IL-10 dampens antitumor immunity and promotes liver metastasis via PD-L1 induction

BACKGROUND & AIMS

The liver is one of the organs most commonly affected by metastasis. The presence of liver metastases has been reported to be responsible for an immunosuppressive microenvironment and diminished immunotherapy efficacy. Herein, we aimed to investigate the role of IL-10 in liver metastasis and to determine how its modulation could affect the efficacy of immunotherapy in vivo.

METHODS

To induce spontaneous or forced liver metastasis in mice, murine cancer cells (MC38) or colon tumor organoids were injected into the cecum or the spleen, respectively. Mice with complete and cell type-specific deletion of IL-10 and IL-10 receptor alpha were used to identify the source and the target of IL-10 during metastasis formation. Programmed death ligand 1 (PD-L1)-deficient mice were used to test the role of this checkpoint. Flow cytometry was applied to characterize the regulation of PD-L1 by IL-10.

RESULTS

We found that Il10-deficient mice and mice treated with IL-10 receptor alpha antibodies were protected against liver metastasis formation. Furthermore, by using IL-10 reporter mice, we demonstrated that Foxp3+ regulatory T cells (Tregs) were the major cellular source of IL-10 in liver metastatic sites. Accordingly, deletion of IL-10 in Tregs, but not in myeloid cells, led to reduced liver metastasis. Mechanistically, IL-10 acted on Tregs in an autocrine manner, thereby further amplifying IL-10 production. Furthermore, IL-10 acted on myeloid cells, i.e. monocytes, and induced the upregulation of the immune checkpoint protein PD-L1. Finally, the PD-L1/PD-1 axis attenuated CD8-dependent cytotoxicity against metastatic lesions.

CONCLUSIONS

Treg-derived IL-10 upregulates PD-L1 expression in monocytes, which in turn reduces CD8+ T-cell infiltration and related antitumor immunity in the context of colorectal cancer-derived liver metastases. These findings provide the basis for future monitoring and targeting of IL-10 in colorectal cancer-derived liver metastases.

IMPACT AND IMPLICATIONS

Liver metastasis diminishes the effectiveness of immunotherapy and increases the mortality rate in patients with colorectal cancer. We investigated the role of IL-10 in liver metastasis formation and assessed its impact on the effectiveness of immunotherapy. Our data show that IL-10 is a pro-metastatic factor involved in liver metastasis formation and that it acts as a regulator of PD-L1. This provides the basis for future monitoring and targeting of IL-10 in colorectal cancer-derived liver metastasis.

Protocol for orthotopic single-lung transplantation in mice as a tool for lung metastasis studies

The transplantation model provides the opportunity to assess the relevance of a molecule of interest for tumor cell extravasation by using a respective genetically modified donor animal. Here, we present a protocol for orthotopic single-lung transplantation in mice as a tool for lung metastasis studies. We describe steps for animal preparation, lung transplantation, and tumor cell injection. We then detail procedures for the direct comparison of tumor cell spreading between the genetically modified left lung and the naive right lung parenchyma. For complete details on the use and execution of this protocol, please refer to Giannou et al. (2023).1.

CD4+ T cell-derived IL-22 enhances liver metastasis by promoting angiogenesis

Metastasis is a cancer-related systemic disease and is responsible for the greatest mortality rate among cancer patients. Interestingly, the interaction between the immune system and cancer cells seems to play a key role in metastasis formation in the target organ. However, this complex network is only partially understood. We previously found that IL-22 produced by tissue resident iNKT17 cells promotes cancer cell extravasation, the early step of metastasis. Based on these data, we aimed here to decipher the role of IL-22 in the last step of metastasis formation. We found that IL-22 levels were increased in established metastatic sites in both human and mouse. We also found that Th22 cells were the key source of IL-22 in established metastasis sites, and that deletion of IL-22 in CD4+ T cells was protective in liver metastasis formation. Accordingly, the administration of a murine IL-22 neutralizing antibody in the establishment of metastasis formation significantly reduced the metastatic burden in a mouse model. Mechanistically, IL-22-producing Th22 cells promoted angiogenesis in established metastasis sites. In conclusion, our findings highlight that IL-22 is equally as important in contributing to metastasis formation at late metastatic stages, and thus, identify it as a novel therapeutic target in established metastasis.

Minimally invasive intrathoracic negative-pressure therapy and flexible thoracoscopy (FlexVATS) for patients with pleural empyema

To determine whether a new surgical method using a flexible endoscope (FlexVATS) to perform sparing debridement and apply negative-pressure therapy without extensive decortication may be an alternative treatment option for empyema. Surgical treatment of pleural empyema is associated with considerable postoperative complications and mortality rates, and alternative treatment options are being explored to improve patient outcomes. This was a prospective case series. Seventeen consecutive patients treated with FlexVATS between February 2021 and August 2022 were included in the study. Only patients for whom FlexVATS was the first therapeutic intervention for pleural empyema were included. Treatment success, defined as infection resolution, was the primary endpoint of the study. The secondary endpoints were length of hospital stay, 90-day mortality, and empyema cavity volume reduction. Patients who had previously been treated for pleural empyema by either drainage or surgery were excluded. The trial was performed as a single-centre study at a tertiary medical centre in Germany. In total, 17 patients with pleural empyema were included in the study. The median (IQR) duration of vacuum treatment was 15 days (8-35 days). Twelve of the 17 (71%) patients were successfully treated, and a significant reduction in the empyema cavity volume was observed. 41% of the dressing changes were performed outside the operating room. Compared with a historic cohort of conventionally treated patients (decortication via VATS or thoracotomy), the 90-day mortality rates tended to be lower without reaching statistical significance. Three patients (18%) died in hospital during treatment. No negative pressure-therapy-related complications were observed. FlexVATS therapy is a promising alternative therapy for both healthy and debilitated patients with pleural empyema. Larger randomised trials are required to validate this treatment option.

