Evaluation of Radiation Therapy Treatment Plans in a Randomized Phase 2 Trial Comparing 2 Schedules of Twice-Daily Thoracic Radiation Therapy in Limited Stage Small Cell Lung Cancer

PURPOSE

There is limited clinical data for recommendations on how to deliver thoracic radiation therapy (TRT) concurrently with chemotherapy in limited-stage small cell lung cancer. We reviewed radiation therapy treatment plans in a randomized phase 2 trial comparing high-dose with standard-dose twice-daily TRT to assess treatment planning techniques, dose-volume data for target volumes and organs at risk (OARs), evaluate compliance with the protocol, associations with radiation-induced toxicity, and whether an imbalance in treatment planning parameters might be a reason for the large survival benefit of the higher dose (median overall survival 43.6 vs 22.6 months).

METHODS AND MATERIALS

In the study, 170 patients were to receive 4 courses of platinum/etoposide and were randomized to receive twice-daily TRT of 60 Gy/40 fractions (fx) or 45 Gy/30 fx. TRT treatment plans for those who received 1 or more fx of TRT (n = 166) were analyzed.

RESULTS

The most common treatment planning technique was 3-dimensional conformal radiation therapy (67%). The 75th percentile of the reported dose-volume parameters for the OARs were within the protocol-recommended limits for both groups. Mean doses to the esophagus of 25.5 Gy (IQR, 20.2-31.3; 60 Gy/40 fx) and 24.3 Gy (IQR, 20.3-27.5; 45 Gy/30 fx) were associated with 21% and 18% ≥ grade 3 acute esophagitis, respectively. In the 60 Gy/40 fx group, a mean dose to the lungs of 16.5 Gy (IQR, 15.8-16.9), V20 Gy of 29.5% (IQR, 28.8-30.4), and V5 Gy of 65.6% (IQR, 61.5-68.7) led to ≥ grade 3 pneumonitis in 4% of the patients. There was no ≥ grade 3 pneumonitis in the 45 Gy/30 fx group. The treatment planning techniques, the percentage change in volumes between original and redelineated OARs, planning target volumes, relative doses, and laterality were well balanced between the randomly assigned groups.

CONCLUSIONS

Considering the incidences of severe radiation-induced toxicities were within the range of other recent trials, the reported doses to the OARs appear to be safe. Treatment planning parameters were well balanced between the randomly assigned groups, supporting that the survival benefit of the twice-daily 60 Gy/40 fx TRT schedule was due to the higher dose.

Patient-Reported Experiences and Associated Factors in a Norwegian Radiotherapy Setting: An Explorative Cross-Sectional Study

Introduction

Radiotherapy is the main treatment modality in cancer. There is sparse knowledge on how patients with cancer experience their radiotherapy trajectory, and which factors might be associated with patients' experiences.

Objectives

The aim of the present study was to explore how adults with cancer receiving radiotherapy evaluate the quality of their care, utilizing a patient-reported experience measure, and how patient- and service-related characteristics are associated with their evaluation.

Methods

An explorative cross-sectional study using a self-completed questionnaire to assess patients' radiotherapy experiences was performed. Participants were recruited consecutively, within their last week of treatment, from two different hospitals in Norway from January 2021 to January 2022. Four hundred and eighty paper questionnaires were distributed to recruited patients, 240 at each hospital. Questionnaires were self-completed at home and returned by mail. The instrument person-centered coordinated care experience questionnaire (P3CEQ) was used. In addition to this, participants completed the European Organization of Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30) and The Sense of Coherence 13 scale (SOC-13). Data were analyzed using descriptive statistics, parametric tests, and unadjusted/adjusted linear regression models were estimated.

Results

The study included 373 patients. Patients evaluated quality of care in terms of P3CEQ scores, with a mean score of 19.5 (standard deviation = 5.4). Lowest scores were identified in areas concerning person-centeredness and service coordination. There were no significant differences in P3CEQ scores between the younger and older groups. Having a partner and better SOC-13 scores were independently associated with the overall patient-reported experience score, whereas age was not.

Conclusion

Patient-reported experience scores indicate that improvements are needed in some areas, such as informing and involving patients in the planning and coordination of their care. Findings suggest paying special attention to patients without a partner to offer patients the best possible care.

Psychometric Properties of the Person-Centred Coordinated Care Experience Questionnaire (P3CEQ) in a Norwegian Radiotherapy Setting

BACKGROUND

The number of older adults with cancer is increasing. Radiotherapy is an important treatment modality in cancer, and may cause side effects and distress. Patient-reported experience measures aim to measure patients' experience with health care. This can help health care services to improve in line with patients' needs. To assess how Norwegian patients receiving radiotherapy experience their care, a valid and reliable tool is required. We selected the Person-centred coordinated care experience questionnaire as a tool. The aim of the study is to validate the Norwegian version of this questionnaire in a radiotherapy setting.

METHODS

A feasibility study of the Person-centred coordinated care experience questionnaire and a cross-sectional study - testing psychometric properties of the questionnaire in a Norwegian radiotherapy setting - were conducted. Participants were recruited from two different hospitals in Norway. Patient characteristics and item scores are described using descriptive statistics. We performed an exploratory factor analysis, and applied principal component analysis with a varimax rotation. Cronbach's α was used to assess internal consistency.

