Transanal full-thickness excision for rectal neoplasm: is it advisable to leave the defect open?

PURPOSE

After a full-thickness total wall excision of a rectal tumor, suturing the defect is generally recommended. Recently, due to various contradictory studies, there is a trend to leave the defects open. Therefore, this study aimed to determine whether leaving the defect open is an adequate management strategy compared with suturing it closed based on postoperative outcomes and recurrences.

METHODS

A retrospective review of our prospectively maintained database was conducted. Adult patients who underwent transanal surgery for rectal neoplasm in our institution from 1997 to 2019 were analyzed. Patients were divided into two groups: sutured (group A) or unsutured (group B) rectal defect. The primary outcomes were morbidity (early and late) and recurrence.

RESULTS

In total, 404 (239 men) patients were analyzed, 143 (35.4%) from group A and 261 (64.6%) from group B. No differences were observed in tumor size, distance from the anal verge or operation time. The overall incidence of complications was significantly higher in patients from group B, which nearly double the rate of group A. With a mean follow-up of 58 (range, 12-96) months, seven patients presented with a rectal stricture, all of them from group B.

CONCLUSIONS

We acknowledge the occasional impossibility of closing the defect in patients who undergo local excision; however, when it is possible, the present data suggest that there may be advantages to suturing the defect closed.

SARS-CoV-2 variant Delta rapidly displaced variant Alpha in the United States and led to higher viral loads

We report on the sequencing of 74,348 SARS-CoV-2 positive samples collected across the United States and show that the Delta variant, first detected in the United States in March 2021, made up the majority of SARS-CoV-2 infections by July 1, 2021 and accounted for >99.9% of the infections by September 2021. Not only did Delta displace variant Alpha, which was the dominant variant at the time, it also displaced the Gamma, Iota, and Mu variants. Through an analysis of quantification cycle (Cq) values, we demonstrate that Delta infections tend to have a 1.7× higher viral load compared to Alpha infections (a decrease of 0.8 Cq) on average. Our results are consistent with the hypothesis that the increased transmissibility of the Delta variant could be due to the ability of the Delta variant to establish a higher viral load earlier in the infection as compared to the Alpha variant.

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Alpha was dominant in spring 2021 and went extinct in fall 2021 in the United States

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Delta also displaced Gamma, Iota, and Mu variants

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On average, viral load was ∼1.7× higher in Delta infections versus Alpha infections

Using symptom-based case predictions to identify host genetic factors that contribute to COVID-19 susceptibility

Epidemiological and genetic studies on COVID-19 are currently hindered by inconsistent and limited testing policies to confirm SARS-CoV-2 infection. Recently, it was shown that it is possible to predict COVID-19 cases using cross-sectional self-reported disease-related symptoms. Here, we demonstrate that this COVID-19 prediction model has reasonable and consistent performance across multiple independent cohorts and that our attempt to improve upon this model did not result in improved predictions. Using the existing COVID-19 prediction model, we then conducted a GWAS on the predicted phenotype using a total of 1,865 predicted cases and 29,174 controls. While we did not find any common, large-effect variants that reached genome-wide significance, we do observe suggestive genetic associations at two SNPs (rs11844522, p = 1.9x10-7; rs5798227, p = 2.2x10-7). Explorative analyses furthermore suggest that genetic variants associated with other viral infectious diseases do not overlap with COVID-19 susceptibility and that severity of COVID-19 may have a different genetic architecture compared to COVID-19 susceptibility. This study represents a first effort that uses a symptom-based predicted phenotype as a proxy for COVID-19 in our pursuit of understanding the genetic susceptibility of the disease. We conclude that the inclusion of symptom-based predicted cases could be a useful strategy in a scenario of limited testing, either during the current COVID-19 pandemic or any future viral outbreak.

Emergence and rapid transmission of SARS-CoV-2 B.1.1.7 in the United States

The highly transmissible B.1.1.7 variant of SARS-CoV-2, first identified in the United Kingdom, has gained a foothold across the world. Using S gene target failure (SGTF) and SARS-CoV-2 genomic sequencing, we investigated the prevalence and dynamics of this variant in the United States (US), tracking it back to its early emergence. We found that, while the fraction of B.1.1.7 varied by state, the variant increased at a logistic rate with a roughly weekly doubling rate and an increased transmission of 40%–50%. We revealed several independent introductions of B.1.1.7 into the US as early as late November 2020, with community transmission spreading it to most states within months. We show that the US is on a similar trajectory as other countries where B.1.1.7 became dominant, requiring immediate and decisive action to minimize COVID-19 morbidity and mortality.

Genomic epidemiology identifies emergence and rapid transmission of SARS-CoV-2 B.1.1.7 in the United States

As of January of 2021, the highly transmissible B.1.1.7 variant of SARS-CoV-2, which was first identified in the United Kingdom (U.K.), has gained a strong foothold across the world. Because of the sudden and rapid rise of B.1.1.7, we investigated the prevalence and growth dynamics of this variant in the United States (U.S.), tracking it back to its early emergence and onward local transmission. We found that the RT-qPCR testing anomaly of S gene target failure (SGTF), first observed in the U.K., was a reliable proxy for B.1.1.7 detection. We sequenced 212 B.1.1.7 SARS-CoV-2 genomes collected from testing facilities in the U.S. from December 2020 to January 2021. We found that while the fraction of B.1.1.7 among SGTF samples varied by state, detection of the variant increased at a logistic rate similar to those observed elsewhere, with a doubling rate of a little over a week and an increased transmission rate of 35-45%. By performing time-aware Bayesian phylodynamic analyses, we revealed several independent introductions of B.1.1.7 into the U.S. as early as late November 2020, with onward community transmission enabling the variant to spread to at least 30 states as of January 2021. Our study shows that the U.S. is on a similar trajectory as other countries where B.1.1.7 rapidly became the dominant SARS-CoV-2 variant, requiring immediate and decisive action to minimize COVID-19 morbidity and mortality.

Genotyping of the Galactosemia GALT 591 A>G Mutation by Pyrosequencing

Introduction/Objective

This project aimed to design a pyrosequencing assay capable of genetically analyzing the presence of GALT 591 A>G mutation for the diagnosis of galactosemia. Galactosemia is an autosomal recessive disorder that affects enzyme activity of galactose-1-phosphate uridylytransferase (GALT). This enzyme is responsible for proper processing of galactose to glucose; if not broken down the accumulation of galactose in the body results in developmental delays, clouding of the eyes, speech difficulties, and intellectual disabilities. Pyrosequencing offers a valuable platform in assessing whether patients are wild type unaffected (A:A), heterozygous carrier (A:G), or homozygous affected (G:G) at the alleles within the GALT 591 locus by measuring percentage of the wild type A allele and the mutant G allele.

Methods

PCR primers were designed for the mutation locus, and PCR amplification was optimized for the target 77 bp product, with verification by gel electrophoresis. The pyrosequencing assay was designed and validated on the Qiagen PyroMark Q24 instrument. Control samples included commercially purchased DNA from the Coriell Cell Repository.

Results

One hundred and thirty-three reactions were utilized to establish the following assay validation parameters: accuracy (100% for G:G, 95% for A:G and A:A), precision (determined by mean and standard deviation with a standard deviation of 0.6 for G:G, 4.55 for A:G and 4.85 for A:A), and limit of detection (10 ng DNA pre-PCR and 2 µL of PCR product loaded). Twenty-six blinded samples were utilized to test assay clinical performance, as compared against a high resolution melt curve assay.

Conclusion

It was determined that detection of GALT 591 A>G via pyrosequencing is highly sensitive and specific with a clinical sensitivity of 100% and a clinical specificity of 95.83%. It was concluded that this assay could be applied in a clinical environment for GALT 591 A>G genotyping to aid in galactosemia diagnosis.

