Cognitive decrements in 1991 Gulf War veterans: associations with Gulf War illness and neurotoxicant exposures in the Boston Biorepository, Recruitment, and Integrative Network (BBRAIN) cohorts

BACKGROUND

During deployment, veterans of the 1991 Gulf War (GW) were exposed to multiple war-related toxicants. Roughly a third of these veterans continue to exhibit neurotoxicant induced symptoms of Gulf War Illness (GWI), a multi-faceted condition that includes fatigue, pain and cognitive decrements. When studied empirically, both deployed veterans with exposures and those who meet the criteria for GWI are more likely to show deficits in the area of neuropsychological functioning. Although studies have shown cognitive impairments in small sample sizes, it is necessary to revisit these findings with larger samples and newer cohorts to see if other areas of deficit emerge with more power to detect such differences. A group of researchers and clinicians with expertise in the area of GWI have identified common data elements (CDE) for use in research samples to compare data sets. At the same time, a subgroup of researchers created a new repository to share these cognitive data and biospecimens within the GWI research community.

METHODS

The present study aimed to compare cognitive measures of attention, executive functioning, and verbal memory in a large sample of GWI cases and healthy GW veteran controls using neuropsychological tests recommended in the CDEs. We additionally subdivided samples based on the specific neurotoxicant exposures related to cognitive deficits and compared exposed versus non-exposed veterans regardless of case criteria status. The total sample utilized cognitive testing outcomes from the newly collated Boston, Biorepository, Recruitment, and Integrative Network (BBRAIN) for GWI.

RESULTS

Participants included 411 GW veterans, 312 GWI (cases) and 99 healthy veterans (controls). Veterans with GWI showed significantly poorer attention, executive functioning, learning, and short-and-long term verbal memory than those without GWI. Further, GW veterans with exposures to acetylcholinesterase inhibiting pesticides and nerve gas agents, had worse performance on executive function tasks. Veterans with exposure to oil well fires had worse performance on verbal memory and those with pyridostigmine bromide anti-nerve gas pill exposures had better verbal memory and worse performance on an attention task compared to unexposed veterans.

CONCLUSIONS

This study replicates prior results regarding the utility of the currently recommended CDEs in determining impairments in cognitive functioning in veterans with GWI in a new widely-available repository cohort and provides further evidence of cognitive decrements in GW veterans related to war-related neurotoxicant exposures.

Laparoscopic Excision of Retroperitoneal Adnexal Cyst

STUDY OBJECTIVE

To demonstrate the laparoscopic excision of a retroperitoneal adnexal cyst and describe the advanced surgical techniques and anatomic considerations in a patient with previous abdominopelvic surgery.

DESIGN

Stepwise demonstration of advanced laparoscopic techniques with narrated video footage.

SETTING

Adnexal masses after hysterectomy are a common reason for repeat abdominal surgery.1 Up to 9% of patients may require future adnexal surgery if ovarian preservation was chosen at the time of hysterectomy.2 Indications for surgery can include persistent adnexal masses, masses with concern for malignancy, chronic pelvic pain, and risk-reducing surgery.2 This patient is a 53-year-old postmenopausal female with a history of a total abdominal hysterectomy and left salpingectomy who underwent excision of an 8 cm retroperitoneal left adnexal cyst (Still 1).

INTERVENTIONS

Excision of a retroperitoneal adnexal cyst can be performed through a laparoscopic approach with several key strategies: CONCLUSION: Knowledge of retroperitoneal anatomy is crucial in the surgical management of retroperitoneal adnexal masses because dissection can be technically challenging and anatomy may be distorted due to pelvic adhesive disease. Use of advanced laparoscopic techniques and understanding surgical planes are important for safe dissection. High and early ligation of the infundibulopelvic ligament at the pelvic brim and a complete ureterolysis with parametrial excision are often necessary to remove all ovarian tissue to prevent an ovarian remnant.

Growing pains: strategies for improving ergonomics in minimally invasive gynecologic surgery

PURPOSE OF REVIEW

To evaluate factors contributing to the development of work-related musculoskeletal disorders (WMSDs) and review strategies for mitigating ergonomic strain in minimally invasive gynecologic surgery.

