Outcomes of initially nonoperative management of diverticulitis with abscess formation in immunosuppressed patients. DIPLICAB study COLLABORATIVE group

AIM

Management of diverticulitis with abscess formation in immunosuppressed patients (IMS) remains unclear. The main objective of the study was to assess short- and long-term outcomes between IMS and immunocompetent patients (IC). The secondary aim was to identify risk factors for emergency surgery.

METHODS

A nationwide retrospective cohort study was performed at 29 Spanish referral centres between 2015-2019 including consecutive patients with first episode of diverticulitis classified as modified Hinchey Ib or II. IMS included immunosuppressive therapy, biologic therapy, malignant neoplasm with active chemotherapy and chronic steroid therapy. A multivariate analysis was performed to identify independent risk factors to emergency surgery in IMS.

RESULTS

A total of 1395 patients were included; 118 IMS and 1277 IC. There were no significant differences in emergency surgery between IMS and IC (19.5% and 13.5%, p = 0.075) but IMS was associated with higher mortality (15.1% vs. 0.6%, p < 0.001). Similar recurrent episodes were found between IMS and IC (28% vs. 28.2%, p = 0.963). Following multivariate analysis, immunosuppressive treatment, p = 0.002; OR: 3.35 (1.57-7.15), free gas bubbles, p < 0.001; OR: 2.91 (2.01-4.21), Hinchey II, p = 0.002; OR: 1.88 (1.26-2.83), use of morphine, p < 0.001; OR: 3.08 (1.98-4.80), abscess size ≥5 cm, p = 0.001; OR: 1.97 (1.33-2.93) and leucocytosis at third day, p < 0.001; OR: 1.001 (1.001-1.002) were independently associated with emergency surgery in IMS.

CONCLUSION

Nonoperative management in IMS has been shown to be safe with similar treatment failure than IC. IMS presented higher mortality in emergency surgery and similar rate of recurrent diverticulitis than IC. Identifying risk factors to emergency surgery may anticipate emergency surgery.

Fournier's gangrene and fecal diversion. When, in which patients, and what type should I perform?

INTRODUCTION

Fournier's gangrene (FG) is a necrotizing fasciitis affecting the perineum and urogenital tissue. The mortality rate is high although early detection and aggressive debridement can reduce mortality by up to 16%. The prevalence of sequelae is very high and a colostomy is often necessary to control the perineal wound.

MATERIAL AND METHODS

A retrospective study was carried out to recruit all patients operated on by the General Surgery and Urology Departments with a diagnosis of GF at the University Hospital over 22 years. Mortality, the Fournier gangrene severity index (FGSI), and fecal diversion (either surgical (colostomy) or straight (Flexi-seal)) are collected.

RESULTS

A total of 149 patients met the inclusion criteria. FG's most frequent cause was a perianal abscess (107 patients-72%). Eighteen patients (12%) died of a specific cause of FG. Age (p = 0.014) and patients with an oncological history (p = 0.038) both were the only mortality risk factors for mortality according to logistic regression. Fifty patients required some form of fecal diversion in the postoperative period (32 colostomies and 18 Flexi-seal). Neither the use of postoperative fecal diversion (surgical or Flexi-seal) nor the timing of its use had any effect on postoperative mortality.

CONCLUSIONS

One in eight patients died in the immediate postoperative period secondary to FG. Despite improved outcomes, 22% required a colostomy during admission. However, neither the performance of a colostomy nor the timing was associated with decreased FG-associated mortality. Non-invasive methods should be used first and surgical bowel diversion should be postponed as long as possible.

Anastomotic leak in colorectal cancer surgery: Contribution of gut microbiota and prediction approaches

AIM

To monitor prospectively the occurrence of colorectal anastomotic leakage (CAL) in patients with colon cancer undergoing resectional surgery, characterizing the microbiota in both faeces and mucosal biopsies of anastomosis. In a second stage, we investigated the ability to predict CAL using machine learning models based on clinical data and microbiota composition.

METHOD

A total of 111 patients were included, from whom a faecal sample was obtained, as well as biopsy samples from proximal and distal sites in the healthy margins of the tumour piece. The microorganisms present in the samples were investigated using microbial culture and 16S rDNA massive sequencing. Collagenase and protease production was determined, as well as the presence of genes responsible for expressing enzymes with these activities. Machine learning analyses were developed using clinical and microbiological data.

RESULTS

The incidence of CAL was 9.0%, and CAL was associated with collagenase/protease-producing Enterococcus. Significant differences were found in the microbiota composition of proximal and distal biopsy samples, but not in faecal samples, among patients who developed CAL. Clinical predictors of CAL were 5-day C-reactive protein and heart disease, whereas 3-day C-reactive protein and diabetes were negative predictors.

CONCLUSION

Biopsy samples from surgical margins, rather than faecal samples, are the most appropriate samples for exploring the contribution of the intestinal microbiota to CAL. Enterococci are only enriched in the anastomosis after surgery, and their collagenases and proteases are involved in the degradation of the anastomotic scar.

Diverticulitis with abscess formation: Outcomes of non-operative management and nomogram for predicting emergency surgery: The Diplicab Study Collaborative Group

BACKGROUND

To assess short- and long-term outcomes from non-surgical management of diverticulitis with abscess formation and to develop a nomogram to predict emergency surgery.

