Discharge protocol in acute pancreatitis: an international survey and cohort analysis

There are several overlapping clinical practice guidelines in acute pancreatitis (AP), however, none of them contains suggestions on patient discharge. The Hungarian Pancreatic Study Group (HPSG) has recently developed a laboratory data and symptom-based discharge protocol which needs to be validated. (1) A survey was conducted involving all members of the International Association of Pancreatology (IAP) to understand the characteristics of international discharge protocols. (2) We investigated the safety and effectiveness of the HPSG-discharge protocol. According to our international survey, 87.5% (49/56) of the centres had no discharge protocol. Patients discharged based on protocols have a significantly shorter median length of hospitalization (LOH) (7 (5;10) days vs. 8 (5;12) days) p < 0.001), and a lower rate of readmission due to recurrent AP episodes (p = 0.005). There was no difference in median discharge CRP level among the international cohorts (p = 0.586). HPSG-protocol resulted in the shortest LOH (6 (5;9) days) and highest median CRP (35.40 (13.78; 68.40) mg/l). Safety was confirmed by the low rate of readmittance (n = 35; 5%). Discharge protocol is necessary in AP. The discharge protocol used in this study is the first clinically proven protocol. Developing and testifying further protocols are needed to better standardize patients' care.

Assessment of the level III of Inoue by preoperative endoscopic ultrasound and elastography: a novel approach to predict a periarterial divestment technique in borderline resectable (BR) or locally advanced (LA) pancreatic adenocarcinoma-How I do it

BACKGROUND

Periarterial divestment is a surgical technique to approach borderline resectable (BR) or locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC) with arterial involvement. There are no reports in the literature regarding the role of endoscopic ultrasound and elastography (EUS-EG) in exploring the integrity of Inoue's level III and its correlation with the periarterial divestment technique feasibility. Our research is aimed at exploring the role of EUS-EG in this scenario.

METHODS

We describe our approach to Inoue's level II by EUS-EG in patients with BR and LA pancreatic cancer patients after neoadjuvant chemotherapy.

RESULTS

Between June 2019 and December 2020, four patients out of 25 were eligible to perform a preoperative EUS-EG. In all cases, Inoue's level III integrity was corroborated by EUS-EG and confirmed posteriorly in the surgical scenario where a periarterial divestment technique was feasible. Vein resections were necessary in all cases, with no need for arterial resection. An R0 (> 1 mm) margin was achieved in all patients, and the histopathological assessment showed the presence of neurovascular tissue at the peripheral arterial margin.

CONCLUSION

Preoperatively, EUS-EG is a novel approach to explore the integrity of Inoue's level III and could be helpful to preclude a periarterial divestment technique in borderline resectable or locally advanced pancreatic adenocarcinoma with arterial involvement.

Pancreatic Cancer Surgery: What Matters to Patients?

Pancreatic cancer is a leading cause of cancer-related death, with a poor overall survival rate. Although certain risk factors have been identified, the origins of pancreatic cancer are still not fully understood. Surgical resection remains the primary curative treatment, but pancreatic surgery is still associated with high morbidity and mortality rates, and most patients will experience recurrence. The impact of pancreatic cancer on patients' quality of life is significant, with an important loss of healthy life in affected individuals. Traditional outcome parameters, such as length of hospital stay, do not fully capture what matters to patients during recovery. Patient-centered care is therefore central, and the patient's perspective should be considered in pre-operative discussions. Patient-reported outcome and experience measures (PROMs and PREMs) could play an important role in assessing patient perspectives, but standardized methodology for evaluating and reporting them is needed. This narrative review aims to provide a comprehensive overview of patient perspectives and different patient-reported measures in pancreatic cancer surgery. Understanding the patient perspective is crucial for delivering patient-centered care and improving outcomes for patients with pancreatic cancer.

Whole-Organ Pancreas and Islets Transplantations in UK: An Overview and Future Directions

Whole-organ pancreas and islets transplantations are two therapeutic options to treat type 1 diabetic patients resistant to optimised medical treatment in whom severe complications develop. Selection of the best option for β-cell replacement depends on several factors such as kidney function, patient comorbidities, and treatment goals. For a patient with end-stage kidney disease, the treatment of choice is often a simultaneous transplant of the pancreas and kidney (SPK). However, it remains a major surgical procedure in patients with multiple comorbidities and therefore it is important to select those who will benefit from it. Additionally, in view of the organ shortage, new strategies to improve outcomes and reduce immune reactions have been developed, including dynamic organ perfusion technologies, pancreas bioengineering, and stem cell therapies. The purpose of this article is to review the indications, surgical techniques, outcomes, and future directions of whole-organ pancreas and islets transplantations.

The role of high serum triglyceride levels on pancreatic necrosis development and related complications

BACKGROUND

The relevance of elevated serum triglyceride (TG) levels in the early stages of acute pancreatitis (AP) not induced by hypertriglyceridemia (HTG) remains unclear. Our study aims to determine the role of elevated serum TG levels at admission in developing pancreatic necrosis.