RECENT FINDINGS

Factors associated with increased ergonomic strain and the development of WMSDs include increasing patient body mass index (BMI), smaller surgeon hand size, noninclusive design of instruments and energy devices and improper positioning of surgical equipment. Each type of minimally invasive surgery (laparoscopic, robotic, vaginal) confers its own ergonomic risk to the surgeon. Recommendations have been published regarding optimal ergonomic surgeon and equipment positioning. Intraoperative breaks and stretching are effective in reducing surgeon discomfort. Formal training in ergonomics has not yet been widely implemented, but educational interventions have been effective in reducing surgeon discomfort and can improve surgeon recognition of suboptimal ergonomics.

SUMMARY

Considering the serious downstream effects of WMSDs on surgeons, it is imperative to implement strategies for WMSD prevention. Optimal positioning of the surgeons and operative equipment should be routine. Intraoperative breaks and stretching should be incorporated during procedures and between every case. Formal education in ergonomics should be provided to surgeons and trainees. Additionally, more inclusive instrument design by industry partners should be prioritized.

Genetic association between the APOE ε4 allele, toxicant exposures and Gulf war illness diagnosis

INTRODUCTION

Exposure to nerve agents, pyridostigmine bromide (PB), pesticides, and oil-well fires during the 1991 Gulf War (GW) are major contributors to the etiology of Gulf War Illness (GWI). Since the apolipoprotein E (APOE) ε4 allele is associated with the risk of cognitive decline with age, particularly in the presence of environmental exposures, and cognitive impairment is one of the most common symptoms experienced by veterans with GWI, we examined whether the ε4 allele was associated with GWI.

METHODS

Using a case-control design, we obtained data on APOE genotypes, demographics, and self-reported GW exposures and symptoms that were deposited in the Boston Biorepository and Integrative Network (BBRAIN) for veterans diagnosed with GWI (n = 220) and healthy GW control veterans (n = 131). Diagnosis of GWI was performed using the Kansas and/or Center for Disease Control (CDC) criteria.

RESULTS

Age- and sex-adjusted analyses showed a significantly higher odds ratio for meeting the GWI case criteria in the presence of the ε4 allele (Odds ratio [OR] = 1.84, 95% confidence interval [CI = 1.07-3.15], p ≤ 0.05) and with two copies of the ε4 allele (OR = 1.99, 95% CI [1.23-3.21], p ≤ 0.01). Combined exposure to pesticides and PB pills (OR = 4.10 [2.12-7.91], p ≤ 0.05) as well as chemical alarms and PB pills (OR = 3.30 [1.56-6.97] p ≤ 0.05) during the war were also associated with a higher odds ratio for meeting GWI case criteria. There was also an interaction between the ε4 allele and exposure to oil well fires (OR = 2.46, 95% CI [1.07-5.62], p ≤ 0.05) among those who met the GWI case criteria.

CONCLUSION

These findings suggest that the presence of the ε4 allele was associated with meeting the GWI case criteria. Gulf War veterans who reported exposure to oil well fires and have an ε4 allele were more likely to meet GWI case criteria. Long-term surveillance of veterans with GWI, particularly those with oil well fire exposure, is required to better assess the future risk of cognitive decline among this vulnerable population.

Ice-POP: Ice Packs for Postoperative Pain: A Randomized Controlled Trial

STUDY OBJECTIVE

To evaluate the benefit of ice packs as a supplement to standard pain management following laparoscopic hysterectomy (LH).

DESIGN

This Institutional Review Board-approved randomized controlled trial involved patients undergoing LH for benign conditions. Subjects were randomized to receive standard enhanced recovery after surgery pain management or standard enhanced recovery after surgery plus ice packs.

SETTING

Two academic tertiary care centers PATIENTS: Patients undergoing planned outpatient LH with the minimally invasive gynecologic surgery team between February 2019 and November 2020 were considered. Patients with chronic pain, current opioid use ≥1 week, or planned overnight hospitalizations were excluded. Primary outcome data were available for 51 subjects (24 control, 27 intervention).

INTERVENTIONS

Ice packs were placed on the abdomen in the operating room.