RESULTS

24 patients participated in the feasibility test, and 176 were included in the cross-sectional study where we explored the psychometric properties of the Person-centred coordinated care experience questionnaire. Three factors were identified. Internal consistency was established for the ten-item scale, with Cronbach's α = 0.698.

CONCLUSION

Conclusions must consider the Norwegian setting and health care context. We found that the Norwegian version of the Person-centred coordinated care experience questionnaire is a relevant, valid, and reliable tool to provide insight into different areas of patients' experiences upon receiving radiotherapy. However, further testing on a larger sample is necessitated.

Radiobiological treatment planning evaluation of inverse planning simulated annealing for cervical cancer high-dose-rate brachytherapy

AIM

To compare five inverse treatment plans with one conventional manually-optimized plan for cervical cancer brachytherapy (BT) using radiobiological parameters combined with dosimetric and volumetric parameters.

MATERIALS AND METHODS

Five inverse treatment plans were calculated using an inverse planning simulated annealing (IPSA) algorithm for each of four fractions for 12 cervical cancer patients treated with high-dose-rate (HDR) brachytherapy. The inverse treatment plans were compared to a manually-optimized plan used for the actual treatment of the patients. The comparison of the plans was performed with respect to the probability of cure without complication (P+).

RESULTS

Overall, the manually optimized plan scored the best results; however, the probability of cure without complication is within an acceptable clinical range for all the plans.

CONCLUSION

Although there are still considerable uncertainties in the radiobiological parameters, the radiobiological plan evaluation method presents itself as a potential complement to physical dosimetric methods.

Dosimetric evaluation of manually and inversely optimized treatment planning for high dose rate brachytherapy of cervical cancer

BACKGROUND

To compare five inverse treatment planning methods with the conventional manually optimized planning approach for brachytherapy of cervical cancer with respect to dosimetric parameters.

MATERIAL AND METHODS

Eighteen cervical cancer patients treated with magnetic resonance imaging (MRI)-guided high dose rate (HDR) brachytherapy were included in this study. Six plans were created for each of the 4 HDR brachytherapy fractions for each patient: 1 manually optimized and 5 inversely planned. Three of these were based on inverse planning simulated annealing (IPSA) with and without extra constraints on maximum doses of the target volume, and different constraints on doses to the organs at risk (OARs). In addition there were two plans based on dose to target surface points. The resulting dose-volume histograms were analyzed and compared from the dosimetric point of view by quantifying specific dosimetric parameters, such as clinical target volume (CTV) D₉₀, CTV D₁₀₀, conformal index (COIN), and D₂cm3 for rectum, bladder and the sigmoid colon.

RESULTS

Manual optimization led to a mean target coverage of 78.3% compared to 87.5%, 91.7% and 82.5% with the three IPSA approaches (p < 0.001). Similar COIN values for manual and inverse optimization were found. The manual optimization led to better results with respect to the dose to the OARs expressed as D₂cm3. Overall, the best results were obtained with manual optimization and IPSA plans with volumetric constraints including maximum doses to the target volume.

CONCLUSIONS

Dosimetric evaluation of manual and inverse optimization approaches is indicating the potential of IPSA for brachytherapy of cervical cancer. IPSA with constraints of maximum doses to the target volume is closer related to manual optimization than plans with constraints only to minimum dose to the target volume and maximum doses to OARs. IPSA plans with proper constraints performed better than those based on dose to target surface points and manually optimized plans.

Adaptive brachytherapy of cervical cancer, comparison of conventional point A and CT based individual treatment planning

BACKGROUND

Locally advanced cervical cancer is commonly treated with external radiation therapy combined with local brachytherapy. The brachytherapy is traditionally given based on standard dose planning with prescription of dose to point A. Dosimetric aspects when changing from former standard treatment to individualized treatment plans based on computed tomography (CT) images are here investigated.

MATERIAL AND METHODS

Brachytherapy data from 19 patients with a total of 72 individual treatment fractions were retrospectively reviewed. Standard library plans were analyzed with respect to doses to organs at risk (OARs), and the result was compared to corresponding delivered individualized plans. The theoretical potential of further optimization based on prescription to target volumes was investigated. The treatments were performed with a Fletcher applicator.

RESULTS

For standard treatment planning, the tolerance dose limits were exceeded in the bladder, rectum and sigmoid in 26%, 4% and 15% of the plans, respectively. This was observed most often for the smallest target volumes. The individualized planning of the delivered treatment gave the possibility of controlling the dose to critical organs to below certain limits. The dose was still prescribed to point A. An increase in target dose coverage was achieved when additional individual optimization was performed, while still keeping the dose to the OARs below predefined limits. Relatively low average target coverage, especially for the largest volumes was however seen.

CONCLUSION

The individualized delivered treatment plans ensured that doses to OARs were within acceptable limits. This was not the case in 42% of the corresponding standard plans. Further optimized treatment plans were found to give an overall better dose coverage. In lack of MR capacity, it may be favorable to use CT for planning due to possible protection of OARs. The CT based target volumes were, however, not equivalent to the volumes described in magnetic resonance imaging (MRI) based recommendations. Prescription and assessment of dose, when introducing such target volumes, should be evaluated and preferably compared to well known treatment regimens.