Publisher Correction: Feasibility and effects of enhanced recovery vs. conventional care after emergency colon surgery for patients with left colon perforation

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Isoflurane disrupts excitatory neurotransmitter dynamics via inhibition of mitochondrial complex I

BACKGROUND

The mechanisms of action of volatile anaesthetics are unclear. Volatile anaesthetics selectively inhibit complex I in the mitochondrial respiratory chain. Mice in which the mitochondrial complex I subunit NDUFS4 is knocked out [Ndufs4(KO)] either globally or in glutamatergic neurons are hypersensitive to volatile anaesthetics. The volatile anaesthetic isoflurane selectively decreases the frequency of spontaneous excitatory events in hippocampal slices from Ndufs4(KO) mice.

METHODS

Complex I inhibition by isoflurane was assessed with a Clark electrode. Synaptic function was measured by stimulating Schaffer collateral fibres and recording field potentials in the hippocampus CA1 region.

RESULTS

Isoflurane specifically inhibits complex I dependent respiration at lower concentrations in mitochondria from Ndufs4(KO) than from wild-type mice. In hippocampal slices, after high frequency stimulation to increase energetic demand, short-term synaptic potentiation is less in KO compared with wild-type mice. After high frequency stimulation, both Ndufs4(KO) and wild-type hippocampal slices exhibit striking synaptic depression in isoflurane at twice the 50% effective concentrations (EC₅₀). The pattern of synaptic depression by isoflurane indicates a failure in synaptic vesicle recycling. Application of a selective A₁ adenosine receptor antagonist partially eliminates isoflurane-induced short-term depression in both wild-type and Ndufs4(KO) slices, implicating an additional mitochondria-dependent effect on exocytosis. When mitochondria are the sole energy source, isoflurane completely eliminates synaptic output in both mutant and wild-type mice at twice the (EC₅₀) for anaesthesia.

CONCLUSIONS

Volatile anaesthetics directly inhibit mitochondrial complex I as a primary target, limiting synaptic ATP production, and excitatory vesicle endocytosis and exocytosis.

Graded SiGe waveguides with broadband low-loss propagation in the mid infrared

Mid-infrared (mid-IR) silicon photonics is expected to lead key advances in different areas including spectroscopy, remote sensing, nonlinear optics or free-space communications, among others. Still, the inherent limitations of the silicon-on-insulator (SOI) technology, namely the early mid-IR absorption of silicon oxide and silicon at λ~3.6 µm and at λ ~8.5 µm respectively, remain the main stumbling blocks that prevent this platform to fully exploit the mid-IR spectrum (λ ~2-20 µm). Here, we propose using a compact Ge-rich graded-index Si_1-xGe_x platform to overcome this constraint. A flat propagation loss characteristic as low as 2-3 dB/cm over a wavelength span from λ = 5.5 µm to 8.5 µm is demonstrated in Ge-rich Si_1-xGe_x waveguides of only 6 µm thick. The comparison of three different waveguides design with different vertical index profiles demonstrates the benefit of reducing the fraction of the guided mode that overlaps with the Si substrate to obtain such flat low loss behavior. Such Ge-rich Si_1-xGe_x platforms may open the route towards the implementation of mid-IR photonic integrated circuits with low-loss beyond the Si multi-phonon absorption band onset, hence truly exploiting the full Ge transparency window up to λ ~15 µm.

[Situs inversus of the optic nerve. A case report]

INTRODUCTION

Situs inversus of the optic nerve is a congenital anomaly characterised by the emergence of the vessels in the retina towards the nose rather than in a temporal direction. It is caused by an anomalous insertion of the optic stalks into the optic vesicle that gives rise to dysversion of the head of the optic nerve. It is not an isolated condition and usually appears jointly with tilted disc syndrome and in patients with myopia. It is characterised by the presence of inferior conus atrophy, deficiencies in the temporal visual field, refraction defects and ambliopy.

CASE REPORT

A 22 years-old female who attended an ophthalmological examination due to severe frontal headaches accompanied by halos and loss of sharpness in her sight. From the results of the ophthalmetric and ophthalmological examination she was diagnosed as suffering from a condition consistent with this congenital anatomical anomaly.

CONCLUSIONS

Situs inversus of the optic nerve is a rare condition that may appear in isolation or accompanied by other pathologies. Application of the visual field test and new diagnostic techniques, such as optical coherence tomography, facilitates the differential diagnosis of this situation. Its prevalence remains unknown, as it is not included in the register of rare diseases. Moreover, the scant number of patients studied and the scarce literature on this anomaly do not allow us to know whether the defects it causes develop over time. It would therefore be important to perform an ophthalmological follow-up of patients with situs inversus of the optic nerve.

Ge-rich graded-index Si1-xGex waveguides with broadband tight mode confinement and flat anomalous dispersion for nonlinear mid-infrared photonics

This work explores the use of Ge-rich graded-index Si_1-xGex rib waveguides as building blocks to develop integrated nonlinear optical devices for broadband operation in the mid-IR. The vertical Ge gradient concentration in the waveguide core renders unique properties to the guided optical mode, providing tight mode confinement over a broadband mid-IR wavelength range from λ = 3 µm to 8 µm. Additionally, the gradual vertical confinement pulls the optical mode upwards in the waveguide core, overlapping with the Ge-rich area where the nonlinear refractive index is larger. Moreover, the Ge-rich graded-index Si_1-xGex waveguides allow efficient tailoring of the chromatic dispersion curves, achieving flat anomalous dispersion for the quasi-TM optical mode with D ≤ 14 ps/nm/km over a ~1.4 octave span while retaining an optimum third-order nonlinear parameter, γeff. These results confirm the potential of Ge-rich graded-index Si_1-xGex waveguides as an attractive platform to develop mid-IR nonlinear approaches requiring broadband dispersion engineering.

A multicentre comparison of a fast track or conventional postoperative protocol following laparoscopic or open elective surgery for colorectal cancer surgery

AIM

The introduction of multimodal or fast track (FT) rehabilitation and laparoscopy in colorectal surgery has improved patient recovery and shortened hospital stay (HS). This study aimed to determine the influence of laparoscopic or open surgery on the postoperative recovery of colorectal cancer patients having a conventional care (CC) or FT protocol in the postoperative period.

METHOD

A multicentre prospective study was controlled with a retrospective group. The prospective group included 300 patients having elective colorectal resection for cancer. The retrospective control group included 201 patients with the same characteristics who were treated before the introduction of the programme. The patients were divided into four groups including laparoscopy + FT, open surgery + FT, laparoscopy + CC, and open surgery + CC. The primary end-points were HS and morbidity. Secondary end-points included mortality and reoperation rates.

RESULTS

The overall median HS was 7 days. The median HS for laparoscopy + FT was 5 days, open + FT 6 days, laparoscopy + CC 9 days and open + CC 10 days (P < 0.001). In the regression model the laparoscopy + FT group had the greatest reduction in HS (P < 0.001). A significant reduction in HS was observed in the laparoscopy + FT group compared with laparoscopy + CC (P < 0.001). The overall patient morbidity was 30.6%. The logistic regression model adjusted for propensity score showed no statistically significant differences between the study groups regarding all other end-points.

CONCLUSION

Colorectal cancer patients who underwent laparoscopic surgery within a multimodal rehabilitation protocol experienced the shortest HS and the lowest morbidity.

The cellular building blocks of breathing

Respiratory brainstem neurons fulfill critical roles in controlling breathing: they generate the activity patterns for breathing and contribute to various sensory responses including changes in O2 and CO2. These complex sensorimotor tasks depend on the dynamic interplay between numerous cellular building blocks that consist of voltage-, calcium-, and ATP-dependent ionic conductances, various ionotropic and metabotropic synaptic mechanisms, as well as neuromodulators acting on G-protein coupled receptors and second messenger systems. As described in this review, the sensorimotor responses of the respiratory network emerge through the state-dependent integration of all these building blocks. There is no known respiratory function that involves only a small number of intrinsic, synaptic, or modulatory properties. Because of the complex integration of numerous intrinsic, synaptic, and modulatory mechanisms, the respiratory network is capable of continuously adapting to changes in the external and internal environment, which makes breathing one of the most integrated behaviors. Not surprisingly, inspiration is critical not only in the control of ventilation, but also in the context of "inspiring behaviors" such as arousal of the mind and even creativity. Far-reaching implications apply also to the underlying network mechanisms, as lessons learned from the respiratory network apply to network functions in general.