Gamified Learning to Restore the Forest Landscape in Afghanistan

Implementing digital learning approaches in fragile contexts offer opportunities and challenges at the same time. The following article describes an ongoing project by the German development cooperation organization GIZ (Deutsche Gesellschaft für Internationale Zusammenarbeit GmbH) with the target to reforest areas of Afghanistan and conduct corresponding capacity building activities in the country. The international and Afghan stakeholders are facing a variety of challenges such as threats on personal safety and security, connectivity and electricity breakdowns as well as working with a partwise illiterate and digital illiterate target group. The three steps of the capacity building process of the project will be described and explained - the training of trainers, the training of the NGOs as well as the training of the final target group. Elements of the digital training are gamified and adapted to the Afghan culture, specifically focusing storytelling, roleplay as well as social learning.

[Sepsis after cat bite-How medical history, physical examination and interdisciplinary cooperation influence disease progression]

A 67-year-old woman with symptoms of shock was admitted to hospital with a suspected diagnosis of acute pulmonary artery embolism. After ruling out a thromboembolic event, sepsis was diagnosed by using the SOFA score. A CT scan of the chest with contrast revealed phlegmonous inflammation of the subcutis at the level of the right upper arm. After taking two pairs of peripheral blood samples, calculated antibiotic therapy with piperacillin/tazobactam was administered. After administration of an initial volume bolus, the patient could be transferred to the general medical ward in a stable condition with normal serum lactate level. On day one after hospital admission, blood cultures were positive for Pasteurella multocida, a gramnegative rod that belongs to the oral flora of dogs and cats. Intensified history revealed that the patient had been bitten on the forearm by her cat 2 weeks earlier. The patient did not present to a general practitioner. Despite antibiotic therapy, the patient developed increasing leukocytosis with progressive pain and swelling in the area of the right upper arm and the right ankle. On recommendation of the department of infectious diseases antibiotic therapy was escalated to imipenem and transesophageal echocardiography was performed. Endocarditic vegetations could be ruled out. Despite further escalation of the antibiotic regimen, spontaneous pus discharge occurred at the right ankle. A CT scan of the chest as well as the foot and the right ankle with contrast showed new abscess formations in the right thoracic wall between the pectoralis major and minor muscles as well as extensive abscesses in the extensor compartment of the right lower leg. On day 12 after admission, surgical drainage of multiple abscesses was performed, with rapid improvement in general condition and normalized leukocytes. A further six operations were necessary before the patient could be discharged home after 7 weeks of inpatient treatment.

Long-Term Improvement of Chronic Low-Grade Inflammation After Bariatric Surgery

PURPOSE

Bariatric surgery (BS) was shown to improve inflammatory markers in previous short-term follow-up studies. The aim of the present study was to assess the long-term effects of BS on chronic low-grade inflammation markers related to severe obesity. Moreover, the meaning of the type of BS procedure as well as the remission of type 2 diabetes (T2D) for inflammatory status up to 4 years after BS was analyzed.

MATERIALS AND METHODS

In a retrospective cohort study including 163 patients at baseline, inflammatory and metabolic parameters were assessed at 4 time points: before surgery (baseline), 6 months after surgery (visit 1), 2 years after surgery (visit 2), and 4 years after surgery (visit 3). Univariate regression analysis was used to identify variables that were thought to determine change in inflammatory parameters.

RESULTS

CRP, hs-CRP, leucocytes, and ferritin significantly declined in the mid- and long-term according to the U-shaped curve of weight loss (p<0.001). Change in body mass index (BMI) at long-time follow-up showed a significant linear effect on change in leucocytes (B=0.082; p<0.001) and change in hs-CRP (B=0.03; p<0.05). There was a strong, positive correlation between T2D and hs-CRP at visit 2 (r_s=0.195; p<0.05) and visit 3 (r_s=0.36; p=0.001). With regard to type of surgery and gender, there were no significant differences in inflammatory parameters.

CONCLUSION

BS is able to reduce obesity-related chronic low-grade inflammation up to 4 years after surgical intervention. The improvement in metaflammation is related to the change in BMI and remission of T2D in the long-term.

Bariatric Surgery Is Protective Against Renal Function Decline in Severely Obese Patients in the Long-Term

PURPOSE

This study aims to assess the long-term renal effects of bariatric surgery (BS) in severely obese patients over a follow-up period of up to 11 years.

MATERIALS AND METHODS

In a retrospective cohort study including 102 patients, patients were stratified by eGFR at baseline and divided into three groups: (1) reduced, (2) normal, and (3) increased filtration rate. Adjustments for age- and sex-related decline in eGFR were performed. We used uni- and multivariate regression analysis to identify variables that were thought to determine change in eGFR.

RESULTS

Over a median follow-up of 8.5 years (interquartile range 2.7), eGFR declined from 96.1 ± 20.7 to 84.9 ± 21.0 ml/min (p < 0.001). Among patients with (1), eGFR remained stable (69.1 ± 19.3 ml/min). Among patients with (2), eGFR declined from 99.7 ± 13.3 ml/min to 88.7 ± 19.4 ml/min (p < 0.001). Among patients with (3), eGFR decreased to normal levels (94.2 ± 17.7 ml/min, p < 0.001). Age- and sex-adjusted eGFR increased (6.4 ± 14.4 ml/min; p < 0.05) among patients with reduced filtration rate. Among patients with normal filtration rate, adjusted eGFR remained stable during follow-up (-1.3 ± 15.2 ml/min; n.s.). Among patients with increased filtration rate, adjusted eGFR decreased and remained within the normal range (-13.2 ± 12.2 ml/min; p < 0.001). Change in eGFR showed a negative correlation with eGFR at baseline (B = -0.31; p < 0.001), change in LDL-cholesterol (B = -0.09; p < 0.05), and a negative correlation with treatment requiring hypertension (B = -9.36; p = 0.001).

CONCLUSION

BS is protective against renal function decline in severely obese patients in the long term.