METHODS

We analyzed the clinical data collected prospectively from patients with AP. According to TG levels measured in the first 24 h after admission, we stratified patients into four groups: Normal TG (< 150 mg/dL), Borderline-high TG (150-199 mg/dL), High TG (200-499 mg/dL) and Very high TG (≥ 500 mg/dL). We analyzed the association of TG levels and other risk factors with the development of pancreatic necrosis.

RESULTS

A total of 211 patients were included. In the Normal TG group: 122, in Borderline-high TG group: 38, in High TG group: 44, and in Very high TG group: 7. Pancreatic necrosis developed in 29.5% of the patients in the Normal TG group, 26.3% in the Borderline-high TG group, 52.3% in the High TG group, and 85.7% in the Very high TG group. The trend analysis observed a significant association between higher TG levels and pancreatic necrosis (p = 0.001). A multivariable analysis using logistic regression showed that elevated TG levels ≥ 200 mg/dL (High TG and Very high TG groups) were independently associated with pancreatic necrosis (OR: 3.27, 95% CI - 6.27, p < 0.001).

CONCLUSIONS

An elevated TG level at admission ≥ 200 mg/dl is independently associated with the development of pancreatic necrosis. The incidence of pancreatic necrosis increases proportionally with the severity of HTG.

The 'land of fires': epidemiological research and public health policy during the waste crisis in Campania, Italy

The region of Campania, South Italy rose to prominence in the mid-2000s due to the illegal disposal of waste by the Camorra during the local waste management crisis. Several lines of evidence have identified a link between exposure to toxic waste and adverse health outcomes in the local populations. Critically, studies since 2017 have strongly suggested that this link is causal in nature. The uncertainty of evidence polarised the Italian epidemiological community and partly undermined the precautionary principle in public health policy, leading to years of delay in the deployment of appropriate interventions. The crisis also sparked concerns about pollution of soil, water, and agricultural products. The contrast between political responses and protests from local communities shows analogies with environmental emergencies of a larger scale. Beyond law enforcement actions to prosecute illegal waste disposal activity, future mitigation of risks for affected populations will require coordinated efforts in environmental policy (land reclamation, improved waste management) and public health (i.e. extensive epidemiological surveillance, screening and prevention programs). By summarising evidence over the last two decades, this review aims to construct a cohesive interdisciplinary narrative of the events in the Campanian waste crisis.

EASY-APP: An artificial intelligence model and application for early and easy prediction of severity in acute pancreatitis

Background

Acute pancreatitis (AP) is a potentially severe or even fatal inflammation of the pancreas. Early identification of patients at high risk for developing a severe course of the disease is crucial for preventing organ failure and death. Most of the former predictive scores require many parameters or at least 24 h to predict the severity; therefore, the early therapeutic window is often missed.

Methods

The early achievable severity index (EASY) is a multicentre, multinational, prospective and observational study (ISRCTN10525246). The predictions were made using machine learning models. We used the scikit‐learn, xgboost and catboost Python packages for modelling. We evaluated our models using fourfold cross‐validation, and the receiver operating characteristic (ROC) curve, the area under the ROC curve (AUC), and accuracy metrics were calculated on the union of the test sets of the cross‐validation. The most critical factors and their contribution to the prediction were identified using a modern tool of explainable artificial intelligence called SHapley Additive exPlanations (SHAP).

Results

The prediction model was based on an international cohort of 1184 patients and a validation cohort of 3543 patients. The best performing model was an XGBoost classifier with an average AUC score of 0.81 ± 0.033 and an accuracy of 89.1%, and the model improved with experience. The six most influential features were the respiratory rate, body temperature, abdominal muscular reflex, gender, age and glucose level. Using the XGBoost machine learning algorithm for prediction, the SHAP values for the explanation and the bootstrapping method to estimate confidence, we developed a free and easy‐to‐use web application in the Streamlit Python‐based framework (http://easy‐app.org/).

Conclusions

The EASY prediction score is a practical tool for identifying patients at high risk for severe AP within hours of hospital admission. The web application is available for clinicians and contributes to the improvement of the model.

The role of procalcitonin as a prognostic factor for acute cholangitis and infections in acute pancreatitis: a prospective cohort study from a European single center

BACKGROUND

Infection in acute pancreatitis will worsen the disease prognosis. The aim of our study was to analyze the role of procalcitonin as a prognostic biomarker for infections and clinical severity.

METHOD

A prospective single-cohort observational study of patients diagnosed of acute pancreatitis (n = 152) was designed. PCT determination was tested on admission (first 72 h). Infections (biliary, extrapancreatic and infected pancreatic necrosis), need for antibiotics, urgent ERCP and severity scores for acute pancreatitis was assessed. ROC curves were designed and the area under the curve was calculated. Logistic regression for multivariate analysis was performed to evaluate the association between procalcitonin optimal cut-off level and major complications.

