Mixed-polarization phenotype of ascites-associated macrophages in human ovarian carcinoma: correlation of CD163 expression, cytokine levels and early relapse

Ovarian cancer is typically accompanied by the occurrence of malignant ascites containing large number of macrophages. It has been suggested that these tumor-associated macrophages (TAMs) are skewed to alternative polarization (M2) and thereby play an essential role in therapy resistance and metastatic spread. In our study, we have investigated the nature, regulation and clinical correlations of TAM polarization in serous ovarian cancer. Macrophage polarization markers on TAMs and ascites cytokine levels were analyzed for 30 patients and associated with relapse-free survival (RFS) in a prospective study with 20 evaluable patients. Surface expression of the M2 marker CD163 on TAMs was inversely associated with RFS (p < 0.01). However, global gene expression profiles determined for 17 of these patients revealed a mixed-polarization phenotype unrelated to the M1/M2 classification. CD163 surface expression also correlated with the ascites levels of IL-6 and IL-10 (p < 0.05), both cytokines induced CD163 expression, and their ascites levels showed a clear inverse association with RFS (p < 0.01). These findings define a subgroup of patients with high CD163 expression, high IL-6 and/or IL-10 levels and poor clinical outcome.

Regulation of TAK1/TAB1-mediated IL-1β signaling by cytoplasmic PPARβ/δ

The peroxisome proliferator-activated receptor subtypes PPARα, PPARβ/δ, PPARγ are members of the steroid hormone receptor superfamily with well-established functions in transcriptional regulation. Here, we describe an unexpected cytoplasmic function of PPARβ/δ. Silencing of PPARβ/δ expression interferes with the expression of a large subset of interleukin-1β (IL-1β)-induced target genes in HeLa cells, which is preceded by an inhibition of the IL-1β-induced phosphorylation of TAK1 and its downstream effectors, including the NFκBα inhibitor IκBα (NFKBIA) and the NFκBα subunit p65 (RELA). PPARβ/δ enhances the interaction between TAK1 and the small heat-shock protein HSP27, a known positive modulator of TAK1-mediated IL-1β signaling. Consistent with these findings, PPARβ/δ physically interacts with both the endogenous cytoplasmic TAK1/TAB1 complex and HSP27, and PPARβ/δ overexpression increases the TAK1-induced transcriptional activity of NFκB. These observations suggest that PPARβ/δ plays a role in the assembly of a cytoplasmic multi-protein complex containing TAK1, TAB1, HSP27 and PPARβ/δ, and thereby participates in the NFκB response to IL-1β.

[Evaluation of the "initiative pain-free clinic" for quality improvement in postoperative pain management. A prospective controlled study]

AIM

Demonstration of improved postoperative pain management by implementation of the S3 guidelines on treatment of acute perioperative and posttraumatic pain, by the integrated quality management concept "quality management acute pain" of the TÜV Rheinland or by participation in the benchmark project "Quality improvement in postoperative pain management" (QUIPS).

METHODS

A prospective controlled study (pre-post design) was carried out in hospitals with various levels of care comparing three hospital groups (n = 17/7/3, respectively). Group 1: participation in the QUIPS project (intraclinic and interclinic comparison of outcome data of postoperative pain treatment), group 2: participation in the quality management acute pain program (certified by TÜV Rheinland), group 3: control group with no involvement in either of the two concepts. In all three groups, an anonymous data collection was performed consisting of patient-reported pain intensity, side effects, pain disability and patient satisfaction. Pain therapy intervention was carried out only in group 2 by an integrated quality management concept (certification project: Quality management acute pain) with a package of measures to improve structure, process and outcome quality.

RESULTS

The TÜV Rheinland certified clinics (group 2) showed a significant improvement in the pre-post comparison (before versus after certification) in the areas maximum pain (from visual analogue scale VAS 4.6 to 3.7), stress pain (5.3 to 3.9), pain-related impairment (proportion of patients with pain-linked decreased mobility and movement 26% to 16.1%, coughing and breathing 23.1% to 14.3%) and patient satisfaction (from 13.2 to 13.7; scale 0 completely unsatisfied, 15 very satisfied). The clinics with participation in QUIPS for 2 years also showed a significant improvement in stress pain (numeric rating scale NRS for pain 4.5 to 4.2), pain-linked-limitation of coughing and breathing (28% to 23.6%), and patient satisfaction (from 11.9 to 12.4). There were no differences in postoperative nausea and vomiting between any of the groups.

