Pudendal Neuralgia: Two case reports with laparoscopic nerve decompression

Pudendal neuralgia (PN) is a rare and underestimated condition. The reported incidence by the International Pudendal Neuropathy Association is 1/100000. However, the actual rate may be significantly higher, with a propensity for women. It is most frequently caused by an entrapment of the nerve at the level of the sacrospinous and sacrotuberous ligament, also known as pudendal nerve entrapment syndrome. Due to the late diagnosis and inadequate management, pudendal nerve entrapment syndrome often leads to considerable reduction in the quality of life and high health care costs. The diagnosis is made using Nantes Criteria, in conjunction with the patient's clinical history and physical findings. Clinical examination with an accurate assessment of the territory of the neuropathic pain is mandatory to set the therapeutic strategy. The aim of the treatment is to control the symptoms and it usually starts with conservative approaches which include analgesics, anticonvulsants, and muscle relaxants. Surgical nerve decompression can be proposed after failure of conservative management. The laparoscopic approach is a feasible and appropriate technique to explore and decompress the pudendal nerve, and to rule out other pelvic conditions that can cause similar symptomatology. In this paper, the clinical history of two patients affected by compressive PN is reported. Both patients underwent laparoscopic pudendal neurolysis suggesting that the treatment for PN should be individualised and carried out by a multidisciplinary team. When conservative treatment fails, laparoscopic nerve exploration and decompression is an adequate option to propose and should be performed by a trained surgeon.

Colorectal endometriosis: ample data without definitive recommendations

The preoperative work-up and optimal surgical approach to colorectal endometriosis is a highly studied topic lacking definitive recommendations. Synthesis of the available data can be extremely challenging for surgeons due to the heterogeneity of existing comparisons, a variety of studied surgical outcomes, and a predominant focus on operative complications. While these considerations are extremely important for surgeons performing such complex gynaecologic surgery there is still much to be desired with regards to evidence based guidelines for the preoperative assessment and surgical technique for colorectal endometriosis. Having an established guideline stating in which clinical situations endometriosis surgeons should performing rectovaginal shaving, versus discoid excision, versus segmental resection would be extremely important for all pelvic surgeons, even those operating in high-volume centres dedicated to the surgical management of complex endometriosis. This perspective highlights the shortcomings of the available data and attempts to create an algorithm surgeons can follow when performing surgery for colorectal endometriosis. This algorithm is based on our expert opinion after synthesising available data.

Multiple comparisons of diversity indices invaded by Lantana camara

Current study assessed the impact of Lantana camara invasion on native plant diversity in Pothohar region of Pakistan. The approach used for study was random samplings and comparisons of diversity indices [number of species (S), abundance (N), species richness (R), evenness (Jꞌ), Shannon diversity index (Hꞌ) and Simpson index of dominance (λ)] with two categorical factors i.e., invaded and non-invaded (control). Control plots harboured by an average of 1.74 more species/10m2. The control category was diverse (Hꞌ=2.56) than invaded category (Hꞌ=1.56). The higher value of species richness in control plots shows heterogeneous nature of communities and vice versa in invaded plots. At multivariate scale, ordination (nMDS) and ANOSIM showed significant magnitude of differences between invaded and control plots at all sites. The decrease in studied diversity indices in invaded over control sites indicated that plant communities become less productive due to Lantana invasion.

1 vs 3 days laparoscopic suturing courses: is it feasible to design a valid training curriculum?

BACKGROUND

Laparoscopic skills are unlikely to be achieved exclusively in the operating theatre, so simulation training has become mandatory to acquire specific psychomotor skills to be merged in a more complex procedure.

OBJECTIVE

To compare 3-day vs. 1-day laparoscopic suturing courses and to better address participants' needs according to their level of experience.

METHODS

Observational cohort study conducted between January 2017 and December 2018 including 107 participants amongst which 61 attended a 3-day and 46 the 1-day suturing course.

RESULTS

Data analysis showed no significant difference in the pre-test suturing scores between the two groups. On each course, when comparing the pre- and post-tests results, the participants reached a statistically significant improvement in both precision and knotting score (p< 0.01). However, when comparing the two types of courses, the data showed a better performance in the post-session test for those attending the 3-day course (p<0.05), as well as a higher mean score improvement (4.7 vs. 2.8; p<0.05) and time needed to complete exercises (-270s vs. -150s; p<0.05). Furthermore, grouping the participants according to their experience, the experts achieved a significantly better improvement attending the 3-day course, when compared to the beginners.

CONCLUSIONS

Both 3 and 1-day course are successful in improving laparoscopic suturing skills regardless of the participant's experience. However experienced participants benefit more from a longer course while the 1-day one should be dedicated to pre-surgical competences acquisition.