Mentorship Programs in Bariatric Surgery Reduce Perioperative Complication Rate at Equal Short-Term Outcome-Results from the OPTIMIZE Trial

OBJECTIVES

The aim of this study was to determine the efficacy of coaching on outcome in low volume centers of excellence and to evaluate the influence of mentorship programs on the center development.

BACKGROUND

The number of bariatric procedures has increased steadily in the last years. Providing nationwide bariatric care on a high professional level needs structures to train and guide upcoming centers and ensure high quality in patient care.

METHODS

A prospective multicentered, observational study including laparoscopic sleeve gastrectomies (SG) and Roux-en-Y gastric bypass (RYGB) procedures was performed. Twelve emerging bariatric centers were coached by five experienced bariatric centers. Surgeons of the mentor centers gave guidance on pre- and postsurgical management of their patients including complications and proctored the first interventions. The results were compared regarding operative outcomes, percentage of excess weight loss, complications, and resolution of comorbidities.

RESULTS

A total of 214 of 293 patients (73.0%) completed the study. The most frequently reported complications were wound infection (4.4%), disorder of emptying stomach/new reflux (2.4%), anastomotic leaks, intra-abdominal secondary hemorrhage, and dumping syndrome (2.0% each). The mortality rate was zero. We found no difference in overall complication rates or resolution of obesity-related comorbidities when comparing experienced surgeons with less experienced surgeons.

CONCLUSIONS

Our results suggest that under the conditions of the practices of this study, coaching and mentoring were associated with comparable outcomes both in experienced and emerging centers. In addition, mentorship programs ensure equal outcome quality in terms of improvement of obesity-associated comorbidities.

TRIAL REGISTRATION

NCT Number: NCT01754194 .

Adaptive changes in pancreas post Roux-en-Y gastric bypass induced weight loss

BACKGROUND

Obesity has been shown to trigger adaptive increases in pancreas parenchymal and fat volume. Consecutively, pancreatic steatosis may lead to beta-cell dysfunction. However, it is not known whether the pancreatic tissue components decrease with weight loss and pancreatic steatosis is reversible following Roux-en-Y gastric bypass (RYGB). Therefore, the objective of the study was to investigate the effects of RYGB-induced weight loss on pancreatic volume and glucose homeostasis.

METHODS

Eleven patients were recruited in the Obesity Centre of the University Medical Centre Hamburg-Eppendorf. Before and 6 months after RYGB, total GLP-1 levels were measured during oral glucose tolerance test. To assess changes in visceral adipose tissue and pancreatic volume, MRI was performed. Measures of glucose homeostasis and insulin indices were assessed. Fractional beta-cell area was estimated by correlation with the C-peptide-to-glucose ratio; beta-cell mass was calculated by the product of beta-cell area and pancreas parenchymal weight.

RESULTS

Pancreas volume decreased from 83.8 (75.7-92.0) to 70.5 (58.8-82.3) cm³ (mean [95% CI], P = .001). The decrease in total volume was associated with a significant decrease in fat volume. Fasting insulin and C-peptide were lower post RYGB. HOMA-IR levels decreased, whereas insulin sensitivity increased (P = .03). This was consistent with a reduction in the estimated beta-cell area and mass.

CONCLUSIONS

Following RYGB, pancreatic volume and steatosis adaptively decreased to "normal" levels with accompanying improvement in glucose homeostasis. Moreover, obesity-driven beta-cell expansion seems to be reversible; however, future studies must define a method to more accurately estimate functional beta-cell mass to increase our understanding of glucose homeostasis after RYGB.

Upper Gastrointestinal Endoscopy prior to Bariatric Surgery-Mandatory or Expendable? An Analysis of 801 Cases

BACKGROUND

Upper gastrointestinal pathologies are common in bariatric patients. Preoperative esophagogastroduodenal endoscopy (EGD) should detect and treat pathologies that might alter the type of bariatric surgery. However, clinical consequences of these findings are often insignificant. The aim of this study was to assess the influence of preoperative endoscopy in our cohort and its clinical consequences.

METHODS

We conducted a retrospective analysis of endoscopic findings in patients under evaluation for bariatric surgery. Endoscopic findings were compared to preoperative risk factors as well as postoperative complications, and its clinical consequences were analyzed.

RESULTS

Data was available for 801 patients. Abnormal endoscopic findings were found in 65.7% of all patients. The most common conditions were gastritis (32.1%) and gastroesophageal reflux (24.8%). Malignancies were observed in 0.5% of all patients. We observed early-stage adenocarcinoma of the esophagus in two patients through our routine preoperative evaluation. Helicobacter pylori infections were detected in preoperative biopsies in only 3.7% of all patients. Patients who reported reflux symptoms had a higher rate of pathological EGDs (74.2 vs. 64.9%, p .019). We did not find any other risk factors for a pathological endoscopy. The postoperative complication rate was 11.2%. Leakage rate was 1.1%. Mortality rate was 0.4%. We did not find any correlation between the incidence of postoperative complications and preoperative endoscopic findings.

CONCLUSIONS

Relevant findings in routine preoperative endoscopy are rare but have significant influence on decision-making in bariatric patients and should be assessed as a necessary diagnostic tool.

Autoimmune Renal Disease Is Exacerbated by S1P-Receptor-1-Dependent Intestinal Th17 Cell Migration to the Kidney

Th17 cells are most abundant in the gut, where their presence depends on the intestinal microbiota. Here, we examined whether intestinal Th17 cells contribute to extra-intestinal Th17 responses in autoimmune kidney disease. We found high frequencies of Th17 cells in the kidneys of patients with antineutrophil cytoplasmatic antibody (ANCA)-associated glomerulonephritis. We utilized photoconversion of intestinal cells in Kaede mice to track intestinal T cell mobilization upon glomerulonephritis induction, and we found that Th17 cells egress from the gut in a S1P-receptor-1-dependent fashion and subsequently migrate to the kidney via the CCL20/CCR6 axis. Depletion of intestinal Th17 cells in germ-free and antibiotic-treated mice ameliorated renal disease, whereas expansion of these cells upon Citrobacter rodentium infection exacerbated pathology. Thus, in some autoimmune settings, intestinal Th17 cells migrate into target organs, where they contribute to pathology. Targeting the intestinal Th17 cell "reservoir" may present a therapeutic strategy for these autoimmune disorders.