METHODS

This nationwide retrospective cohort study was performed in 29 Spanish referral centers, including patients with a first episode of a diverticular abscess (modified Hinchey Ib-II) from 2015 to 2019. Emergency surgery, complications, and recurrent episodes were analyzed. Regression analysis was used to assess risk factors, and a nomogram for emergency surgery was designed.

RESULTS

Overall, 1,395 patients were included (1,078 Hinchey Ib and 317 Hinchey II). Most (1,184, 84.9%) patients were treated with antibiotics without percutaneous drainage, and 194 (13.90%) patients required emergency surgery during admission. Percutaneous drainage (208 patients) was associated with a lower risk of emergency surgery in patients with abscesses of ≥5 cm (19.9% vs 29.3%, P = .035; odds ratio 0.59 [0.37-0.96]). The multivariate analysis showed that immunosuppression treatment, C-reactive protein (odds ratio: 1.003; 1.001-1.005), free pneumoperitoneum (odds ratio: 3.01; 2.04-4.44), Hinchey II (odds ratio: 2.15; 1.42-3.26), abscess size 3 to 4.9 cm (odds ratio: 1.87; 1.06-3.29), abscess size ≥5 cm (odds ratio: 3.62; 2.08-6.32), and use of morphine (odds ratio: 3.68; 2.29-5.92) were associated with emergency surgery. A nomogram was developed with an area under the receiver operating characteristic curve of 0.81 (95% confidence interval: 0.77-0.85).

CONCLUSION

Percutaneous drainage must be considered in abscesses ≥5 cm to reduce emergency surgery rates; however, there are insufficient data to recommend it in smaller abscesses. The use of the nomogram could help the surgeon develop a targeted approach.

Quality of life and outcomes after rubber band ligation for haemorrhoidal disease

PURPOSE

The main objective of this study was to assess the impact on quality of life after rubber band ligation (RBL) in patients with symptomatic grade II-III haemorrhoids who did not improve after 6 months of conservative treatment, using quality of life scores.

METHODS

This was a prospective cohort observational study where patients with haemorrhoidal disease and indication for RBL were included between December 2019 and December 2020. RBL was offered as first-line treatment in this group. Patient´s quality of life was assessed by scores: HDSS (Hemorrhoidal Disease Symptom Score) and SHS (Short Health Scale).Secondary objectives were: to evaluate the rate of patients requiring one or more RBL procedures, to establish the overall success rate of RBL and to analyse complications.

RESULTS

A total of 100 patients were finally included. Regarding the impact on quality of life after RBL, a significant reduction was found in the HDSS and SHS scores (p < 0.001). The main improvement was found in the first month and it was maintained until the sixth month. A high degree of satisfaction with the procedure was reported by 76% of patients. The overall success rate of banding was 89%. A 12% complication rate was detected, the most frequent complication was severe anal pain (58.3%) and self-limiting bleeding (41.7%).

CONCLUSION

Rubber band ligation, as a treatment for symptomatic grade II-III haemorrhoids that do not respond to medical treatment, leads to a significant improvement in patients' symptoms and quality of life. It also has a high degree of satisfaction between patients.

Can physiological stimulation prior to ileostomy closure reduce postoperative ileus? A prospective multicenter pilot study

BACKGROUND

The aim of this study was to assess the impact of ileostomy closure following preoperative physiological stimulation (PPS) on postoperative ileus (POI) in patients with loop ileostomy after low anterior resection for rectal cancer.

METHODS

Patients who underwent ileostomy closure between January 2017 and February 2020 in two tertiary referral centers were prospectively included. PPS stimulation was compared to standard treatment. Stimulation was carried out daily during the 15 days prior to ileostomy closure by the patient's self-instillation of 200 ml of fecal contents from the ileostomy bag via the efferent loop, using a rectal catheter. Standard treatment (ST) consisted of observation. Outcomes measures were POI, morbidity, stimulation feasibility, and predictors to ileus.

RESULTS

A total of 58 patients were included [42 males and 16 females, median age 67 (43-85) years]. PPS was used in 24 patients, who completed the entire stimulation process, and ST in 34 patients. No differences in preoperative factors were found between the two groups. POI was significantly lower in the PPS group (4.2%) vs the ST group (32.4%); p < 0.01, OR: 0.05 (CI 95% 0.01-0.65). The PPS group had a shorter time to restoration of bowel function (1 day vs 3 days) p = 0.02 and a shorter time to tolerance of liquids (1 day vs 2 days), p = 0.04. Age (p = 0.01), open approach at index surgery, p = 0.03, adjuvant capecitabine (p = 0.01). and previous abdominal surgeries (p = 0.02) were associated with POI in the multivariate analysis. C-reactive-protein values on the 3rd (p = 0.02) and 5th (p < 0.01) postoperative day were also associated with POI.

CONCLUSIONS

PPS for patients who underwent ileostomy closure after low anterior resection for rectal cancer is feasible and might reduce POI.

Risk Factors for Anastomotic Leakage Following Total or Subtotal Colectomy

Introduction A higher rate of anastomotic leakage (AL) is reported after ileosigmoid anastomosis (ISA) or ileorectal anastomosis (IRA) in total or subtotal colectomy (TSC) compared with colonic or colorectal anastomosis. The main aim of the present study was to assess potential risk factors for AL after ISA or IRA and to investigate determinants of morbidity.