Inner ear insult ablates the arousal response to hypoxia and hypercarbia

INTRODUCTION

Sudden Infant Death Syndrome (SIDS) remains the leading cause of infant mortality in Western societies. A prior study identified an association between hearing suppression on the newborn hearing test and subsequent death from SIDS. This is the first finding of an abnormality in SIDS cases prior to death. A following study identified that inner ear dysfunction precipitates a marked suppression of the hypercapnic ventilatory response (HCVR). Failure of arousal has been proposed to be a key component in SIDS. The objective of the present study was to assess whether inner ear dysfunction not only weakens the hypercapnic response, but also plays a role in suppressing the arousal response to suffocating gas mixtures.

METHODS

Wild-type mice (n=28) received intra-tympanic gentamicin (IT-Gent) injections bilaterally or unilaterally to precipitate inner ear hair cell dysfunction. Three control groups (n=22) received intra-tympanic saline (IT-Saline) bilaterally or unilaterally (right or left), or intra-peritoneal gentamicin (IP-Gent). The body movement arousal responses to severe hypoxia-hypercarbia combined (5% CO2 in nitrogen) were tested under light anesthesia 8 days following the administration of gentamicin or saline.

RESULTS

After injections, the bilateral and unilateral IT-Gent-treated animals behaved similarly to controls, however the HCVR as well as the arousal movements in response to severe hypoxia-hypercarbia were suppressed in IT-Gent-treated animals compared to control animals (P<0.05). Thus the HCVR was significantly decreased in the bilateral (n=9) and unilateral IT-Gent-treated mice (n=19) compared to bilateral (n=7) and unilateral IT-Saline (n=9) control groups (p<0.05). Arousal movements were suppressed in the bilateral IT-Gent group (n=9) compared to bilateral IT-Saline controls (n=7, P<0.0001) and in the unilateral IT-Gent group (n=19) compared to unilateral IT-Saline controls (n=10, P<0.0001).

DISCUSSION

The findings support the theory that inner ear dysfunction could be relevant in the pathophysiology of SIDS. The inner ear appears to play a key role in arousal from suffocating gas mixtures that has not been previously identified.

Inner ear insult suppresses the respiratory response to carbon dioxide

Compensated respiratory acidosis has been observed in a significant number of patients with active vestibular disease. We therefore hypothesized that the inner ear may play an unrecognized integral role in respiratory control. To test this premise, we investigated whether mice with induced inner ear injury demonstrated any alteration in their respiratory response to inhaled carbon dioxide (CO(2)). Experimental mice and control mice were included in two separate experiments. Intra-tympanic gentamycin injections were administered to induce inner ear damage in experimental animals. Hearing loss and vestibular dysfunction were tested 1-week after injections to confirm presence of inner ear insult, following which the animal's respiratory response to inhalation of 8% CO(2) was examined. Mice with inner ear injury (n=60) displayed a significantly diminished hypercapnic ventilatory response (HCVR). This contrasted with the normal HCVR seen in control mice that had not undergone tympanic injections (n=30), controls that received tympanic injections with saline (n=5), and controls that had gentamicin administered systemically (n=5). In response to inspired CO(2), the mean respiratory frequency of control mice increased by an average of 50% over their baseline values for both parts of the experiment. In contrast, the ear-damaged experimental group mean values increased by only three breaths per minute (bpm) (2%) in the first experiment and by 28 bpm (11%) in the second experiment. Inner ear damage significantly reduces the respiratory response to CO(2) inhalation. In addition to the established role of the inner ear organ in hearing and balance, this alludes to an unidentified function of the inner ear and its interconnecting neuronal pathways in respiratory regulation. This finding may offer valuable new clues for disease states with abnormal respiratory control where inner ear dysfunction may be present.

[Ethylene glycol intoxication: a case report]

Ethylene glycol intoxication is one of the most serious acute poisonings due to the high toxicity that can result in death if not treated rapidly. We report the case of a patient who presented to the intensive care unit with a hypertensive crisis associated to a renal insufficiency. Laboratories investigations which revealed metabolic acidosis and elevated anion gap, highlighted an unexpected ethylene glycol intoxication. Clinical and psychiatric feature lead to suspect a chronic ingestion. Spontaneous recovery occured without specific treatment.

Pemetrexed acts as an antimyeloma agent by provoking cell cycle blockade and apoptosis

Multiple myeloma (MM) is a malignancy of terminally differentiated B lymphocytes, characterized by accumulation of a monotypic plasma cell population in the bone marrow, monoclonal immunoglobulin in serum and/or urine and osteolytic lesions. Despite recent advances in the treatment, MM remains an incurable disease. This calls for an effort to develop novel therapeutics in order to eradicate the disease. Here we have evaluated the potential antimyeloma action of Pemetrexed, an antifolate drug that has shown promising results in other neoplastic diseases. Pemetrexed had a potent antimyeloma effect on cell lines sensitive and resistant to conventional therapeutic agents, and was also efficient on fresh cells from patients and in a murine MM model. Furthermore, Pemetrexed abrogated the protective action on MM cell death of several growth factors produced by the bone marrow microenvironment. Mechanistic studies indicated that Pemetrexed provoked this action by a combined effect that included cell cycle blockade, probably by p21 upregulation, and induction of apoptosis through caspase-dependent and -independent mechanisms. These data, together with the fact that Pemetrexed is already licensed for the therapy of other neoplastic diseases, opens the possibility for the inclusion of Pemetrexed in the therapeutic armamentarium to battle MM.

Cell populations and adhesion molecules expression in conjunctiva before and after bone marrow transplantation

We were interested to analyse the composition of the cellular infiltrate and adhesion molecules expression in the conjunctiva before and at least one hundred days after autologous and allogenic bone marrow transplantation (BMT) and its relation with the presence of dry eye. We used immunohistochemistry on cryopreserved human conjunctiva with monoclonal antibodies to T-lymphocytes (CD3, CD4 and CD8), B-lymphocytes (CD19), macrophages (CD14), natural killer cells (NK, CD57), intercellular adhesion molecule 1 (ICAM-1), E-selectin, vascular cell adhesion molecule-1 (VCAM-1), lymphocyte function associated antigen-1 (LFA-1), very late antigen-4 (VLA-4), interleukin 2 receptor (IL2r, CD25) and HLA-DR. Our autologous recipients had no graft-versus-host disease (GVHD) but allogenic patients had chronic GVHD. After autologous BMT the conjunctiva had significantly more: (1) T lymphocytes (CD3+, CD4+, CD8+) in the epithelium; (2) CD4+ and CD14+ cells in the stroma; and (3) VLA-4 expression in the stroma than before BMT. After allogenic BMT, the conjunctiva exhibited a significant increase of: (1) CD3+ and CD14+ cells in the epithelium; (2) T lymphocytes (CD3+, CD4+, CD8+) and CD14+ cells in the stroma; and (3) VLA-4 and LFA-1 expression in the stroma than before BMT. After the engraftment, the comparison between autologous and allogenic recipients revealed that: (1) there were no significant differences in adhesion molecule expression; (2) the epithelium of autologous recipients had significantly more CD3+ cells; and (3) the stroma of allogenic patients had significantly more CD3+ and CD8+ cells. Among allogenic recipients, CD14+ cells were significantly increased both in the epithelium and in the stroma of patients with signs or symptoms of dry eye in comparison with patients without ocular involvement. Additionally, those having keratoconjunctivitis sicca (KCS) had CD4/CD8 ratios significantly higher than those without KCS. In conclusion, in the conjunctiva after autologous BMT a subclinical cell mediated immune reaction seems to take place. The conjunctivitis of chronic GVHD is complex, with T cells and macrophages dramatically contributing to the process.