Immunological combination treatment holds the key to improving survival in pancreatic cancer

Advances in surgery, peri-operative care and systemic chemotherapy have not significantly improved the prognosis of pancreatic cancer for several decades. Early clinical trials of immunotherapy have yielded disappointing results proposing other means by which the tumour microenvironment serves to decrease the immune response. Additionally, the emergence of various subtypes of pancreatic cancer has emerged as a factor for treatment responses with immunogenic subtypes carrying a better prognosis. Herein we discuss the reasons for the poor response to checkpoint inhibitors and outline a rationale why combination treatments are likely to be most effective. We review the therapies which could provide optimal synergistic effects to immunotherapy including chemotherapy, agents targeting the stroma, co-stimulatory molecules, vaccinations and methods of immunogenic tumour priming including radiofrequency ablation. Finally, we discuss reasons why peri-operative and in particular neoadjuvant combination treatments are likely to be most effective and should be considered for early clinical trials.

Sexual dysfunction and central obesity in patients with first episode psychosis

Background

In recent years the association between sexual dysfunction (SD) and obesity in the general population has drawn major attention. Although sexual dysfunction is common in psychosis, its relationship with weight gain and obesity remains unclear.

Aims

To investigate the association between sexual dysfunction and obesity in a cohort of patients with first episode psychosis.

Method

Sexual function was assessed in a cohort of patients with first episode psychosis using the Sexual Function Questionnaire (SFQ). Anthropometric measures, including weight, BMI, waist, waist–hip ratio were investigated. Additionally, leptin and testosterone were investigated in male patients.

Results

A total of 116 patients (61 males and 55 females) were included. Of these 59% of males and 67.3% of females showed sexual dysfunction (SD) according to the SFQ. In males, higher SFQ scores were significantly correlated with higher BMI (Std. β = 0.36, P = 0.01), higher leptin levels (Std. β = 0.34, P = 0.02), higher waist–hip ratio (Std. β = 0.32, P = 0.04) and lower testosterone levels (Std. β = −0.44, P = 0.002). In contrast, in females, SFQ scores were not associated with any of these factors.

Conclusions

While sexual dysfunction is present in both female and male patients with their first episode of psychosis, only in males is sexual dysfunction associated with increased BMI and waist–hip ratio. The association between SD, BMI, low levels of testosterone and high levels of leptin suggest that policies that lead to healthier diets and more active lifestyles can be beneficial at least, to male patients.

An algorithm to avoid missed open-book pelvic fractures

OBJECTIVE

In polytrauma patients, to limit the pelvic space favouring internal bleeding, the use of pelvic binders is now a standard practice. In case of external pelvic binder placement with anatomic reduction of the symphyseal and sacroiliac joints, delayed diagnosis and missed injuries could occur. The aim of this study is to document the risk of missed diagnosis, as well as to identify a possible algorithm for optimal management of traumatized patients with pelvic binders, in order to reach an early diagnosis of pelvic fractures without additional risks.

CASE REPORT

We report three cases of open-book pelvic fractures that were initially missed. The external pelvic binders applied had adequately reduced the fractures. The computed tomography on arrival excluded a diastasis of the symphysis pubis. On removal of the pelvic binder and repetition of the radiological imaging, the fractures were evidenced.

CONCLUSIONS

We have accordingly created an algorithm for polytrauma patients to determine when the pelvic binder should be released before radiological imaging and when repeated radiological imaging should be done. The use of this algorithm in trauma centers will help to reduce the number of missed injuries, and the number of late diagnoses as well as will increase the patient survival rates.

Interventional radiofrequency ablation: A promising therapeutic modality in the management of malignant biliary and pancreatic duct obstruction

Background: Malignant biliary and/or pancreatic obstruction has often encountered in the advanced stages of periampullary and cholangicarcinomas. Habib^TM Radiofrequency (RF) ablation has been successfully used in the management of various cancers of liver and pancreas. Percutaneous HPB probe (EMcision Ltd, London, UK) is a new addition to this class of tools. It is an endoluminal Radiofrequency (RF) catheter which works on the principle of ablation and induces coagulative necrosis to recanalize the obstructed duct. The aim of this study is to address the technical details of canalization, feasibilities and outcomes of percutaneous endo-luminal Radiofrequency (RF) catheter in patients with unresectable malignancy with obstructed bile and pancreatic duct (PD). Material and Method: A total of 134 patients with inoperable malignant obstruction of biliary and PD underwent RF based percutaneous endoluminal RF ablation in a tertiary referral centre between December 15^th, 2010 to August 7^th, 2015. This device was used in a sequential manner with an intent to recanalize the obstructed. Following the initial catheter drainage of the duct, subsequent percutaneous endobiliary RF ablation, the metallic stent was placed to recanalize the obstructed bile and PD secondary to unresectable malignancy under real-time fluoroscopic guidance. Results: The percutaneous RF based ablation of obstructed bile duct and PD with metallic stent placement was successfully achieved in 130 (97.01%) cases. The three failures were noted in cases of biliary obstruction whilst, one with PD obstruction. The patency restored in 124 and patients, where the procedure was successfully completed and revealed clinical improvement reported. Conclusion: The percutaneous endoluminal RF based ablation of obstructed duct with metallic stent placement appeared to be a safe, effective procedure and may improve survival in patients with advanced stage cancer presenting with biliary and PD obstruction. Considering the above mentioned evidence, this modality may stand ahead of stenting alone. This could be considered as viable modality in management of such patients where very limited treatment options are available.