A pathogenic role for T cell-derived IL-22BP in inflammatory bowel disease

Intestinal inflammation can impair mucosal healing, thereby establishing a vicious cycle leading to chronic inflammatory bowel disease (IBD). However, the signaling networks driving chronic inflammation remain unclear. Here we report that CD4⁺ T cells isolated from patients with IBD produce high levels of interleukin-22 binding protein (IL-22BP), the endogenous inhibitor of the tissue-protective cytokine IL-22. Using mouse models, we demonstrate that IBD development requires T cell-derived IL-22BP. Lastly, intestinal CD4⁺ T cells isolated from IBD patients responsive to treatment with antibodies against tumor necrosis factor-α (anti-TNF-α), the most effective known IBD therapy, exhibited reduced amounts of IL-22BP expression but still expressed IL-22. Our findings suggest that anti-TNF-α therapy may act at least in part by suppressing IL-22BP and point toward a more specific potential therapy for IBD.

Attachment, Viability and Adipodifferentiation of Pre-adipose Cells on Silk Scaffolds with and Without Co-expressed FGF-2 and VEGF

BACKGROUND/AIM

For application of stem cells and progenitor cells in regenerative medicine, scaffolds for carrying the cells play a key role. One promising biomaterial for scaffold generation is silk because of its mechanical strength, good cytocompatibility and low immunogenicity. Furthermore, bioengineering of silk proteins enable co-expression of various growth, differentiation and angiogenic factors on silk fibers, which may promote cell growth, differentiation and angiogenesis. This study aimed to test cytocompatibility and growth/differentiation of pre-adipose cells on scaffolds with and without expressed growth factors fibroblast growth factor-2 (FGF-2) and vascular endothelial growth factor (VEGF).

MATERIALS AND METHODS

Disk-form scaffolds of 15×3 mm (diameter × thickness) were manufactured in two different densities using silk with and without expressed growth factors FGF-2 or VEGF. Pre-adipose cells were prepared from fatty tissues of patients undergoing operation. Cells (1.6×10(6)) were seeded onto each of the silk-scaffold disks, that were placed into wells of 12-well culturing plates. Adipose-differentiation was induced using differentiation medium containing DMEM/F-12, insulin, pantothenate, biotin, triiodothyronine (T3), transferrin, dexamethasone, isobuthylmethylxanthine and rosiglitazone. Cells on the scaffolds were visualized using a confocal microscope. Viability and adiponectin were measured on days 0, 7 and 14. Expression of adipose-differentiation markers was assessed by means of real-time polymerase chain reaction (RT-PCR).

RESULTS

Pre-adipose cells attached well onto the silk fibers. The highest initial viability was measured on the low-density scaffolds with expressed VEGF. Adipose-differentiation was evident in visible oil droplets and significantly increased adiponectin protein levels were seen in ELISA. Furthermore, increased expression of adipose-differentiation genes were measured in RT-PCR. Adipose-differentiation was more profound in cells on high-density scaffolds. In concordance, viability of cells on high-density scaffolds did not increase, while that of cells on low-density scaffolds doubled over the 14-day experimental period. Slightly enhanced adipose-differentiation was observed in cells on scaffolds with expressed FGF-2 or VEGF.

CONCLUSION

Silk scaffolds exhibit excellent cytocompatibility for human pre-adipose cells and have application potential in tissue engineering and regenerative medicine. VEGF and FGF-2 expressed on silk fibers could have a potential positive effect on pre-adipose cells, while the effect of VEGF should be further addressed in vivo.

Endoscopic ultrasound-guided drainage of abdominal fluid collections after pancreatic surgery: Efficacy and long-term follow-up

BACKGROUND/PURPOSE

Endoscopic ultrasound-guided drainage (EUS-GD) of postoperative abdominal fluid collections (POFC) following pancreatic surgery is used as an alternative or complement to percutaneous drainage (PD) procedure. The present single-center retrospective study evaluates its efficacy and safety.

METHOD

We included consecutive cases with POFC treated by EUS-GD between September 2009 and November 2014 in our department. Technical success, long-term clinical success, recurrence rate and need for surgery were analyzed.

RESULTS

24 procedures in 20 patients (95 % after pancreatic resection) were assessed. Indications for surgery included tumors/lesions located in the pancreas (15/20), chronic pancreatitis (3/20) and duodenal adenoma not completely resectable endoscopically (2/20). EUS-GD was performed within a median of 30 days (IQR: 8.25) for a median fluid collection size of 72.5 mm (IQR: 46.25), requiring a mean of 1.2 sessions with placement of a mean of 2.1 plastic stents (7 Fr/10 Fr) per patient for a mean of 89 days (IQR: 127). Microbiology of aspirated fluid revealed positive cultures in 13 patients, mostly polymicrobial, isolated positive for fungal and 3 multidrug-resistant gram negative (MRGN) in 4 cases. An additional transpapillary drainage was inserted in 1/20 patients. 4/20 patients received PD, mostly before EUS-GD. Technical and clinical success was achieved in 20/20 (100 %) and 18/20 (90 %) patients, respectively, while 2 patients required re-operation. During follow-up (median 630 days after stent removal, range: 45 - 2160), recurrence occurred in 1/18 (5.5 %) patient that was referred for surgery. No death or severe adverse events were noted.

CONCLUSION

EUS-GD is an effective, minimally invasive and safe method for therapy of POFC after pancreatic surgery offering long-term remission in about 95 % of cases.