CONCLUSIONS

The main objective of the certification concept quality management acute pain as a tool for the successful implementation of the S3 guidelines on treatment of acute perioperative and posttraumatic pain, led to a significant improvement in patient outcome. Participation in QUIPS is an ideal supplement to TÜV Rheinland certification and can be recommended as a benchmarking tool to evaluate outcome.

Microbiological stability of solutions containing local anesthetics and opioids in closed infusion systems used for epidural analgesia

Nine solutions containing opiod analgesics and local anesthetics as typically use in epidural catheters were tested for antimicrobial stability. Administration via a pefusor syringe requires several refill processes. It was shown that repetitive refilling of the syringes did not result in any microbiological contamination.

Determination of moderate-to-severe postoperative pain on the numeric rating scale: a cut-off point analysis applying four different methods

BACKGROUND

Cut-off points (CPs) of the numeric rating scale (NRS 0-10) are regularly used in postoperative pain treatment. However, there is insufficient evidence to identify the optimal CP between mild and moderate pain.

METHODS

A total of 435 patients undergoing general, trauma, or oral and maxillofacial surgery were studied. To determine the optimal CP for pain treatment, four approaches were used: first, patients estimated their tolerable postoperative pain intensity before operation; secondly, 24 h after surgery, they indicated if they would have preferred to receive more analgesics; thirdly, satisfaction with pain treatment was analysed, and fourthly, multivariate analysis was used to calculate the optimal CP for pain intensities in relation to pain-related interference with movement, breathing, sleep, and mood.

RESULTS

The estimated tolerable postoperative pain before operation was median (range) NRS 4.0 (0-10). Patients who would have liked more analgesics reported significantly higher average pain since surgery [median NRS 5.0 (0-9)] compared with those without this request [NRS 3.0 (0-8)]. Patients satisfied with pain treatment reported an average pain intensity of median NRS 3.0 (0-8) compared with less satisfied patients with NRS 5.0 (2-9). Analysis of average postoperative pain in relation to pain-related interference with mood and activity indicated pain categories of NRS 0-2, mild; 3-4, moderate; and 5-10, severe pain.

CONCLUSIONS

Three of the four methods identified a treatment threshold of average pain of NRS≥4. This was considered to identify patients with pain of moderate-to-severe intensity. This cut-off was indentified as the tolerable pain threshold.

Genomewide analyses define different modes of transcriptional regulation by peroxisome proliferator-activated receptor-β/δ (PPARβ/δ)

Peroxisome proliferator-activated receptors (PPARs) are nuclear receptors with essential functions in lipid, glucose and energy homeostasis, cell differentiation, inflammation and metabolic disorders, and represent important drug targets. PPARs heterodimerize with retinoid X receptors (RXRs) and can form transcriptional activator or repressor complexes at specific DNA elements (PPREs). It is believed that the decision between repression and activation is generally governed by a ligand-mediated switch. We have performed genomewide analyses of agonist-treated and PPARβ/δ-depleted human myofibroblasts to test this hypothesis and to identify global principles of PPARβ/δ-mediated gene regulation. Chromatin immunoprecipitation sequencing (ChIP-Seq) of PPARβ/δ, H3K4me3 and RNA polymerase II enrichment sites combined with transcriptional profiling enabled the definition of 112 bona fide PPARβ/δ target genes showing either of three distinct types of transcriptional response: (I) ligand-independent repression by PPARβ/δ; (II) ligand-induced activation and/or derepression by PPARβ/δ; and (III) ligand-independent activation by PPARβ/δ. These data identify PPRE-mediated repression as a major mechanism of transcriptional regulation by PPARβ/δ, but, unexpectedly, also show that only a subset of repressed genes are activated by a ligand-mediated switch. Our results also suggest that the type of transcriptional response by a given target gene is connected to the structure of its associated PPRE(s) and the biological function of its encoded protein. These observations have important implications for understanding the regulatory PPAR network and PPARβ/δ ligand-based drugs.

[Estimation of postoperative pain after tonsillectomy in adults using QUIPS: an instrument to improve postoperative pain management]

BACKGROUND

Tonsillectomy leads to strong postoperative pain. Pain management often is not optimal after tonsillectomy. To date, there exists no clear guideline for pain management after tonsillectomy.