Methods We identified 180 consecutive patients in a prospective referral, single center database, in which 83 of the patients underwent TSC with ISA or IRA. Data regarding the clinical characteristics, surgical treatment, and outcome were assessed to determine their association with the cumulative incidence of AL and surgical morbidity.

Results Ileosigmoid anastomosis was performed in 51 of the patients (61.5%) and IRA in 32 patients (38.6%). The cumulative incidence of AL was 15.6% (13 of 83 patients). A higher AL rate was found in patients under 50 years-old (p = 0.038), in the elective-laparoscopic approach subgroup (p = 0.049), and patients in the inflammatory bowel disease (IBD) subgroup (p = 0.009). Furthermore, 14 patients (16.9%) had morbidity classified as Clavien-Dindo ≥ IIIA.

Discussion A relatively high incidence of AL after TSC was observed in a relatively safe surgical procedure. Our findings suggest that the risk of AL may be higher in IBD patients. According to our results, identifying risk factors prior to surgery may improve short-term outcomes.

Choledochal cysts surgical management: Retrospective and historical comparative analysis

INTRODUCTION

Choledochal cysts are rare bile duct dilatations, which have higher prevalence in Asian population. The aim of the study was to analyze clinical and surgical results about biliary cysts management. In addition, a comparative historical analysis was performed.

METHODS

Patients who underwent surgery between January 1988 and December 2019 in a single tertiary level center were retrospectively included. Demographic and clinical patient data; cyst types; diagnostic methods and surgical technique were analyzed, as well as short and long-term follow-up complications. A comparative descriptive study focus on the main historical series was also carried out.

RESULTS

A total of seventeen patients were identified; 58.8% were men. The mean age at diagnosis was 39.9 years (SD: 20.54). The median follow-up was 5 years (IQR 1-15). The most frequent cysts were type I (41.2%). Abdominal pain was the most common presenting symptom (58.8%). Cystic excision with bilio-enteric anastomosis was the main procedure, it was underwent in 85, 7% type I cysts. 29.4% postoperative complications were recorded. Malignancy was not documented in any pathology specimen.

CONCLUSIONS

Choledochal cysts are an uncommon disorder whose diagnosis requires a high level of suspicion. Surgical treatment depends on type of cyst. In most patients with choledochal cysts disease, complete cyst excision with bilio-enteric anastomotic reconstruction is the treatment of choice.

An Immunologic Compatibility Testing Was Not Useful for Donor Selection in Fecal Microbiota Transplantation for Ulcerative Colitis

Fecal microbiota transplantation (FMT) is an effective procedure against Clostridioides difficile infection (CDI), with promising but still suboptimal performance in other diseases, such as ulcerative colitis (UC). The recipient’s mucosal immune response against the donor’s microbiota could be relevant factor in the effectiveness of FMT. Our aim was to design and validate an individualized immune-based test to optimize the fecal donor selection for FMT. First, we performed an in vitro validation of the test by co-culturing lymphocytes obtained from the small intestine mucosa of organ donor cadavers (n=7) and microbe-associated molecular patterns (MAMPs) obtained from the feces of 19 healthy donors. The inflammatory response was determined by interleukin supernatant quantification using the Cytometric Bead Array kit (B&D). We then conducted a clinical pilot study with 4 patients with UC using immunocompetent cells extracted from rectal biopsies and MAMPs from 3 donor candidates. We employed the test results to guide donor selection for FMT, which was performed by colonoscopy followed by 4 booster instillations by enema in the following month. The microbiome engraftment was assessed by 16S rDNA massive sequencing in feces, and the patients were clinically followed-up for 16 weeks. The results demonstrated that IL-6, IL-8, and IL-1ß were the most variable markers, although we observed a general tolerance to the microbial insults. Clinical and colonoscopy remission of the patients with UC was not achieved after 16 weeks, although FMT provoked enrichment of the Bacteroidota phylum and Prevotella genus, with a decrease in the Actinobacteriota phylum and Agathobacter genus. The most relevant result was the lack of Akkermansia engraftment in UC. In summary, the clinical success of FMT in patients with UC appears not to be influenced by donor selection based on the explored recipient’s local immunological response to FMT, suggesting that this approach would not be valid for FMT fecal donor optimization in such patients.

Choledochal cysts surgical management: Retrospective and historical comparative analysis

INTRODUCTION

Choledochal cysts are rare bile duct dilatations, which have higher prevalence in Asian population. The aim of the study was to analyze clinical and surgical results about biliary cysts management. In addition, a comparative historical analysis was performed.

METHODS

Patients who underwent surgery between January 1988 and December 2019 in a single tertiary level center were retrospectively included. Demographic and clinical patient data; cyst types; diagnostic methods and surgical technique were analyzed, as well as short and long-term follow-up complications. A comparative descriptive study focus on the main historical series was also carried out.

RESULTS

A total of seventeen patients were identified; 58.8% were men. The mean age at diagnosis was 39.9 years (SD: 20.54). The median follow-up was 5 years (IQR 1-15). The most frequent cysts were tipe I (41.2%). Abdominal pain was the most common presenting symptom (58.8%). Cystic excision with bilio-enteric anastomosis was the main procedure, it was underwent in 85, 7% type I cysts. 29.4% postoperative complications were recorded. Malignancy was not documented in any pathology specimen.