Decreased frequency of CD73+CD8+ T cells of HIV-infected patients correlates with immune activation and T cell exhaustion

Recent studies indicate that murine Tregs highly express the ENTDP1, as well as the 5'-NT and thereby, suppress Teff function by extracellular adenosine production. Furthermore, CD73 seems to play a role as costimulatory molecule for T cell differentiation. In this study, we analyzed the expression of CD73 on peripheral and lymph nodal Teffs and Tregs in a cohort of 95 HIV patients at different stages of disease, including LTNP and ECs. In contrast to murine Tregs, CD73 was only expressed on a small minority (∼10%) of peripheral Tregs. In contrast, we see high expression of CD73 on peripheral CD8(+) T cells. In HIV infection, CD73 is markedly reduced on all Teffs and Tregs, regardless of the memory subtype. On CD8(+) T cells, a positive correlation between CD73 expression and CD4 counts (P=0.0003) was detected. CD73 expression on CD8(+) T cells negatively correlated with HLA-DR (<0.0001) and PD1 (P=0.0457) expression. The lower CD73 expression on CD8(+) T cells was partially reversible after initiation of ART (P=0.0016). Functionally, we observed that CD8(+)CD73(+) T cells produce more IL-2 upon HIV-specific and unspecific stimulation than their CD73(-) counterparts and show a higher proliferative capacity. These data indicate that down-regulation of CD73 on CD8(+) T cells correlates with immune activation and leads to functional deficits in HIV infection.

Heme oxygenase-1 germ line GTn promoter polymorphism is an independent prognosticator of tumor recurrence and survival in pancreatic cancer

BACKGROUND

Heme oxygenase-1 (HO-1) correlates with aggressive tumor behavior and chemotherapy resistance in pancreatic cancer (PC). We evaluated the prognostic value of the basal transcription controlling germ line GTn repeat polymorphism (GTn) in the promoter region of the HO-1 gene in PC.

PATIENTS AND METHODS

We determined the GTn in 100 controls and 150 PC patients. DNA was extracted from blood leukocytes and GTn determined by PCR, electrophoresis, and sequencing. Clinicopathological parameters, disease-free, and overall survival (DFS, OS) were correlated with GTn.

RESULTS

Three genotypes were defined based on short (S) <25 and long (L) ≥25 GTn repeat alleles. In PC patients, a steadily increasing risk was evident between LL, SL, and SS genotype patients for larger tumor size, presence of lymph node metastasis, poor tumor differentiation and higher recurrence rate (P < 0.001 each). The SS genotype displayed the most aggressive tumor biology. The LL genotype had the best and the SS genotype the worst DFS and OS (P < 0.001 each). The GTn genotype was the strongest prognostic factor for recurrence and survival (P < 0.001 each).

CONCLUSION

The GTn repeat polymorphism is a strong prognostic marker for recurrence and survival in PC patients.

Near-surface structure of a bicontinuous microemulsion with a transition region

The lamellar ordering of bicontinuous microemulsions adjacent to a planar hydrophilic wall is investigated experimentally by grazing-incidence small-angle neutron scattering and theoretically by computer simulations. It is shown that precise depth information in neutron scattering can be obtained by tuning the scattering length density of the overall microemulsion. Neutron reflectometry completes the characterization. The nucleation of a lamellar phase at the wall is observed, and a perforated lamellar transition region is identified at the lamellar-microemulsion interface. The thickness of the lamellar region is about 400 Å, which corresponds to two bilayers.

Compression of random coils due to macromolecular crowding: scaling effects

The addition of a macromolecular crowding agent to a dilute solution of polymer exerts a compressive force that tends to reduce the size of the chain. We study here the effect of changing the size ratio between the random coil and the crowding agent. The compression occurs at lower crowding agent concentration, Φ when polymer molecular weight increases. The Flory exponent ν(Φ) decreases from ν(0)≃0.48 in water down to 0.3 with macromolecular crowding. The effective polymer-polymer interactions change from repulsive to strongly attractive inducing aggregation of the chains. This effect changes drastically for larger polymer sizes, being much more pronounced at high molecular weights.

Association of antidiabetic therapies to glycemic control and to body weight in type 2 diabetes: a German multicenter analysis on 9294 patients

Glycemic and body weight control are two outstanding goals in the treatment of patients with type 2 diabetes that often are not appropriately achieved. This observational study evaluates whether treatment by quality controlled diabetes centers generates an improvement in this regard and focuses on associations with different therapies. Data of 9.294 type 2 diabetic patients (mean age 66.9±11.6 years, mean diabetes duration 12.4±9.2 years) from 103 German diabetes centers were assessed by a standardized, prospective, computer-based diabetes care and outcome documentation system (DPV-Wiss-database). Therapeutic concepts included lifestyle intervention (n=1.813), oral antidiabetics (OAD, n=1.536), insulin (n=4.504) and insulin plus OAD (n=1.441). HbA1c and body weight were compared before and after a stable therapeutical period of 1.07±0.3 years. Change in HbA1c (%): all patients 7.4±1.6-7.0±1.3, lifestyle intervention 7.5±1.9-6.9±1.5, OAD 6.7±1.1-6.5±1.0, insulin 7.6±1.6-7.2±1.4, insulin plus OAD 7.5±1.5-7.2±1.3; each p≤0.05. Change in body weight (kg): all patients +0.08±0.07, n. s.; lifestyle intervention -0.28±0.20, OAD -0.56±0.13, each p<0.05 [metfomin -0.77±0.21, sulfonylurea drugs -0.75±0.34, each p<0.05; glitazones +0.62±0.70, α-glucosidase inhibitors -0.22±0.76, each n. s.], insulin +0.27±0.10, insulin plus OAD +0.63±0.14, each n. s. In summary, lifestyle, metformin or sulfonylurea drug treatment resulted in HbA1c-values below 7.0% plus a significant weight reduction. Insulin treatment-associated concepts resulted in HbA1c-values slightly above 7.0% without body weight alterations. These "real life" data underline that a specialised and quality controlled diabetes care is able to achieve significant treatment results even in patients with disease progression and a high proportion of insulin therapies.

