A narrative review on the non-surgical treatment of chronic postoperative inguinal pain: a challenge for both surgeon and anaesthesiologist

INTRODUCTION

Chronic pain is one of the most frequent clinical problems after inguinal hernia surgery. Despite more than two decades of research and numerous publications, no evidence exists to allow for chronic postoperative inguinal pain (CPIP) specific treatment algorithms.

METHODS

This narrative review presents the current knowledge of the non-surgical management of CPIP and makes suggestions for daily practice.

RESULTS

There is a paucity for high-level evidence of non-surgical options for CPIP. Different treatment options and algorithms have been published for chronic pain patients in the last decades.

DISCUSSION AND CONCLUSION

It is suggested that non-surgical treatment is introduced in the management of all CPIP patients. The overall approach to interventions should be pragmatic, tiered and multi-interventional, starting with least invasive and only moving to more invasive procedures upon lack of effect. Evaluation should be multidisciplinary and should take place in specialized centres. We strongly suggest to follow general guidelines for treatment of persistent pain and to build a database allowing for establishing CPIP specific evidence for optimal analgesic treatments.

P-017 A FRAMEWORK FOR MULTIDISCIPLINARY TEAM MANAGEMENT OF ABDOMINAL WALL RECONSTRUCTION

Aim

Incisional hernias are common and can significantly impact a patient's quality of life. Traditionally, abdominal wall reconstruction (AWR) has been performed by general surgeons, or those with special interest, often working in isolation. However, there is increasing awareness of pre-optimisation, risk stratification, enhanced training, and personalising treatment using a wide range of techniques.

Methods & Results

For complex and higher-risk procedures, Multidisciplinary team (MDT) management is considered the standard of care for optimising outcomes. The lack of standardised protocols and clear evidence in AWR means that surgical management can vary greatly. This makes the MDT process even more important due to the complexity of the decision-making involved. We describe a successful MDT process for complex abdominal wall reconstruction at a tertiary referral centre. Patients are reviewed at weekly AWR meetings with a multidisciplinary team, which includes consultants, advanced clinical practitioners and trainees. This is an opportunity for objective risk stratification, radiological review and assessment of the patient's goals before preoptimization and operative planning. Prospective data is collected on all patients to allow for quality improvement and service development.

Conclusion

MDT management of abdominal wall hernia is gaining popularity but remains poorly established in most regions. The involvement of surgical colleagues and other specialists is crucial in developing this growing field of surgery. We hope to expand our team to include Radiologists and Nutritionists, with the possibility of extending to regional networks, as we continue to explore new techniques and methods in managing complex abdominal wall hernias.

P-155 ROLE OF MDT IN CPIP MANAGEMENT: LITERATURE REVIEW

Abstract

Chronic Post-operative Inguinal Pain (CPIP), is recognised as a long term condition and has a significant effect on patients’ quality of life. CPIP affects 18–30% of patients after an open inguinal hernia repair and 6% of patients after a laparoscopic inguinal hernia repair. CPIP result from several causes such as a pre-operative nerve lesion in other area of the body, an intra-operative nerve injury, or due to the intensity of acute post-operative inflammation and healing. a multidisciplinary clinic would be considered the best approach in order to assess patients’ pain and identify an individual management plan. This review allowed the team to choose which literature could be used to support the implementation of the clinical practice change.

Method

Literature searches were performed using PubMed and Embase databases were searched using key terms to include all related articles in the last ten years. three independent reviewers to choose included and excluded articles with two steps.

Results

Out of 25 articles found by the research, 8 articles included in this review including MDT about CPIP, meeting including criteria after the full articles reviewed. it was important to understand the nature and mechanisms of Chronic Post-operative inguinal hernia. several risk factors have been identified, which may be causing CPIP such as young age, recurrent inguinal hernia repair procedure and presence of pain before the procedure. Because of the complexity of CPIP, many authors concluding that a multidisciplinary approach should be considered the more appropriate method to ensure an effective and safe treatment. This include the need of regular follow up after an inguinal hernia repair to identify the chronic pain and establish an appropriate management plan.

Conclusions

Although the literature review enabled the team to gather useful information about the topic of the clinical practice change; it was evident that more researches and studies need to be completed in order to identify the safest and effective treatment for patients presenting with CPIP.

Atopic Dermatitis: Disease Characteristics and Comorbidities in Smoking and Nonsmoking Patients from the TREATgermany Registry

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disease with a multifactorial genesis including genetic predispositions and environmental risk and trigger factors. One of the latter possibly is smoking, indicated by an increased prevalence of AD in adults and children that are actively or passively exposed to cigarette smoke.

OBJECTIVES

In this study AD characteristics and its atopic comorbidities are compared in smoking and nonsmoking AD patients.

METHODS

TREATgermany is a non-interventional clinical registry which includes patients with moderate to severe AD in Germany. Baseline data of patients included into TREATgermany from inception in June 2016 to April 2020 in 39 sites across Germany was analyzed comparing AD disease characteristics and comorbidities in smokers versus non-smokers.

RESULTS

Of 921 patients, 908 (male: 58.7%) with a mean age of 41.9 ± 14.4 reported their smoking status. The objective Scoring of Atopic Dermatitis (oSCORAD) did not differ between smokers (n=352; 38.8%) and nonsmokers, however lesions' intensity of oozing/crusts and excoriations as well as patient global assessment scores (PGA) of AD severity were higher in smoking as opposed to nonsmoking patients. Smokers reported a lower number of weeks with well-controlled AD and more severe pruritus than nonsmokers. Total IgE levels were more elevated in smokers and they displayed a younger age at initial diagnosis of bronchial asthma. After adjustment for potential confounders, the increased intensity of oozing/crusts, the reduced number of weeks with well-controlled AD and the greater pruritus remained different in smokers compared to nonsmokers. In addition, smoking patients with adult-onset AD showed a 2.5 times higher chance of involvement of the feet.

