 204) and the Ethics Committee for the Faculty of Medicine, Ruhr-Universität Bochum (approval no 15-5477). Results will be published in peer-reviewed journals and will inform future clinical and experimental studies into targeting maladaptive appraisals for the reduction of PTSD symptoms.

TRIAL REGISTRATION NUMBER

NCT02687555.

Synthesis and biological evaluation of a 99mTc-labelled cyclic RGD peptide for imaging the αvβ3 expression

Aim: The αvβ3 integrin is involved in tumour induced angiogenesis and tumour metastasis. We describe the synthesis and evaluation of a 99mTc-labelled RGD analogue for the visualisation of αvβ3 integrin expression. Methods: The linear peptides were assembled on a solid support. Cyclisation was performed under high dilution conditions. For conjugation with the chelator peptide, a water soluble carbodiimide was used. Radiolabelling was carried out due to standard procedures with high radiochemical yield and radiochemical purity. For in vivo evaluation, nude mice bearing αvβ3-positive human melanoma M21 and αv-negative human melanoma M21-L or Balb/c mice bearing αv-positive murine osteosarcoma were used. Results: Activity accumulation of 99mTc-DKCK-RGD 240 min p. i. was 1.1% ID/g in the αvβ3-positive melanoma and 0.3% ID/g in the negative control tumour. In the osteosarcoma model 2.2% ID/g was found 240 min p. i. Planar gamma camera images allowed contrasting visualisation of αvβ3-positive tumours 240 min p. i. Blocking of the tumour using the αvβ3-selective pentapeptide cyclo(-ArgGly-Asp-D-Phe-Val-) reduces activity accumulation in the tumour to background level. However, 240 min p. i. highest activity concentration was found in kidneys resulting in low tumour/kidney ratios. Metabolite analysis 240 min p. i. showed approximately 60% intact tracer in kidneys and 80% in the tumour. Only 24% intact tracer was found in blood 30 min p. i. Conclusion: 99mTc-DKCK-RGD allows imaging of αvβ3-positive tumours in mice. However, pharmacokinetics as well as metabolic stability of the tracer have to be improved for potential clinical application.

Restorative proctocolectomy: an example of how surgery evolves in response to paradigm shifts in care

AIM

Surgical technique constantly evolves in response to the pressure of progress. Ileal pouch anal anastomosis (IPAA) is a good example. We analysed the effect of changes in practice on the technique of IPAA and its outcomes.

METHOD

Patients undergoing primary IPAA at this institution were divided into three groups by date of the IPAA: those operated from 1983 to 1993, from 1994 to 2004 and from 2005 to 2015. Demographics, patient comorbidity, surgical techniques, postoperative outcomes, pouch function and quality of life were analysed.

RESULTS

In all, 4525 patients had a primary IPAA. With each decade, increasing numbers of surgeons were involved (decade I, 8; II, 16; III, 31), patients tended to be sicker (higher American Society of Anesthesiologists score) and three-staged pouches became more common. After an initial popularity of the S pouch, J pouches became dominant and a mucosectomy rate of 12% was standard. The laparoscopic technique blossomed in the last decade. 90-day postoperative morbidity by decade was 38.3% vs 50% vs 48% (P < 0.0001), but late morbidity decreased from 74.2% through 67.1% to 30% (P < 0.0001). Functional results improved, but quality of life scores did not. Pouch survival rate at 10 years was maintained (94% vs 95.2% vs 95.2%; P = 0.06).

CONCLUSION

IPAA is still evolving. Despite new generations of surgeons, a more accurate diagnosis, appropriate staging and the laparoscopic technique have made IPAA a safer, more effective and enduring operation.

Investigating Behavioral and Psychophysiological Reactions to Conflict-Related and Individualized Stimuli as Potential Correlates of Repression