Rehabilitation Programs for Cystic Fibrosis - View from a CF Center

Background:

Rehabilitation programs are comprehensive interventions which effectively improve the health status and reduce costs in chronic respiratory illnesses. Because patients with cystic fibrosis have been discouraged to participate for concerns of microbial cross infection, the efficacy of systematic rehabilitation is unknown for this group.

Methods:

We retrospectively studied 142 cystic fibrosis patients aged 2-46 years who participated in rehabilitation programs taking place in Germany/Switzerland and in Israel, focusing on changes in lung function and weight.

Results:

During 172 stays in 97 patients in Israel and 68 stays in 45 patients rehabilitating in Germany/Switzerland, overall lung function and weight improved. Outcome did not differ between Israel and German/Swiss sites. Interestingly, lung function improved during the initial phase of the stay, whereas weight gain was sustained throughout. The study uncovered gaps in reporting sufficient individual outcome information back to the admitting centre.

Conclusions:

Rehabilitation programs specified for cystic fibrosis patients need to be assessed prospectively to optimize treatment of this life limiting condition.

Is there still place for endoscopic mucosal resection in patients with early oesophageal carcinomas?

e15640

Background: The objective of this study was to investigate whether limited resection of the oesophagogastric junction can be successfully used in the treatment of the patients with early oesophageal carcinomas. Methods: A total of 111 patients with early oesophageal cancer (57 adenocarcinomas, 54 squamous cell carcinomas) had surgical resection with systematic lymphadenectomy (41 thoracoabdominal-TA, 52 transhiatal-TH and 18 with limited resection of the oesophagogastric junction- LROGJ). Results: In all patients, regardless from the surgical procedure, a complete resection (R0) was achieved. The median lymph node yield was significantly higher (p=0.0001) in TA patients (24 LN), compared with TH (14LN) and LROGJ (16LN). The median in hospital and ICU stay were shorter in patients with the LROGJ (12 and 2 days, respectively) compared with the TA (24 and 8 days) and TH patients (23 and 4 days). None of the 43 patients with high grade intraepithelial neoplasia (HGIEN) or oesophageal carcinoma limited to the mucosa had lymphatic spread, as compared with 15 of 68 (22.1%) with affection of the submucosa. Although lymph node metastases were usually limited to locoregional lymph node stations, two patients had metastases in distant lymph nodes (pM1a) The infiltration of the submucosa was accompanied with significant worsening of the overall survival (pT1a vs. pT1b; p=0.002). Multifocal neoplasia was detected in three patients with SCC HGIEN (30%) but not in AC HGIEN! Nine out of 44 (20.4%) patients with early SCC had multifocal neoplasia, compared to 6 out of 53 (11.3%) patients in AC (p=0.322). The sensitivity of the preoperative tumour dept staging (endoscopic ultra sound - EUS; and CT) was astonishing low (only 50% for cT1b), as was the specificity (66.7% for cT1a and only 87.5% for cT1b). On multivariate analysis, only histological tumor type (AC) was independent predictor of survival. Conclusions: Considering the limitations and pitfalls of endoscopic and classical resectional procedures, the quest for alternative and “patient tailored” treatment in patients with early oesophageal carcinoma carries on. A valuable alternative can be the limited resection of the oesophago-gastric junction under sparing of the healthy oesophagus and stomach.

No significant financial relationships to disclose.

[Operative technique and outcome in metabolic surgery: conventional and banded gastric bypass]

BACKGROUND

The prevalence of morbid obesity and its sequelae is increasing in Germany, Europe and worldwide. Bariatric surgery is thus gaining in importance for the treatment of patients with malignant obesity. Creation of a gastric bypass is one of the most frequently performed procedures for obesity.

DISCUSSION

The gastric bypass has been used -since 1966 as a surgical means of weight reduction in obese patients. In the mean time various modifications have been developed. Thus, for example, the laparoscopic procedure represents the current standard. After the operation most patients experience an excess weight loss (EWL) of between 61 and 83 %. The comorbidities of obesity are also markedly improved and in a high percentage even cured after the operation. It is worthy of note that diabetes mellitus type II improves shortly after the operation even before any weight loss has occurred. The suggests that the operation induces more than "just" a loss of weight.

CONCLUSION

For decades the gastric bypass has been a well known standard operation of overweight and, in addition to the reduction in weight, is also a therapy for diabetes mellitus -type II.

Genetic variation may influence obesity only under conditions of diet: analysis of three candidate genes

Under the hypothesis of obesity as a polygenetic disease numerous genes have been associated with an obese phenotype and metabolic co-morbidities. The cannabinoid receptor 1 (CB 1) is part of an underinvestigated system that participates in appetite control. Previous publications suggest that the endocannabinoid systems interact with the better understood leptin-melanocortin axis. Neuropeptide Y (NPY) is a player in the latter. Finally resistin has been shown to influence NPY expression in the brain. In a cohort of 1721 caucasion men and women with a BMI of 25kg/m(2) or more we therefore investigated three candidate polymorphisms at baseline and following 3 months low fat caloric restriction diet by polymerase chain reaction and restriction digestion: the 1359 G/A variant of the cannabinoid receptor 1 (CB1), the L7P variation in neuropeptide Y (NPY) and the -420C>G polymorphism in resistin. Comparing groups according to genotype for each gene separately revealed significant results at baseline only for the CB1 gene. However, upon dieting significant data was found for all 3 genes. Carriers of at least one A allele in CB1 lost more weight and reduced LDL cholesterol more than wildtype patients. LL homocygotes in NPY had a greater reduction in glucose, triglycerides, and LDL cholesterol whereas in resistin carriers of the G allele had a greater reduction in weight and triglycerides. Creating two groups defined by NPY and resistin genotype, respectively, with similar BMI values resulted in significant differences concerning weight loss and metabolic improvement. In conclusion, genetic polymorphisms associated with obesity may become relevant only under the condition of a low calory diet. The presence of a certain genotype may then be beneficial for obesity treatment.