RESULTS

PCT >0.68 mg/dL had higher incidence of global infection, acute cholangitis, bacteraemia, infected pancreatic necrosis, use of antibiotics in general, and need for urgent ERCP. In the multivariate regressions analysis, PCT >0.68 mg/dL at admission demonstrated to be a strong risk factor for complications in acute pancreatitis.

DISCUSSION

PCT levels can be used as a reliable laboratory test to predict infections and the clinical severity of acute pancreatitis. High levels of PCT predict antibiotics prescription as well as the need for urgent ERCP in patients with concomitant clinically severe cholangitis.

Percutaneous tibial nerve stimulation in patients with severe low anterior resection syndrome: randomized clinical trial

BACKGROUND

Treatment of low anterior resection syndrome (LARS) is challenging. Percutaneous tibial nerve stimulation (PTNS) can improve select bowel disorders. An RCT was conducted to assess the efficacy of PTNS compared with sham stimulation in patients with severe LARS.

METHOD

This was a multicentre, double-blind RCT. Patients with major LARS score were allocated to receive PTNS or sham therapy (needle placement simulation without nerve stimulation). The study included 16 sessions of 30 min once a week for 12 consecutive weeks, followed by four additional sessions once a fortnight for the following 4 weeks. The primary endpoint was efficacy of PTNS defined by the LARS score 12 months after treatment. Secondary endpoints included faecal incontinence, quality of life (QoL), and sexual function.

RESULTS

Between September 2016 and July 2018, 46 eligible patients were assigned randomly in a 1 : 1 ratio to PTNS or sham therapy. Baseline characteristics were similar. LARS scores were reduced in both groups, but only patients who received PTNS maintained the effect in the long term (mean(s.d.) score 36.4(3.9) at baseline versus 30.7(11.5) at 12 months; P = 0.018; effect size -5.4, 95 per cent c.i. -9.8 to -1.0), with a mean reduction of 15.7 per cent at 12-month follow-up. The faecal incontinence score was improved after 12 months in the PTNS group (mean(s.d.) score 15.4(5.2) at baseline versus 12.5(6.4) at 12 months; P = 0.018). No major changes in QoL and sexual function were observed in either group. There was no therapy-associated morbidity. Three patients discontinued the study, but none owing to study-related issues.

CONCLUSION

PTNS has positive effects in some patients with major LARS, especially in those with faecal incontinence. Registration number: NCT02517853 (http://www.clinicaltrials.gov).

Evaluation of the modified computed tomography severity index (MCTSI) and computed tomography severity index (CTSI) in predicting severity and clinical outcomes in acute pancreatitis

OBJECTIVE

Our main purpose was to compare the modified computed tomography severity index (MCTSI), computed tomography severity index (CTSI), and acute physiological and chronic health evaluation (APACHE)-II predictions regarding severity according to the revised Atlanta classification 2012 and local complications in acute pancreatitis in a consecutive prospective cohort.

METHODS

One hundred and forty-nine patients diagnosed with acute pancreatitis were prospectively enrolled. APACHE-II, MCTSI, and CTSI were calculated for all cases. Severity parameters included persistent organ or multiorgan failure, length of hospitalization, the need for intensive care, death, and local complications (intervention against necrosis and infected necrosis). Area under the receiver operating characteristic curve (AUROC) was calculated and the value of scoring systems was compared.

RESULTS

Both CTSI and MCTSI were associated significantly with all the evaluated severity parameters and showed a correlation between imaging severity and the worst clinical outcomes. Persistent organ failure, persistent multiorgan failure, and death were found in 30 (20.1%), 20 (13.4%), and 13 (8.7%) patients, respectively. The most common extrapancreatic finding was pleural effusion in 76 (51.0%) patients. The AUROC for CTSI was higher for predicting persistent organ failure (0.749, 95% confidence interval [CI] 0.640-0.857), death (AUROC 0.793, 95% CI 0.650-0.936), intervention against necrosis (AUROC 0.862, 95% CI 0.779-0.945), and infected necrosis (AUROC 0.883, 95% CI 0.882-0.930).

CONCLUSIONS

CT indexes outperformed the classic APACHE-II score for evaluating severity parameters in acute pancreatitis, with a slight advantage of CTSI over MCTSI. CTSI accurately predicted pancreatic infections and the need for intervention.

The role of extra-pancreatic infections in the prediction of severity and local complications in acute pancreatitis

BACKGROUND

The aim of our study was to determine the risk factors for extrapancreatic infection (EPI) occurrence and its predictive power for assessing severity and local complications in acute pancreatitis including infected pancreatic necrosis (IPN).