CONCLUSIONS

German registry data indicate that AD patients who smoke have a higher disease burden with a different distribution pattern of lesions in adult-onset AD.

Microvolt t-wave alternans its clinical significance in the assessment of the risk of sudden cardiac death among patients with hypertrophic cardiomyopathy

Summary

Some patients with hypertrophic cardiomyopathy (HCM) are at significant risk of premature sudden death. Identification of the risk factors may enable effective prevention of adverse cardiac events in these patients. Assessment of the microvolt T-wave alternans (MTWA) is a recognized non-invasive diagnostic test used in risk stratification of sudden cardiac death (SCD). However, the number of reports on the frequency of occurrence of MTWA in HCM is small. Aim: Evaluation of the prognostic value of MTWA in predicting the risk of arrhythmic events (sudden cardiac death, documented VT/VF, appropriate ICD discharge) in patients with HCM.

Material and methods

122 patients with HCM underwent detailed clinical assessment and ECG- and echocardiographic examination. They underwent 24-hour ambulatory ECG monitoring, and the following elements were analysed: 1) arrhythmias, 2) heart rate variability (HRV) and the QT segment, 3) the presence of ventricular late potentials (LP), 4) heart rate turbulence (HRT). MTWA assessment was made during a test on a treadmill (Cambridge Heart). In accordance with the adopted criteria, the test was interpreted as negative, positive or indeterminate. Subsequently, positive and indeterminate results were described collectively as MTWA(+) and negative results as MTWA(−). Then the patients were divided into two groups: Group 1 – 57 patients (46,7%) with MTWA(−), and Group 2 – 65 patients (53,2%) with MTWA(+). In order to stratify the risk, the following were adopted as composite primary endpoints: sudden cardiac death or hospitalization for life-threatening arrhythmias (VT/VF), and appropriate ICD discharge.

Results

The mean follow-up period of the patients was 57±8 months; during that time, events that met the criteria for the endpoint occurred in 16 patients. On the basis of univariate analysis, 10 variables with a significant influence on the occurrence of an event were selected (unexplained syncope, NT-proBNP values elevated above 411 pg/ml, size of the left atrium over 44mm, diastolic thickness of the interventricular septum over 25 mm, the presence of MTWA(+), the QRS width >90 msec, QTc >467 msec, QTd >70 msec, SDNN <110 msec, and sinus rhythm turbulence parameters TS <2,9 ms/2RR). These variables were then included in a multivariate analysis. The model from a Cox regression analysis showed that the presence of unexplained syncope (HR=1,4), MTWA(+) (HR=1,5), size of the left atrium over 44mm (HR=5), and the thickness of the interventricular septum over 25 mm (HR=1,5) increased the risk of sudden events.

Conclusions

1) Patients with hypertrophic cardiomyopathy had a significant percentage of positive results of the microvolt T-wave alternans test (MTWA+), 2) Positive MTWA test result in patients with hypertrophic cardiomyopathy can help to identify patients at risk of sudden cardiac death.

Funding Acknowledgement

Type of funding sources: None.

321 The Darn Technique for Small (< 2 Cm Diameter) Midline Hernias

Aim

Primary midline hernias arising in the linea alba are common. While mesh repair has been shown to reduce recurrence rates even in small hernias, many surgeons still use a suture repair for defects of less than 2 cm. The recent European and Americas Hernia Societies Guidelines recommended suture repair only for hernias <1 cm. A darn is a tension-free repair where, in effect, a “mesh” is hand-woven across the defect in situ.

Method

Eligible patients undergoing this repair between 1 January 2008 and 31 December 2017 were identified from a prospective computer-based medical record system and their case notes reviewed. Inclusion criteria were adult patients with a primary midline abdominal wall defect smaller than 2 cm at the widest point measured intra-operatively. Follow up was by telephone. Those who reported possible recurrence or other symptoms in the region of their repair were reviewed in person.

Results

47 suture-darn repairs were undertaken. Fifteen operations (32%) were performed under local anaesthesia. Forty-one patients were followed up with a mean of 80 ± 35 and median of 87 months after surgery. Six patients (13%) were lost to follow-up. Recurrence was found in two cases (5%) and one patient has since been diagnosed with a new epigastric hernia some 5 cm cranial to the previous repair.

Conclusions

The darn repair for small primary midline hernias is quick and inexpensive with promising long-term results. It can be performed under local anaesthesia. It can serve as an alternative to mesh repair for defects less than 2 cm in maximum dimension.

Algorithm for management of an incarcerated inguinal hernia in the emergency settings with manual reduction. Taxis, the technique and its safety

BACKGROUND

An acute inguinal hernia remains a common emergency surgical condition worldwide. While emergency surgery has a major role to play in treatment of acute hernias, not all patients are fit for emergency surgery, nor are facilities for such surgery always available. Taxis is the manual reduction of incarcerated tissues from the hernia sack to its natural compartment, and can help delay the need for surgery from days to months. The aim of this study was to prepare a safe algorithm for performing manual reduction of incarcerated inguinal hernias in adults.

METHODS

Medline, Scopus, Ovid and Embase were searched for papers related to emergency inguinal hernias and manual reduction. In addition, the British National Formulary and Safe Sedation Practice for Healthcare Procedures: Standards and Guidance were reviewed.