METHODS

In a prospective study 65 tonsillectomy patients were examined at the first postoperative day within the QUIPS project. This allowed a standardised assessment of patients' characteristics, pain parameters, outcome and process parameters. The influence of these parameters on the patients' postoperative pain was estimated with univariate and multivariate statistic analysis.

RESULTS

All patients report of constant slight pain during the first postoperative day after tonsillectomy. Although maximal pain intensity was moderate, overall, patients were satisfied with the pain management. Pain management did not result in relevant side effects. Younger patients suffered significantly more from maximal pain than older patients. The same was obvious for patients who needed pain killers already prior to surgery. Perioperative antibiotic treatment and specific counselling about the possibilities of postoperative pain management reduced pain intensity highly significant in univariate and multivariate analysis. Patients receiving opioids on the ward postoperatively had significantly less pain.

DISCUSSION

QUIPS is a very good tool to evaluate the quality of postoperative pain management in one's own hospital. Next step, a detailed comparison to the best practise of other hospitals participating at QUIPS will follow in order to improve and standardize pain management for adult tonsillectomy patients.

EGF-dependent induction of BCL-xL and p21CIP1/WAF1 is highly variable in HNSCC cells--implications for EGFR-targeted therapies

The anti-apoptotic protein BCL-x(L) and the cell cycle inhibitor p21(CIP1/WAF1) were previously implicated in head and neck cancer. Several reports point to a role of the epidermal growth factor receptor (EGFR, ErbB-1, HER1) in regulating their expression. In the present study, we investigated the influence of EGFR on these tumor-associated factors. HNSCC cell lines were incubated with EGF or with the EGFR-specific kinase inhibitor AG1478. Western blot analysis and quantitative reverse transcription-polymerase chain reaction (qRT-PCR) were deployed to measure BCL-x(L) and p21(CIP1/WAF1) protein and mRNA levels. A dose-dependent rise of BCL-x(L) as well as p21(CIP1/WAF1) protein was noted after incubation with EGF, whereas inhibition with AG1478 reduced basal expression levels. No influence on BCL-2 was seen. Interestingly, qRT-PCR revealed that p21(CIP1/WAF1) but not BCL-x(L) transcript levels were induced after EGF treatment. Taken together, it can be stated that p21(CIP1/WAF1) and BCL-x(L) but not BCL-2 levels are tightly regulated by EGFR in HNSCC cell lines. BCL-x(L) induction appears to be due to protein stabilization rather than transcriptional activation, which is the likely cause of p21(CIP1/WAF1) induction. The noted variability in EGF response of HNSCC cells could reflect frequently observed variations in clinical response rates after implementation of anti-EGFR therapies.

Reverse crosstalk of TGFβ and PPARβ/δ signaling identified by transcriptional profiling

Previous work has provided strong evidence for a role of peroxisome proliferator-activated receptor β/δ (PPARβ/δ) and transforming growth factor-β (TGFβ) in inflammation and tumor stroma function, raising the possibility that both signaling pathways are interconnected. We have addressed this hypothesis by microarray analyses of human diploid fibroblasts induced to myofibroblastic differentiation, which revealed a substantial, mostly reverse crosstalk of both pathways and identified distinct classes of genes. A major class encompasses classical PPAR target genes, including ANGPTL4, CPT1A, ADRP and PDK4. These genes are repressed by TGFβ, which is counteracted by PPARβ/δ activation. This is mediated, at least in part, by the TGFβ-induced recruitment of the corepressor SMRT to PPAR response elements, and its release by PPARβ/δ ligands, indicating that TGFβ and PPARβ/δ signals are integrated by chromatin-associated complexes. A second class represents TGFβ-induced genes that are downregulated by PPARβ/δ agonists, exemplified by CD274 and IL6, which is consistent with the anti-inflammatory properties of PPARβ/δ ligands. Finally, cooperative regulation by both ligands was observed for a minor group of genes, including several regulators of cell proliferation. These observations indicate that PPARβ/δ is able to influence the expression of distinct sets of both TGFβ-repressed and TGFβ-activated genes in both directions.