NPY and TH innervation in human choroidal whole-mounts

To determine the distribution of NPY and TH human choroidal innervation, choroidal whole-mounts were processed for indirect immunofluorescence. An antibody to a component of the neuronal cytoskeleton, neurofilament 200 kDa (NF-200) was used to identify neurons and axons. A double immunostaining was performed, antibodies against NF-200 being combined with antibodies against neuropeptide Y (NPY) and tyroxine hydroxylase (TH). Fibers containing both NPY and TH were distributed in three plexuses, one in the suprachoroid large-sized vessel layer, and two in the medium-sized vessel layer. Intrinsic choroidal neurons (ICNs) containing NPY and TH were observed in the suprachoroid. The TH(+) ICNs were located in the medium-sized vessel layer. Overall, NPY(+) and TH(+) ICNs were more frequent in the central temporal area, both in isolation and forming microganglia. We also detected small spindle elements intensely immunoreactive to TH(+) and distributed mainly in the suprachoroid from the equator to the periphery. In conclusion, the human choroid contains abundant NPY and TH nerve fibers related to chroroidal vascular structures; it further possesses NPY(+) and TH(+) ICNs which contribute to the choroidal self-regulation persisting after sympathetic denervation. Additionally, these ICNs may at least partially explain why the choroidal blood flow does not respond to the factors that influence systemic vascular control. The preferential location of these cells in the submacular area suggests that dysfunction or degeneration of these cells may be a factor in vascular pathologies found in ocular disease, such as diabetic macular edema or age-related macular degeneration.

[ROC (receiver operating characteristics) curve: principles and application in biology]

Laboratory test's diagnostic performances are generally estimated by means of their sensibility, specificity and positive and negative predictive values. Unfortunately, these indices reflect only imperfectly the capacity of a test to correctly classify subjects into clinically relevant subgroups. The appeal to ROC (receiver operating characteristic) curve appears as a tool of choice for this evaluation. Used in the medical domain since the 60s, ROC curve is a graphic representation of the relation existing between the sensibility and the specificity of a test, calculated for all possible cut-off. It allows the determination and the comparison of the diagnostic performances of several tests. It is also used to consider the optimal cut-off of a test, by taking into account epidemiological and medical - economic data of the disease. Used in numerous medical domains, this statistical tool is easily accessible thanks to the development of computer softwares. This article exposes the principles of construction and exploitation of a ROC curve.

Probing the binding site of 800-nm bacteriochlorophyll in the membrane-linked LH2 protein of Rhodobacter capsulatus by local unfolding and chemical modification

The aim of this study was to investigate the function of betaHis20 in the spectral behavior of the 800-nm bacteriochlorophyll (Bchl) of the Rhodobacter capsulatus LH2 protein. In this context, the 800-nm Bchl of the membrane-linked LH2 was used as an intrinsic probe to follow the reversible, denaturant-elicited unfolding of the neighboring protein region. This band was reversibly shifted to approximately 770 nm by acidic pH, suggesting that the environment of the pigment, responsible for its native red shift, was significantly disturbed by the protonation of a chemical group. The reversible acid-induced blue shift was only observed in the presence of unfolding agents (urea and guanidinium chloride). Thus, dismantling of the protein structure facilitated exposure of the basic group to the medium. The acid-base titrations of the spectral shift indicated an apparent pK approximately 6.1, a value consistent with His imidazole being the protonatable group responsible for the acid-induced band shift. The pK values of free N-terminal amino groups are higher and not expected to be lowered by their local environment in the unfolded state of the protein. A similar blue shift of the 800-nm Bchl band was caused by the modifier diethyl pyrocarbonate, which is known to carboxylate the imidazole group of His and free amino groups. It is also shown that the Fourier transform Raman spectrum of diethyl pyrocarbonate-treated LH2 preparations lacks the weak mode at 1695 cm(-1), suggesting that it should be assigned to the B800 Bchl.

Identification of two types of inspiratory pacemaker neurons in the isolated respiratory neural network of mice

In the respiratory network of mice, we characterized with the whole cell patch-clamp technique pacemaker properties in neurons discharging in phase with inspiration. The respiratory network was isolated in a transverse brain stem slice containing the pre-Bötzinger complex (PBC), the presumed site for respiratory rhythm generation. After blockade of respiratory network activity with 6-cyano-7-nitroquinoxalene-2,3-dione (CNQX), 18 of 52 inspiratory neurons exhibited endogenous pacemaker activity, which was voltage dependent, could be reset by brief current injections and could be entrained by repetitive stimuli. In the pacemaker group (n = 18), eight neurons generated brief bursts (0.43 +/- 0.03 s) at a relatively high frequency (1.05 +/- 0.12 Hz) in CNQX. These bursts resembled the bursts that these neurons generated in the intact network during the interval between two inspiratory bursts. Cadmium (200 microM) altered but did not eliminate this bursting activity, while 0.5 microM tetrodotoxin suppressed bursting activity. Another set of pacemaker neurons (10 of 18) generated in CNQX longer bursts (1.57 +/- 0.07 s) at a lower frequency (0.35 +/- 0.01 Hz). These bursts resembled the inspiratory bursts generated in the intact network in phase with the population activity. This bursting activity was blocked by 50-100 microM cadmium or 0.5 microM tetrodotoxin. We conclude that the respiratory neural network contains pacemaker neurons with two types of bursting properties. The two types of pacemaker activities might have different functions within the respiratory network.

Quality of life, health outcomes, and identity for patients with prostate cancer in five different treatment groups

PURPOSE/OBJECTIVES

To describe how different treatments for prostate cancer affect health-related quality of life (QOL), health status, and masculinity.

DESIGN

Longitudinal survey design with descriptive, correlational, and comparative elements.

SETTING

A tertiary medical center and associated clinics in a suburban community in the Southwestern United States.

SAMPLE

185 men with localized prostate cancer were enrolled from five treatment groups: watchful waiting (n = 30), surgery (n = 59), conventional radiation (n = 25), proton-beam radiation (n = 24), and a combination of conventional radiation and proton-beam radiation or mixed-beam radiation (n = 47). At six months, 163 remained on the study; at 12 months, 154 remained: and at 18 months, 153 remained. The average age was 68 years, and 82% of the men were white.

METHODS

Men were enrolled at treatment and given a questionnaire with a self-addressed, stamped envelope for return. Questionnaires were mailed again at 6, 12, and 18 months.

MAIN RESEARCH VARIABLES

Health-related QOL health status, prostate treatment-specific symptoms, and sex-role identity.

FINDINGS

No overall difference in health-related QOL or health status was found, but post-hoc analysis revealed specific differences. The differences existed in sexual functioning and gastrointestinal treatment-specific symptoms. No relationship existed between masculinity and health-related QOL.

CONCLUSIONS

Health-related QOL and health status are similar regardless of type of treatment. Radiation tends to produce more gastrointestinal symptoms, and surgery tends to produce more sexual functioning symptoms. Watchful waiting is associated with poorer general health.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can provide specific treatment-related information to men who are faced with making treatment decisions for prostate cancer and, in consultation with the healthcare team, can select a treatment best sulted to them.

Aminophylline modulation of the mouse respiratory network changes during postnatal maturation

Aminophylline is a respiratory stimulant commonly used for the treatment of central apnea. Experiences from clinical practice, however, revealed that aminophylline is not reliably effective in preterm infants, whereas it is normally effective in infants and mature patients. In an established animal model for postnatal development of respiratory control mechanisms, we therefore examined the hypothesis that the clinical observations reflect a developmental change in the sensitivity of the central respiratory network to methylxanthines. The medullary respiratory network was isolated at different postnatal ages (postnatal days 1-13; P1-P13) in a transverse mouse brain stem slice preparation. This preparation contains the pre-Bötzinger complex (PBC), a region that is critical for generation of respiratory rhythm. Spontaneous rhythmic respiratory activity was recorded from the hypoglossal (XII) rootlets and from neurons in the PBC by using the whole cell patch clamp technique. Bath-applied aminophylline [20 microM] increased the frequency (+41%) in neonatal animals (P1-P6) without affecting the amplitude of respiratory burst activity in XII rootlets. The same concentration of aminophylline did not have any significant effect on the frequency of respiratory XII bursts but increased the amplitude (+31%) in juvenile animals (P7-P13). In the same age group, aminophylline also augmented the amplitude and the duration of respiratory synaptic drive currents in respiratory PBC neurons. The data demonstrate that augmentation of the respiratory output is due to direct enhancement of central respiratory network activity and increase of synaptic drive of hypoglossal motoneurons in juvenile, but not neonatal, animals. This indicates a developmental change in the efficacy of aminophylline to reinforce central respiratory network activity. Therefore, we believe that the variable success in treating respiratory disturbances in premature infants reflects maturational changes in the expression of receptors and/or intracellular signal pathways in the central respiratory network.