RESULTS

A safe technique of manual reduction of an acute inguinal hernia, called GPS (Gentle, Prepared and Safe) Taxis, is described. It should be performed within 24 h from the onset of a painful irreducible lump in groin, and when concomitant symptoms and signs of bowel strangulation are absent. Conscious sedation guidelines should be followed. The most popular drug combination is of intravenous morphine and short-acting benzodiazepine, both titrated carefully for optimal and safe effect. The dose of drugs must be individualised, and the smallest effective dosage should be used to avoid oversedation. Following successful taxis, the patient should undergo a short period of observation. Urgent surgery can be undertaken during the same admission or up to several weeks later.

CONCLUSIONS

Taxis is a benign/non-invasive method for patients with an acute, non-strangulated inguinal hernias. It likely reduces the risk and complications of anaesthesia and surgery in the emergency settings. GPS Taxis should be considered as first line treatment in the majority of patients presenting with an acute inguinal hernia when existing bowel infarction is unlikely.

Abstract PS17-42: A fast and effective 3D preclinical assay system comprised of patient derived breast cancer microtumors combined with DigiWest protein signaling pathway analyses for therapeutic response prediction (Project PRIMO)

In the era of personalized medicine, the ability of pre-selecting individualized therapeutic options and pre-defining their suitability in advance of clinical treatment might facilitate decision making in breast cancer treatment and hence, improve patient outcome. In order to preclinically validate anti-cancer drug efficacy, it is crucial to design a model system that reveals the influence of cellular interactions of the tumor microenvironment and cellular heterogeneity on drug response. Within the PRIMO (Personalized Medicine for tailored cancer therapies) project, such a 3D preclinical model system comprised of patient-derived microtumors (PDM) and autologous tumor-infiltrating lymphocytes (TILs) isolated from fresh primary breast cancer tissue using limited digestion and subsequent culture in defined media in the absence of serum is established. Herein, the heterogeneous cellular composition of isolated PDM is analyzed by FFPE immunohistochemistry and compared to corresponding primary tumor tissue. The composition of autologous TILs influencing individual treatment responses is characterized by multi-color flow cytometry detecting different cell populations, such as tumor-specific CD8+ or regulatory CD4+ T-cells. By using the DigiWest technology, a proprietary high throughput immune assay screening tool, in-depth protein profiling of up to 200 analytes from low amounts of PDM material is performed. The generated protein profiles of PDM are compared to their corresponding primary tumor tissue as well as the pathological receptor grading. Furthermore, differences in activation of key signal transduction pathways are detected and related to treatment responses to small molecules, chemotherapeutics as well as immunotherapeutic agents within PDM and PDM-TIL co-cultures assessed by a functional viability assay in a microplate format. To expand this preclinical model system, we established PDM-co-cultures adding further immune cell types including natural killer (NK) cells or dendritic cells (DC).

In summary, immunohistochemical analyses combined with protein profiling of breast cancer PDM enables drug-mode-of-action analyses, biomarker identification together with personalized therapeutic sensitivity prediction. The platform presented here expands the preclinical repertoire of relevant test systems for efficacy testing of drugs and investigational compounds, pre-identified by protein pathways as well as genetic profiling in personalized medicine of breast cancer.

Citation Format: Nicole Anderle, Felix Ruoff, Simge Yuez, André Koch, Andreas Hartkopf, Sara Brucker, Michael Pawlak, Markus Templin, Christian Schmees. A fast and effective 3D preclinical assay system comprised of patient derived breast cancer microtumors combined with DigiWest protein signaling pathway analyses for therapeutic response prediction (Project PRIMO) [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS17-42.

The darn technique for small (< 2 cm diameter) midline hernias

PURPOSE

Primary midline hernias arising in the linea alba are common. While mesh repair has been shown to reduce recurrence rates even in small hernias, many surgeons still use a suture repair for defects of less than 2 cm. The recent European and Americas Hernia Societies Guidelines recommended suture repair only for hernias smaller than 1 cm. A suture repair implies edge-to-edge or overlapping fascial margins, which necessarily involves tension on the repair. A darn is a tension-free repair where, in effect, a "mesh" is hand-woven across the defect in situ.

METHODS

The darn repair is a modification of the darn techniques for inguinal hernia repair. Eligible patients undergoing this repair at the Royal Infirmary of Edinburgh between 1 January 2008 and 31 December 2017 were identified from a prospective computer-based medical record system and their case notes reviewed. Inclusion criteria were adult patients with a primary midline abdominal wall defect smaller than 2 cm in the widest diameter of the hernia defect measured intra-operatively. Patients were followed up by telephone in 2019. Those who reported possible recurrence or other symptoms in the region of their hernia repair were reviewed in the outpatient clinic.

RESULTS

47 suture-darn repairs were undertaken over the 10-year period. Fifteen of the darn repair operations (32%) were performed under local anaesthesia. Forty-one patients were followed up with a mean of 80 ± 35 and median of 87 months after surgery. Six patients (13%) were lost to follow-up. Recurrence was found in two cases (5%) and one patient has since been diagnosed with a new epigastric hernia some 5 cm cranial to the previous repair.

CONCLUSIONS

The darn repair for small primary midline hernias is quick and inexpensive with promising long-term results. It can be performed under local anaesthesia. It can serve as an alternative to mesh repair for defects less than 2 cm in maximum dimension.