MEASUREMENTS AND MAIN RESULTS

Pain was assessed at multiple time points throughout the study using a visual analogue scale (VAS). Opioid requirement was assessed using morphine milligram equivalent. There was no difference between the groups on any demographic variables. Morphine milligram equivalent requirements were also not different between the groups (p = .63). Postoperative day 1 (POD#1) VAS scores were not different (p = .89). Eighty-five percent of subjects reported feeling that their pain was controlled. Subjects who reported that they did not feel their pain was controlled did not use more opioids on POD#1 (p = .37), nor did they have higher POD#1 VAS scores (p = .55). Eighty-seven percent of the intervention subjects said they would use ice again, and 82.6% of them said they would recommend ice to others. There were no adverse events related to ice. All subjects were prescribed 20 tablets oxycodone and averaged 2.9 (SD 3.4) tablets used after discharge.

CONCLUSION

Ice packs are an acceptable supplement for postoperative pain control, but they do not reduce postoperative pain or opioid usage compared to standard pain management without ice packs.

Neural activity in trigeminal neuralgia patients with sensory and motor stimulations: A pilot functional MRI study

OBJECTIVE

Trigeminal neuralgia (TN) is a neuropathic pain syndrome that typically exhibits paroxysmal pain. However, the true mechanism of pain processing is unclear. We aim to evaluate the neural activity changes, before and after radiofrequency rhizotomy, in TN patients using functional MRI (fMRI) with sensory and motor stimulations.

METHODS

Six patients with classical TN participated in the study. Each patient underwent two boxcar paradigms of fMRI tasks: air-sensation and jaw-clenching around 1-3 weeks before and after the surgical intervention. McGill Pain Questionnaire (MPQ) was used to evaluate the pain intensity prior to fMRI study.

RESULTS

Before rhizotomy, the jaw-clenching stimulation yielded reduced brain activation in primary motor (M1) and primary (SI) and secondary somatosensory (SII) cortices. Following intervention, activation in those regions returned to near normal levels observed in healthy subjects. For air-sensation stimulation, several pain and pain modulation regions such as right thalamus, right putamen, insula, and brainstem, were activated before the intervention, but subsided after the intervention. This correlated well with the change of MPQ scores (p < 0.01).

CONCLUSIONS

In our study, we observed significant pain reduction accompanied by increased motor activities after rhizotomy in patients with TN. We hypothesize that the reduced motor activities identified in fMRI may be reversed after the treatment with radiofrequency rhizotomy. More research is warranted.

Omental evisceration in a gravid woman following second-trimester laparoscopy: A case report

Surgeons performing laparoscopy in pregnancy are developing specific practices to improve care of gravid women. In this case, a pregnant 26-year-old patient underwent laparoscopic ovarian cystectomy in the second trimester, with cyst wall removal through an 8 mm umbilical port site incision. She returned four days later with pain and drainage from the umbilicus, and examination under anesthesia revealed omental evisceration through the umbilical incision. The patient healed well following excision of affected omentum, reapproximation of fascia in a simple, interrupted fashion, and closure of skin in a subcuticular fashion. Due to increased intra-abdominal pressure associated with a gravid uterus and other factors, port site closure for incisions smaller than 10 mm may improve healing and prevent complications of laparoscopic surgery in pregnancy.

Postoperative Bladder Filling After Outpatient Laparoscopic Hysterectomy and Time to Discharge: A Randomized Controlled Trial

OBJECTIVE

To determine whether backfilling the bladder postoperatively will reduce time to discharge in patients undergoing outpatient laparoscopic hysterectomy.

METHODS

In a single-blind, randomized, controlled trial among women undergoing outpatient laparoscopic hysterectomy, patients were randomly assigned to a backfill-assisted void trial or a trial of spontaneous voiding. The primary outcome was time to discharge assessed by length of time spent in the postanesthesia care unit. Secondary outcomes included time to first spontaneous void, urinary retention rates, and postoperative complications within 8 weeks. We estimated that 152 patients (76/group) would provide greater than 80% power to identify a 30-minute difference in the primary outcome with a SD of 56 minutes and a two-sided α of 0.05.