Resection vs drainage in treatment of chronic pancreatitis: long-term results of a randomized trial

BACKGROUND & AIMS

Tailored organ-sparing procedures have been shown to alleviate pain and are potentially superior in terms of preservation of endocrine and exocrine function as compared with standard resection (Whipple) for chronic pancreatitis with inflammatory pancreatic head tumor. Long-term results comparing these 2 procedures have not been published so far. The aim of this study was to report on long-term results of a randomized trial comparing a classical resective procedure (pylorus-preserving Whipple) with an extended drainage procedure (Frey) for chronic pancreatitis.

METHODS

All patients who participated in a previously published randomized trial on the perioperative course comparing both procedures were contacted with a standardized, validated, quality of life and pain questionnaire. Additionally, patients were seen in the outpatient clinic to assess endocrine and exocrine pancreatic function by an oral glucose tolerance test and fecal chymotrypsin test.

RESULTS

There were no differences between both groups regarding quality of life, pain control, or other somatic parameters after a median of 7 years postoperatively. Correlations among continuous alcohol consumption, endocrine or exocrine pancreatic function, and pain were not found.

CONCLUSIONS

Both procedures provide adequate pain relief and quality of life after long-term follow-up with no differences regarding exocrine and endocrine function. However, short-term results favor the organ-sparing procedure.

[A sizeable chance--surgical management of profound obesity concurrent with post-traumatic osteoarthrosis]

In times of plentiful nutrition an environmental advantage turns into a problem - obesity. Apart from an increase in morbidity and overall mortality the development of osteoarthrosis is well documented. Pre-arthrotic conditions may arise from trauma and can lead, depending on the pattern of injury, to full-blown arthrosis. The presence of obesity can play the role of a relevant progressive factor in this setting. Here we report about the case of an obese man (BMI 53.5 kg/m(2)), who suffered a fracture of the femoral head with acetabular participation (Pipkin IV) as well as a fracture of the tibial plateau. Operative management and rehabilitation were followed by gastric bypass surgery for weight reduction. The case is discussed with regard to the present literature.

Is the frequency of self-monitoring of blood glucose related to long-term metabolic control? Multicenter analysis including 24,500 patients from 191 centers in Germany and Austria

Blood glucose measurements are generally accepted components of a modern diabetes self-management. The value of self-monitoring of blood glucose (SMBG) is, however, discussed controversially and only a few studies addressed the efficacy of SMBG under real-life conditions so far. In order to investigate whether the frequency of SMBG is related to long-term metabolic control, data from the DPV-Wiss-database, a standardized,prospective, computer-based documentation of diabetes care and outcome, were analyzed for patients with type 1(n = 19,491) and type 2 (n = 5,009) diabetes from 191 centers in Germany and Austria. Local HbA1c reference ranges were mathematically adjusted to the DCCT reference. For each patient, data from the most recent year of diabetes care were used. On average,patients with type 1 diabetes performed 4.4 blood glucose measurements/day. Corrected for age, gender, diabetes duration,on intensified (>or=4 daily injections or CSII) therapy (HbA1c reduction of 0.32% for one additional SMBG/day) compared to patients on conventional (1-3 daily injections) therapy(HbA1c-reduction of 0.16% for one additional SMBG/day). In 2,021 patients with insulin-treated type 2 diabetes (2.7 measurements/day), more frequent SMBG was associated with better metabolic control (HbA1c-reduction of 0.16% for one additionalSMBG/day, p < 0.0001), while in 2,988 patients on OAD or diet alone (2.0 measurements/day), more frequent blood glucose measurements were associated with higher HbA1c-levels(HbA1c-increase of 0.14% for one additional SMBG/day,p < 0.0001). These data indicate that more frequent SMBG are associated with better metabolic control in both, patients with type 1 and insulin-treated type 2 diabetes. Since no benefit ofSMBG on metabolic control was found in patients with type 2 diabetes on OAD or diet alone, SMBG should primarily be recommended for those patients with suboptimal metabolic control whereas the benefit of SHBG in non-insulin-treated patients with adequate HbA1c-levels remains uncertain.insulin therapy and center difference, the SMBG frequency was associated with better metabolic control (HbA1c-reduction of0.26% for one additional SMBG/day, p < 0.0001). HbA1c-reduction with higher frequency of SMBG was more pronounced in patients Blood glucose measurements are generally accepted components of a modern diabetes self-management. The value of self-monitoring of blood glucose (SMBG) is, however, discussed controversially and only a few studies addressed the efficacy of SMBG under real-life conditions so far. In order to investigate whether the frequency of SMBG is related to long-term metabolic control, data from the DPV-Wiss-database, a standardized,prospective, computer-based documentation of diabetes care and outcome, were analyzed for patients with type 1(n = 19,491) and type 2 (n = 5,009) diabetes from 191 centers in Germany and Austria. Local HbA1c reference ranges were mathematically adjusted to the DCCT reference. For each patient, data from the most recent year of diabetes care were used. On average,patients with type 1 diabetes performed 4.4 blood glucose measurements/day. Corrected for age, gender, diabetes duration,insulin therapy and center difference, the SMBG frequency wasassociated with better metabolic control (HbA1c-reduction of 0.26% for one additional SMBG/day, p < 0.0001). HbA1c-reduction with higher frequency of SMBG was more pronounced in patients on intensified (>or= 4 daily injections or CSII) therapy (HbA1c reduction of 0.32% for one additional SMBG/day) compared to patients on conventional (1-3 daily injections) therapy(HbA1c-reduction of 0.16% for one additional SMBG/day). In 2,021 patients with insulin-treated type 2 diabetes (2.7 measurements/day), more frequent SMBG was associated with better metabolic control (HbA1c-reduction of 0.16% for one additionalSMBG/day, p < 0.0001), while in 2,988 patients on OAD or diet alone (2.0 measurements/day), more frequent blood glucose measurements were associated with higher HbA1c-levels(HbA1c-increase of 0.14% for one additional SMBG/day, p < 0.0001). These data indicate that more frequent SMBG are associated with better metabolic control in both, patients with type 1 and insulin-treated type 2 diabetes. Since no benefit of SMBG on metabolic control was found in patients with type 2 diabetes on OAD or diet alone, SMBG should primarily be recommended for those patients with suboptimal metabolic control whereas the benefit of SHBG in non-insulin-treated patients with adequate HbA1c-levels remains uncertain.