HepaChip-MP - a twenty-four chamber microplate for a continuously perfused liver coculture model

HepaChip microplate (HepaChip-MP) is a microfluidic platform comprised of 24 independent culture chambers with continuous, unidirectional perfusion. In the HepaChip-MP, an automated dielectrophoresis process selectively assembles viable cells into elongated micro tissues. Freshly isolated primary human hepatocytes (PHH) and primary human liver endothelial cells (HuLEC) were successfully assembled as cocultures aiming to mimic the liver sinusoid. Minimal quantities of primary human cells are required to establish micro tissues in the HepaChip-MP. Metabolic function including induction of CYP enzymes in PHH was successfully measured demonstrating a high degree of metabolic activity of cells in HepaChip-MP cultures and sufficient sensitivity of LC-MS analysis even for the relatively small number of cells per chamber. Further, parallelization realized in HepaChip-MP enabled the acquisition of dose-response toxicity data of diclofenac with a single device. Several unique technical features should enable a widespread application of this in vitro model. We have demonstrated fully automated preparation of cell cultures in HepaChip-MP using a pipetting robot. The tubeless unidirectional perfusion system based on gravity-driven flow can be operated within a standard incubator system. Overall, the system readily integrates in workflows common in cell culture labs. Further research will be directed towards optimization of media composition to further extend culture lifetime and study oxygen gradients and their effect on zonation within the sinusoid-like microorgans. In summary, we have established a novel parallelized and scalable microfluidic in vitro liver model showing hepatocyte function and anticipate future in-depth studies of liver biology and applications in pre-clinical drug development.

Baseline characteristics, disease severity and treatment history of patients with atopic dermatitis included in the German AD Registry TREATgermany

BACKGROUND

The Atopic Dermatitis (AD) TREATgermany registry was initiated by the German Society for Dermatology (DDG) in 2011 to evaluate the 'real-life' situation of health care for patients with AD.

OBJECTIVES

Interim data analysis on baseline characteristics as well as current and prescribed systemic treatments of the TREATgermany registry patients.

METHODS

Patients (≥18 years) with moderate-to-severe AD [objective (o)SCORAD > 20], or with current or previous anti-inflammatory systemic treatment for AD within 24 months, were included and are followed up over at least 24 months. To assess clinical signs, the eczema area severity index (EASI, 0-72), the oSCORAD (0-83) and the Investigator Global Assessment (IGA; 6-point scale) were used. The disease severity was globally scored by the patients [Patient Global Assessment (PGA); six-step Likert scale]. Disease symptoms were assessed by the patient-oriented eczema measure (POEM, 0-28) and numeric rating scales (NRS, 0-10). Health-related quality of life was measured using the dermatological life quality index (DLQI, 0-30).

RESULTS

A total of 612 patients were recruited across 32 sites between 06/2016 and 01/2019 (mean age: 42.6 ± 14.2 years; mean oSCORAD: 40.8 ± 16.3). The mean POEM score was 16.3 ± 7.5. Pruritus was rated highest among subjective symptoms (NRS: 5.4 ± 2.7). The mean DLQI value was 11.3 ± 7.5. The frequency of arterial hypertension was lower (20.8%) compared with the general population, whilst this was higher for depression (10%). More than 60% of the patients had received systemic glucocorticosteroids, and 36.8% had received cyclosporine A prior to inclusion. Dupilumab was the leading substance documented as either 'current' (12.1%) or 'prescribed' (31.4%) at baseline.

CONCLUSIONS

These 'real-life' data clearly demonstrate the substantial disease burden. Most of TREATgermany patients were already treated with or prescribed dupilumab at baseline. Moreover, current findings indicate the urgent need for further alternative agents in order to achieve a perceptible improvement of quality of life of patients with moderate-to-severe AD.

PGRMC1 effects on metabolism, genomic mutation and CpG methylation imply crucial roles in animal biology and disease

Background

Progesterone receptor membrane component 1 (PGRMC1) is often elevated in cancers, and exists in alternative states of phosphorylation. A motif centered on PGRMC1 Y180 was evolutionarily acquired concurrently with the embryological gastrulation organizer that orchestrates vertebrate tissue differentiation.

Results

Here, we show that mutagenic manipulation of PGRMC1 phosphorylation alters cell metabolism, genomic stability, and CpG methylation. Each of several mutants elicited distinct patterns of genomic CpG methylation. Mutation of S57A/Y180/S181A led to increased net hypermethylation, reminiscent of embryonic stem cells. Pathways enrichment analysis suggested modulation of processes related to animal cell differentiation status and tissue identity, as well as cell cycle control and ATM/ATR DNA damage repair regulation. We detected different genomic mutation rates in culture.

Conclusions

A companion manuscript shows that these cell states dramatically affect protein abundances, cell and mitochondrial morphology, and glycolytic metabolism. We propose that PGRMC1 phosphorylation status modulates cellular plasticity mechanisms relevant to early embryological tissue differentiation.

PGRMC1 phosphorylation affects cell shape, motility, glycolysis, mitochondrial form and function, and tumor growth

BACKGROUND

Progesterone Receptor Membrane Component 1 (PGRMC1) is expressed in many cancer cells, where it is associated with detrimental patient outcomes. It contains phosphorylated tyrosines which evolutionarily preceded deuterostome gastrulation and tissue differentiation mechanisms.

RESULTS

We demonstrate that manipulating PGRMC1 phosphorylation status in MIA PaCa-2 (MP) cells imposes broad pleiotropic effects. Relative to parental cells over-expressing hemagglutinin-tagged wild-type (WT) PGRMC1-HA, cells expressing a PGRMC1-HA-S57A/S181A double mutant (DM) exhibited reduced levels of proteins involved in energy metabolism and mitochondrial function, and altered glucose metabolism suggesting modulation of the Warburg effect. This was associated with increased PI3K/AKT activity, altered cell shape, actin cytoskeleton, motility, and mitochondrial properties. An S57A/Y180F/S181A triple mutant (TM) indicated the involvement of Y180 in PI3K/AKT activation. Mutation of Y180F strongly attenuated subcutaneous xenograft tumor growth in NOD-SCID gamma mice. Elsewhere we demonstrate altered metabolism, mutation incidence, and epigenetic status in these cells.