RESULTS

Between June 2017 to May 2018, 202 women were screened, 162 women were randomized, and results were analyzed for 153 women. Seventy-five patients (group A) who had a backfill-assisted voiding trial and 78 patients (group B) who had a spontaneous voiding trial were included in the analysis. The mean time to discharge was 273.4 minutes for group A vs 283.2 minutes for group B, which was not found to be significant (P=.45). The mean time to first spontaneous void was 181.1 minutes in group A vs 206.0 minutes in group B. There was a statistically significant reduction of 24.9 minutes in time to first spontaneous void with patients randomized to the backfill group (P=.04). Five of 75 patients (6.7%) in group A and 10 of 78 patients (12.8%) in group B developed urinary retention postoperatively and required recatheterization before discharge, which was also not significant (P=.20).

CONCLUSION

Bladder filling before removing the Foley catheter is a simple procedure shown to reduce time to first spontaneous void, but not time to discharge in patients undergoing outpatient laparoscopic hysterectomy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03126162.

Utility of a chemotherapy toxicity prediction tool for older patients in a community setting

Background

Expert groups have recommended incorporation of a geriatric assessment into clinical practice for older patients starting oncologic therapy. However, that practice is not standard primarily because of resource limitations. In the present study, we evaluated the effect on treatment decisions by oncologists in the community oncology setting of a brief geriatric assessment tool that estimates risk of toxicity.

Methods

This prospective longitudinal study in 5 community oncology practices in British Columbia involved patients 70 years of age and older starting a new cytotoxic chemotherapy regimen. Clinical personnel completed a brief validated geriatric assessment tool-the Cancer and Aging Research Group chemotherapy toxicity tool (carg-tt)-that estimates the risk of grade 3 or greater toxicity in older patients. Physicians were asked if the carg-tt changed their treatment plan or prompted extra supports. Patients were followed to assess the incidence of toxicity during treatment.

Results

The study enrolled 199 patients between July 2016 and February 2018. Mean age was 77 years. Treatment was palliative in 61.4% of the group. Compared with physician judgment, the carg-tt predicted higher rates of toxicity. In 5 patients, treatment was changed based on the carg-tt. In 38.5% of the patients, data from the tool prompted extra supports. Within the first 3 cycles of treatment, 21.3% of patients had experienced grade 3 or greater toxicity.

Conclusions

This study demonstrates that use of a brief geriatric assessment tool is possible in a broad community oncology practice. The tool modified the oncologist's supportive care plan for a significant number of older patients undertaking cytotoxic chemotherapy.

Antenatal corticosteroids for preterm premature rupture of membranes: single or repeat course?

OBJECTIVE

The aim of this article is to determine the risk of maternal chorioamnionitis and neonatal morbidity in women with preterm premature rupture of membranes (PPROM) exposed to one corticosteroid course versus a single repeat corticosteroid steroid course.

STUDY DESIGN

Secondary analysis of a cohort of women with singleton pregnancies and PPROM. The primary outcome was a clinical diagnosis of maternal chorioamnionitis. Using multivariate logistic regression, we controlled for maternal age, race, body mass index, diabetes, gestational age at membrane rupture, preterm labor, and antibiotic administration. Neonatal morbidities were compared between groups controlling for gestational age at delivery.

RESULTS

Of 1,652 women with PPROM, 1,507 women received one corticosteroid course and 145 women received a repeat corticosteroid course. The incidence of chorioamnionitis was similar between groups (single course = 12.3% vs. repeat course = 11.0%; p = 0.8). Women receiving a repeat corticosteroid course were not at increased risk of chorioamnionitis (adjusted odds ratio, 1.28; 95% confidence interval, 0.69-2.14). A repeat course of steroids was not associated with an increased risk of any neonatal morbidity.

CONCLUSION

Compared with a single steroid course, our findings suggest that the risk of maternal chorioamnionitis or neonatal morbidity may not be increased for women with PPROM receiving a repeat corticosteroid course.