METHODS

Clinical data of 176 AP patients prospectively enrolled were analysed. EPI analysed were bacteraemia, lung infection, urinary tract infection and catheter line infection. Risk factors analysed were: Leukocyte count, C-reactive protein, liver function test, serum calcium, serum glucose, Blood urea nitrogen, mean arterial pressure at admission, total parenteral nutrition (TPN), enteral nutrition, hypotension, respiratory, cardiovascular and renal failure at admission, persistent systemic inflammatory response (SIRS) and intrapancreatic necrosis. Severity outcomes assessed were defined according to the Atlanta Criteria definition for acute pancreatitis. The predictive accuracy of EPI for morbidity and mortality was measured using area-under-the-curve (AUC) receiver-operating characteristics.

RESULTS

Forty-four cases of EPI were found (25%). TPN (OR:9.2 CI95%: 3.3-25.7), APACHE-II>8 (OR:6.2 CI95%:2.48-15.54) and persistent SIRS (OR:2.9 CI95%: 1.1-7.8), were risk factors related with EPI. Bacteraemia, when compared with others EPI, showed the best accuracy in predicting significantly persistent organ failure (AUC:0.76, IC95%:0.64-0.88), ICU admission (AUC:0.80 IC95%:0.65-0.94), and death (AUC:0.73 CI95%:0.54-0.91); and for local complications including IPN (AUC:0.72 CI95%:0.53-0.92) as well. Besides, it was also needed for an interventional procedure against necrosis (AUC:0.74 IC95%: 0.57-0.91). When bacteraemia and IPN occurs, bacteraemia preceded infected necrosis in all cases. On multivariate analysis, risk factor for IPN were lung infection (OR:6.25 CI95%1.1-35.7 p = 0.039) and TPN (OR:22.0CI95%:2.4-205.8, p = 0.007), and for mortality were persistent SIRS at first week (OR: 22.9 CI95%: 2.6-203.7, p = 0.005) and Lung infection (OR: 9.7 CI95%: 1.7-53.8).

CONCLUSION

In our study, EPI, played a role in predicting the severity and local complications in acute pancreatitis.

Activation of a Ribosomal S6 Protein Kinase in Rapidly Emerging Diethylnitrosamine-Induced Gamma - Glut Amyltranspeptidase-Positive Hyperplastic Liver Lesions of the Rat

The gamma-glutamyl transpeptidase (GGT)-positive hyperplastic liver lesions which developed in the Fisher 344 rat 7 and 60 days following a single carcinogenic dose of diethylnitrosamine (DENA, 200 mg/kg body weight), short-term dietary exposure to 0.02 % 2-acetylaminofluorene (AAF) to suppress the growth of normal hepatocytes, and partial hepatectomy to actuate rapid growth of DENA altered hepatocytes not suppressed by AAF, showed an increased activity of a kinase which specifically phosphorylates the ribosomal S6 protein in vitro. Sham-operated animals showed, on the contrary, no GGT-positive cells and low S6 kinase activity, under the same conditions. After partial hepatectomy, activation of S6 kinase and elevated levels of phosphorylated S6 protein in vitro were detected in the early phases of « normal » hepatocyte proliferation, during liver regeneration, in DENA-treated, GGT-negative preparations, when the « selection » agent AAF was omitted from the diet. The observed activation of S6 kinase in GGT-positive hepatocytes and/or liver nodules could represent an early manifestation of the enhanced proliferation of altered hepatocytes during tumor induction and/or promotion under these conditions.

Binding properties of mono- and dimeric pyridine dicarboxamide ligands to human telomeric higher-order G-quadruplex structures

Here, we report on the in vitro binding properties of the known pyridine dicarboxamide G-quadruplex ligand 360A and a new dimeric analogue (360A)2A to human telomeric DNA higher-order G-quadruplex (G4) structures. This study points to original binding features never reported for G4 ligands, and reveals a greater efficiency for the dimeric ligand to displace RPA (a ssDNA binding protein involved in telomere replication) from telomeric DNA.

The effects of iPod and text-messaging use on driver distraction: a bio-behavioral analysis

This study was designed to empirically examine the effects of iPod device and text-messaging activities on driver distraction. Sixty participants were asked to perform a driving simulation task while searching for songs using an iPod device or text messaging. Driving errors as measured by lane deviations were recorded and analyzed as a function of the distracters. Physiological measures (EEG) were also recorded during the driving phases in order to measure participant levels of cortical arousal. It was hypothesized that iPod use and text messaging would result in a profound effect on driving ability. The results showed a significant effect of iPod use and text-messaging on driving performance. Increased numbers of driving errors were recorded during the iPod and text-messaging phases than the pre- and post-allocation phases. Higher levels of Theta activity were also observed during the iPod and Text-messaging phase than the pre- and post-allocation phases. Implications for in-vehicle systems design, training, and safety are also discussed.

Physician-assessed and patient-reported outcome measures in chemotherapy-induced sensory peripheral neurotoxicity: two sides of the same coin

BACKGROUND

The different perception and assessment of chemotherapy-induced peripheral neurotoxicity (CIPN) between healthcare providers and patients has not yet been fully addressed, although these two approaches might eventually lead to inconsistent, possibly conflicting interpretation, especially regarding sensory impairment.