Relative biological effectiveness of photon energies used in brachytherapy and intraoperative radiotherapy techniques for two breast cancer cell lines

BACKGROUND

Partial breast irradiation (IORT or brachytherapy) differ from external radiation of whole breast in terms of irradiated volumes, fractionation, radiation energy and dose rate; all factors influencing the treatment outcome in a complex manner. Theoretically obtained RBE values comparing effects of radiation used in IORT and external therapy are published, but experimental studies are required to confirm these data. The aim of this study is to establish such RBE values for two breast cancer cell lines.

MATERIALS AND METHODS

Colony formation of breast cancer cell lines (MCF-7 and T-47D) were studied after photon irradiation with qualities and dose rates used in IORT, brachytherapy and external radiation. RBE values from survival data were used to compare effects.

RESULTS

Increasing the photon energy (dose rate 0.2 Gy/min) from 50 kV (Intrabeam) to 380 keV (¹⁹²Ir source) and 6 MV (linear accelerator) yielded an increase in the cell survival, whereas increasing the dose rate to 6 Gy/min had minor effect. Average RBE values for 50 kV with 6 MV as reference radiation varied from about 1.4 (for doses < 5 Gy) to > 1.9 (for doses < 0.02 Gy) for MCF-7 cells and from about 1.4 to > 3.1 for T-47D cells for the same dose levels. Corresponding RBE values for 380 keV radiation were about 1.4 for MCF-7 cells and 1.3-2.3 for T-47D cells.

CONCLUSION

RBE data for breast cancer cells exposed to radiation used in IORT, brachytherapy or external radiation differ among the cell lines tested. The values are in agreement with published theoretical and experimental work.

The Influence of Charge Density of Chitosan in the Compaction of the Polyanions DNA and Xanthan

In this study the relative importance of valence and charge density of the polycation chitosan on the compaction process of DNA and xanthan is investigated. Chitosans with approximately equal valence but differing in their charge density were employed to form polyelectrolyte complexes with the two polyanions. The resulting structures (toroids, rods, and globules) have been visualized by AFM. For DNA-chitosan the complexation process was additionally studied by utilizing the fluorescent probe ethidium bromide. The results show that not only the total charge per chitosan molecule (valence), but also the charge density is important in determining the association with polyanions such as DNA and xanthan. Furthermore, it is demonstrated that the pH at which the complexation takes place is an important parameter in the complexation process, influencing the structures formed.

Influence of chitosan structure on the formation and stability of DNA-chitosan polyelectrolyte complexes

The interactions between DNA and chitosans varying in fractional content of acetylated units (FA), degree of polymerization (DP), and degree of ionization were investigated by several techniques, including an ethidium bromide (EtBr) fluorescence assay, gel retardation, atomic force microscopy, and dynamic and electrophoretic light scattering. The charge density of the chitosan and the number of charges per chain were found to be the dominating factors for the structure and stability of DNA-chitosan complexes. All high molecular weight chitosans condensed DNA into physically stable polyplexes; however, the properties of the complexes were strongly dependent on FA, and thereby the charge density of chitosan. By employing fully charged oligomers of constant charge density, it was shown that the complexation of DNA and stability of the polyplexes is governed by the number of cationic residues per chain. A minimum of 6-9 positive charges appeared necessary to provide interaction strength comparable to that of polycations. In contrast, further increase in the number of charges above 9 did not increase the apparent binding affinity as judged from the EtBr displacement assay. The chitosan oligomers exhibited a pH-dependent interaction with DNA, reflecting the number of ionized amino groups. The complexation of DNA and the stability of oligomer-based polyplexes became reduced above pH 7.4. Such pH-dependent dissociation of polyplexes around the physiological pH is highly relevant in gene delivery applications and might be one of the reasons for the high transfection activity of oligomer-based polyplexes observed.

DNA-polycation complexation and polyplex stability in the presence of competing polyanions

Polyelectrolyte complex (polyplex) formation was studied by employing tapping mode atomic force microscopy (AFM) and an ethidium bromide fluorescence assay. The polycations chitosan and poly-L-lysine were used to compact DNA and the stability of the polyplexes was evaluated upon exposure to competing polyanions (alginate and xanthan). Furthermore, the relative preference of these polycations for DNA and the competing polyanion was investigated. The results showed that neither poly-L-lysine nor chitosan displayed any selectivity in binding to DNA relative to the competing polyanions, demonstrating the importance of electrostatics in the binding of a polycation to a polyanion. However, the ability of the polyanions to destabilize the DNA-polycation complexes depended on both the polyanion and the polycation employed, indicating that polymer-specific properties are also important for the complexation behavior and polyplex stability. Destabilization experiments further showed that annealing yielded complexes that were less prone to disruption upon subsequent exposure to alginate. Annealing experiments of plasmid DNA-chitosan complexes showed an increased fraction of rods following temperature treatment, indicating that the rods most likely are the more stable morphology for this system.