Role of inspiratory pacemaker neurons in mediating the hypoxic response of the respiratory network in vitro

In severe hypoxia the breathing frequency is modulated in a biphasic manner: an initial increase (augmentation) is followed by a depression and cessation of breathing (apnea). Using a mouse slice preparation that contains the functional respiratory network, we aimed at identifying the neurons responsible for this frequency modulation. Whole-cell patch recordings revealed that expiratory neurons become tonically active during anoxia, indicating that these neurons cannot be responsible for the respiratory frequency modulation. Inspiratory neurons tended to depolarize (by 6.9 mV; n = 9), and the frequency of rhythmic activity was significantly increased during anoxia (from 0.16 to 0.4 Hz; n = 9). After the blockade of network activity with 6-cyano-7-nitroquinoxaline-2, 3-dione, most inspiratory neurons became tonically active (72%; n = 25, non-pacemaker). In anoxia, the membrane potential of these non-pacemaker neurons did not change (-0.26 mV; n = 6), and their tonic activity ceased. Only a subpopulation of inspiratory neurons remained rhythmically active in the absence of network activity (pacemaker neurons, 28%, 7 of 25 inspiratory neurons). In anoxia two subgroups of pacemaker neurons were differentiated; one group showed a transient increase in the bursting activity, followed by a decrease and cessation of rhythmic activity. These neurons tended to depolarize (by 10.3 mV) during anoxia. The second group remained rhythmic during the entire anoxic exposure and exhibited no depolarization. The time course of the frequency modulation in all pacemaker neurons resembled that of the intact network. We conclude that pacemaker neurons are primarily responsible for the frequency modulation in anoxia and that in the respiratory network there is a strict separation between rhythm- and pattern-generating mechanisms.

Reconfiguration of the neural network controlling multiple breathing patterns: eupnea, sighs and gasps [see comment]

Are different forms of breathing derived from one or multiple neural networks? We demonstrate that brainstem slices containing the pre-Bötzinger complex generated two rhythms when normally oxygenated, with striking similarities to eupneic ('normal') respiration and sighs. Sighs were triggered by eupneic bursts under control conditions, but not in the presence of strychnine (1 microM). Although all neurons received synaptic inputs during both activities, the calcium channel blocker cadmium (4 microM) selectively abolished sighs. In anoxia, sighs ceased, and eupneic activity was reconfigured into gasping, which like eupnea was insensitive to 4 microM cadmium. This reconfiguration was accompanied by suppression of synaptic inhibition. We conclude that a single medullary network underlies multiple breathing patterns.

Effects of acid pH and urea on the spectral properties of the LHII antenna complex from the photosynthetic bacterium Ectothiorhodospira sp

The aim of this study was to investigate the spectral modifications of the LHII antenna complex from the purple bacterium Ectothiorhodospira sp. upon acid pH titration both in the presence and absence of urea. A blue shift specifically and reversibly affected the B850 band around pH 5.5-6.0 suggesting that a histidine residue most probably participated in the in vivo absorption red shifting mechanism. This transition was observed in the presence and absence of urea. Under strong chaotropic conditions, a second transition occurred around pH 2.0, affecting the B800 band irreversibly and the B850 reversibly. Under these conditions a blue shift from 856 to 842 nm occurred and a new and strong circular dichroism signal from the new 842 nm band was observed. Reverting to the original experimental conditions induced a red shift of the B850 band up to 856 nm but the circular dichroism signal remained mostly unaffected. Under the same experimental conditions, i.e. pH 2.1 in the presence of urea, part of the B800 band was irreversibly destroyed with concomitant appearance of a band around 770 nm due to monomeric bacteriochlorophyll from the disrupted B800. Furthermore, Gaussian deconvolution and second derivative of the reverted spectra at pH 8.0 after strong-acid treatment indicated that the new B850 band was actually composed of two bands centered at 843 and 858 nm. We ascribed the 858 nm band to bacteriochlorophylls that underwent reversible spectral shift and the 843 nm band to oligomeric bacteriopheophytin formed from a part of the B850 bacteriochlorophyll. This new oligomer would be responsible for the observed strong and mostly conservative circular dichroism signal. The presence of bacteriopheophytin in the reverted samples was definitively demonstrated by HPLC pigment analysis. The pheophytinization process progressed as the pH decreased below 2.1, and at a certain point (i.e. pH 1.5) all bacteriochlorophylls, including those from the B800 band, became converted to oligomeric bacteriopheophytin, as shown by the presence of a single absorption band around 843 nm and by the appearance of a single main elution peak in the HPLC chromatogram which corresponded to bacteriopheophytin.

Anoxic ATP depletion in neonatal mice brainstem is prevented by creatine supplementation

BACKGROUND

Sufficient ATP concentrations maintain physiological processes and protect tissue from hypoxic damage. With decreasing oxygen concentration, ATP synthesis relies increasingly on the presence of phosphocreatine.

AIM

The effect of exogenously applied creatine on phosphocreatine and ATP concentrations was studied under control and anoxic conditions.

METHODS

Pregnant mice were fed orally with creatine monohydrate (2 g/kg body weight/day). Brainstem slices from these mice pups were compared with those from pups of non-creatine supplemented pregnant mice. Measurements were performed under normoxic and anoxic conditions. In addition, brainstem slices from non-creatine treated mice pups were incubated for 3 hours in control artificial cerebrospinal fluid (CSF) (n = 10) or in artificial CSF containing 200 microM creatine (n = 10). ATP and phosphocreatine contents were determined enzymatically in single brainstem slices.

RESULTS

ATP concentrations were in the same range in all preparations. However, there was a significant increase of phosphocreatine in the brainstems from pups of creatine fed mice when compared with the brainstems of pups from non-creatine treated mice or in non-incubated brainstems of control animals. After 30 minutes anoxia, ATP as well as phosphocreatine concentrations remained significantly higher in creatine pretreated slices compared with controls.

CONCLUSION

The data indicate that exogenous application of creatine is effective in neuroprotection.

The role of the hyperpolarization-activated current in modulating rhythmic activity in the isolated respiratory network of mice

We examined the role of the hyperpolarization-activated current (I(h)) in the generation of the respiratory rhythm using a spontaneously active brainstem slice of mice. This preparation contains the hypoglossus (XII) nucleus, which is activated in-phase with inspiration and the pre-Bötzinger complex (PBC), the presumed site for respiratory rhythm generation. Voltage-clamp recordings (n = 90) indicate that cesium (Cs) (5 mM) blocked 77.2% of the I(h) current, and ZD 7288 (100 microM) blocked 85.8% of the I(h) current. This blockade increased the respiratory frequency by 161% in Cs and by 150% in ZD 7288 and increased the amplitude of integrated population activity in the XII by 97% in Cs and by 162% in ZD 7288, but not in the PBC (Cs, by 19%; ZD 7288, by -4.56%). All inspiratory PBC neurons (n = 44) recorded in current clamp within the active network revealed a significantly decreased frequency of action potentials during the interburst interval and an earlier onset of inspiratory bursts after I(h) current blockade. However, hyperpolarizing current pulses evoked only in a small proportion of inspiratory neurons (0% of type I; 29% of type II neurons) a depolarizing sag. Most of the neurons expressing an I(h) current (86%) were pacemaker neurons, which continued to generate rhythmic bursts after inactivating the respiratory network pharmacologically with CNQX alone or with CNQX, AP-5, strychnine, bicuculline, and carbenoxolone. Cs and ZD 7288 increased the frequency of pacemaker bursts and decreased the frequency of action potentials between pacemaker bursts. Our findings suggest that the I(h) current plays an important role in modulating respiratory frequency, which is presumably mediated by pacemaker neurons.