CONCLUSIONS

Choledochal cysts are an uncommon disorder whose diagnosis requires a high level of suspicion. Surgical treatment depends on type of cyst. In most patients with choledochal cysts disease, complete cyst excision with bilio-enteric anastomotic reconstruction is the treatment of choice.

Biological mesh reconstruction versus primary closure for preventing perineal morbidity after extralevator abdominoperineal excision: a multicentre retrospective study

AIM

The aim of the study was to compare the incidence of perineal hernia and the perineal wound morbidity following extralevator abdominoperineal excision (ELAPE) between two groups - primary perineal closure and reconstruction with a biological mesh.

METHOD

One hundred and forty-seven consecutive patients who underwent ELAPE for primary rectal cancer between January 2007 and December 2018 in two tertiary referral centres were retrospectively identified from prospective databases. Perineal closure was carried out via primary closure or with a biological mesh (porcine dermal collagen mesh). Outcome measures were perineal hernia and perineal wound morbidity (infection, dehiscence, persistent sinus and chronic pain).

RESULTS

A total of 139 patients were included in the study. A prophylactic mesh was used in 80 (57.5%) and primary closure was practised in 59 (42.4%) patients. The median follow-up was 30 (interquartile range 46.88) months. Thirty patients (21.6%) developed perineal hernia. No significant differences were found between prophylactic mesh and primary closure (16.3% vs 23.3%, P = 0.07). The median period between surgery and hernia diagnosis was 8 months in the primary closure group and 24 months in the mesh group (P < 0.01). Perineal wound morbidity was significantly higher in the prophylactic mesh group (55% vs 33.9%, P < 0.01).

CONCLUSION

In our study, the use of a biological mesh did not reduce the rate of perineal hernia, although it did delay its appearance. Perineal closure using a biological mesh may increase perineal morbidity, both acute and chronic.

Prophylactic Use of Negative Pressure Wound Therapy Reduces Surgical Site Infections in Elective Colorectal Surgery: A Prospective Cohort Study

Background: The main purpose was to assess the efficacy of negative pressure wound therapy (NPWT) for surgical site infection (SSI) in elective open and laparoscopic open-assisted colorectal surgery. The primary end point was to establish SSI within 30 days post-operatively. The secondary aim was hospital stay and to assess SSI predictors in a multivariable analysis. Patients and Methods: A prospective cohort study was undertaken between January 2017 and December 2018 in patients undergoing elective colorectal surgery, both through open and minimally invasive approaches, to whom NPWT or fully occlusive dressing were applied. Baseline data were compared between the two groups and multivariable analysis was performed to identify SSI risk factors. Results: Two hundred patients were included: 100 NPWT patients and 100 closed dressing patients. No differences between the two groups were found. The incidence of SSI in the control dressing group was 19% versus 9% in the NPWT group, which was substantially different (odds ratio [OR] 0.30; 95% confidence interval [CI] 0.11-0.83; p = 0.02). No differences were found in hospital length of stay (12.33 d in NPWT group vs. 12.39 d in the control group; p = 0.82). A body mass index (BMI) of 30-35 (p = 0.04), BMI >35 (p = 0.03), and midline wound (p = 2.68) were found to be predictors of SSI in multivariable analysis. Conclusion: The prophylactic use of NPWT in laparotomy incisions for patients undergoing elective colorectal surgery (both through open and laparoscopic approach) is associated with a reduction in SSI rates.

Relevance of positive resection margins in ductal pancreatic adenocarcinoma and prognostic factors

INTRODUCTION

Currently, R1 resection is defined by the presence of tumor cells within <1mm of the resection margin. The main aim of this study was to analyze the impact of positive margins (R1) on survival outcomes in pancreatic cancer.

METHODS

We performed a retrospective analysis with multivariate regression analysis of a prospective database from 2008-2017, which included resection margin status, expanded resection margin (R1<1mm), vascular resection, lymphatic involvement, surgical complications, tumor differentiation grade and adjuvant treatment.

RESULTS

A total of 80 patients were analyzed: 42 (52%) R1; 38 (48%) R0. No differences were found in the composition of the two groups except for the vascular resection, which was more frequent in the R1 group: 12 (21%) vs 2 (3%). Overall survival in the R0 group was 19 months vs 24 months in the R1 group (p=0.13). Wide R1 (R1<1mm) had an overall survival of 21 months versus 31 months in wide R0 (p=0.55). In the multivariate analysis, only lymph node involvement (p=0.02, HR=2.88), tumor differentiation (p=0.02, HR=3.2) and adjuvant therapy (p<0.01; HR=0.21) were found to be factors related to survival.

CONCLUSIONS

R1 resection is not an independent risk factor. Lymph node involvement, differentiation grade and adjuvant treatment are prognostic factors. The benefit of expanding the resection margins should be demonstrated. More studies are needed to assess the impact of the resection margin.

Experience, complications and prognostic factors of the ileoanal pouch in ulcerative colitis: An observational study

INTRODUCTION

Ileoanal pouch following restorative proctocolectomy is the treatment for ulcerative colitis after failed medical treatment. Our main aim was to evaluate early and late morbidity associated with restorative proctocolectomy. The secondary aim was to assess risk factors for pouch failure.