Glycosaminoglycan destabilization of DNA–chitosan polyplexes for gene delivery depends on chitosan chain length and GAG properties

Chitosan-based gene delivery systems are promising candidates for non-viral gene therapy. A wide range of chitosans has been studied to optimize the properties of the DNA-chitosan complexes to yield high transfection efficiencies. An important parameter to control is the polyplex stability to allow transport towards the cells, subsequent internalization and release of DNA intracellularly. The stability of the DNA-chitosan complexes was here studied after exposure to heparin and hyaluronic acid (HA) using atomic force microscopy (AFM) and ethidium bromide (EtBr) fluorescence assay. To study the effect of polycation chain length on the polyplex stability, chitosans with a degree of polymerization (DP) varying from approximately 10 to approximately 1000 were employed for DNA compaction. Whereas HA was unable to dissociate the complexes, the degree of dissociation caused by heparin depended on both the chitosan chain length and the amount of chitosan used for complexation. When increasing the chitosan concentration, larger heparin concentrations were required for polyplex dissociation. Furthermore, increasing the chitosan chain length yielded more stable complexes. Varying the chitosan chain length thus provides a tool for controlling the ability of the polyplex to deliver therapeutic gene vectors to cells.

Force spectroscopy of collagen fibers to investigate their mechanical properties and structural organization

Tendons are composed of collagen and other molecules in a highly organized hierarchical assembly, leading to extraordinary mechanical properties. To probe the cross-links on the lower level of organization, we used a cantilever to pull substructures out of the assembly. Advanced force probe technology, using small cantilevers (length <20 microm), improved the force resolution into the sub-10 pN range. In the force versus extension curves, we found an exponential increase in force and two different periodic rupture events, one with strong bonds (jumps in force of several hundred pN) with a periodicity of 78 nm and one with weak bonds (jumps in force of <7 pN) with a periodicity of 22 nm. We demonstrate a good correlation between the measured mechanical behavior of collagen fibers and their appearance in the micrographs taken with the atomic force microscope.

Improved chitosan-mediated gene delivery based on easily dissociated chitosan polyplexes of highly defined chitosan oligomers

Nonviral gene delivery systems based on conventional high-molecular-weight chitosans are efficient after lung administration in vivo, but have poor physical properties such as aggregated shapes, low solubility at neutral pH, high viscosity at concentrations used for in vivo delivery and a slow dissociation and release of plasmid DNA, resulting in a slow onset of action. We therefore developed highly effective nonviral gene delivery systems with improved physical properties from a series of chitosan oligomers, ranging in molecular weight from 1.2 to 10 kDa. First, we established structure-property relationships with regard to polyplex formation and in vivo efficiency after lung administration to mice. In a second step, we isolated chitosan oligomers from a preferred oligomer fraction to obtain fractions, ranging from 10 to 50-mers, of more homogeneous size distributions with polydispersities ranging from 1.01 to 1.09. Polyplexes based on chitosan oligomers dissociated more easily than those of a high-molecular-weight ultrapure chitosan (UPC, approximately a 1000-mer), and released pDNA in the presence of anionic heparin. The more easily dissociated polyplexes mediated a faster onset of action and gave a higher gene expression both in 293 cells in vitro and after lung administration in vivo as compared to the more stable UPC polyplexes. Already 24 h after intratracheal administration, a 120- to 260-fold higher luciferase gene expression was observed compared to UPC in the mouse lung in vivo. The gene expression in the lung was comparable to that of PEI (respective AUCs of 2756+/-710 and 3320+/-871 pg luciferase x days/mg of total lung protein). In conclusion, a major improvement of chitosan-mediated nonviral gene delivery to the lung was obtained by using polyplexes of well-defined chitosan oligomers. Polyplexes of oligomer fractions also had superior physicochemical properties to commonly used high-molecular-weight UPC.

Structural Analysis of Chitosan Mediated DNA Condensation by AFM: Influence of Chitosan Molecular Parameters

Chitosan is a nontoxic and biodegradable polysaccharide that has recently emerged as a promising candidate for gene delivery. Here the ability of various chitosans, differing in the fractional content of acetylated units (F(A)) and the degree of polymerization (DP), to compact DNA was studied. Polyplexes made from mixing plasmid DNA with chitosan yielded a blend of toroids and rods, as observed by AFM. The ratios between the fractions of toroids and rods were observed to decrease with increasing F(A) of the chitosan, indicating that the charge density of chitosan, proportional to (1 - F(A)), is important in determining the shape of the compacted DNA. The amount of chitosan required to fully compact DNA into well-defined toroidal and rodlike structures were found to be strongly dependent on the chitosan molecular weight, and thus its total charge. A higher charge ratio (+/-) was needed for the shorter chitosans, showing that an increased concentration of the low DP chitosan could compensate for the reduced interaction strength of the individual ligands with DNA. Employing chitosans with different molecular parameters offers the possibility of designing DNA-chitosan polyplexes with various geometries, reflecting various chitosan-DNA interaction strengths, which is necessary for the evaluation of efficient gene delivery vehicles.