PATIENTS AND METHODS

A cohort of 281 subjects with stable CIPN was evaluated with the National Cancer Institute-Common Toxicity Criteria (NCI-CTC v. 2.0) sensory scale, the clinical Total Neuropathy Score (TNSc©), the modified Inflammatory Neuropathy Cause and Treatment (INCAT) sensory sumscore (mISS) and the European Organization for Research and Treatment of Cancer CIPN specific self-report questionnaire (EORTC QOL-CIPN20).

RESULTS

Patients' probability estimates showed that the EORTC QLQ-CIPN20 sensory score was overall more highly related to the NCI-CTC sensory score. However, the vibration perception item of the TNSc had a higher probability to be scored 0 for EORTC QLQ-CIPN20 scores lower than 35, as vibration score 2 for EORTC QLQ-CIPN20 scores between 35 and 50 and as grade 3 or 4 for EORTC QLQ-CIPN20 scores higher than 50. The linear models showed a significant trend between each mISS item and increasing EORTC QLQ-CIPN20 sensory scores.

CONCLUSION

None of the clinical items had a perfect relationship with patients' perception, and most of the discrepancies stood in the intermediate levels of CIPN severity. Our data indicate that to achieve a comprehensive knowledge of CIPN including a reliable assessment of both the severity and the quality of CIPN-related sensory impairment, clinical and PRO measures should be always combined.

The chemotherapy-induced peripheral neuropathy outcome measures standardization study: from consensus to the first validity and reliability findings

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) is a debilitating and dose-limiting complication of cancer treatment. Thus far, the impact of CIPN has not been studied in a systematic clinimetric manner. The objective of the study was to select outcome measures for CIPN evaluation and to establish their validity and reproducibility in a cross-sectional multicenter study.

PATIENTS AND METHODS

After literature review and a consensus meeting among experts, face/content validity were obtained for the following selected scales: the National Cancer Institute-Common Toxicity Criteria (NCI-CTC), the Total Neuropathy Score clinical version (TNSc), the modified Inflammatory Neuropathy Cause and Treatment (INCAT) group sensory sumscore (mISS), the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, and CIPN20 quality-of-life measures. A total of 281 patients with stable CIPN were examined. Validity (correlation) and reliability studies were carried out.

RESULTS

Good inter-/intra-observer scores were obtained for the TNSc, mISS, and NCI-CTC sensory/motor subscales. Test-retest values were also good for the EORTC QLQ-C30 and CIPN20. Acceptable validity scores were obtained through the correlation among the measures.

CONCLUSION

Good validity and reliability scores were demonstrated for the set of selected impairment and quality-of-life outcome measures in CIPN. Future studies are planned to investigate the responsiveness aspects of these measures.

Peripheral neurotoxicity of oxaliplatin in combination with 5-fluorouracil (FOLFOX) or capecitabine (XELOX): a prospective evaluation of 150 colorectal cancer patients

BACKGROUND

To report our prospective experience on the incidence and pattern of oxaliplatin (OXA)-induced peripheral neuropathy (OXA-IPN) in patients with colorectal cancer (CRC) treated with either FOLFOX-4 or XELoda + OXaliplatin (XELOX).

PATIENTS AND METHODS

One hundred and fifty patients scheduled to be treated with either FOLFOX or XELOX for CRC were prospectively monitored at baseline and followed-up during chemotherapy. The incidence and severity of symptoms secondary to OXA-IPN were recorded using three different types of assessment, i.e. the motor and neurosensory National Cancer Institute common toxicity criteria, version 3.0 (NCI-CTCv3), the clinical version of the total neuropathy score (TNSc) and electrophysiological scores.

RESULTS

Patients treated with either FOLFOX-4 or XELOX manifested similar incidence rates and severities of acute OXA-IPN. However, FOLFOX-4 was associated with increased incidence of chronic neurotoxicity, compared with XELOX-treated patients (n = 64/77 versus 44/73; P = 0.002), at a very similar OXA median cumulative dose during both regimens. Both the NCI-CTCv3 and TNSc demonstrated that the severity of cumulative OXA-IPN in FOLFOX-4-treated patients is higher than in those treated with XELOX.

CONCLUSION

The incidence of acute neurotoxicity during FOLFOX-4 therapy is similar to XELOX. However, it seems that FOLFOX-4 is more neurotoxic than XELOX in terms of cumulative OXA-IPN, despite comparable OXA cumulative dose.

DNA structural changes as the basis for a nanomolecular device

There is currently great interest in the design of nanodevices that are capable of performing movements. Protein molecular machines are abundant in biology but it has recently been proposed that nucleic acids could also act as nanomolecular machines in model systems. Several types of movements have been described with DNA machines: rotation, extension-contraction and "scissor-like" opening and closing. Here we analyze the properties of a simple and robust device composed of a single 21-base-long oligonucleotide which relies on a duplex/quadruplex equilibrium fueled by the sequential addition of DNA single-strands, generating a DNA duplex as a by-product. The interconversion between two well-defined topological states induces a five nanometer two-stroke, linear motor type movement, which is detected by FRET spectroscopy.