METHODS

A retrospective, observational, single-center study was performed. Patients who had undergone restorative proctocolectomy for a preoperative diagnosis of ulcerative colitis from 1983-2015 were included. Early (<30 days) and late (>30 days) adverse events were analyzed. Pouch failure was defined as the need for pouch excision or when ileostomy closure could not be performed. Univariate and multivariate analyses were performed to assess pouch failure risk factors.

RESULTS

The study included 139 patients. One patient subsequently died in the early postoperative period. Mean follow-up was 23 years. Manual anastomoses were performed in 54 patients (39%). Early adverse events were found in 44 patients (32%), 15 of which (11%) had anastomotic fistula. Late adverse events were found in 90 patients (65%), and pouch-related fistulae (29%) were the most commonly found in this group. Pouch failure was identified in 42 patients (32%). In the multivariate analysis, age >50 years (p<0.01; HR: 5.55), handsewn anastomosis (p<0.01; HR: 3.78), pouch-vaginal (p=0.02; HR: 2.86), pelvic (p<0.01; HR: 5.17) and cutaneous p=0.01; HR: 3.01) fistulae were the main pouch failure risk factors.

CONCLUSION

Restorative proctocolectomy for a preoperative diagnosis of ulcerative colitis has high morbidity rates. Long-term outcomes could be improved if risk factors for failure are avoided.

Sinosanal undifferentiated carcinoma with liver metastasis: surgical management

Background

Sinonasal undifferentiated carcinoma (SNUC) is a rare tumor with poor prognosis and high incidence of distant metastasis, even when a good loco-regional control is achieved.

Case

We report the case of a 43-year-old female with SNUC diagnosis. Craniofacial resection with orbital exenteration and radiotherapy in tumor bed and lymph node chain was performed. After 10 months, SNUC hepatic relapse (sIII and sVIII) is diagnosed. We administered chemotherapy and then, surgical resection was carried out. After surgery, two new relapses were diagnosed, at 9 and 21 months where surgical management was performed in both cases. 56 months after SNUC diagnosis, the patient has no evidence of recurrence.

Discussion

Recommended oncological clinical guidelines for distant metastases in SNUC are chemotherapy. Surgical management in oligometastatic disease in SNUC should be considered.

Two biomarker-directed randomized trials in European and Chinese patients with nonsmall-cell lung cancer: the BRCA1-RAP80 Expression Customization (BREC) studies

BACKGROUND

In a Spanish Lung Cancer Group (SLCG) phase II trial, the combination of BRCA1 and receptor-associated protein 80 (RAP80) expression was significantly associated with outcome in Caucasian patients with nonsmall-cell lung cancer (NSCLC). The SLCG therefore undertook an industry-independent collaborative randomized phase III trial comparing nonselected cisplatin-based chemotherapy with therapy customized according to BRCA1/RAP80 expression. An analogous randomized phase II trial was carried out in China under the auspices of the SLCG to evaluate the effect of BRCA1/RAP80 expression in Asian patients.

PATIENTS AND METHODS

Eligibility criteria included stage IIIB-IV NSCLC and sufficient tumor specimen for molecular analysis. Randomization to the control or experimental arm was 1 : 1 in the SLCG trial and 1 : 3 in the Chinese trial. In both trials, patients in the control arm received docetaxel/cisplatin; in the experimental arm, patients with low RAP80 expression received gemcitabine/cisplatin, those with intermediate/high RAP80 expression and low/intermediate BRCA1 expression received docetaxel/cisplatin, and those with intermediate/high RAP80 expression and high BRCA1 expression received docetaxel alone. The primary end point was progression-free survival (PFS).

RESULTS

Two hundred and seventy-nine patients in the SLCG trial and 124 in the Chinese trial were assessable for PFS. PFS in the control and experimental arms in the SLCG trial was 5.49 and 4.38 months, respectively [log rank P = 0.07; hazard ratio (HR) 1.28; P = 0.03]. In the Chinese trial, PFS was 4.74 and 3.78 months, respectively (log rank P = 0.82; HR 0.95; P = 0.82).

CONCLUSION

Accrual was prematurely closed on the SLCG trial due to the absence of clinical benefit in the experimental over the control arm. However, the BREC studies provide proof of concept that an international, nonindustry, biomarker-directed trial is feasible. Thanks to the groundwork laid by these studies, we expect that ongoing further research on alternative biomarkers to elucidate DNA repair mechanisms will help define novel therapeutic approaches.

TRIAL REGISTRATION

NCT00617656/GECP-BREC and ChiCTR-TRC-12001860/BREC-CHINA.

Mapping and characterization of novel parthenocarpy QTLs in tomato

Parthenocarpy is the development of the fruit in absence of pollination and/or fertilization. In tomato, parthenocarpy is considered as an attractive trait to solve the problems of fruit setting under unfavorable conditions. We studied the genetics of parthenocarpy in two different lines, IL5-1 and IVT-line 1, both carrying Solanum habrochaites chromosome segments. Parthenocarpy in IL5-1 is under the control of two QTLs, one on chromosome 4 (pat4.1) and one on chromosome 5 (pat5.1). IVT-line 1 also contains two parthenocarpy QTLs, one on chromosome 4 (pat4.2) and one on chromosome 9 (pat9.1). In addition, we identified one stigma exsertion locus in IL5-1, located on the long arm of chromosome 5 (se5.1). It is likely that pat4.1, from IL5-1 and pat4.2, from IVT-line 1, both located near the centromere of chromosome 4 are allelic. By making use of the microsynteny between tomato and Arabidopsis in this genetic region, we identified ARF8 as a potential candidate gene for these two QTLs. ARF8 is known to act as an inhibitor for further carpel development in Arabidopsis, in absence of pollination/fertilization. Expression of an aberrant form of the Arabidopsis ARF8 gene, in tomato, has been found to cause parthenocarpy. This candidate gene approach may lead to the first isolation of a parthenocarpy gene in tomato and will allow further use in several crop species.