First Report of Downy Mildew of Quinoa Caused by Peronospora farinosa f. sp. chenopodii in Denmark

Downy mildew, caused by Peronospora farinosa (Fr.) Fr. f. sp. chenopodii Byford, is the most important disease of quinoa (Chenopodium quinoa Willd.) in the high mountainous areas of the Andes in South America (1), where the crop originated. While quinoa is not well known outside its traditional growing area, interest in this crop is increasing rapidly due to its high nutrient quality, many uses for human consumption, and agronomic characteristics of the plant; it is one of the most drought, salt, and frost tolerant crops known (2). From 1990 to 2001, several field trials were conducted in Denmark to study the performance of quinoa germ plasm of different origin under Danish conditions. Natural infection by downy mildew was observed each year on a range of cultivars, as well as on the common weed species, C. album L., which was observed growing near the quinoa. In 2001, 25 isolates of P. farinosa were collected from a field trial at the experimental station of the Royal Veterinary and Agricultural University in Taastrup, Denmark, from two Dutch quinoa cultivars (Carmen and Atlas) and one Danish breeding line (G205). Plants showed typical downy mildew symptoms: chlorotic lesions on the upper leaf surface and grayish spore masses on the lower leaf surface. Microscopic examination of the material showed the presence of dichotomously branched sporangiophores (200 to 400 μm long), which tapered to a blunt point and produced ellipsoidal, light brown sporangia with mean dimensions of 22 × 18 μm. The isolates were propagated and maintained by inoculation of detached quinoa leaves of two highly susceptible Peruvian cultivars (Toledo and Pandela) with a sporangium suspension (10⁵ sporangia per ml), followed by incubation on water agar plates (10 to 15 leaves per plate) at 15°C and 12 h light/dark for 9 to 11 days. All isolates grew readily on these cultivars, and microscopic examination of the pathogen showed the same morphology as the original isolate. When the isolates were tested for their virulence on a range of quinoa cultivars with different geographic origin, specific interactions between host genotype and pathogen isolate were observed, measured as the degree of sporulation in the detached leaf assay, suggesting the presence of several pathotypes. To our knowledge, this is the first report of P. farinosa on quinoa in Denmark. Downy mildew should be considered as a potential problem for future large-scale quinoa production in Europe. References: (1) S. Danielsen. (Abstr.) Phytopathology 90(suppl):S17, 2000. (2) N. W. Galwey. Biologist 36:267, 1989.

Heterothallism in Peronospora farinosa f.sp. chenopodii, the causal agent of downy mildew of quinoa (Chenopodium quinoa)

Heterothallism in Peronospora farinosa f.sp. chenopodii, the causal agent of downy mildew of quinoa (Chenopodium quinoa) is reported for the first time. Downy mildew is the most important disease of this crop in the Andean region. Eight single-lesion isolates from different regions in Peru and Bolivia were crossed in all possible combinations using a detached leaf assay, to determine the mating system of the downy mildew pathogen. The presence of two mating types, P1 and P2, was revealed showing that P. farinosa f.sp. chenopodii is heterothallic. It is suggested that frequent sexual reproduction is an important evolutionary force in this pathogen in South America.

Oligosaccharide binding to family 11 xylanases: both covalent intermediate and mutant product complexes display (2,5)B conformations at the active centre

The glycoside hydrolase sequence-based classification reveals two families of enzymes which hydrolyse the beta-1,4-linked backbone of xylan, xylanases, termed families GH-10 and GH-11. Family GH-11 xylanases are intriguing in that catalysis is performed via a covalent intermediate adopting an unusual (2,5)B (boat) conformation, a conformation which also fulfils the stereochemical constraints of the oxocarbenium ion-like transition state. Here, the 1.9 A structure of a nucleophile, E94A, mutant of the Xyn11 from Bacillus agaradhaerens in complex with xylotriose is presented. Intriguingly, this complex also adopts the (2,5)B conformation in the -1 subsite, with the vacant space provided by the Glu-->Ala mutation allowing the sugar to adopt the alpha-configuration at C1. The structure of the covalent 2-deoxy-2-fluoroxylobiosyl-enzyme intermediate has been extended to atomic (1.1 A) resolution.

In vitro selection of enzymatically active lipase variants from phage libraries using a mechanism-based inhibitor

The 'detergent lipase' Lipolase, from Thermomyces lanuginosa was subjected to a combinatorial protein engineering/phage display approach with the aim of identifying new enzyme variants with improved characteristics in the presence of detergents. First it was demonstrated that wild-type Lipolase could be produced in Escherichia coli retaining full activity and be displayed as an active enzyme fused to coat protein 3 on E. coli phage M13. A phagemid library designed to result in approximately two to three mutations per lipase gene was then constructed. Nine amino acids located in two regions close to the active site were targeted for randomization. Selections using a mechanism-based biotinylated inhibitor showed that phages displaying Lipolase could be specifically enriched from a population of control phages. Selections on a library phage stock in the presence of inhibitor and a commercial powder detergent resulted in a step-wise increase in the proportion of active clones. Analysis of 84 active clones revealed that they all expressed lipase activity, but with lower activities than that of a wild-type Lipolase-producing clone. In six of the seven most active clones a wild-type serine at position 83 had been replaced by threonine, a substitution known to alter the substrate chain length preference of Lipolase variants. Furthermore, the selection had enriched enzyme variants with a high degree of conservatism in one of the variegated regions, suggesting that this region is important for enzymatic activity and that the designed selection procedure was relevant. The selected variants contained primarily basic amino acid residues within the other variegated region. Taken together, the described results show that selection protocols based on enzymatic activity can be designed for this enzyme class which should be of importance for future protein engineering attempts.