Unraveling the mechanism for respiratory rhythm generation

Breathing is generated by a neuronal network located within the caudal brainstem. One area of particular significance for respiratory rhythm generation is the pre-Bötzinger (preBotC) complex in the ventrolateral medulla. An important step towards understanding the cellular and network basis by which neurons within this region generate the respiratory rhythm was made in a recent study by Koshiya and Smith.(1) Using simultaneous image analysis and electrophysiological techniques these authors identified a discrete population of synaptically-coupled pacemaker neurons within the preBotC. They postulated that these neurons constitute the minimal essential network component (kernel) for generating the respiratory rhythm. BioEssays 22:6-9, 2000.

Differential responses of respiratory nuclei to anoxia in rhythmic brain stem slices of mice

The response of the neonatal respiratory system to hypoxia is characterized by an initial increase in ventilation, which is followed within a few minutes by a depression of ventilation below baseline levels. We used the transverse medullary slice of newborn mice as a model system for central respiratory control to investigate the effects of short-lasting periods of anoxia. Extracellular population activity was simultaneously recorded from the ventral respiratory group (VRG) and the hypoglossus (XII) nucleus (a respiration-related motor output nucleus). During anoxia, respiratory frequency was modulated in a biphasic manner and phase-locked in both the VRG and the XII. The amplitude of phasic respiratory bursts was increased only in the XII and not in the VRG. This increase in XII burst amplitude commenced approximately 1 min after the anoxic onset concomitant with a transient increase in tonic activity. The burst amplitude remained elevated throughout the entire 5 min of anoxia. Inspiratory burst amplitude in the VRG, in contrary, remained constant or even decreased during anoxia. These findings represent the first simultaneous extracellular cell population recordings of two respiratory nuclei. They provide important data indicating that rhythm generation is altered in the VRG without a concomitant alteration in the VRG burst amplitude, whereas the burst amplitude is modulated only in the XII nucleus. This has important implications because it suggests that rhythm generation and motor pattern generation are regulated separately within the respiratory network.

[Acute transverse cervical myelitis following hepatitis B vaccination. Evolution of anti-HBs antibodies]

BACKGROUND

The cause and effect relationship between anti-HBV immunization using recombinant vaccine and the development of a neurological event, including flare-ups of multiple sclerosis, is a widely debated issue.

CASE REPORT

A previously asymptomatic 16-year-old girl was a hyper-responder to anti-HBV vaccine. Subsequent to a booster shot of anti-HBV recombinant vaccine, she developed regressive acute cervical transverse myelitis with intrathecal oligochonal IgG secretion and a hypersignal on the MRI T2 sequences of the cord.

DISCUSSION

The distinction between a first episode of multiple sclerosis or post-vaccinal acute myelitis in this case will depend upon subsequent course, but this observation points out the very high level of persistent post-vaccinal immunization which can be acquired by a hyper-responder.

Long-term effects of prior heat shock on neuronal potassium currents recorded in a novel insect ganglion slice preparation

Brief exposure to high temperatures (heat shock) induces long-lasting adaptive changes in the molecular biology of protein interactions and behavior of poikilotherms. However, little is known about heat shock effects on neuronal properties. To investigate how heat shock affects neuronal properties we developed an insect ganglion slice from locusts. The functional integrity of neuronal circuits in slices was demonstrated by recordings from rhythmically active respiratory neurons and by the ability to induce rhythmic population activity with octopamine. Under these "functional" in vitro conditions we recorded outward potassium currents from neurons of the ventral midline of the A1 metathoracic neuromere. In control neurons, voltage steps to 40 mV from a holding potential of -60 mV evoked in control neurons potassium currents with a peak current of 10.0 +/- 2.5 nA and a large steady state current of 8.5 +/- 2.6 nA, which was still activated from a holding potential of -40 mV. After heat shock most of the outward current inactivated rapidly (peak amplitude: 8.4 +/- 2.4 nA; steady state: 3.6 +/- 2.0 nA). This current was inactivated at a holding potential of -40 mV. The response to temperature changes was also significantly different. After changing the temperature from 38 to 42 degrees C the amplitude of the peak and steady-state current was significantly lower in neurons obtained from heat-shocked animals than those obtained from controls. Our study indicates that not only heat shock can alter neuronal properties, but also that it is possible to investigate ion currents in insect ganglion slices.

Calcium currents of rhythmic neurons recorded in the isolated respiratory network of neonatal mice

To obtain a quantitative characterization of voltage-activated calcium currents in respiratory neurons, we performed voltage-clamp recordings in the transverse brainstem slice of mice from neurons located within the ventral respiratory group. It is assumed that this medullary region contains the neuronal network responsible for generating the respiratory rhythm. This study represents one of the first attempts to analyze quantitatively the currents in respiratory neurons. The inward calcium currents of VRG neurons consisted of two components: a high voltage-activated (HVA) and a low voltage-activated (LVA) calcium current. The activation threshold of the HVA current was at -40 mV. It was fully activated (peak voltage) between -10 and 0 mV. The half-maximal activation (V50) was at -27. 29 mV +/- 1.15 (n = 24). The HVA current was inactivated completely at a holding potential of -35 mV and fully deinactivated at a holding potential of -65 mV (V50, -52.26 mV +/- 0.27; n = 18). The threshold for the activation of the LVA current was at -65 mV. This current had its peak voltage between -50 and -40 mV (mean, V50 = -59. 15 mV +/- 0.21; n = 15). The LVA current was inactivated completely at a holding potential of -65 mV and deinactivated fully at a holding potential of -95 mV (mean, V50 = -82.40 mV +/- 0.32; n = 38). These properties are consistent with other studies suggesting that the LVA current is a T-type current. The properties of these inward currents are discussed with respect to their role in generating Ca2+ potentials that may contribute to the generation of the mammalian respiratory rhythm.

Reconfiguration of the respiratory network at the onset of locust flight

Reconfiguration of the respiratory network at the onset of locust flight. J. Neurophysiol. 80: 3137-3147, 1998. The respiratory interneurons 377, 378, 379 and 576 were identified within the suboesophageal ganglion (SOG) of the locust. Intracellular stimulation of these neurons excited the auxillary muscle 59 (M59), a muscle that is involved in the control of thoracic pumping in the locust. Like M59, these interneurons did not discharge during each respiratory cycle. However, the SOG interneurons were part of the respiratory rhythm generator because brief intracellular stimulation of these interneurons reset the respiratory rhythm and tonic stimulation increased the frequency of respiratory activity. At the onset of flight, the respiratory input into M59 and the SOG interneurons was suppressed, and these neurons discharged in phase with wing depression while abdominal pumping movements remained rhythmically active in phase with the slower respiratory rhythm (Fig. ). The suppression of the respiratory input during flight seems to be mediated by the SOG interneuron 388. This interneuron was tonically activated during flight, and intracellular current injection suppressed the respiratory rhythmic input into M59. We conclude that the respiratory rhythm generator is reconfigured at flight onset. As part of the rhythm-generating network, the interneurons in the SOG are uncoupled from the rest of the respiratory network and discharge in phase with the flight rhythm. Because these SOG interneurons have a strong influence on thoracic pumping, we propose that this neural reconfiguration leads to a behavioral reconfiguration. In the quiescent state, thoracic pumping is coupled to the abdominal pumping movements and has auxillary functions. During flight, thoracic pumping is coupled to the flight rhythm and provides the major ventilatory movements during this energy-demanding locomotor behavior.

The Guttmann Institute of Barcelona

The Guttmann Institute is a hospital specialised in the comprehensive rehabilitation and medical/surgical treatment of persons suffering from spinal cord injury or from other severe physical disabilities. It opened in Barcelona in 1965 and was the first hospital in Spain dedicated to the treatment of paraplegic and tetraplegic patients, and the one which introduced into Spain the comprehensive approach to spinal cord injury developed by Sir Ludwig Guttmann at the Stoke Mandeville Hospital in the UK. The Guttmann Institute Foundation is a non-profit-making foundation and its hospital, the Guttmann Institute, forms part of the Public Service Hospital Network. The Guttmann Institute has a wide-ranging, multi-disciplinary group of staff made up of specialised professionals; and it has the appropriate resources for the provision of thorough medical attention from a technical, scientific and human point of view.