CONCLUSIONS

Altogether, these results indicate that mutational manipulation of PGRMC1 phosphorylation status exerts broad pleiotropic effects relevant to cancer and other cell biology.

Current trends in hernia surgery in NHS England

BACKGROUND

Mesh is recommended for the repair of most hernias when prevention of recurrence is the primary endpoint. However, mesh may be associated with increased complications for the patient. The aim of this study was to quantify the use of mesh for abdominal wall hernia surgery in NHS England in recent years.

MATERIALS AND METHODS

The NHS Digital Secondary Uses Service database for 2016/17 and 2017/18 was interrogated for numbers of patient undergoing elective primary hernia surgery. Using the specific hernia code inguinal (T201-9), umbilical (T241-9), incisional (T251-9) and other abdominal wall hernia (T271-9), the use of mesh or suture repair was determined. Recurrent and emergency hernia surgery were excluded. All data were provided by NHS RightCare.

RESULTS

There are almost 100,000 hernia repairs performed annually in NHS England. For every four hernias, three are repaired with mesh. The percentage repaired by mesh varies by hernia type. Mesh repairs in inguinal, umbilical and incisional hernias accounted for 95%, 50% and 82%, respectively.

CONCLUSIONS

Mesh repair for all hernia types is more common than suture repair. However, for umbilical and other abdominal wall hernias, a significant proportion are repaired without the use of mesh.

Progesterone receptor membrane component 1 is phosphorylated upon progestin treatment in breast cancer cells

Menopausal hormone therapy, using estrogen and synthetic progestins, is associated with an increased risk of developing breast cancer. The effect of progestins on breast cells is complex and not yet fully understood. In previous in vitro and in vivo studies, we found different progestins to increase the proliferation of Progesterone Receptor Membrane Component-1 (PGRMC1)-overexpressing MCF7 cells (MCF7/PGRMC1), suggesting a possible role of PGRMC1 in transducing membrane-initiated progestin signals.

Understanding the activation mechanism of PGRMC1 by progestins will provide deeper insights into the mode of action of progestins on breast cells and the often-reported phenomenon of elevated breast cancer rates upon progestin-based hormone therapy. In the present study, we aimed to further investigate the effect of progestins on receptor activation in MCF7 and T47D breast cancer cell lines. We report that treatment of both breast cancer cell lines with the progestin norethisterone (NET) induces phosphorylation of PGRMC1 at the Casein Kinase 2 (CK2) phosphorylation site Ser181, which can be decreased by treatment with CK2 inhibitor quinalizarin. Point mutation of the Ser181 phosphorylation site in MCF7/PGRMC1 cells impaired proliferation upon NET treatment. This study gives further insights into the mechanism of differential phosphorylation of the receptor and confirms our earlier hypothesis that phosphorylation of the CK2-binding site is essential for activation of PGRMC1. It further suggests an important role of PGRMC1 in the tumorigenesis and progression of breast cancer in progestin-based hormone replacement therapy.

H1-antihistamine-refractory chronic spontaneous urticaria: it's worse than we thought - first results of the multicenter real-life AWARE study

BACKGROUND

Most data on chronic spontaneous urticaria (CSU) originate from highly selected patient populations treated at specialized centres. Little is known about CSU patient characteristics and the burden of CSU in routine clinical practice. AWARE (A World-wide Antihistamine-Refractory chronic urticaria patient Evaluation) is an ongoing global study designed to assess chronic urticaria in the real-life setting.

OBJECTIVE

To describe the baseline characteristics of the first 1539 German AWARE patients with H1-antihistamine-refractory CSU.

METHODS

This prospective non-interventional study included patients (18-75 years) with a diagnosis of H1-antihistamine-refractory CSU for > 2 months. Baseline demographic and disease characteristics, comorbidities, and pharmacological treatments were recorded. Quality of life (QoL) was assessed using the dermatology life quality index (DLQI), chronic urticaria QoL questionnaire (CU-Q₂ oL), and angioedema QoL questionnaire (AE-QoL, in cases of angioedema). Previous healthcare resource utilization and sick leave data were collected retrospectively.

RESULTS

Between March and December 2014, 1539 patients were assessed in 256 sites across Germany. The percentage of females, mean age, and mean body mass index were 70%, 46.3 years, and 27 kg/m² , respectively. The mean urticaria control test score was 7.9, one in two patients had angioedema, and the most frequent comorbidities were chronic inducible urticaria (CIndU; 24%), allergic rhinitis (18.2%), hypertension (18.1%), asthma (12%), and depression (9.5%). Overall, 57.6% of patients were receiving at least one pharmacological treatment including second-generation H1-antihistamines (46.3%), first-generation H1-antihistamines (9.1%), and corticosteroids (15.8%). The mean DLQI, total CU-Q₂ oL, and total AE-QoL scores were 8.3, 36.2, and 46.8, respectively. CSU patients reported frequent use of healthcare resources, including emergency services (29.7%), general practitioners (71.9%), and additional allergists or dermatologists (50.7%).

CONCLUSIONS AND CLINICAL RELEVANCE

This study reveals that German H1-antihistamine-refractory CSU patients have high rates of uncontrolled disease, angioedema, and comorbid CIndU, are undertreated, have impaired QoL, and rely heavily on healthcare resources.