Evaluation of the use of Sr2+ in alginate immobilization of cells

In recent years the method of immobilization of living cells in Ca-alginate beads has gained a wide range of applications. In all cases high chemical stability of the immobilization material and mild conditions for the cells are prerequisites. However, in long-term experiments that may last for several days Ca-alginate may dissolve due to an exchange of Ca2+ with Na+, forming fluid Na-alginate. As well as Ca-alginate, the more chemically stable Sr-alginate and Ba-alginate are materials that have been used for the immobilization of living cells. In this study, the effects of Ca2+, Sr2+ and Ba2+ on growth, viability and intracellular free calcium concentration in a human leukemic T cell line (Jurkat) were investigated. The findings in this study, and the fact that Sr-alginate has a considerably higher chemical stability than Ca-alginate, led to the conclusion that Sr-alginate is a more suitable material for use in the entrapment of living cells in long-term studies.

Efficient gene targeted random mutagenesis in genetically stable Escherichia coli strains

We describe a method to generate in vivo collections of mutants orders of magnitude larger than previously possible. The method favors accumulation of mutations in the target gene, rather than in the host chromosome. This is achieved by propagating the target gene on a plasmid, in Escherichia coli cells, within the region preferentially replicated by DNA polymerase I (Pol I), which replicates only a minor fraction of the chromosome. Mutagenesis is enhanced by a conjunction of a Pol I variant that has a low replication fidelity and the absence of the mutHLS system that corrects replication errors. The method was tested with two reporter genes, encoding lactose repressor or lipase. The proportion of mutants in the collection was estimated to reach 1% after one cycle of growth and 10% upon prolonged cell cultivation, resulting in collections of 10(12)-10(13) mutants per liter of cell culture. The extended cultivation did not affect growth properties of the cells. We suggest that our method is well suited for generating protein variants too rare to be present in the collections established by methods used previously and for isolating the genes that encode such variants by submitting the cells of the collections to appropriate selection protocols.

Identification of a major B-cell epitope of the Plasmodium falciparum glutamate-rich protein (GLURP), targeted by human antibodies mediating parasite killing

The antigenicity of the glutamate-rich protein (GLURP) of Plasmodium falciparum was comprehensively evaluated in epitope-mapping studies utilizing a phage display library, synthetic peptides and anti-GLURP IgG preparations previously shown to promote strong antibody-dependent cellular inhibition (ADCI) effects. We identified six major B-cell epitopes within the nonrepetitive region R0, corresponding to amino acid residues 173 to 187 (P1), 193 to 207 (P3), 216 to 229 (P4), 264 to 288 (P11), 343 to 357 (P10), and 407 to 434 (S3). Of these, four (P1, P3, P4, and S3) were frequently recognized by high-titered IgG antibodies in plasma samples from immune Liberian adults (prevalence: 29.1-45.0%). The three epitopes P1, P3, and P4 contained a common motif (seven out of nine positions are identical) and may thus constitute a family of structurally related epitopes. This leaves two distinct epitopes, one (P3) representing this new epitope family and S3 as targets for biologically active antibodies. Human IgG antibodies from single plasma samples were affinity-purified against these peptides. P3-specific IgG preparations were consistently more effective in ADCI than S3-specific IgG. Among the different GLURP epitopes, we therefore suggest that the P3 epitope is potentially the most important epitope in GLURP for the development of clinical immunity to malaria in man.

Design and synthesis of triglyceride analogue biotinylated suicide inhibitors for directed molecular evolution of lipolytic enzymes

The design, synthesis, and inhibition properties of two new triglyceride analogue biotinylated suicide inhibitors (2) and (3) for directed molecular evolution of lipolytic enzymes by phage-display is described.

A novel biotinylated suicide inhibitor for directed molecular evolution of lipolytic enzymes

A bifunctional activity label (8) for directed molecular evolution of lipolytic enzymes has been designed and synthesized. The structure is composed of a 4-nitrophenyl activated phosphonate, that is, a suicide substrate of lipases/esterases, connected to a biotin moiety through a spacer containing a disulfide bridge. The phosphonate (3) was prepared by Michaelis-Arbuzov reaction of trimethylsilyl-protected 11-bromoundecanol (2) with triethyl phosphite. The deprotected omega-hydroxyalkylphosphonate (4) was transformed into an active N-hydroxysuccinimide carbonate (5) followed by 4-nitrophenyl activation of the phosphonate using standard procedures. The biotinylated phosphonate inhibitor (8) was then synthesised by coupling the phosphonate inhibitor (6) to the epsilon-amino-caproic acid and cystamine containing biotinyl spacer (7). The function of all relevant groups of the final activity label (8) (biotin-label, cleavable disulfide bridge, phosphonate-inhibitor) have been successfully tested with the commercial lipase Lipolase (Novo Nordisk). Hence, a tool for directed molecular evolution of lipolytic enzymes has been developed.

Leisure-time physical activity and psychosocial well-being in adolescents after cancer diagnosis

This preliminary study examined the relationship between leisure time physical activity (LTPA) and psychosocial well-being in 53 adolescents who were previously diagnosed with cancer. Participants completed a mailed, self-administered questionnaire in which they recalled their LTPA (including leisure time exercise and organized sport) at three time points (prediagnosis, treatment, and posttreatment). They also reported their current psychosocial well-being by using measures of depression and self-concept. Examination of the LTPA data revealed four main patterns across the cancer experience that were labeled maintainers (active at all three time points), temporary relapsers (active prediagnosis, inactive during treatment, active posttreatment), permanent relapsers (active prediagnosis, inactive during treatment, inactive posttreatment), and nonparticipants (inactive at all three time points). Multivariate analyses of variance indicated that self-concept differed significantly across the four organized sport patterns. Follow-up univariate analyses revealed significant differences for general self-concept, physical abilities, parental relations, same sex relations, and opposite sex relations with effect sizes ranging from medium-large to large. Post hoc tests generally showed that the maintainers exhibited superior scores on psychosocial well-being compared with the other three patterns. It was concluded that LTPA patterns across the cancer experience may be related to psychosocial well-being in adolescents after cancer diagnosis but that further research is warranted.