Percutaneous Image-Guided Pancreatic Duct Drainage: Technique, Results and Expected Benefits

PURPOSE

The aim of this study is to provide a technical detail and feasibility of percutaneous image-guided pancreatic duct (PD) drainage and to discuss its subtleties in a series of patients with obstructed PD.

MATERIALS AND METHODS

Thirty patients presenting with PD obstruction from pancreatic head tumour or pancreatitis were subjected to percutaneous image-guided PD drainage under a guidance of ultrasound or computed tomography. Following the successful puncture of PD, a locking loop drainage catheter was placed using conventional guidewire techniques under real-time fluoroscopy guidance.

RESULTS

The percutaneous drainage of obstructed PD was completed in 29 (96.7%) patients as an independent therapeutic intent or as a bridge to further percutaneous procedures. Clinical improvement following drainage was documented by the gradual reduction in clinical symptoms, including pain, nausea and fever and improved blood test results, showing the significant decrease of amylase concentration. The amount of pancreatic fluid drained post procedure was between 300 and 900 mL/day. No major procedure-related complications were observed. Subsequently, 14 of 29 patients underwent further procedures, including endoluminal placement of metal stent with or without radiofrequency ablation, balloon assisted percutaneous descending litholapaxy (BAPDL), endoluminal biopsy and balloon dilatation using the same drainage tract.

CONCLUSION

The percutaneous PD drainage appears to be a safe and effective procedure. It should be considered in patients with obstructed PD secondary to malignancy, pancreatitis etc., where endoscopic retrograde cannulation has been failed or impracticable. The procedure can also be contemplated either as an independent treatment option or as an initial step for the subsequent therapeutic endoluminal procedures.

Thrombospondin-4 mediates TGF-β-induced angiogenesis

TGF-β is a multifunctional cytokine affecting many cell types and implicated in tissue remodeling processes. Due to its many functions and cell-specific effects, the consequences of TGF-β signaling are process-and stage-dependent, and it is not uncommon that TGF-β exerts distinct and sometimes opposing effects on a disease progression depending on the stage and on the pathological changes associated with the stage. The mechanisms underlying cell- and process-specific effects of TGF-β are poorly understood.

We are describing a novel pathway that mediates induction of angiogenesis in response to TGF-β1. We found that in endothelial cells (EC) TSP-4, a secreted extracellular matrix (ECM) protein is upregulated in response to TGF-β1 and mediates the effects of TGF-β1 on angiogenesis.

Upregulation of TSP-4 does not require the synthesis of new protein, is not caused by decreased secretion of TSP-4, and is mediated by activation of SMAD3. Using Thbs4^−/− mice and TSP-4 shRNA, we found that TSP-4 mediated pro-angiogenic functions on cultured EC and angiogenesis in vivo in response to TGF-β1. We observed ~ 3-fold increases in tumor mass and levels of angiogenesis markers in animals injected with TGF-β1, and these effects did not occur in Thbs4^−/− animals. Injections of an inhibitor of TGF-β1 signaling SB431542 also decreased the weights of tumors and cancer angiogenesis.

Our results from in vivo angiogenesis models and cultured EC document that TSP-4 mediates upregulation of angiogenesis by TGF-β1. Upregulation of pro-angiogenic TSP-4 and selective effects of TSP-4 on EC may contribute to stimulation of tumor growth by TGF-β despite the inhibition of cancer cell proliferation.

Simulation study of accelerator based quasi-mono-energetic epithermal neutron beams for BNCT

Filtered neutron techniques were applied to produce quasi-mono-energetic neutron beams in the energy range of 1.5-7.5 keV at the accelerator port using the generated neutron spectrum from a Li (p, n) Be reaction. A simulation study was performed to characterize the filter components and transmitted beam lines. The feature of the filtered beams is detailed in terms of optimal thickness of the primary and additive components. A computer code named "QMNB-AS" was developed to carry out the required calculations. The filtered neutron beams had high purity and intensity with low contamination from the accompanying thermal, fast neutrons and γ-rays.