[Differentiated application of recommended guideline techniques for treatment of inguinal hernia]

The new worldwide guidelines of all international hernia societies only recommend the mesh-based methods TEP, TAPP and Lichtenstein. The best mesh-free technique, the Shouldice operation, should only be used if the patient has declined the use of a mesh or no mesh is available. The systematic use of the Shouldice technique for smaller inguinal hernias and younger men should be confined to study settings. A tailored approach should be taken for mesh-based procedures to minimize the risk to patients. Due to lower pain rates the laparoendoscopic techniques TEP and TAPP are the methods of choice for primary male unilateral inguinal hernia. They are also preferred for female patients as they improve the diagnostics of femoral hernias as well as for bilateral inguinal hernias in female and male patients. The Lichtenstein operation tends to be recommended for scrotal hernia, following previous pelvic surgery, vascular surgery, liver cirrhosis, radiotherapy and intolerance of general anesthesia. This also applies for recurrent hernia following a previous laparoendoscopic primary operation. Similarly, recurrent hernia after a primary suture or mesh procedure should be repaired using the TEP or TAPP technique. In emergency procedures for incarceration the diagnostic superiority of laparoscopy and the ability to reposition the incarcerated organs should be utilized. The inguinal hernia can then be repaired at the same time or later depending on whether there is any local infection.

Effects of high and low sodium diet on blood pressure and heart rate in mice lacking the functional grainyhead-like 1 gene

Hypertension is a major health problem throughout the world because of its high prevalence and its association with increased risk of cardiovascular disease. Two independent studies discovered a locus conferring susceptibility to essential hypertension on chromosome 2, in the 2p25 region, but the causative gene remains unknown. Grainyhead-like 1 (GRHL1) is one of the genes located in this region. Our experiments determined that the Grhl1 -null mice, when fed standard diet, have the same blood pressure as their wild type littermate controls. However, we discovered that blood pressure of these mice increases following high sodium diet and decreases when they are fed low sodium diet, and similar effects were not observed in the control wild type littermates. This suggests that the Grhl1 -null mice are sensitive to the development of salt-sensitive hypertension. Thus it is possible that the GRHL1 gene is involved in the regulation of blood pressure, and it may be the causative gene for the locus of susceptibility to essential hypertension in the 2p25 region.

Addressing aquatic hazard classification for metals, metal compounds and alloys in marine systems

New International Maritime Organization regulations require shippers to classify all solid bulk cargo to indicate whether they are Harmful to the Marine Environment (HME). The objective of this work was to adapt the freshwater Transformation/Dissolution Protocol (T/DP) to marine water to provide a method to determine, when compared with marine Ecotoxicity Reference Values (ERVs), whether a metal-bearing substance is HME. The substances examined were: Cu2O powder; Ni metal powder; Co3O4 powder; and a Ni-Co-Fe alloy, as wire cuttings, which were the same substances examined in the freshwater T/D validation study and afforded comparisons of the reactivity, or measure of the rate and extent of metal release from the metal-bearing substances in freshwater versus marine conditions. The marine T/D method is suitable for conducting examinations of metal-bearing substances with a wide range of reactivities, from the relatively reactive Cu2O powder and the alloy to the Co3O4 powder, which was the least reactive.

Expression of Serine/Threonine Protein-Kinases and Related Factors in Normal Monkey and Human Retinas: The Mechanistic Understanding of a CDK2 Inhibitor Induced Retinal Toxicity

Protein-kinase inhibitors are among the most advanced compounds in development using the new drug discovery paradigm of developing small-molecule drugs against specific molecular targets in cancer. After treatment with a cyclin dependent kinase CDK2 inhibitor in monkey, histopathological analysis of the eye showed specific cellular damage in the photoreceptor layer. Since this CDK2 inhibitor showed activity also on other CDKs, in order to investigate the mechanism of toxicity of this compound, we isolated cones and rods from the retina of normal monkey and humans by Laser Capture Microdissection. Using Real-Time PCR we first measured the expression of cyclin dependent protein-kinases (CDK)1, 2, 4, 5, Glycogen synthase kinase 3β (GSK3β) and microtubule associated protein TAU. We additionally verified the presence of these proteins in monkey eye sections by immunohistochemistry and immunofluorescence analysis and afterwards quantified GSK3β , phospho-GSK3β and TAU by Reverse Phase Protein Microarrays. With this work we demonstrate how complementary gene expression and protein-based technologies constitute a powerful tool for the understanding of the molecular mechanism of a CDK2 inhibitor induced toxicity. Moreover, this investigative approach is helpful to better understand and characterize the mechanism of species-specific toxicities and further support a rational, molecular mechanism-based safety assessment in humans.

The New 3D Printed Left Atrial Appendage Closure with a Novel Holdfast Device: A Pre-Clinical Feasibility Animal Study

INTRODUCTION

Many patients undergoing cardiac surgery have risk factors for both atrial fibrillation (AF) and stroke. The left atrial appendage (LAA) is the primary site for thrombi formation. The most severe complication of emboli derived from LAA is stroke, which is associated with a 12-month mortality rate of 38% and a 12-month recurrence rate of 17%. The most common form of treatment for atrial fibrillation and stroke prevention is the pharmacological therapy with anticoagulants. Nonetheless this form of therapy is associated with high risk of major bleeding. Therefore LAA occlusion devices should be tested for their ability to reduce future cerebral ischemic events in patients with high-risk of haemorrhage.

AIM

The aim of this study was to evaluate the safety and feasibility of a novel left atrial appendage exclusion device with a minimally invasive introducer in a swine model.

MATERIALS AND METHODS

A completely novel LAA device, which is composed of two tubes connected together using a specially created bail, was designed using finite element modelling (FEM) to obtain an optimal support force of 36 N at the closure line. The monolithic form of the occluder was obtained by using additive manufacturing of granular PA2200 powder with the technology of selective laser sintering (SLS). Fifteen swine were included in the feasibility tests, with 10 animals undergoing fourteen days of follow-up and 5 animals undergoing long-term observation of 3 months. For one animal, the follow-up was further prolonged to 6 months. The device was placed via minithoracotomy. After the observation period, all of the animals were euthanized, and their hearts were tested for LAA closure and local inflammatory and tissue response.