Preclinical modeling of EGFR-specific antibody resistance: oncogenic and immune-associated escape mechanisms

To define the molecular basis of secondary resistance to epidermal growth factor receptor (EGFR)-specific antibodies is crucial to increase clinical benefit in patients. The limited access to posttreatment tumor samples constitutes the major barrier to conduct these studies, representing preclinical experimentation as a useful alternative. Anti-EGFR antibody-based therapy has been reported to mediate tumor regression by interrupting oncogenic signals and, more recently, by inducing antitumor immunological responses. However, resistance models have been focused only on tumor escape associated with EGFR blockade, whereas studies describing immune-associated escape mechanisms have not been reported thus far. To address this idea, we modeled resistance induction in D122 metastasis-bearing C57BL/6 mice treated with 7A7 (an anti-murine EGFR antibody). Similarly to patients receiving EGFR-specific antibodies, 7A7 resistance promotion represents an important drawback to successful therapy. Characterization of primary cultures derived from metastasis in 7A7-treated mice revealed a high frequency of tumor variants resistant to in vivo and in vitro antibody treatment. We showed, for the first time, the convergence of alterations in oncogenic and immunological pathways in 7A7-resistant variants. To identify key molecules behind resistance, seven 7A7-resistant variants were screened. HER3 overexpression and PTEN deficiency leading to hyperactivation of protumoral downstream signaling were found in these variants as a consequence of 7A7-mediated EGFR inhibition. Concomitantly, we found a high percentage of resistant variants carrying abnormalities in the constitutive and/or interferon gamma (IFN-γ)-inducible major histocompatibility complex I (MHC-I) expression. A significant decrease in mRNA levels for MHC-I heavy chains, β2-microglogulin and antigen processing machinery genes as well as transcriptional alterations in IFN-γ pathway components were identified as the main mechanisms underlying MHC-I expression defects in 7A7-resistant variants. Notably, these defects have not been previously associated with EGFR-specific antibody resistance, providing novel immunological escape mechanisms. This study has strong implications for the development of new combination strategies to overcome anti-EGFR antibodies refractoriness.

Executive dysfunction in frontotemporal dementia is related to abnormalities in frontal white matter tracts

Cognitive deficits in behavioral-variant frontotemporal dementia (bvFTD) and AD are linked to frontal and temporal lobe gray matter (GM) pathology. The aim of this study was to assess the relative contribution of white (WM) and GM abnormalities to cognitive dysfunction in bvFTD and AD. Fractional anisotropy (FA) for the corpus callosum, cingulum (Cg), and uncinate fasciculus (Unc) was determined in 17 bvFTD and 10 AD patients who underwent neuropsychological testing. Regressions were performed to assess the relative contribution of WM and GM abnormalities to cognitive deficits. Multiple regression analysis revealed that in bvFTD, the left anterior Cg FA was related to executive function, the right anterior Cg FA to visual-spatial attention and working memory, the right posterior Cg to visual-constructional abilities and the left Unc FA to Modified Trails Errors. After adding corresponding GM volumes, the left anterior Cg FA, the right anterior cingulate FA, the right posterior cingulate FA and the left uncinate FA remained significant predictors of the cognitive tasks. In the AD group, the left posterior Cg FA and right descending Cg FA were related to visual recall performance but did not remain significant predictors when GM volumes were added to the regression. These results suggest that reduced integrity of specific WM tracts contribute to cognitive deficits observed in bvFTD after accounting for GM atrophy. In AD, memory impairment was related to WM tract injury but this relationship was no longer observed when GM volumes were included.

Outpatient total hip arthroplasty

Patients younger than 65 years were studied to determine what percentage of patients would enroll in a study of outpatient total hip arthroplasty, its safety, and benefits of the program. Of 192 eligible patients, 69 (36%) enrolled, and 53 (77%) of these went home the same day of surgery. Of 53, 44 maintained a diary for the first 3, weeks and 52 completed a satisfaction questionnaire at 6 weeks. Patients were followed for 6 months for occurrence of complications. There were no medical readmissions. Of 52 patients who completed a 6 week questionnaire, 50 (96%) were satisfied with the decision to have outpatient total hip arthroplasty. There were no objective physical benefits identified. This study reports the distribution of acceptance and completion of same day discharge for patients with total hip arthroplasty in a metropolitan population. It confirms safety in selected patients.