Effect of Physical Exercise on some Hematological Parameters in Female Athletes in Bangladesh

INTRODUCTION

Long term physical training has been considered to adversely affect the performance of athletes especially the females. It may be due to the iron depletion caused by hemolysis or hemodilution results from plasma volume expansion. This study aims to assess the effect of heavy exercise on hemoglobin concentration and some other hematological parameters in female athletes.

METHODS

This cross sectional study was carried out in the Department of physiology, Dhaka Medical College, Dhaka, from July 2010-June 2011. A total number of 105 females (70 athletes and 35 non athletes) between 15-25 years of age were recruited. The 35 apparently healthy female non athletes were taken as control (Group-A) and 70 female athletes comprise the study group (Group-B). According to sporting category, Group-B was further subdivided as B1:Runners and B2:Cyclists. Hemoglobin percentages (Hb %), red blood cell (RBC) concentration, packed cell volume (PCV), serum iron, serum ferritin and total iron binding capacity (TIBC) were measured in fasting state after two months training. Statistical analysis was done by using SPSS/ win.15.0 for comparison between the groups, using student's unpaired "t" test.

RESULTS

Mean Hb%, RBC, PCV, iron and ferritin level were significantly (P<0.001) lower in athletes than those of control group. Within the study groups, runner's serum iron and ferritin level were lower than cyclists. TIBC significantly (P<0.001) rose in Group-B2 in comparison to Group-A.

CONCLUSIONS

The current study showed that intense physical exercise leads to early stages of Hb%, RBC, PCV, iron and ferritin depletion which might compromise the health and performance of athletes.

Semi-spherical Radiofrequency Bipolar Device - A New Technique for Liver Resection: Experimental In Vivo Study on the Porcine Model

The incidence of colorectal carcinoma is still growing in the Czech Republic and also all around the world. With success of oncological treatment is also growing a number of potential patients with liver metastases, who can profit from surgical therapy. The aim of this study was to confirm on porcine models that this method by using new surgical device is effective and safe for patients who have to undergo liver resection. The primary hypothesis of the study was to evaluate whether this new device is able to consistently produce homogeneous and predictable areas of coagulation necrosis without the Pringle maneuver of vascular inflow occlusion. The secondary hypothesis of the study was to compare the standard linear radiofrequency device and a new semi-spherical bipolar device for liver ablation and resection in a hepatic porcine model. Twelve pigs were randomly divided into two groups. Each pig underwent liver resection from both liver lobes in the marginal, thinner part of liver parenchyma. The pigs in first group were operated with standard using device and in the second group we used new developed semi-spherical device. We followed blood count in 0(th), 14(th) and 30(th) day from operation. 14(th) day from resection pigs underwent diagnostic laparoscopy to evaluate of their state, and 30(th) day after operation were all pigs euthanized and subjected to histopathological examination. Histopathological evaluation of thermal changes at the resection margin showed strong thermal alteration in both groups. Statistical analysis of collected dates did not prove any significant (p < 0.05) differences between standard using device and our new surgical tool. We proved safety of new designed semi-spherical surgical. This device can offer the possibility of shortening the ablation time and operating time, which is benefit for patients undergoing the liver resection.

Management of arterial lines and blood sampling in intensive care: a threat to patient safety

In 2008, the UK National Patient Safety Agency (NPSA) made recommendations for safe arterial line management. Following a patient safety incident in our intensive care unit (ICU), we surveyed current practice in arterial line management and determined whether these recommendations had been adopted. We contacted all 241 adult ICUs in the UK; 228 (94.6%) completed the survey. Some NPSA recommendations have been widely implemented - use of sodium chloride 0.9% as flush fluid, two-person checking of fluids before use - and their practice was consistent. Others have been incompletely implemented and many areas of practice (prescription of fluids, two-person checking at shift changes, use of opaque pressure bags, arterial sampling technique) were highly variable. More importantly, the use of the wrong fluid as an arterial flush was reported by 30% of respondents for ICU practice, and a further 30% for practice elsewhere in the hospital. Our survey provides evidence of continuing risk to patients.

The role of early ¹⁸F-FDG PET/CT in prediction of progression-free survival after ⁹⁰Y radioembolization: comparison with RECIST and tumour density criteria

PURPOSE

This study evaluated the ability of (18)F-FDG PET/CT imaging to predict early response to (90)Y-radioembolization in comparison with contrast-enhanced CT (CECT) using RECIST and lesion density (Choi) criteria. Progression-free survival (PFS) in patients with liver metastases at 2 years and decline in tumour markers were the primary end-points of the study.