Selective lesioning of the cat pre-Bötzinger complex in vivo eliminates breathing but not gasping

1. To examine the functional importance of the pre-Bötzinger complex for breathing we micro-injected, under in vivo conditions, the calcium channel blocker omega-conotoxin GVIA and the sodium channel blocker tetrodotoxin (TTX) into the ventrolateral medulla of adult cats, while monitoring respiratory rhythmic motor output in the phrenic nerve. 2. omega-Conotoxin GVIA caused a highly localized synaptic ablation by blocking presynaptic N-type calcium channels. When injecting 5-60 fmol omega-conotoxin GVIA unilaterally, the amplitude of phrenic nerve activity decreased bilaterally and sometimes disappeared, indicating central apnoea. These effects were reversible and could only be induced in a very localized area of the pre-Botzinger complex. By injecting omega-conotoxin GVIA several times during an experiment and analysing the areas where injections affected respiratory activity, it was possible to map exactly the anatomical extent of the area critical for respiratory rhythm generation. 3. Following the precise localization of the pre-Bötzinger complex with omega-conotoxin GVIA, we injected TTX to induce an irreversible inactivation of this region. TTX injected unilaterally into the pre-Bötzinger complex irreversibly reduced the amplitude of phrenic nerve activity. Bilateral TTX injections eliminated respiratory rhythmic activity, causing a persistent central apnoea. 4. After bilateral lesioning of the pre-Bötzinger complex, it was still possible to induce gasping during hypoxia or asphyxia, indicating that respiration and gasping are generated by two different neuronal networks. 5. We propose that omega-conotoxin GVIA as employed in this study to investigate the functional role of the pre-Bötzinger complex can also be used as a general pharmacological approach to map other neuronal networks. We call this the 'omega-conotoxin GVIA tracing' method.

The hypoxic response of neurones within the in vitro mammalian respiratory network

1. The transverse brainstem slice preparation containing the pre-Bötzinger complex (PBC) was used in mice to study developmental changes of the response of the in vitro respiratory network to hypoxia. This preparation generates at different postnatal stages (postnatal days (P) 0-22) spontaneous rhythmic activity in hypoglossal (XII) rootlets that occur in synchrony with periodic bursts of neurones in the PBC. 2. In slices from P0-4 mice, hypoxia did not significantly affect the amplitude of rhythmic synaptic drive potentials in four of five inspiratory neurones. Hypoxia reduced, but did not suppress, the amplitude of synaptic drive potentials in only one inspiratory neurone. Spike discharge and phasic 'inspiratory' hyperpolarizations of six expiratory neurones were suppressed during hypoxia revealing a phasic 'inspiratory' depolarization. 3. The coupling between rhythmic activity in PBC neurones and XII bursts occurred under control conditions in preparations from P0-4 mice in a 1:1 manner (n = 11) and from mice older than P5 in a 3:1 manner (n = 9). During hypoxia, PBC and XII activity were linked in a 1:1 manner in all slices. 4. In six of fourteen inspiratory PBC neurones, the amplitude of synaptic drive potentials of slices from mice older than P8 was increased during the period of augmentation, reduced during the period of depression and suppressed during a hypoxic response which we refer to as central apnoea. Augmentation led to a weak-to-moderate membrane depolarization which on average was 4.8 +/- 3.7 mV. This depolarization was followed by a hyperpolarization of 6.2 +/- 4.1 mV only in four inspiratory neurones. In the majority of neurones (n = 9), however, membrane depolarization remained stable and was not followed by hyperpolarization. In expiratory neurones (n = 12) from this age group hypoxia suppressed phasic hyperpolarizations that occurred in synchrony with XII bursts. As similarly seen in inspiratory neurones, membrane potentials were depolarized by 5.1 +/- 4.1 mV during the period of hypoxic augmentation. 5. The hypoxic response of respiratory neurones within the pre-Bötzinger complex resembles the response of neurones that were previously described under in vivo conditions. Thus we conclude that the 'transverse rhythmic slice' is a good model for studying the hypoxic response of the respiratory network under in vitro conditions.

Creatine protects the central respiratory network of mammals under anoxic conditions

The effect of creatine (Cr) on the response of the respiratory center to anoxia was analyzed at different postnatal stages in a brainstem slice preparation of mice. Spontaneous rhythmic activity was recorded from hypoglossal rootlets (XII) and from identified neurons within the preBötzinger complex using the whole cell patch clamp technique. The hypoxic response was evaluated in slices from animals (n = 46), which received normal nutrition (controls, n = 16), from litters of animals fed with Cr (2 g/kg/day; nutrition group, n = 8), or after incubating slices for 3 h in Cr (200 microM) (incubation group, n = 22). ATP was measured in slices from controls and Cr-incubated slices which underwent 30-min anoxia. In neonatal animals (P0-5), amplitudes of hypoglossal bursts increased initially during anoxia by 14% in controls and by 41% in Cr-supplemented animals when compared with preanoxic values. Hypoglossal burst duration increased by 3% in controls, but by 18% in the Cr-nutrition group. In brainstem slices, the initial increase of amplitudes changed from 14% (controls) to 59% (Cr incubation) and prolongation of bursts from 3% (controls) to 37% (Cr incubation) compared with preanoxic values. In juvenile controls (P6-13), burst amplitude and duration increased by 12 and 14% during early anoxia when referred to preanoxic values. In slices from Cr-pretreated animals, increases of 48% (amplitude) and 21% (burst duration) occurred. The ATP levels remained constant during a 30-min anoxic period in the Cr-pretreated group compared with a decrease of 44% in slices from controls. Our data suggest that Cr can ameliorate hypoxic energy failure. Further studies will examine the neuroprotective potential in humans.

Respiratory rhythm generation in mammals: synaptic and membrane properties

Respiratory rhythm generation depends on a complex interaction between synaptic and membrane properties of functionally defined neurons. To gain a better understanding of how inhibitory and excitatory synaptic inputs lead to the generation of the respiratory rhythm we analyzed the depolarization pattern of respiratory neurons that were recorded in the transverse slice preparation of mice (P8-22) and the in vivo adult cat. Using voltage-calmp recordings from respiratory neurons and specific antagonists for inhibitory synaptic transmission we demonstrate under in vitro conditions, that inspiratory (n = 7) and post-inspiratory neurons (n = 13) received concurrent glycinergic and glutamatergic synaptic input during inspiration. A similar conclusion was gained with chloride injections into in vivo respiratory neurons. The inhibitory input was essential not only for generating the characteristic depolarization pattern of respiratory neurons, but also for switching the respiratory rhythm between inspiration and post-inspiration. The generation of the depolarization pattern depends also on intrinsic membrane properties. Negative current injections reveal that excitatory synaptic input was amplified by intrinsic bursting properties in some inspiratory neurons (n = 4) recorded in vitro. Although such properties have not been described under in vivo conditions our findings suggest that with respect to inspiratory, post-inspiratory and late-inspiratory neurons, the principle network organization is similar under both in vitro and in vivo conditions.

Developmental changes in the hypoxic response of the hypoglossus respiratory motor output in vitro

The transverse brain stem slice of mice containing the pre-Bötzinger complex (PBC), a region essential for respiratory rhythm generation in vitro, was used to study developmental changes of the response of the in vitro respiratory network to severe hypoxia (anoxia). This preparation generates, at different postnatal stages [postnatal day (P)0-22], spontaneous rhythmic activity in hypoglossal (XII) rootlets that are known to occur in synchrony with periodic bursts of neurons in the PBC. It is assumed that this rhythmic activity reflects respiratory rhythmic activity. At all examined stages anoxia led to a biphasic response: the frequency of rhythmic XII activity initially increased ("primary augmentation") and then decreased ("secondary depression"). In neonates (P0-7), anoxia did not significantly affect the amplitude of integrated XII bursts. Secondary depression never led to a cessation of rhythmic activity. In mice older than P7, augmentation was accompanied by a significant increase in the amplitude of XII bursts. A significant decrease of the amplitude of XII bursts occurred during secondary depression. This depression led always to cessation of rhythmic activity in XII rootlets. The anoxia-induced response of the respiratory rhythmic XII motor output is biphasic and changes during development in a similar way to the in vivo respiratory network. Whether this biphasic response is due to a biphasic response of the respiratory rhythm generator and/or to a biphasic modulation of the XII motor nucleus remains unresolved and needs further cellular analysis. We propose that the transverse slice is a useful model system for examination of the mechanisms underlying the hypoxic response.