Long-term outcome of acute tubular necrosis: a contribution to its natural history

As long-term outcome studies of acute renal failure (ARF) are scarce and non-homogeneous, we studied 187 consecutive acute tubular necrosis (ATN) patients without previous nephropathies, discharged alive from our hospital between October 77 and December 92 and followed-up until December 99 (range 7-22 years; median 7.2). Variables were analyzed at the time of the acute episode and during follow-up. In 2000-2001 a clinical evaluation was made in 58 of the 82 patients still alive. Ten patients were lost to follow-up and 95 died. In 59% death was related with the disease present when the ATN developed. Kaplan-Meir survival curve showed 89, 67, 50, and 40% at 1, 5, 10, and 15 years, respectively, after discharge. Survival curves were significantly better (log-rank P<0.001) among the youngest, those surviving a polytrauma, those without comorbidity and surprisingly those treated in intensive care units. The proportional Cox model showed that age (hazard ratio (HR) 1.04 per year of age; P=0.000), presence of comorbid factors (HR 4.29; P=0.006), surgical admission (HR 0.45; P=0.000), and male sex (HR 1.72; P=0.020) were the variables associated with long-term follow-up. In the evaluated patients renal function was normal in 81%. Long-term outcome after ARF depends on absence of co-morbid factors, cause of initial admission and age. Although the late mortality rate is high and related with the original disease, renal function is adequate in most patients.

Mycophenolate mofetil tolerability and dose changes in tacrolimus-treated renal allograft recipients

Mycophenolate mofetil (MMF) reduces acute rejection episodes (AREs) and may be associated with better renal graft survival than azathioprine. However, MMF-related adverse events are frequent; dose reduction or even withdrawal are quite common. Between 1999 and 2003, 115 renal transplantation patients were treated with tacrolimus, MMF, and steroids. An observational study was undertaken until graft loss (n = 7), death with a functioning graft (n = 2), or October 31, 2005 (mean follow-up-50 months). We assessed MMF dose reductions due to adverse events with the possible consequences on AREs and graft function. Treated acute ARE occurred in 11.3% of recipients, all of which were steroid-responsive. The median MMF initial daily dose was 1000 mg. In 44 patients (38.3%), the MMF dose was not changed; in 48 (41.7%) it was reduced; and in 23 (20%), withdrawn. The causes for dose modification were diarrhea (n = 33, 28.7% of all patients), leukopenia (n = 22, 19.1%), both of these (n = 7, 6.1%), or other events (n = 9, 7.8%). No AREs were attributed to MMF dose changes. Tacrolimus blood levels were higher at 3 years and serum creatinine values at 4 years among patients with dose changes (8.43 +/- 2.42 vs 7.37 +/- 2.23 ng/mL; P = .051 and 1.75 +/- 0.71 vs 1.48 +/- 0.38 mg/dL; P = .038, respectively). The need for MMF dose reduction or withdrawal was frequent in our patients with diarrhea or leukopenia during treatment with tacrolimus, MMF, and steroids. These adverse event-related changes were not associated with AREs, but produced deleterious effects on long-term graft function.

Conversion From Calcineurin Inhibitors to Everolimus in Kidney Transplant Recipients With Malignant Neoplasia

Cancer has been reported to be more common among kidney transplant recipients than waiting-list patients or the general population. Use of anticalcineurin agents and azathioprine are relevant risk factors. Nine renal allograft recipients (seven men and two women) of mean age 67.6 (55-77) years and mean time after transplantation of 30.7 (58-216) months were switched to everolimus-based immunosuppression because of the presence of biopsy-proven malignancies (eight patients) or neurological tacrolimus toxicity (one patient). One patient with posttransplant lymphoproliferative disease also received chemotherapy with a good evolution at 6 months. He showed an initial increase in the protein to creatinine ratio (peak 3.3 mg/mg at 3 months) that was controlled by increasing the enalapril dose. One patient with skin cancer and severe atheromatosis (baseline SCr 2.5 mg/dL, creatinine clearance 17 mL/min, and protein to creatinine ratio 3.2 mg/mg), had cyclosporine and everolimus overlapped for 25 days, showing a continued poor evolution requiring dialysis initiation at 3 months after switch. The other six patients with recurrent skin cancers had good cancer evolution, with no new skin tumors and regression of skin lesions in three, including not biopsied actinic keratosis. Sudden switching from calcineurin inhibitors to everolimus is safe and may be used in long-term transplant recipients with malignancies. In patients with advanced chronic nephropathy this approach appeared to be less beneficial.