[Cholecystectomy in the laparoscopic era]

Since 1991 laparoscopic cholecystectomy has been performed on 323 patients; 47 patients underwent conversion to open surgery. In the same period, 46 patients were primarily selected for open cholecystectomy. Half the patients were operated on because of gallbladder colic (the sole symptom). Conversion to open operation (14%) occurred not so much because of peroperative complications, but rather because of anatomical problems. On the fourth postoperative day, one patient died of septicaemia caused by iatrogenic diathermy damage to the duodenum. One patient developed a stricture of the choledochus as a result of ischemia. This was caused by dissecting the choledochus, having mistaken it for the ductus cysticus which was missing in this anatomic variant.

The glutamate-rich protein (GLURP) of Plasmodium falciparum is a target for antibody-dependent monocyte-mediated inhibition of parasite growth in vitro

Monocyte-dependent as well as direct inhibitory effects of antimalarial antibodies point toward antigens accessible at the time of merozoite release as targets for biologically active antibodies capable of mediating protection against Plasmodium falciparum. The glutamate-rich protein (GLURP), being an antigen associated with mature schizont-infected erythrocytes, was therefore the object of the present investigation, in which we analyzed whether anti-GLURP antibodies can either interfere directly with merozoite invasion or act indirectly by promoting a monocyte-dependent growth inhibition, antibody-dependent cellular inhibition. GLURP-specific human immunoglobulin G (IgG) antibodies, from pooled IgG of healthy Liberian adults who were clinically immune to malaria, were purified by affinity chromatography on columns containing R0 (N-terminal nonrepetitive region of GLURP) or R2 (C-terminal repetitive region of GLURP) recombinant protein or synthetic peptides as ligands. Analysis of the pattern of reactivity of highly purified anti-GLURP antibodies led to the definition of at least four B-cell epitopes. One epitope was specific for R0, two were specific for R2, and the fourth displayed cross-reactivity between R0 and R2. None of the purified IgG antibodies had direct invasion-inhibitory effects, even at high concentrations. In contrast, when allowed to cooperate with monocytes, all anti-GLURP IgG preparations mediated a strong monocyte-dependent parasite growth inhibition in a dose-dependent manner.

Membrane topology analysis of the Escherichia coli cytosine permease

The Escherichia coli codBA operon encodes cytosine permease (CodB) and cytosine deaminase (CodA). CodB mediates uptake of exogenously supplied cytosine, and CodA catalyses the hydrolytic deamination of cytosine to uracil and ammonia. The hydropathic profile of CodB indicates that it is an integral cytoplasmic membrane protein possessing several transmembrane-spanning domains. The membrane topology of CodB was investigated by using gene fusions containing varying lengths of the amino-terminus of CodB fused to either alkaline phosphatase (AP) or beta-galactosidase (BG). The AP activities expressed by the CodB-AP fusions are consistent with a topological model in which the amino- and the carboxy-termini of CodB are located in the cytoplasm, and in which CodB possesses 12 membrane-spanning segments. The enzyme activities of most of the CodB-BG fusions support the model. However, the results obtained with some of the CodB-BG fusions illustrate the limitations of using BG as a reporter protein in studies of membrane protein topology.

[Surgical treatment of acute intestinal ischemia. Successful treatment with embolectomy of the superior mesenteric artery]

We describe a patient with acute intestinal ischemia successfully treated with embolectomy of the superior mesenteric artery. Over the last four years, 11 patients with the same disease were treated with bowel resection at Nordland Regional Hospital. The mortality rate after bowel resection was 45%. Long duration of symptoms, and high frequency of associated cardiovascular disease was characteristic. In elderly patients with acute abdominal pain and cardiovascular disease, a diagnosis of acute mesenterial ischemia should be seriously considered. In patients with acute mesenteric ischemia and no bowel necrosis, embolectomy must be considered in preference to bowel resection.

[Surgical treatment of abdominal aortic aneurysms. Risk factors and complications]

Between January 1985 and April 1991 156 patients underwent surgery for abdominal aortic aneurysm at Nordland Regional Hospital. Of these, 90 underwent elective surgery; 36 were operated on for symptomatic aneurysm; 30 for ruptured aneurysm. The mortality rates were respectively 10%, 14% and 47%. Surgery for aortic aneurysm is on the increase. Advanced age, and associated serious cardiac disease predispose to postoperative complications and death. To reduce mortality better preoperative evaluation and treatment are essential.