The neuronal mechanisms of respiratory rhythm generation

New, improved in vivo and in vitro approaches have led to a better understanding of the mechanisms that generate respiratory rhythm, which depends on a complex interaction between network and intrinsic membrane properties. The pre-Bötzinger complex in the ventrolateral medulla is particularly important for respiratory rhythm generation. This complex can be studied in isolation, and it contains all the known types of respiratory neurons that are now amenable to detailed cellular and molecular analyses.

Colonic J-pouch rectal reconstruction--is it really a neorectum?

PURPOSE

The aim of this study was to determine whether a colonic J-pouch has similar properties to that of a normal rectum, including recovery of rectoanal coordination.

METHODS

Ten patients with colonic J-pouch-anal anastomosis (anastomotic distance from anal verge, 3.5 (range, 2.0-4.5) cm for low rectal cancer (7 men; mean age, 64.7 (range, 44-76) years) were studied clinically and in the anorectal physiology laboratory at least one year after operation. Results were compared with a series of ten matched patients who underwent high anterior resection for upper rectal carcinoma (anastomotic height, 12.7 (range, 9.5-16) cm).

RESULTS

Although results seemed to be slightly better in the group with the rectum preserved, no statistical differences could be found either in functional outcome or anorectal physiology. One-half of the patients with colonic J-pouch (neorectum) had a positive rectoanal inhibitory reflex.

CONCLUSION

Addition of a colon pouch neorectum would appear to improve function to the level of those patients with a high anastomosis and "normal" rectum.

Postnatal changes in the mammalian respiratory network as revealed by the transverse brainstem slice of mice

1. Spontaneous rhythmic activity in hypoglossal (XII) rootlets is generated at all postnatal stages from postnatal day (P) 0 to P22 in the transverse brainstem slice of mice containing the pre-Bötzinger complex (PBC). The PBC is known to be a region essential for respiratory rhythm generation. It contains neurones generating periodic bursts that occur in synchrony with rhythmic XII activity. This synchrony indicates that the rhythmic PBC activity generated by the transverse slice is the central respiratory rhythm. 2. The strength of coupling between XII bursts and PBC bursts decreased during early postnatal development. In younger mice (P0-4) each burst in XII rootlets corresponded to one burst in the PBC. In older mice (P5-18) one burst in XII rootlets occurred only every third to fourth burst in PBC neurones. 3. Cycle length and burst duration of rhythmic XII activity did not change significantly during the first three postnatal weeks. However, the pattern of XII bursts changed from decrementing (P0-7) to bell shaped (P8-18) while the rate of rise of XII bursts decreased significantly. 4. The rate of rise of rhythmic depolarizations in neurones of the PBC discharging in phase with XII bursts ('inspiratory neurones') decreased with postnatal development. During interburst intervals, membrane potentials of neurones of older mice (P6-18) were characterized by waves of synaptic input that were not observed in neonatal animals (P0-5). 5. Blockade of glycine receptors by strychnine increased the frequency of rhythmic XII activity in neonatal and older mice (P0-22). Although in expiratory PBC neurones glycinergic transmission was blocked at 10 microM strychnine, in inspiratory PBC neurones and XII rootlets even higher concentrations of up to 50 microM strychnine failed to abolish rhythmic activity.

Intraoperative ultrasonography in the diagnosis of hepatic metastases during surgery for colorectal cancer

Approximately 20-25% of colorectal cancers have hepatic metastases at the time of operation and occult liver secondaries appear in 10-30% of curatively operated cases. Intraoperative liver ultrasonography has been reported to be the most accurate method for detecting colorectal metastases. A consecutive series of 119 colorectal cancer patients was studied by routine extracorporeal preoperative ultrasound (EUS), inspection and palpation of the liver at laparotomy and intraoperative liver ultrasound (IUS). 19 patients had liver metastases at the time of surgery. In eight, diagnosis was by EUS. Inspection and palpation yielded a further seven, and IUS alone a further four. Additional lesions were detected in 3 patients after preoperative ultrasound and in 6 patients following intraoperative palpation of the liver. In a further 4 cases IUS demonstrated additional metastases. Follow up for a median 38 months (12-59) was by clinical examination and six monthly liver ultrasound. During this time 8 patients, who were thought to have a clear liver, developed hepatic metastases. The mean time from surgery to the detection of occult hepatic metastases was 14.7 (8-26) months and 4 of these appeared in the second year. Intraoperative ultrasonography is a sensitive and useful method in detecting liver metastases, and may improve clinical staging and the selection of patients for further therapy. However some occult hepatic metastases will remain undetected.

Colonic J pouch-anal anastomosis after rectal excision for carcinoma: functional outcome

A consecutive series of 23 patients with colonic J pouch-anal anastomosis for low rectal cancer (17 men; mean age 64.4 (range 44-76) years) was studied prospectively. The mean distance from the pouch-anal anastomosis to the anal verge was 3.5 (range 2.0-4.5) cm. During follow-up one patient died from an unrelated cause and four developed metastases, two local and two hepatic. In 19 surviving patients a mean of 7 months after ileostomy closure mean bowel frequency was 2.1 (range 1-4) per day, five patients had urgency and four had mild faecal seepage up to three times per week, and seven patients had some degree of incomplete evacuation. In 13 patients there were no manometric differences before and after surgery with respect to maximum tolerated volume or maximum resting pressure, but maximum squeeze pressure was significantly lower after surgery (mean 189 versus 132 cmH2O before and after surgery respectively, P < 0.05). Colonic pouch reconstruction should be considered as an alternative to straight coloanal anastomosis in patients undergoing very low anterior resection.

Functionally intact in vitro preparation generating respiratory activity in neonatal and mature mammals

The present report describes a novel rhythmically active brainstem slice preparation that generates respiratory activity spontaneously in both mice and rats of varying maturational states. The brainstems of neonatal (0-4 days) and mature (3-8 weeks) mice and rats were isolated and a 600- to 750-microns thick slice cut to include the dorsomedial and the ventrolateral regions of the complete rostro-caudal extent of the medulla. This plane of section we have termed "tilted-sagittal". Rhythmically discharging neurones were recorded extracellularly from both the dorsal and ventral regions of the slice. The recording sites of these neurones were found in the hypoglossal motonucleus (XII) and in areas of the ventrolateral medulla that includes the ventral respiratory group (VRG) region. Histological examination revealed the preservation of neuronal structures important for cardiorespiratory regulation and reflex control including the nucleus of the solitary tract as well as the nucleus ambiguus. In addition, pontine structures including the A5 region were also preserved. Rhythmic activity was found only in slices where the ambiguual column was preserved in its entirety. The mean frequency of discharge of XII neurones was 20 and 10 bursts per minute in neonates and mature rodents respectively. In preparations of mature animals we demonstrate that this frequency increased significantly (P < 0.05) by either raising temperature from 29 degrees C to 38 degrees C (54%), elevating extracellular potassium concentration from 4 to 7.5 mM (52%), blocking potassium channels (20%) or decreasing pH from 7.4 to 7.0 (18%). The burst duration to frequency ratio of XII and VRG rhythmic neurones was similar and therefore indicative of a common brainstem oscillator. Consistent with this finding was that rhythmic activity in the VRG persisted despite removal of the dorsomedial region of the slice. In contrast, rhythmic XII neurones became tonic following mechanical disconnection of the VRG.