METHODS

A total of 121 liver lesions were evaluated in 25 patients (14 men, 11 women) with liver-dominant metastatic colorectal cancer who underwent (18)F-FDG PET/CT and CECT before and 6-8 weeks after treatment. Changes in SUV(max), tumour density measured in terms of Hounsfield units and the sum of the longest diameters (LD) were calculated for the target liver lesions in each patient. The patient responses to treatment were categorized using EORTC PET criteria, tumour density criteria (Hounsfield units) and RECIST, and were correlated with the responses of tumour markers and 2-year PFS using Kaplan-Meier plots and the log-rank test for comparison. Multivariate proportional hazards (Cox) regression analysis was performed to assess the effect of relevant prognostic factors on PFS.

RESULTS

Using (18)F-FDG PET/CT response criteria, 15 patients had a partial response (PR) and 10 patients had stable disease (SD), while using RECIST only 2 patients had a PR and 23 had SD. Two patients had a PR, 21 SD and 2 progressive disease using tumour density criteria. The mean changes in SUV(max), sum of the LDs and tumour density after treatment were 2.9 ± 2.6, 7.3 ± 14.4 mm and 1.9 ± 13.18 HU, respectively. Patients who had a PR on (18)F-FDG PET/CT had a mean decrease of 44.5 % in SUV(max) compared to those with SD who had a decrease of only 10.3 %. The decreases in SUV(max) and sum of the LDs were significant (p < 0.0001, p < 0.05, respectively) while the decrease in tumour density was not (p > 0.1065). The responses on the (18)F-FDG PET/CT studies were highly correlated with the responses of tumour markers (p < 0.0001 for LDH, p = 0.01 for CEA and p = 0.02 for Ca19-9), while the responses on the CECT studies using both RECIST and tumour density criteria were not significantly correlated with the responses of tumour markers. The responses on (18)F-FDG PET/CT studies also significantly predicted PFS (the median PFS in those with a PR was 12.0 months and in those with SD was 5 months, p < 0.0001), while RECIST and tumour density did not significantly predict PFS. Multivariate analysis demonstrated that responses on (18)F-FDG PET/CT studies and decreases in SUV(max) of ≤ 2.0 were the strongest predictors of PFS.

CONCLUSION

Early response assessment to (90)Y-radioembolization using (18)F-FDG PET/CT is superior to RECIST and tumour density, demonstrating a correlation with tumour markers and significantly predicting PFS in patients with liver metastases. This could enable early response-adapted treatment strategies to be employed.

Treatment options in pemphigus

The therapy of pemphigus is one of the miracles of modern medicine, having transformed an almost invariably fatal disease into one whose mortality is now approximately 5%. Nonetheless, major challenges remain in further decreasing mortality and reducing the side effects of the potent medications used to treat this disease. The cornerstone of treatment remains the use of systemic steroids. The role of adjuvants, such as immunosuppressive and anti-inflammatory drugs, as ''steroid-sparing'' agents, remains to be defined, as there are little randomized trial data that provides objective evidence of their effectiveness. More recently, biologicals, such as IVIg and rituximab, have been introduced; the first to speed the control of active disease unresponsive to conventional treatment and the second to increase the proportion of patients in whom a complete clinical remission can be induced.

Antitumor activity of a new cholesterol derivative (24-ethyl-cholestane- 3β, 5α,6α-triol) in solid tumors

e13541

Oxysterols are oxygenated derivatives of cholesterol. They have nuclear receptors and have been shown to pass cell membranes and the blood-brain barrier at a faster rate than cholesterol itself. In addition, oxysterols have been ascribed a number of important roles in connection with cholesterol turnover, atherosclerosis, apoptosis, and necrosis. Oxysterols have been shown to have antitumor effects on experimental models. These compounds however may be toxic and to our knowledge, although some derivatives have been tested in animals, none have reached the clinical level. 24-ethyl-cholestane- 3β,5α,6α-triol is a new oxysterol developed in our lab. An oral form of this compound has been tested in mice and rats and has shown neither acute nor chronic toxicity. It has also been tested on animal tumor models and on human cancer xenografts. The results of these tests were very promising showing an anti-tumor activity on a panel of tumor cell lines. Our experiments on humans have shown no toxicity for this drug. Many patients with a variety of solid tumors all of whom have received many lines of chemotherapy and considered refractory to any conventional therapy have received this new drug. We observed in most of these patients a rapid and dramatic improvement in their quality of life and a fast pain control. Some patients could stop taking high doses of opioids within 1 or 2 days. A high rate of clinical benefit has also been observed in a variety of solid tumors including lung, breast, pancreatic, ovarian and uterine cancers, associated in some cases with a sharp decrease in tumor markers. Some patients with brain tumors (glioblastomas) have also responded to this therapy.