Interaction Between Omeprazole and Tacrolimus in Renal Allograft Recipients: A Clinical-Analytical Study

Omeprazole is a proton pump inhibitor with a number of pharmacokinetic drug interactions due to interference with cytochrome P450. Some studies show absence of relevant interaction between omeprazole and cyclosporine, but little is known about possible interactions between omeprazole and tacrolimus. In vitro studies suggest such interference, but no clinical data are available so far. We assessed interactions between omeprazole and tacrolimus among patients fulfilling two criteria: (1) renal allograft recipients receiving immunosuppression based on tacrolimus and acid-related disorder prophylaxis with omeprazole 20 mg/d since the day of the transplant procedure and (2) stopped omeprazole when it was considered unnecessary. Fifty-one transplant recipients received concomitant immunosuppression with MMF-prednisone (n = 47) or azathioprine-prednisone (n = 1), or rapamycin-prednisone (n = 2) or only prednisone (n = 1). omeprazole was stopped after 6.2 +/- 3 months of treatment. Tacrolimus doses and levels were recorded during 3 outpatient visits before omeprazole withdrawal (Pre3/Pre2/Pre1), at the withdrawal visit (Susp), and at 3 visits after withdrawal (Pos1/Pos2/Pos3). Weight gain was significant (72.5 +/- 13 kg Pre3; 73.4 +/- 13 kg Susp; 74 +/- 12.9 kg Pos3, P < .0001) and serum creatinine (SCr) decreased (1.70 +/- 0.49 mg/dL Pre3; 1.63 + 0.49 Susp; 1.58 +/- 0.48 Pos3, P < .0001). The progressive decrease in tacrolimus doses and levels was significant (ANOVA including the 7 visits <0.01 in all cases); whereas the level/dose ratio remained constant. Tacrolimus doses and levels continued a slow, progressive and significant decrease without any relevant change between visits during on versus off omeprazole. This clinical-analytical study supported the conclusion that an omeprazole-tacrolimus interaction is not clinically relevant. Despite possible competition or interaction at the molecular level, clinical management was not significantly affected in renal allograft recipients.

Wisconsin and Celsior solutions in renal preservation: a comparative preliminary study

The aim of this study was to evaluate the efficacy of the Celsior (C) solution for flushing and cold storage of cadaveric renal allografts. Among 177 cadaveric renal allografts harvested and transplanted in our unit, 138 were preserved with the University of Wisconsin (W) solution and 39 with the C solution. The mean age of the recipients was 48.1 +/- 13.5 years, including 107 men and 70 women. The immunosuppressive regimens were tacrolimus-based (n = 118) or cyclosporine-based (n = 59). Grafts perfused with W solution were obtained from older donors than those perfused with C solution (42.3 +/- 16.9 vs 38.1 +/- 12.5 years; P = .017) and had been transplanted to older recipients (49.5 +/- 14.4 vs 43.3 +/- 13.0 years; P = .017). The prevalence of delayed graft function (DGF) was similar in the 2 groups (39.1% in the W group vs 23.7% in the C group; P = .097), as well as the incidence of primary nonfunction grafts (5.8% vs 2.7%; P = .427). The serum creatinine value at 1 month was significantly higher among grafts preserved with W versus solution (1.9 +/- 0.9 vs 1.5 +/- 0.5 mg/dL; P = .000) as well as at 12 months (1.63 +/- 0.5 vs 1.35 +/- 0.4 mg/dL; P = .003). There were no differences in graft survival at 12 months (97% C group vs 88% W group; P = .069). Our results showed that C solution was equivalent to W solution with respect to DGF and primary function of kidneys. The differences in renal function may have been due to differences in donor and recipient ages.

Lumbar Bone Mineral Density After Kidney Transplantation: A Three-Year Prospective Study

Osteopenia is a common complication after transplantation. However, prospective long-term studies are scarce and most were performed in patients on cyclosporine and high-dose steroids. In 65 patients with functioning grafts, 41 males and 24 females, 50 on tacrolimus-based immunosuppression and 15 on cyclosporine-based immunosuppression, bone mineral density (BMD) was measured in the lumbar spine (L2-L4) and femoral neck (FN) using dual X-ray absorptiometry (DEXA) in the first month after transplantation (baseline) and at 1, 2, and 3 years. At baseline, BMD was similar to the control population both in L2-L4 (z score = -0.421) and in FN (z score = -0.518). During the follow-up, 3 types of patterns were identified: BMD increased in L2-L4 in 25 patients (38.5%), remained stable in 20 patients (30.8%), and decreased in 20 patients (30.8%). BMD losses appeared mainly during the first year (0.964 +/- 0.162 baseline; 0.904 +/- 0.161 at 1 year, 0.886 +/- 0.140 at 3 years; analysis of variance [ANOVA] P < .001). However, the improvement was maintained throughout the follow-up (0.860 +/- 0.176 g/cm2 at baseline; 0.901 +/- 0.161 at 1 year; 0.954 +/- 0.178 at 3 years; ANOVA P < .001) and there was a parallel increase of BMD in FN (0.712 +/- 0.144 at baseline; 0.744 +/- 0.249 at 1 year; 0.826 +/- 0.184 at 3 years; ANOVA P < .01). There were no differences between both groups in graft function, intact parathyroid hormone (iPTH) levels, number of postmenopausal women, or steroid doses. About one third of patients had bone loss during the first year after transplantation. We were unable to identify any risk factor for this complication in patients on low-dose steroids.