Grazing-incidence small-angle X-ray scattering from thin polymer films with lamellar structures – the scattering cross section in the distorted-wave Born approximation

Grazing-incidence small-angle X-ray or neutron scattering of thin polymer films reveals information about the ordering and preferential orientations of the phase-separated microdomains within the films. The grazing-incidence geometry enhances the surface sensitivity; however, the scattering has to be treated within the framework of the distorted-wave Born approximation. In this work, the case of thin films with lamellar mesostructure is studied, where the orientation of the lamellae is either perpendicular or parallel to the film interfaces. For perpendicular lamellae, Bragg rods are found, which are extended along the film normal, whereas for parallel lamellae, peaks along the film normal appear. The positions of the maxima present in the latter case are explained by accounting for refraction at the film surface and reflection at the film–substrate interface. The results are relevant for thin films of lamellar diblock copolymers.

Tumor-cell homing to lymph nodes and bone marrow and CXCR4 expression in esophageal cancer

BACKGROUND

The chemokine and bone marrow-homing receptor CXCR4 has been implicated in metastatic dissemination of various cancers. We investigated CXCR4 expression in esophageal cancer specimens and its association with survival, lymph node microinvolvement, and bone marrow micrometastasis.

METHODS

We analyzed frozen tumor specimens from 136 patients with completely resected esophageal cancer for CXCR4 expression by immunohistochemistry. Lymph node microinvolvement and bone marrow micrometastasis were assessed by immunohistochemistry with monoclonal antibodies Ber-EP4 (against epithelial cell adhesion molecule) and pancytokeratin A45-B/B3 (against several cytokeratins), respectively. Associations between CXCR4 expression and clinicopathologic features, including tumor stage, histologic grade, lymph node metastasis and microinvolvement, bone marrow micrometastasis, and survival, were investigated with Fisher's test, log-rank test, and Cox multivariable analysis. All statistical tests were two-sided.

RESULTS

CXCR4 protein was expressed in 75 (55%) of 136 esophageal tumors examined. CXCR4 expression was statistically significantly associated with reduced median overall and disease-specific survival, compared with CXCR4 nonexpression (P < .001; log-rank test). The median overall survival of patients with CXCR4-positive tumors was 20 months and with CXCR4-negative tumors, 76 months (difference = 56 months, 95% confidence interval [CI] = 4 to 108 months; P < .001). The median disease-specific survival of patients with CXCR4-positive tumors was 25 months and with CXCR4-negative tumors was 97 months (difference = 72 months, 95% CI = 34 to 110 months; P < .001). CXCR4 expression was statistically significantly associated with increased lymph node microinvolvement (P < .001) and with increased bone marrow micrometastasis (P < .001). In multivariable analysis, CXCR4 expression, compared with its nonexpression, was identified as the independent variable that was most strongly associated with reduced disease-specific survival (relative risk [RR] of death = 2.03, 95% CI = 1.20 to 3.41; P = .008) and overall survival (RR of death = 2.18, 95% CI = 1.33 to 3.59; P = .002).

CONCLUSION

CXCR4 expression was associated with poor clinical outcome in esophageal cancer patients. CXCR4 may have a role in early metastatic spread because its expression was associated with micrometastases to both the lymph nodes and bone marrow. Thus, CXCR4 should be explored further as a target for adjuvant therapy for micrometastatic disease.

Influence of thymidylate synthase and p53 protein expression on clinical outcome in patients with colorectal cancer

AIMS

Thymidylate synthase (TS) and tumor suppressor p53 are two proteins with an influence on tumor resistance to radio-chemotherapy that is well known. For this reason we tested the effect of TS and p53 expression on clinical outcome (tumor recurrence and survival) in patients after curative tumor resection, especially in patients who received adjuvant radio-chemotherapy.

PATIENTS AND METHODS

A total of 120 patients with colorectal cancer were included in the study. A curative resection was possible in 83 patients, and 30 of this group received adjuvant therapy. For the immunohistochemical staining of tumor specimens, monoclonal antibody (mAb) TS 106 against TS and mAb DO-1 against p53 protein were used. TS positivity was defined as a moderate to high staining intensity in the cytoplasma of cells and p53 positivity as nuclear staining of tumor cells in >10% of these cells.

RESULTS

Thymidylate synthase immunoreactivity was found in 59% of all cases and p53 staining in 51%. No relation between clinicopathological features and p53 expression was found in contrast to TS expression, where a highly significant association of TS-positive cases with tumor invasion (pT) was observed. Curatively resected patients with a TS-positive tumor developed tumor recurrence/distant metastases significantly more often than TS negative tumors. The same result was found when comparing p53-positive with p53-negative tumors and TS+/p53+ with TS-/p53- tumors. TS expression was highly significantly associated with poor survival and was the strongest independent prognostic factor in multivariate analysis, followed by lymph node status.

CONCLUSION

Thymidylate synthase expression seems to be an independent prognostic factor and a possible predictor of tumor recurrence in patients with colorectal cancer.

Quantum states and generalized observables: a simple proof of Gleason's theorem

A quantum state can be understood in a loose sense as a map that assigns a value to every observable. Formalizing this characterization of states in terms of generalized probability distributions on the set of effects, we obtain a simple proof of the result, analogous to Gleason's theorem, that any quantum state is given by a density operator. As a corollary we obtain a von Neumann-type argument against noncontextual hidden variables. It follows that on an individual interpretation of quantum mechanics the values of effects are appropriately understood as propensities.