No significant financial relationships to disclose.

The anatomic localization of circulating tumor cells and the immediate impact of surgery and radiofrequency ablation

e22004

Background: There are few data on the impact of immediate and differing surgical interventions on circulating tumor cells (CTCs), nor their compartmentalization or localization in different anatomic vascular sites. Methods: CTCs from consecutive patients with colorectal liver metastases were quantitated prior to and immediately after open surgery, laparoscopic resection, open radiofrequency ablation (RFA) or percutaneous RFA. For individuals undergoing open surgery, either hepatic resections or open RFA, CTCs were examined in both systemic and portal circulation by measuring CTCs in samples derived from the peripheral vein, an artery, the portal vein and hepatic vein. Results: A total of 29 consecutive patients with colorectal liver metastases were included with a median age of 55 (range 30 - 88 years). CTCs were localized to the hepatic portosystemic macrocirculation with significantly greater numbers than in the systemic vasculature. Surgical procedures led to a statistically significant fall in CTCs at all sites measured (p<0.05). Conversely, RFA, either open or percutaneous was associated with an increase in CTCs. Conclusions: Surgical resection of metastases but not RFA decreases CTC levels. In patients with colorectal liver metastases, CTCs are localized to the hepatic (and probably pulmonary) macrocirculations. This may explain why metastases in sites other than the liver and lungs, are infrequently observed in cancer.

No significant financial relationships to disclose.

Cystic tumors of the biliary tract: a complete excision is crucial

Intrahepatic cystic tumors are rare liver tumors whose diagnosis is based on a wide range of imaging modalities. Surgical management and prognosis are not clearly defined. The medical records of patients with a diagnosis of intrahepatic cystic tumor managed in our unit were reviewed. Two patients were successfully treated by surgery. One of these two patients had to undergo a second laparotomy to obtain complete removal of the tumor. Another patient developed tumor recurrence after an incomplete incision of the cystic lesion previously performed abroad. She was referred to our unit but was deemed unresectable and therefore was referred for a liver transplantation. We report 3 cases of hepatic cystic tumors, showing some difficult issues related to the diagnosis and management of this condition and underlining the importance of performing a complete surgical excision to avoid early recurrence of the tumor.

Minimally invasive and selective hydrodynamic gene therapy of liver segments in the pig and human

This paper highlights our experience of the transfer of hydrodynamic gene therapy (HGT) from the large animal, the pig, into clinical practice. The modification of balloon catheters and the development of a minimally invasive technique to allow selective isolation of liver segments for HGT in the large animal and human are described. Finally, our preliminary results from a phase I clinical study of HGT for thrombopoietin (TPO) in cirrhotic patients with thrombocytopenia are discussed. Based on these provisional data, minimally invasive selective HGT of liver segments appears to be technically safe, but further work is required to optimize the efficiency of gene transfer in order to achieve clinical benefit.

Hepatic resection using heat coagulative necrosis. First report of successful trisegmentectomy after hypertrophy induction

INTRODUCTION

Intraoperative blood loss has been identified as one of the major mortality predictors for liver surgery. Different strategies have been used in the past to minimize blood loss during resection. A new method using heat coagulative necrosis in healthy tissue at the resection plane to achieve a bloodless resection has been described 3 years ago and has already gained acceptance for peripheral resections. A further developmental stage of this method is now available with the so-called Habib 4x sealer. So far, only resections ranging from segmentectomies to hemihepatectomies are reported.

MATERIALS AND METHODS

In the case reported here, the new method was challenged to perform an extended hepatic resection in a patient suffering from colorectal liver metastases. The resection was performed in a hybrid technique of regular hilar preparation and parenchymal dissection using the sealer.

CONCLUSION

The method showed to be safe and efficient even for an extended resection.

Anti-inflammatory, anti-nociceptive and antipyretic effects of extracts of Phrygilanthus acutifolius flowers

This study was intended to evaluate the anti-inflammatory, antipyretic and analgesic activities of aqueous and ethanol extracts of Phrygilanthus acutifolius flowers in several experimental standard models in rats, following oral administration. The results showed that the aqueous extract significantly reduced the oedema induced by carrageenan within 1-5 h post-dosing at all dose levels used. On the analgesia property, acetic acid-induced writhing was significantly reduced. In the formalin test, the extract also significantly decreased the painful stimulus in both phases of the test. The tail immersion confirms central acting analgesic property of the extracts. Overall, the analgesic tests conducted revealed that the extract had central and peripheral properties. Its effects on pyresis were also appreciable. It significantly reduced fever at doses greater than 200 mg/kg within 2 h on yeast-induced hyperthermia in rats.