Background: Repression is considered as a central defense mechanism in psychodynamic theory. It refers to the process by which "unbearable" mental contents (e.g., those related to internal conflicts) are kept out of consciousness. The process of repression is probably closely related to concepts of emotion regulation derived from a different theoretical background. This relationship is particularly relevant because it relates repression to current research in the affective neurosciences as well as to experimental studies on emotion regulation. Due to its complex and highly individual nature, repression has been notoriously difficult to investigate. We investigated repression with an individualized experiment in healthy subjects in order to establish methods to study repression in clinical populations. To this end we operationalized repression using individualized experimental conditions, and then studied potential behavioral [memory and reaction time (RT)] and psychophysiological correlates [skin conductance response (SCR)]. Method: Twenty-nine healthy female subjects were asked to freely associate to individualized cue sentences. Sentences were generated from individual psychodynamic interviews based on operationlized psychodynamic diagnosis (OPD), and were comprised of three different types: positive, negative non-conflictual, and negative conflict-related sentences. Subjects were asked to name the first three associations coming into their mind. Afterward, the remaining time was used for free association. SCR during each association trial and RT of the first given association were recorded. The memory for the first three associations was subsequently tested in an unexpected recall. Results: Associations to conflict-related cue sentences were associated with longer RTs and increased SCRs. Moreover, the unexpected recall task showed memory for these associations to be reduced. Conclusion: We interpret these findings as possible correlates of repression, in line with a history of experimental research into repression using non-individualized cues. Consequently, we suggest that this experimental paradigm could serve to investigate repression in clinical populations.

[Concordance of DSM-5®-Diagnoses Based on Diagnostic Interviews with People with Mental Disorders and Relatives or Friends: Implications for Psychological Autopsy Studies]

BACKGROUND

The evaluation whether a person who died by suicide suffered from a psychiatric disorder poses a diagnostic problem on psychological autopsy studies and is debated controversially.

OBJECTIVE

Do patients and relatives or friends agree on DSM-5^®-diagnoses?

METHODS

A sample of N=20 inpatients and their relatives or friends were interviewed using a structured-clinical interview. In total agreement on 78 patient-based and 72 relatives- or friends-based diagnoses could be assessed.

RESULTS

Agreement of patients' and relatives' or friend's diagnoses was low. Moderate concordance was found for the following diagnoses: Posttraumatic Stress Disorder, Somatic Symptom Disorder, Borderline Personality Disorder, and Binge-Eating Disorder. Only for the Persistent Depressive Disorder, the Binge-Eating Disorder, and the Borderline Personality Disorder good positive predictive values (0.75-0.80) were observed.

CONCLUSION

On the basis of interviews with relatives or friends, no reliable diagnostic decisions can be made.

Short-term outcomes of laparoscopic versus open total colectomy with ileorectal anastomosis: a case-matched analysis from a nationwide database

BACKGROUND

In the current study, we aimed to compare peri- and postoperative 30-day outcomes of patients undergoing laparoscopic versus open total colectomy with ileorectal anastomosis in a case-matched design using data procedure-targeted database.

METHODS

Patients who underwent elective total colectomy with ileorectal anastomosis in 2012 and 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Patients were divided into two groups according to the type of surgical approach (laparoscopic and open). Laparoscopic and open groups were matched (1:1) based on age, gender, diagnosis, body mass index, and American Society of Anesthesiologists classification. Comorbidities, perioperative, and short-term (30-day) postoperative outcomes were compared between the matched groups.

RESULTS

We identified 1442 patients-549 in the laparoscopic group and 893 patients in the open group. After case matching, there were 326 patients in each group. There were 48 (14.7%) patients who had conversion in the laparoscopic group. The open group had a higher proportion of patients with ascites [0 (0%) vs. 7 (2.1%) p = 0.015], preoperative weight loss [26 (8.0%) vs. 45 (13.8%) p = 0.018], and contaminated wound classifications [Clean/Contaminated 261 (80%) vs. 240 (74%), Contaminated 55 (16.9%) vs. 54 (16.6%), and Dirty/Infected 8 (2.5%) vs. 28 (8.6%), (p = 0.003)]. The laparoscopic group had a significantly longer operative time (242 ± 98 vs. 202 ± 116 min, p < 0.001), shorter hospital stay (9.4 ± 8.5 vs. 13.3 ± 10.7 days, p < 0.001), and lower ileus rate (23.9 vs. 31.0%, p = 0.045) than the open group. After adjusting for covariates, the differences in terms of operative time and hospital stay remained significant [odds ratio (OR): 0.79, confidence interval (CI) 0.74-0.85 and OR 1.36, CI 1.21-1.52, p < 0.001, respectively].

CONCLUSIONS

Laparoscopic approach for total colectomy with ileorectal anastomosis is associated with a shorter hospital stay but longer operative time compared with an open approach.

What are the consequences of enlarging the extraction site to exteriorize a large specimen during laparoscopic surgery for Crohn's enteritis?

AIM

The implications of extraction site enlargement for the removal of large specimens during laparoscopic surgery for Crohn's disease have not been clearly described; such a description is the aim of this study.