RESULTS

After the defined observation period, all fifteen hearts were explanted. In all cases the full closure of the LAA was achieved. The macroscopic and microscopic evaluation of the explanted hearts showed that all devices were securely integrated in the surrounding tissues. No pericarditis or macroscopic signs of inflammation at the site of the device were found. All pigs were in good condition with normal weight gain and no other clinical symptoms.

CONCLUSION

This novel 3D printed left atrial appendage closure technique with a novel holdfast device was proven to be safe and feasible in all pigs. A benign healing process without inflammation and damage to the surrounding structures or evidence of new thrombi formation was observed. Moreover, the uncomplicated survival and full LAA exclusion in all animals demonstrate the efficacy of this novel and relatively cheap device. Further clinical evaluation and implementation studies should be performed to introduce this new technology into clinical practice.

Abstract P2-02-13: EpCAM-independent enrichment approach for isolation of circulating tumor cells (CTCs) in breast cancer - What can be found in the EpCAM-depleted fraction?

Circulating tumor cells (CTCs) are the potential precursors of metastatic disease. Many assays have been established for the enumeration of CTCs. However, major limitations include the reliance on the expression of the cell surface marker epithelial cell adhesion molecule (EpCAM). These approaches may not detect CTCs that either express no/low levels of EpCAM or undergo epithelial-to-mesenchymal transition (EMT). We present an enrichment strategy combining different antibodies specific for surface proteins and extracellular matrix (ECM) components to capture EpCAMneg cell lines and EpCAMneg CTCs from EpCAM-depleted breast cancer blood samples. Expression of proteins (Trop2, CD49f, cMet, CK8, CD44, ADAM8, CD146, TEM8, CD47) was verified by immunofluorescence on EpCAM-positive (e.g. MCF7, SKBR3) and -negative (MDA-MB-231) breast cancer cell lines; antibodies and ECM proteins (e.g. hyaluronic acid (HA), collagen I, laminin) were further spotted in a single- and multi-arrayed format onto glass slides (Schott, NEXTERION® AL) and coupled to immunomagnetic beads (Dynabeads/Adembeads). Tumor cell adhesion of EpCAMpos/neg cell lines was visualized by Coomassie/MitoTracker; EpCAMneg CTCs enriched via functionalized Adem-/Dynabeads were identified by immunofluorescence staining for anti-pan-Cytokeratin(CK)-FITC/anti-CD45 AF647/DAPI and quantified manually by microscopy. Regarding cell lines, marginal binding of EpCAMneg MDA-MB-231 cells to EpCAM-antibodies could be observed. Efficient adhesion/capturing of EpCAMneg cells could be achieved via HA and immobilized antibodies against CD49f and Trop2. By analyzing 29 EpCAM-depleted fractions from 25 metastatic breast cancer patients, we were able to identify EpCAMneg CTCs in 69% of the samples [range 1-24] applying Trop2, CD49f, cMet, CK8 and/or HA magnetic enrichment. Accessorily, EpCAMneg dual-positive (CKpos/CD45pos) cells could be traced in 28 out of 29 samples [range 1-480]. Herein, we demonstrate an enhanced enrichment strategy to optimize capturing of EpCAMneg CTCs by targeting various cell surface antigens with antibody mixtures and ECM components. Thereby, potential relevant CTCs can be gathered and subjected to subsequent molecular analysis.

Citation Format: Fehm T, Schneck H, Gierke B, Pawlak M, Templin M, Niederacher D, Neubauer H. EpCAM-independent enrichment approach for isolation of circulating tumor cells (CTCs) in breast cancer - What can be found in the EpCAM-depleted fraction?. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-02-13.

The genetic background of climacteric symptoms in women during menopause

The subject of the study is the evaluation of the correlation between the polymorphism of candidate genes in the etiology of depression and the occurrence of the symptoms of the climacteric syndrome in women during menopause. The group subjected to the study comprised of 203 women aged between 42-65 years: 71 of them still menstruated (premenopausal group) and 132 at least one year after the last period (postmenopausal group), admitted to the Department of Gynecological Endocrinology at the University of Medical Sciences in Poznan with symptoms of the climacteric syndrome All the examined women were evaluated according to the degree of severity of the climacteric syndrome symptoms using the Kupperman index and the concentration of FSH, LH hormones, 17β-estradiol, PRL, total testosterone, and DHEAS in peripheral blood serum. Among the candidate genes in the aetiology of depression the following were selected for the research: the serotonergic system receptor genes: 5HTR2A, 5HTR1B, 5HTR2C, TPH 1, TPH2, and MAO-A; the genes of noradrenergic and dopaminergic systems (COMT, NET), the genes of the GABAergic (GABRBl) system, a gene of the estrogen receptor (ESR1), and the genes of the enzymes crucial in the methyl cycle (MTHRF, MTR, and MTHFD1). With regards to the correlation between the examined polymorphisms and the occurrence of the symptoms of the climacteric syndrome, the associations analysis indicated a connection between GABRBl.TaqI polymorphism and the occurrence of vertigo in premenopausal women (0.0198; after correction: 0.0497 CC to CA). The correlation was also found regarding the examined polymorphisms and the concentration of the examined hormones in blood serum: TPH1.MaeI polymorphism and the LH concentration in the postmenopausal group (0.004; after correction: 0.014 CC to CA), NET.Eco1471 polymorphism, and the 17β-estradiol concentration in the postmenopausal group (0.0208; after correction: 0.048 GG to GA) and HTR2AMspI polymorphism and PRL concentration in all examined women (0.03; after correction: 0.038 TT to CT).