Open label phase II studies of modified vaccinia ankara expressing the tumor antigen 5T4 given in conjunction with IFL and FOLFOX chemotherapy regimens: Final analysis of safety and immunogenicity of MVA 5T4 given before, during and after chemotherapy

2527

Background: 5T4 is a tumour associated antigen that is widely expressed on the surface of most human adenocarcinomas, including colorectal, but rarely in normal cells. Modified Vaccinia Ankara (MVA) has been employed as a vaccine vector to deliver 5T4. Previously, MVA-5T4 has been evaluated in a phase I/II clinical trial in stage IV colorectal cancer patients. MVA-5T4 was shown to be safe and well tolerated and induced 5T4 specific immune responses in most patients. Furthermore, 5T4 specific antibody titres correlated with clinical benefit. Methods: Two open label phase II clinical trials were initiated in which patients with advanced colorectal cancer received MVA-5T4 in conjunction with either 5-FU/leukovorin and irinotecan (TV2-IFL; n=19 patients) or 5-FU/leukovorin and oxaliplatin (TV2-FOLFOX; n=17 patients). MVA-5T4 was administered up to 6 times, 2 prior to, 2 during and 2 post-chemotherapy. The primary objectives were to assess the safety and immunogenicity of MVA-5T4 given in combination with chemotherapy. Results: Recruitment to both trials is complete and MVA-5T4 was well tolerated in all ITT patients, with no serious adverse events being associated with MVA-5T4. 5T4-specific cellular and humoral immune responses were monitored before, during and after chemotherapy in all 23 per protocol patients (n=12 for TV2-IFL and n=11 for TV2-FOLFOX). Following vaccination, all 23 patients mounted 5T4 cellular and/or humoral responses. Immune responses were detectable during chemotherapy in the majority of patients. IFNγ ELISPOT responses to 5T4 peptides revealed precursor frequencies as high as 1 in 1000 PBMCs. Assessment of clinical responses in all PP patients demonstrated an overall response rate of 65% across both trials. Conclusions: MVA-5T4 is safe and well tolerated when administered in conjunction with IFL and FOLFOX chemotherapy regimens. Furthermore, 5T4 specific immune responses are induced in all per protocol patients and can be boosted or maintained during chemotherapy. Encouraging clinical responses have been observed and 5T4 immune responses shown to correlate with clinical benefit.

[Table: see text]

Interferon-alpha2a is sufficient for promoting dendritic cell immunogenicity

Type I interferons (IFNs) are widely used therapeutically. IFN-alpha2a in particular is used as an antiviral agent, but its immunomodulatory properties are poorly understood. Dendritic cells (DCs) are the only antigen-presenting cells able to prime naive T cells and therefore play a crucial role in initiating the adaptive phase of the immune response. We studied the effects of IFN-alpha2a on DC maturation and its role in determining Th1/Th2 equilibrium. We found that IFN-alpha2a induced phenotypic maturation of DCs and increased their allostimulatory capacity. When dendritic cells were stimulated simultaneously by CD40 ligation and IFN-alpha2a, the production of interleukin (IL)-10 and IL-12 was increased. In contrast, lipopolysaccharide (LPS) stimulation in the presence of IFN-alpha2a mainly induced IL-10 release. The production of IFN-gamma and IL-5 by the responder naive T cells was also amplified in response to IFN-alpha2a-treated DCs. Furthermore, IL-12 production by IFN-alpha2a-treated DCs was enhanced further in the presence of anti-IL-10 antibody. Different results were obtained when DCs were treated simultaneously with IFN-alpha2a and other maturation factors, in particular LPS, and then stimulated by CD40 ligation 36 h later. Under these circumstances, IFN-alpha2a did not modify the DC phenotype, and the production of IL-10/IL-12 and IFN-gamma/IL-5 by DCs and by DC-stimulated naive T cells, respectively, was inhibited compared to the effects on DCs treated with maturation factors alone. Altogether, this work suggests that IFN-alpha2a in isolation is sufficient to promote DC activation, however, other concomitant events, such as exposure to LPS during a bacterial infection, can inhibit its effects. These results clarify some of the in vivo findings obtained with IFN-alpha2a and have direct implications for the design of IFN-alpha-based vaccines for immunotherapy.

[Modification of the liver resection technique with radiofrequency coagulation]

INTRODUCTION

Since the introduction of liver resection, intraoperative blood loss is considered to be a major risk factor for perioperative morbidity and mortality. Radiofrequency energy-an established technique for in situ ablation-was used to facilitate liver resection by creating a nearly bloodless tissue plane.

METHODS

After thorough manual and sonographic exploration of the liver, the planned and marked resection plane was coagulated by radiofrequency and then transected. Seven patients with liver metastases of colorectal carcinoma were operated on employing this technique.