METHOD

An institutional database was queried to identify patients undergoing laparoscopic resection for Crohn's disease through midline incision between 1995 and 2013. Perioperative outcomes were compared among cases completed through their initial extraction site (L), completed after increasing the length of the initial extraction site (IL) for specimen exteriorization, and cases converted to open surgery (C). Univariate and multivariate statistical analyses were performed.

RESULTS

Out of 309 patients, 52 required IL and 36 required C. Heavier, older, male patients were more likely to require IL or C. There were no differences in disease behaviour (P = 0.260), procedures performed (P = 0.12) or postoperative morbidity (P = 0.33). IL and L groups had a comparable initial length of hospital stay (LOS), which was shorter than in the C group. While there were no significant differences in causes of readmission (P = 0.31), IL had increased readmission rates compared with L [odds ratio (OR) 2.80, P = 0.021] or C (OR 13.89, P = 0.015). When combining initial and readmission LOS, C and IL groups had comparable overall LOS [median ratio (MR) 1.09, P = 0.57], which was significantly longer than in the L group (MR 1.27, P = 0.02).

CONCLUSION

Extraction site enlargement during laparoscopic surgery for enteric Crohn's disease had no impact on primary LOS. However, the shorter initial LOS was offset by increased readmission rates when compared with formal conversion. The threshold to convert in case of anticipated difficulty due to a large specimen should be low.

Tuning Mesenchymal Stem Cell Response onto Titanium-Niobium-Hafnium Alloy by Recombinant Fibronectin Fragments

Since metallic biomaterials used for bone replacement possess low bioactivity, the use of cell adhesive moieties is a common strategy to improve cellular response onto these surfaces. In recent years, the use of recombinant proteins has emerged as an alternative to native proteins and short peptides owing to the fact that they retain the biological potency of native proteins, while improving their stability. In the present study, we investigated the biological effect of two different recombinant fragments of fibronectin, spanning the 8-10th and 12-14th type III repeats, covalently attached to a new TiNbHf alloy using APTES silanization. The fragments were studied separately and mixed at different concentrations and compared to a linear RGD, a cyclic RGD and the full-length fibronectin protein. Cell culture studies using rat mesenchymal stem cells demonstrated that low to medium concentrations (30% and 50%) of type III 8-10th fragment mixed with type III 12-14th fragment stimulated cell spreading and proliferation compared to RGD peptides and the fragments separately. On the other hand, type III 12-14th fragment alone or mixed at low volume percentages ≤50% with type III 8-10th fragment increased alkaline phosphatase levels compared to the other molecules. These results are significant for the understanding of the role of fibronectin recombinant fragments in cell responses and thus to design bioactive coatings for biomedical applications.

Integrin α5β1 and p53 convergent pathways in the control of anti-apoptotic proteins PEA-15 and survivin in high-grade glioma

Integrin α5β1 expression is correlated with a worse prognosis in high-grade glioma. We previously unraveled a negative crosstalk between integrin α5β1 and p53 pathway, which was proposed to be part of the resistance of glioblastoma to chemotherapies. The restoration of p53 tumor-suppressor function is under intensive investigations for cancer therapy. However, p53-dependent apoptosis is not always achieved by p53-reactivating compounds such as Nutlin-3a, although full transcriptional activity of p53 could be obtained. Here we investigated whether integrin α5β1 functional inhibition or repression could sensitize glioma cells to Nutlin-3a-induced p53-dependent apoptosis. We discovered that α5β1 integrin-specific blocking antibodies or small RGD-like antagonists in association with Nutlin-3a triggered a caspase (Casp) 8/Casp 3-dependent strong apoptosis in glioma cells expressing a functional p53. We deciphered the molecular mechanisms involved and we showed the crucial role of two anti-apoptotic proteins, phosphoprotein enriched in astrocytes 15 (PEA-15) and survivin in glioma cell apoptotic outcome. PEA-15 is under α5β1 integrin/AKT (protein kinase B) control and survivin is a p53-repressed target. Moreover, interconnections between integrin and p53 pathways were revealed. Indeed PEA-15 repression by specific small-interfering RNA (siRNA)-activated p53 pathway to repress survivin and conversely survivin repression by specific siRNA decreased α5β1 integrin expression. This pro-apoptotic loop could be generalized to several glioma cell lines, whatever their p53 status, inasmuch PEA-15 and survivin protein levels were decreased. Our findings identify a novel mechanism whereby inhibition of α5β1 integrin and activation of p53 modulates two anti-apoptotic proteins crucially involved in the apoptotic answer of glioma cells. Importantly, our results suggest that high-grade glioma expressing high level of α5β1 integrin may benefit from associated therapies including integrin antagonists and repressors of survivin expression.