Molecular recognition of quadruplex DNA by quinacridine derivatives

The interaction of monomeric and dimeric quinacridines with quadruplex DNA has been investigated using a variety of biophysical methods. Both series of compounds were shown to exhibit a high affinity for the G4 conformation with two equivalent binding sites. As shown from the SPR and dialysis experiments the macrocyclic dimer appears more selective than its monomeric counterpart.

Interaction of an acridine dimer with DNA quadruplex structures

The reactivation of telomerase activity in most cancer cells supports the concept that telomerase is a relevant target in oncology, and telomerase inhibitors have been proposed as new potential anticancer agents. The telomeric G-rich single-stranded DNA can adopt an intramolecular G-quadruplex structure in vitro, which has been shown to inhibit telomerase activity. The C-rich sequence can also adopt a quadruplex (intercalated) structure (i-DNA). Two acridine derivatives were shown to increase the melting temperature of the G- quadruplex and the C-quadruplex at 1 microM dye concentration. The increase in Tm value of the G-quadruplex was associated with telomerase inhibition in vitro. The most active compound, "BisA", showed an IC(50) value of 0.75 microM in a standard TRAP assay.

Backbone dynamics of Tet repressor alpha8intersectionalpha9 loop

A set of single Trp mutants of class B Tet repressor (TetR), in which Trp residues are located from positions 159 to 167, has been engineered to investigate the dynamics of the loop joining the alpha-helices 8 and 9. The fluorescence anisotropy decay of most mutants can be described by the sum of three exponential components. The longest rotational correlation time, 30 ns at 10 degrees C, corresponds to the overall rotation of the protein. The shortest two components, on the subnanosecond and nanosecond time scale, are related to internal motions of the protein. The initial anisotropy, in the 0.16-0.22 range, indicates the existence of an additional ultrafast motion on the picosecond time scale. Examination of physical models for underlying motions indicates that librational motions of the Trp side chain within the rotameric chi(1) x chi(2) potential wells contribute to the picosecond depolarization process, whereas the subnanosecond and nanosecond depolarization processes are related to backbone dynamics. In the absence of inducer, the order parameters of these motions, about 0.90 and 0.80 for most positions, indicate limited flexibility of the loop backbone. Anhydrotetracycline binding to TetR induces an increased mobility of the loop on the nanosecond time scale. This suggests that entropic factors might play a role in the mechanism of allosteric transition.

Trp scanning analysis of Tet repressor reveals conformational changes associated with operator and anhydrotetracycline binding

We analysed the conformational states of free, tet operator-bound and anhydrotetracycline-bound Tet repressor employing a Trp-scanning approach. The two wild-type Trp residues in Tet repressor were replaced by Tyr or Phe and single Trp residues were introduced at each of the positions 162-173, representing part of an unstructured loop and the N-terminal six residues of alpha-helix 9. All mutants retained in vivo inducibility, but anhydrotetracycline-binding constants were decreased up to 7.5-fold when Trp was in positions 169, 170 and 173. Helical positions (168-173) differed from those in the loop (162-167) in terms of their fluorescence emission maxima, quenching rate constants with acrylamide and anisotropies in the free and tet operator-complexed proteins. Trp fluorescence emission decreased drastically upon atc binding, mainly due to energy transfer. For all proteins, either free, tet operator bound or anhydrtetracycline-bound, mean fluorescence lifetimes were determined to derive quenching rate constants. Solvent-accessible surfaces of the respective Trp side chains were calculated and compared with the quenching rate constants in the anhydrotetracycline-bound complexes. The results support a model, in which residues in the loop become more exposed, whereas residues in alpha-helix 9 become more buried upon the induction of TetR by anhydrotetracycline.

Pancreatic regeneration after subtotal distal resection in rats. Effects of bombesin and octreotide by the in vivo bromodeoxyuridine uptake technique

Forty male Wistar rats were randomly allocated to four treatment groups after 90% distal pancreatectomy: group A (control) received saline (0.5 ml subcutaneously); group B received bombesin (BBS; 10 microg/kg intraperitoneally); group C received octreotide (2.5 microg/kg subcutaneously), and group D received BBS and octreotide. All substances were injected three times a day until sacrifice after 28 days. BBS increased pancreas weight (p = 0.003) and DNA synthesis (p < 0.001), as measured by a bromodeoxyuridine nuclear-labeling index (BrdU LI). The simultaneous administration of octreotide significantly decreases the remnant pancreas weight (p = 0.016) as compared to group B rats; however the BrdU LI is not significantly reduced in group D as compared to group B. BBS administration promotes regeneration of the remnant pancreas in terms of hypertrophy and hyperplasia. Although octreotide appears to significantly reduce the pancreatic weight increase induced by BBS, it does not reduce DNA synthesis and cell proliferation.