Gene therapy for hypertension: a review of potential targets

Somatic gene delivery approaches have received wide attention as a new technique for studying gene expression and as a potential therapeutic tool in treating both inherited and acquired diseases. Recent studies using nonviral and viral vectors have shown great promise for gene therapy in hypertensive diseases. Potential targets for prospective gene therapy in hypertension include vasopressor renin-angiotensin system components and a number of vasodilator polypeptides such as tissue kallikrein-kinin, atrial natriuretic peptide, adrenomedullin and nitric oxide synthase. Antisense inhibition with oligonucleotides or cDNAs encoding renin, angiotensinogen, angiotensin-converting enzyme and angiotensin receptors has been shown to cause a prolonged blood pressure reduction in spontaneously hypertensive rats. To evaluate the therapeutic potential of vasodilator proteins or peptides in high blood pressure, we delivered the genes encoding human tissue kallikrein, atrial natriuretic peptide, nitric oxide synthase, and adrenomedullin into hypertensive rat models and showed that a single injection resulted in a significant and sustained reduction of blood pressure for several weeks. The potency and duration of blood pressure reduction depends on the dose and the promoter of the gene administered, age and sex of the hypertensive animals as well as the vehicle used for gene delivery. Somatic gene transfer of human tissue kallikrein or atrial natriuretic peptide not only attenuated hypertension but also exerted a protective effect against salt-induced renal damage and cardiac hypertrophy in Dahl salt-sensitive rats after high salt loading. These results suggest that the application of antisense inhibition of vasopressors, or gene delivery of vasodepressors for gene therapy, may have potential in treating human hypertension, and cardiovascular and renal disorders.

Association between CpG island methylation of the WWOX gene and its expression in breast cancers

OBJECTIVES

The aim of the present study was to evaluate the expression of the WWOX gene in breast carcinoma and to analyze the relationship between its expression and methylation.

METHODS

Methylation of the WWOX promoter and exon 1 as well as WWOX expression were determined by methylation-specific PCR, reverse transcription PCR and immunohistochemistry in 20 breast cancer tissue samples and corresponding nonneoplastic tissues. The expression of WWOX protein was evaluated by immunohistochemistry in 2 breast cancer cell lines.

RESULTS

WWOX mRNA expression was reduced in breast cancer tissues as compared to adjacent tissues (p < 0.001). WWOX mRNA and protein expression was significantly reduced in breast cancer tissues with methylated WWOX CpG islands when compared to tissues without methylation (p < 0.001 and p = 0.008, respectively). Immunohistochemical analysis also showed that WWOX levels were significantly decreased in tissues with WWOX methylation (p = 0.001). WWOX mRNA and protein expression was greatly reduced in MDA-MB-231 cells, partly due to the methylation of WWOX CpG islands, and recovered after hydralazine treatment.

CONCLUSIONS

Differential regulation of the WWOX gene plays an important role in the carcinogenesis of breast cancer, due partially to methylation of the WWOX DNA CpG islands.

Imaging and navigation measurement of acetabular component position in THA

There are six different definitions of acetabular position based on observed inclination and anteversion made in either the (1) anterior pelvic plane or (2) coronal planes and based on whether each of the observations made in one of these two planes is (1) anatomic, (2) operative, or (3) radiographic. Anteroposterior pelvic tilt is the angle between the anterior pelvic plane and the coronal plane of the body. The coronal plane is a functional plane and the anterior pelvic plane is an anatomic pelvic plane. A cup may be in the "safe zone" by one definition but may be out of the "safe zone" by another definition. We reviewed published studies, analyzed the difference in varying definitions, evaluated the influence of the anterior pelvic tilt, and provided methods to convert from one definition to another. We recommend all inclination and anteversion measurements be converted to the radiographic inclination and anteversion based on the coronal plane, which is equivalent to the inclination and anteversion on the anteroposterior pelvic radiograph.

Increased expression of osteopontin in patients with triple-negative breast cancer

BACKGROUND

Patients with triple-negative [oestrogen receptor (ER) negative, progesterone receptor (PR) negative, and human epidermal growth factor receptor 2 (HER-2/neu) negative] breast cancer, accounting for about 15% of breast cancer cases, are associated with aggressive histology, poor prognosis and shorter survival. Osteopontin is a chemokine-like phosphorylated glycoprotein that plays important role in cancer progression and is found to be a metastasis-associated protein in breast cancer. The goal of the study was to evaluate osteopontin protein expression levels in triple-negative breast carcinomas to determine if they correlated with clinicopathological parameters, thus providing additional support for osteopontin functioning and better understanding of triple-negative breast cancer.