Transcriptional profiling identifies functional interactions of TGF β and PPAR β/δ signaling: synergistic induction of ANGPTL4 transcription

Peroxisome proliferator-activated receptors (PPARs) not only play a key role in regulating metabolic pathways but also modulate inflammatory processes, pointing to a functional interaction between PPAR and cytokine signaling pathways. In this study, we show by genome-wide transcriptional profiling that PPARβ/δ and transforming growth factor-β (TGFβ) pathways functionally interact in human myofibroblasts and that a subset of these genes is cooperatively activated by TGFβ and PPARβ/δ. Using the angiopoietin-like 4 (ANGPTL4) gene as a model, we demonstrate that two enhancer regions cooperate to mediate the observed synergistic response. A TGFβ-responsive enhancer located ∼8 kb upstream of the transcriptional start site is regulated by a mechanism involving SMAD3, ETS1, RUNX, and AP-1 transcription factors that interact with multiple contiguous binding sites. A second enhancer (PPAR-E) consisting of three juxtaposed PPAR response elements is located in the third intron ∼3.5 kb downstream of the transcriptional start site. The PPAR-E is strongly activated by all three PPAR subtypes, with a novel type of PPAR response element motif playing a central role. Although the PPAR-E is not regulated by TGFβ, it interacts with SMAD3, ETS1, RUNX2, and AP-1 in vivo, providing a possible mechanistic explanation for the observed synergism.

Long-term efficacy and safety of combined prolonged-release oxycodone and naloxone in the management of non-cancer chronic pain

OBJECTIVE

The aim of this study was to assess safety and efficacy of fixed combination oxycodone prolonged release (PR)/naloxone PR in terms of both analgesia and improving opioid-induced bowel dysfunction (OIBD) and associated symptoms, such as opioid-induced constipation (OIC), in adults with chronic non-cancer pain.

STUDY DESIGN

These were open-label extension studies in which patients who had previously completed a 12-week, double-blind study received oxycodone PR/naloxone PR for up to 52 weeks. The analgesia study assessed pain using the modified Brief Pain Inventory-Short Form (BPI-SF). The bowel function study assessed improvements in constipation using the Bowel Function Index (BFI).

RESULTS

At open-label baseline in the analgesia study (n = 379), mean score [+/- standard deviation (SD)] for the BPI-SF item 'average pain over the last 24 h' was 3.9 +/- 1.52, and this remained low at 6 months (3.7 +/- 1.59) and 12 months (3.8 +/- 1.72). Mean scores for BPI-SF item 'sleep interference', and the BPI-SF 'pain' and 'interference with activities' subscales also remained low throughout the 52-week study. In the bowel function study (n = 258), mean BFI score (+/- SD) decreased from 35.6 +/- 27.74 at the start of the extension study to 20.6 +/- 24.01 after 12 months of treatment with oxycodone PR/naloxone PR. Pain scores also remained low and stable during this study. Adverse events in both extension phases were consistent with those associated with opioid therapy; no additional safety concerns were observed.

CONCLUSION

Results from these two open-label extension studies demonstrate the long-term efficacy and tolerability of fixed combination oxycodone PR/naloxone PR in the treatment of chronic pain. Patients experienced clinically relevant improvements in OIBD while receiving effective analgesic therapy.

Room for improvement: nurses' and physicians' views of a post-operative pain management program

BACKGROUND

The practice of post-operative pain therapy continues to be a problem. We conducted a survey among nurses and physicians about their views of an established post-operative pain management program.

METHODS

A questionnaire was sent to all nurses and physicians of nine surgical wards (general, trauma, cardio-thoracic and oromaxillofacial surgery and gynecology). Questions were developed from qualitative interviews with staff. Patient data were derived from a post-operative pain registry.

RESULTS

Seventy-eight physicians and nurses answered; the overall response rate was 23%. Post-operative pain therapy had high personal priority on an 11-point numeric rating scale (mean 9.08+/-1.27 standard deviation), but the success of pain management on the ward was rated as 7.32+/-1.37. Staff rating of success tended to correspond with patients' actual pain ratings. Knowledge of pain therapy was assessed as 6.85+/-1.82; nurses consistently rated levels higher than physicians. Staff over- or underestimated the painfulness of typical procedures and females rated procedures as more painful than men. There was considerable confusion about responsibilities and duties. 10.7% of staff perceived time delays exceeding 6 h between a request for acute pain services (APS) consultation and administration of medication to the patient. Invited comments suggested improvement in personnel education, team coordination, communication with patients and speed of action to increase the quality of pain therapy.

CONCLUSION

Despite staff's high personal priority and well-established APS and pain management program, post-operative pain therapy still leaves room for improvement. Considerable confusion about responsibilities and duties underlines the importance of better organizational approaches.