Structural investigation of Tet repressor loop 154-167: a time-resolved fluorescence study of three single Trp mutants

We have studied the time-resolved fluorescence of three engineered Tet repressor (TetR) mutants bearing a single Trp residue at positions 162, 163, and 165 in the C-terminal part of the loop joining helices 8 and 9. Detailed analysis indicates that, at 20 degrees, the fluorescence decay of each Trp can be described as the sum of three exponential components with lifetimes in the 1-, 3-, and 6-ns range. Emission wavelength and temperature dependence studies are consistent with a model in which these components are due to the existence of three classes of Trp residues non-interconverting on the nanosecond timescale. Within the framework of the rotamer model, the weak temperature dependence of the lifetimes strongly suggests that the secondary structure of the loop, at least in the 162-165 range, is not altered with temperature. The equilibrium between the rotamers is characterized by an enthalpy-entropy compensation effect which strongly suggests the involvement of background structural regions of TetR in the thermodynamics of the process. The very high deltaH degrees and TdeltaS degrees observed (up to 18 kcal/ mol) should reflect the temperature-dependent conformational change of a large part of the protein which would alter the rotamer distribution of the Trp residues. Taken together, our results are consistent with the existence of (at least) two conformations of the loop and suggest a model for loop motion.

[Gangrenous cystitis. Case report]

A rare case of gangrenous cystitis is described. The questions of the incidence of this pathology are discussed, considering its rareness after the antibiotics age. The etiology of this disease is probably multifactorial and it is never possible to identify a unique cause. The gangrenous cystitis doesn't present with any typical symptomatology, out with urinary troubles common to many urologic diseases. Surgery is often performed in emergency without a preoperative defined diagnosis. Surgical treatment has changed with time from a simple bladder cavity draining to the resection of the necrotized bladder wall. In our case a total cystectomy with uretero-ileocutaneostomy, in two times, was performed. This procedure allowed the patient a good quality of life (1 year of follow-up).

[Unusual cause of gastric bleeding: leiomyoma]

The gastric leiomyoma is a rare non-epithelial tumor of the stomach that can either be asymptomatic (autoptical diagnosis) or, on the contrary, suddenly appear with severe gastric hemorrhage. The authors review the literature and report their own experience concerning 6 cases of gastric leiomyoma observed during 5 years. They discuss the clinical presentation, the difficulties of diagnosis and the therapeutic choices.

Effect of octreotide on pancreatic regeneration in rats measured by bromodeoxyuridine uptake

OBJECTIVE

To study the effects of up to 60 days intermittent octreotide on regeneration of rat pancreas stimulated by cholecystokinin after 70% distal resection. DESIGN. Random controlled experimental study.

SETTING

University hospital, Italy.

MATERIALS

60 Male Wistar rats.

INTERVENTIONS

Distal resection of splenic and gastric lobes of pancreas (70% of whole gland). Rats were allocated to three groups (n = 20 in each): group A (control) were given saline solution 0.5 ml; group B were given cholecystokinin 300 ng/kg; and group C were given cholecystokinin 300 ng/kg and octreotide 2.5 micrograms/kg. All substances were injected subcutaneously twice a day until death. Four rats were killed weekly for four weeks, and the remainder at 60 days.

MAIN OUTCOME MEASURES

Increase in weight of the gland as a percentage of the weight of the whole gland, and DNA synthesis measured by bromodeoxyuridine (BrdU) nuclear labelling index.

RESULTS

In the cholecystokinin alone group pancreatic weight had increased significantly on days 21 and 28 (95% confidence intervals (CI) - 13.8 to 12.2 and -44.1 to 19.7, respectively) and the BrdU index had increased significantly at 21 (0.56 to 0.80), 28 (0.26 to 1.3), and 60 (0.09 to 0.51) days compared with the control group. In the group given both cholecystokinin and octreotide the weight was significantly lower than in the cholecystokinin alone group at 21 and 28 days (95% CI - 1.02 to 66.7 and 3.5 to 34.7, respectively) and the BrdU index was significantly lower at 28 days (0.40 to 1.19).

CONCLUSIONS

Octreotide seems to reduce the pancreatic regeneration induced by cholecystokinin in rats after 70% distal resection. To our knowledge this has not previously been shown, and the mechanism must be elucidated further.

[Splenic abscess: case report and review of the literature]

After the observation of a case of splenic abscess the authors make a review of the literature. It is important to note that splenic abscesses are increasing in number because of some particular situations that can help their development. The diagnosis is not always easy and quick, because of the frequent lack of a typical symptomatology, and the later the diagnosis, the worse the prognosis. Besides, classical surgical therapy must be considered for selected cases, a conservative therapy that can be very useful for patients in very poor conditions.