RESULTS

A nearly bloodless transection of the parenchyma could be achieved in all cases. Only two patients received blood transfusions: one due to a low preoperative hemoglobin and one due to extended additional abdominal surgery. Procedure-related complications included one case of a second-degree burn to the thigh and one case of postoperative bile leakage requiring hemihepatectomy.

CONCLUSIONS

Radiofrequency-assisted resection offers a valuable additional option in liver surgery, especially in patients with an increased risk of intraoperative bleeding (cirrhosis, coagulopathy).

Caecal volvulus following laparoscopy-assisted sigmoid colectomy for sigmoid volvulus

CASE PRESENTATION. We report a case of caecal volvulus in a patient who underwent laparoscopy-assisted sigmoid resection for sigmoid volvulus 1 year previously. DISCUSSION. Clinico-radiological features and the management of metachronous sigmoid and caecal volvulus are discussed.

Vitamin A status of patients presenting with pulmonary tuberculosis and asymptomatic HIV-infected individuals, Dar es Salaam, Tanzania

Serum vitamin A was determined in a cross-sectional study of 100 HIV-positive and -negative tuberculosis patients and 144 blood donors. Tuberculosis patients were seen again after 2 months of treatment. Mean vitamin A was lowest among tuberculosis patients co-infected with HIV, and was lower among HIV-positive than -negative donors. Mean vitamin A rose significantly at 2 months in HIV-negative patients, and not in -positive patients. HIV infection was the strongest predictor of low vitamin A. Vitamin A deficiency is common in tuberculosis and HIV infection, particularly in those patients who are dually infected, and nutritional supplementation may be beneficial.

DNA adducts, detected by 32P postlabelling, in human cholangiocarcinoma

BACKGROUND

Reported mortality from intrahepatic cholangiocarcinoma (CCa) has risen steeply in the UK and other industrialised countries over the past 30 years, the cause of which has not been explained. DNA adduct formation is promutagenic and demonstrates exposure to a DNA damaging agent. It is a key step in chemically induced carcinogenesis. We hypothesise that the increase in CCa mortality is caused by a rise in a genotoxic environmental agent(s), causing cholangiocyte DNA damage.

AIMS

To investigate and compare tumour and tumour adjacent CCa tissue, and non-cancer control bile duct tissue, for DNA adducts as a biomarker of genotoxin exposure.

METHODS

DNA from 32 intrahepatic CCa patients (and in 28 cases DNA from adjacent non-tumour tissue) and from biliary ducts of seven non-cancer patients were investigated for the presence of DNA adducts using the nuclease P1 method of (32)P postlabelling. DNA adduct levels (number of adducts/10(8) nucleotides) were quantified.

RESULTS

There was no significant difference in relative adduct labellings (RALs) between tumour adjacent DNA (median 8.6, range 1.2-51.6) and CCa DNA (7.2, 1.8-48.4). However, RALs were significantly higher in DNA from cancer patients (tumour adjacent and CCa DNA) compared with non-cancer patient DNA (2.9, 0.6-11.5; p=0.032, two tailed Mann-Whitney U test). Different adduct patterns were also seen in CCa compared with non-cancer patients.

CONCLUSION

Quantitative and qualitative differences in adducts between cancer and non-cancer patients support the hypothesis that genotoxins may play a role in the development of intrahepatic CCa.

[Gene therapy of liver tumors: results of the first clinical studies]

Only a small percentage of primary and secondary liver tumours is suitable for surgical resection. Gene therapy represents a novel strategy that seems to be effective both, in vitro and in vivo. The use of tumour suppressor gene p53 therapy, suicide gene therapy, immune gene therapy and therapy with replication-competent oncolytic adenoviruses in liver tumours already entered the first clinical trials. In patients with hepatocellular carcinoma, the first clinical trials in phase I and II showed good tolerance and low toxicity to gene therapy. However, the clinical benefit for the patients treated either with wild type p53 or E1B deleted adenoviruses were marginal.

Intravascular micropump for augmented liver perfusion: first in vivo experience

The aim of this study was to assess the in vivo performance of a new microaxial rotary blood pump developed for long-term intraportal implantation. The pump, measuring 7 mm in diameter, has a single stage impeller and is powered by a microelectric motor. The pump was implanted into the portal vein in 13 large white pigs under general anesthesia. All animals recovered after the portal pump implantation, and they were observed until the pump failed. The 2 longest running pumps performed for 40 and 36 h, respectively. Either thrombus formation or technical problems, especially in the bearings, were the main causes of pump failure during the experiment. No local or systemic adverse effects were observed during the portal pumping period. Full recovery of the animals following intraportal pump implantation was achieved. However, further technical improvements to the pump are required to maintain a longer performance in vivo.