The improvement of hirsutism and the decrease of testosterone concentration in the peripheral blood serum after removing an endometrioid ovarian cyst

The study describes the case of a patient, in which as a result of removing an endometrioid ovarian cyst, there was an improvement as regards hirsutism and the decrease of testosterone concentration in the serum of peripheral blood.

Depressive symptoms' pattern in postmenopausal women

The study was conducted to elucidate the problem of depressive symptoms' pattern in climacteric women. The study included 128 postmenopausal women aged 47-65 years admitted to the Department of Gynecological Endocrinology, Poznan University of Medical Science because of climacteric symptoms. The authors assessed the intensity of climacteric symptoms with the Kupperman index and the severit of depressive symptoms with the Hamilton depression scale. They measured BMI of all studied women. The average score of the Hami ton scale in the studied group was 11 points (SD ± 7 points). No depressive symptoms were found in 40 (31.2%) of the study participants. A slight increase in the severity of the depression symptoms was found in 64 (50%) and 23 (29.9%) displayed depressive symptoms at moderate severity, while one (1.3%) study participant was diagnosed with very severe depressive symptoms. Depressive symptoms observe most often were: somatic symptoms of anxiety and fear experienced in 90 (70.2%), light and interrupted sleep reported in 88 (68.6%), an general symptoms in 88 (68.6%) of the study participants.

EpCAM-Independent Enrichment of Circulating Tumor Cells in Metastatic Breast Cancer

Circulating tumor cells (CTCs) are the potential precursors of metastatic disease. Most assays established for the enumeration of CTCs so far–including the gold standard CellSearch—rely on the expression of the cell surface marker epithelial cell adhesion molecule (EpCAM). But, these approaches may not detect CTCs that express no/low levels of EpCAM, e.g. by undergoing epithelial-to-mesenchymal transition (EMT). Here we present an enrichment strategy combining different antibodies specific for surface proteins and extracellular matrix (ECM) components to capture an EpCAM^low/neg cell line and EpCAM^neg CTCs from blood samples of breast cancer patients depleted for EpCAM-positive cells. The expression of respective proteins (Trop2, CD49f, c-Met, CK8, CD44, ADAM8, CD146, TEM8, CD47) was verified by immunofluorescence on EpCAM^pos (e.g. MCF7, SKBR3) and EpCAM^low/neg (MDA-MB-231) breast cancer cell lines. To test antibodies and ECM proteins (e.g. hyaluronic acid (HA), collagen I, laminin) for capturing EpCAM^neg cells, the capture molecules were first spotted in a single- and multi-array format onto aldehyde-coated glass slides. Tumor cell adhesion of EpCAM^pos/neg cell lines was then determined and visualized by Coomassie/MitoTracker staining. In consequence, marginal binding of EpCAM^low/neg MDA-MB-231 cells to EpCAM-antibodies could be observed. However, efficient adhesion/capturing of EpCAM^low/neg cells could be achieved via HA and immobilized antibodies against CD49f and Trop2. Optimal capture conditions were then applied to immunomagnetic beads to detect EpCAM^neg CTCs from clinical samples. Captured CTCs were verified/quantified by immunofluorescence staining for anti-pan-Cytokeratin (CK)-FITC/anti-CD45 AF647/DAPI. In total, in 20 out of 29 EpCAM-depleted fractions (69%) from 25 metastatic breast cancer patients additional EpCAM^neg CTCs could be identified [range of 1–24 CTCs per sample] applying Trop2, CD49f, c-Met, CK8 and/or HA magnetic enrichment. EpCAM^neg dual-positive (CK^pos/CD45^pos) cells could be traced in 28 out of 29 samples [range 1–480]. By single-cell array-based comparative genomic hybridization we were able to demonstrate the malignant nature of one EpCAM^neg subpopulation. In conclusion, we established a novel enhanced CTC enrichment strategy to capture EpCAM^neg CTCs from clinical blood samples by targeting various cell surface antigens with antibody mixtures and ECM components.

High cut-off dialysis in chronic haemodialysis patients

BACKGROUND

Haemodialysis patients suffer from chronic systemic inflammation and high incidence of cardiovascular disease. One cause for this may be the failure of diseased kidneys to eliminate immune mediators. Current haemodialysis treatment achieves insufficient elimination of proteins in the molecular weight range 15-45 kD. Thus, high cut-off dialysis might improve the inflammatory state.

DESIGN

In this randomized crossover trial, 43 haemodialysis patients were treated for 3 weeks with high cut-off or high-flux dialysis. Inflammatory plasma mediators, monocyte subpopulation distribution and leucocyte gene expression were quantified.

RESULTS

High cut-off dialysis supplemented by a low-flux filter did not influence the primary end-point, expression density of CD162 on monocytes. Nevertheless, treatment reduced multiple immune mediators in plasma. Such reduction proved - at least for some markers - to be a sustained effect over the interdialytic interval. Thus, for example, soluble TNF-receptor 1 concentration predialysis was reduced from median 13·3 (IQR 8·9-17·2) to 9·7 (IQR 7·5-13·2) ng/mL with high cut-off while remaining constant with high-flux treatment. The expression profile of multiple proinflammatory genes in leucocytes was significantly dampened. Treatment was well tolerated although albumin losses in high cut-off dialysis would be prohibitive against long-term use.

CONCLUSIONS

The study shows for the first time that a dampening effect of high cut-off dialysis on systemic inflammation is achievable. Earlier studies had failed due to short study duration or insufficient dialysis efficacy. Removal of soluble mediators from the circulation influences cellular activation levels in leucocytes. Continued development of less albumin leaky membranes with similar cytokine elimination is justified.