[Solitary ulcer of the rectum]

The authors review their five-year experience of solitary rectal ulcers. A revision of the most recent literature enables them to outline the characteristics of the disease with reference to its epidemiology, anatomopathology and clinical features. The discussion focuses on the problem of treatment which must be based on a thorough and in-depth knowledge of pathogenetic mechanisms. The paper outlines two theories, the hamortomatous one and the so-called mechanical theory involving the hinge valve, which are referred to by most researchers. The question of treatment is then discussed illustrating the possibility of resorting to surgical-type treatment which appears to be the most suitable for the definitive resolution of the problem. But since, at least in the light of the authors' personal experience; the majority of patients belong to an age group in which other pathologies are often present, the medical treatment option appears to be more rational. The re-education of the alvus achieved using suggestions not only of a dietary type but also regarding the behaviour and correct position to assume during defecation appears, at least theoretically, sufficient to obtain a marked improvement. The local application of therapeutical AIDS, if necessary strengthened by the action of drugs taken systemically, brings considerable further benefit to the patient who cannot and/or does not which to undergo surgery.

[Granulosa cell tumor of Abrikossof]

The authors report a case of Abrikossof's tumor that came under their observation. The reappraisal of the literature permits to review on this disorder that was unknown until few years ago. Electronic microscope and immunohistochemical study allowed to recognize the real origin of this tumor. It arises from peripheric nervous tissue particularly from Schwann's cells. This neoplasm must be considered as benign, especially when of small dimensions. In case of rapidly growing or larger than 8 cm forms a widely exeretic surgery and a careful follow-up, because of the possibility of finding tumors in other district of the body.

[Appendicular mucocele. Clinical cases and review of the literature]

The authors report three cases of mucocele of the appendix. They review the literature on this argument and discuss the hypotheses on etiology, pathologic and clinical classification, problems in diagnosis, principles of therapy and prognosis.

Ribosomal protein S6 kinase and protein kinase C activation by epidermal growth factor after temporary renal ischemia

An initial event in cell response to growth factors is the change in the state of phosphorylation of a number of cellular proteins playing a role in cell proliferation. The effects of a single dose of exogenously administered epidermal growth factor (EGF) on renal serine/threonine protein kinases such as ribosomal protein S6 kinase(s) and protein kinase C (PKC) and on [3H]thymidine incorporation into tubule cell nuclei have been studied during the regenerative repair response after temporary renal ischemia in the rat, followed by reperfusion for up to 72 h. During the postischemic reflow, the PKC and S6 kinase activities increased at 24 and 72 h, respectively. EGF anticipated both increases: the PKC at 4 and the S6 kinase(s) at 24 h. Associated with this EGF-induced rise of S6 kinase activity, a significant increase in renal tubule cell proliferation was observed. These studies suggest the presence of a growth factor-activated serine/threonine phosphorylation cascade in the rat kidney participating in the regulation of cell growth during recovery from an ischemic insult.

Human papilloma virus infection and Ki-ras oncogene in paraffin-embedded squamous carcinomas of the cervix

42 paraffin-embedded squamous cervical carcinomas were screened for the presence of human papilloma virus (HPV; 6b, 11, 16, 18) and for activation of the Ki-ras oncogene family by polymerase chain reaction. In 72% of cases we found one or more HPV types, but no mutations of the Ki-ras gene (codon 12-1 and 61-1, 61-2 and 61-3) were found. We conclude that mutations of the Ki-ras oncogene, at the positions analyzed, are not likely to be involved in the events leading to cervical carcinogenesis.

[Primary stones of the common bile duct]

Primary stones can probably form, although rarely, in the common bile duct. The authors report a series of six cases which they considered as primary common duct stone disease and, in order to get more precise information on this problem, they review the literature on the subject. This disease would be caused by the presence of a lithogenic bile which, with a chronic obstruction of the Vater's ampulla, could let lithiasic particles accumulate in the common bile duct. On the basis of this hypothesis and in order to perform a correct procedure that allows easy drainage of the bile to the intestine to the chronic use of litholytic drugs.

[Mondor syndrome. Etiopathogenesis and case report]

The Authors observed and report a case of Mondor's syndrome in a male. In the attempt to identify the real origin in this peculiar thrombophlebitis they reviewed the recent literature. It is apparently impossible to drawn definitive conclusions from the different studies on this subject. Anyway Mondor's syndrome looks suitable for inclusion in the group of jumping thrombophlebitis. Therefore the real cause of the venous accident should be a pathologic situation next to the venous branch where the thrombophlebitis has broken out.

[Tumors of the small intestine. Case reports and comments]

Tumours of the small intestine are extremely rare and have a particularly severe prognosis. The impossibility of making an early diagnosis due to the scarcity of precise symptoms during the early stages of the disease and the lack of safe instrumental tests limits the results of treatment which is essentially surgical. In order to contribute to the study of the disease and improve its prognosis, the authors report the cases which they have observed and review the literature.