[Surgical treatment of aortic occlusion and obliterating aorto-iliac arteriosclerosis]

From 1985 to March 1991, 83 patients with the diagnosis aortoiliac obliteration and aortic occlusion were operated on at the Department of Surgery, Nordland Central Hospital. The main symptom was claudicatio intermittens. 16 patients had pain while at rest, and two had gangrene. The surgical technique was either Y-prosthesis or thrombendarterectomy. Four patients (4.8%) died postoperatively, three of myocardial infarction and one of intestinal ischemia and peritonitis. In our study 66 patients with aortoiliacal atherosclerosis were compared with 17 patients with aortic occlusion. Patients with aortoiliacal atherosclerosis demonstrated by angiography had much more severe infrainguinal arterial pathology. In the occlusion group the postoperative outcome, as measured by ankle/brachial index, was significantly better (p < 0.01). The study included four female patients less than 50 years of age with total infrarenal aortic occlusion. Their symptoms and signs are discussed.

[Abdominal aortic surgery. Transperitoneal or retroperitoneal approach?]

During the past five years a retroperitoneal approach was used in 34 patients and the transabdominal route in 49 patients for treatment of abdominal aortosclerosis. Both groups were identical with respect to age, sex and preoperative morbidity. In patients with previous laparotomy the retroperitoneal approach was always chosen. There was no significant difference with regard to postoperative complications. The only significant difference between the two groups after the operation was a trend towards earlier defecation among the patients treated by the retroperitoneal approach. We can not demonstrate any important advantage or disadvantage of the retroperitoneal approach. The transabdominal approach provides an opportunity to examine the abdominal organs for malignancy. We found one asymptomatic gastric cancer. The retroperitoneal approach is particularly suitable in patients who have undergone laparotomy before for expected severe abdominal adhesions.

Characterization of the Escherichia coli codBA operon encoding cytosine permease and cytosine deaminase

The nucleotide sequence of a 3.1 kb segment carrying the cytosine deaminase gene (codA) from Escherichia coli was determined. The sequence revealed the presence of two open reading frames, the first (codB) specifying a highly hydrophobic polypeptide and the second specifying cytosine deaminase. A two-codon overlap between the two reading frames indicates that they constitute an operon. Transcription of the operon was found to be regulated by exogenous purines. Polypeptides specified by each of the two reading frames were expressed in minicells, and the codB gene product was found to be highly enriched in the membrane fraction. Uptake experiments showed that the CodB protein is required for cytosine transport into the cell and that the intracellular accumulation of cytosine correlated with the codB gene dose. A topological model for the cytosine permease in the cytoplasmic membrane is proposed.

Mutagenic activity of nine N,N-disubstituted hydrazines in the Salmonella/mammalian microsome assay

The mutagenic activity of N,N-dimethyl-, N,N-diethyl-, N,N-dibutyl-, N,N-diisobutyl-, N,N-di(p-tolyl)-, N-ethyl-N-phenyl-, N,N-dibenzyl-, N,N-diphenyl- and N,N-diisopropylhydrazine was examined in the Salmonella/mammalian microsome assay using the strains TA1535, TA1537, TA97, TA98, TA100, TA102 and TA1530. All nine hydrazines were mutagenic in at least one tester strain, although of borderline significance for some of the compounds. The mutagenic potencies of the hydrazines varied 2-3 orders of magnitude, from very weak to moderate mutagenic activity. In general, the addition of S9 resulted in a lowering of the mutagenic activity and a lowering of the toxic properties of the hydrazines. The test results were relatively difficult to evaluate due to toxic effects of many of the test compounds on the test bacteria which may have resulted in an underestimation of the mutagenic potencies of some of the compounds. The pattern of mutagenic activity of the hydrazines in the different tester strains indicates that more than one mechanism of action may be involved in the mutagenicity.

Splenic injury--a prospective multicentre diagnostic study

One hundred and forty-seven patients with splenic injury were entered in a prospective multicentre study including 18 hospitals. The diagnosis was made by scintigraphy in 55 patients, ultrasonography in 51 and computed axial tomography in 31. Exploratory laparotomy was performed in 52 patients, in 23 of these after a positive peritoneal lavage. Splenic injury was found in 33 per cent of the ultrasound examinations, indicated in another 20 per cent and not indicated in 16 per cent. In 31 per cent increased intraperitoneal effusion was the only finding. There was a tendency towards an underestimation of the injury by ultrasonography. Peritoneal lavage was positive in all examinations.

A single dose tinidazole and doxycycline prophylaxis in elective surgery of colon and rectum. A prospective controlled clinical multicenter study

Antimicrobial prophylaxis with agents active against aerobic and anaerobic micro-organisms leads to a significant reduction of infectious complications following colorectal surgery. A single dose (1600 mg) of tinidazole (a nitroimidazole derivate) and doxycycline (400 mg) will provide serum and tissue values well above minimum inhibitory concentration (MIC) values for more than 24 hours. To reduce the unwanted side effects and cost of prolonged antimicrobial prophylaxis, a prospective controlled clinical multicenter study comparing the effect of a single dose before operation of tinidazole and doxycycline to five days of prophylaxis before operation in 234 patients undergoing elective colorectal surgery was undertaken. Six patients given a single dose of prophylaxis before operation (n = 118) developed infectious complication (5.1%). Prolongation of prophylaxis before operation for four days after operation (n = 116) did not lead to any further reduction of infectious complications. A single dose of tinidazole and doxycycline before operation is a simple and effective prophylaxis against infectious complications following elective colorectal surgery.