[The first myocardial infarct in the elderly patient]

Acute myocardial infarction (AMI) in patients over 65 years of age represent more than half of the patients with AMI. Among them, between 60 and 80% represent the first AMI. The objective of this study is to evaluate the behavior of AMI in this group of patients. The clinical charts of patients over 65 years of age with ischemic heart disease admitted into the hospital during the past two years, were reviewed. We used the international criteria (clinical, ECG, enzymatic, echocardiographic and scintigraphic studies) for the diagnosis of AMI. Patients with previous AMI were excluded. We included 274 patients (68% males and 32% females). The age varied from 65 to 91 years with an average of 71.7 +/- 5.3 years. Typical symptoms were present in 90.5% and atypical in 9.5% of the cases, being the latest most frequent in those over 75 years of age.

RISK FACTORS

cigarette smoking was present in 60% of the patients, hypertension in 52% and diabetes mellitus in 37%. Both of them were associated in 21%. In 144 cases (52.5%) the MI localization was anterior and in 130 (47.5%) inferior; among them 47 patients (36%) had extension to the right ventricle and 7 (2.5%) had a non Q AMI.

COMPLICATIONS

Type I-II VPCs of Bernard Lown were present in 18% and type V 10.2%. Compete AV block in 14.2% (all of them with inferior wall MI); bifascicular block in 55 and mitral insufficiency due to papillary muscle dysfunction in 6.5%.(ABSTRACT TRUNCATED AT 250 WORDS)

High F1.2 fragment of prothrombin, thrombin-antithrombin III complex (TAT) and soluble fibrin plasma levels demonstrate hypercoagulability induced during loco-regional thrombolytic therapy with rt-PA

In order to investigate the coagulation and fibrinolysis state in arterial peripheral thrombosis and thrombolysis, we studied 33 consecutive patients (mean age = 65, range: 28-88), 25 males and 8 females diagnosed of acute or subacute lower limb arterial thrombosis, treated with an intrathrombus infusion of rt-PA (0.1 mg/Kg/h) for three hours. Plasma levels of antithrombin III (AT-III), protein C (PC), plasminogen (Pg) and alpha 2-antiplasmin (AP), total and free protein S (PS), thrombin-antithrombin III complex (TAT), F1.2 fragment of prothrombin (F1.2), fibrinogen (Fg), soluble fibrin monomers (FM), tissue-plasminogen activator (t-PA), plasminogen activator inhibitor 1 (PAI-1), total fibrinogen/fibrin degradation products (TDP) and D dimer (DD) were determined prior to the therapeutic regime, at the end of the treatment, and 24 hours later. Levels of AT-III and protein C were somewhat low during the complete study. There was an increase in t-PA, TDP and D Dimer and a decrease of fibrinogen, alpha 2-antiplasmin and plasminogen at 3 hours. An elevation of TAT, fibrin monomers and F1.2 levels was found at three hours. A positive correlation between TAT and F1.2 was observed (r = 0.57, p < 0.05). There was also a positive correlation between soluble fibrin and TAT (r = 0.59, p < 0.05) and with F1.2 (r = 0.56. p < 0.05). These latter facts reflect an hypercoagulable situation induced during loco-regional thrombolytic therapy.

Is endoscopic gastric cytology worthwhile? An evaluation of 903 cases of carcinoma

From 1978 to 1989, 4,772 endoscopic cytological examinations of the stomach have been done in our laboratory, including 903 patients with a final diagnosis of gastric carcinoma. There were seven false-positive results among 3,810 examinations done in patients without malignant disease (specificity 99.8%). Cytology yielded positive results in 785 of 903 carcinomas (sensitivity 86.9%), while biopsies were positive in 826 of 895 cases (sensitivity 92.3%). Both techniques combined resulted in positive diagnoses in 886 of 903 malignancies (sensitivity 98.1%). Cytology was positive in 52 patients with negative biopsies as well as in eight patients in whom biopsies had not been obtained. Thus cytology added 60 positive diagnoses (6.7%) to the overall diagnostic results. These results suggest that endoscopic cytology is useful for avoiding unnecessary delays caused by having to perform repeated endoscopic biopsies. It should be done as a routine procedure in those institutions in which significant numbers of gastric carcinomas are studied and where an experienced gastrointestinal cytology laboratory is available.

Effect of larval crowding on adult mating behaviour in Drosophila melanogaster

The effect of larval density on male mating success has been investigated with two strains of Drosophila melanogaster, a wild strain and a mutant strain, under low and high larval competition, and four different genotypic frequencies. The results show a strong sexual selection against mutant males when flies have been raised under low larval competition. Under high larval competition, there is a reduction in mating disadvantage of mutant males. In both instances, a frequency-dependent sexual selection exists. These results explain adequately the evolution of experimental populations where egg to adult viability and male mating success are the most important components of fitness.

Allometry of the limb long bones of insectivores and rodents

In an attempt to investigate the relationships between allometry and locomotory adaptations, we studied the long limb bones of 45 species of insectivores and rodents. Animals ranged from a few grams to about 50 kilograms. Diameter and length of the bones and body mass (when known) were recorded. Regressions of diameter to length, diameter to body mass, and length to body mass were calculated by the least-squares and Model II, or major axis, methods. The results obtained do not agree with the predictions of either the theory of geometric similarity or the theory of elastic similarity. The discrepancies could be due to the fact that animals studied exhibit various modes of locomotion. Moreover, the allometric relationships of the different locomotor patterns are better reflected in insectivores and rodents than in other groups of mammals. The use of a single regression analysis seems to be inadequate when the sample includes a large range of body sizes.