MATERIALS AND METHODS

A database of 239 patients, in whom all three markers (ER, PR, and HER-2/neu) were available, was reviewed. We performed osteopontin protein expression analyses by means of immunohistochemistry on 117 breast carcinoma tissue samples, and then assessed the mean value of osteopontin expression against triple-negative status and clinicopathological parameters.

RESULTS

Of the 239 patients in the study, 47 were classified as triple negative. Of the 117 osteopontin-test patients in this cohort, mean osteopontin levels were significantly higher in the triple-negative breast cancers than in non-triple-negative subtype (P = 0.035). TNM (tumours, nodes, metastases) stage were significantly associated with osteopontin levels (P = 0.038). Univariate analysis showed tumour cell osteopontin positivity above an optimized cut-point to be significantly associated with decreased disease-free survival, but not overall survival. In the multivariate model, osteopontin was an independent prognostic factor for disease-free survival.

CONCLUSIONS

Patients with osteopontin overexpression develop predominantly triple-negative tumours. Osteopontin overexpression is associated with tumour aggressiveness and poor prognosis.

Dendritic cell vaccination induces tumor epitope-specific Th1 immune response in medullary thyroid carcinoma

The existence of inherited aggressive forms of medullary thyroid carcinoma (MTC) and their resistance to classical therapies make it a prime candidate for adoptive immunotherapy. Highly potent antigen-presenting cells, namely dendritic cells (DCs), may serve as an interesting tool for anticancer vaccination. Here we report on the IN VITRO findings of a vaccination trial in five MTC patients, who were treated with a new DC generation protocol consisting of granulocyte-macrophage colony-stimulating factor and interferon-alpha (IFN-DCs). These cells were pulsed with tumor-specific calcitonin and administered twice. In two patients who responded to therapy we found a large increase (in mean 2.9+/-1.9%) of antigen-specific IFN-gamma-secreting CD4+ cells as well as an increase of granzyme B positive CD8+ cells (mean 2.2+/-0.2%) in the peripheral blood. In parallel, a decrease of CD4+/CD25+/FoxP3+ regulatory T cells was seen. Importantly, IN VITRO stimulation of PBMC with 10 different 15mer calcitonin peptides resulted in the identification of two HLA class II epitope regions within the central part of full-length calcitonin. These data were in accordance with the results drawn from the computer-based algorithm epitope prediction software SYFPEITHI. Measurement of different pro- and anti-angiogenic factors did not allow for a distinct outcome of prediction of the treated patients. In summary, we have demonstrated that immunization with IFN-DCs leads to a tumor epitope-specific immune response in MTC patients and may, therefore, represent a promising tool for future vaccination trials.

The emotional state of the patient after total hip and knee arthroplasty

The new processes of total hip and knee arthroplasty partly engendered by mini-incision surgery have helped patients achieve all three goals of their operation: pain relief, improvement in function, and satisfaction. Satisfaction means the patient is no longer self-conscious about their disability and has regained the ability to live in their world in their usual way. The emotional state of the patient preoperatively, in the hospital, and during recovery will affect their feeling of satisfaction. Proper preoperative education makes patients more optimistic, and they anticipate fewer problems. In the hospital, a multimodal pain management program limits the use of parenteral narcotics and avoids the side effects of nausea and vomiting, which is the most important factor for in-hospital satisfaction. Recovery with an active physical therapy program individualized for the abilities and goals of the patient improves function and satisfaction. Surgeons must understand the expectations of the patient, direct them to realistic goals, and use the new processes of patient care to allow patients to exceed their expectations.

Kallikrein-kinin system in inflammatory bowel diseases: Intestinal involvement and correlation with the degree of tissue inflammation

BACKGROUND

Tissue kallikrein and its natural inhibitor, kallistatin, play opposite roles in the generation of bradykinin, a potent mediator of inflammation. Observations on experimental models and humans with ulcerative colitis suggest a pathogenetic role of the kallikrein-kinin system in inflammatory bowel diseases.

AIM

To evaluate tissue kallikrein and kallistatin in intestinal tissue samples from Crohn's disease and ulcerative colitis patients with different degrees of disease involvement.

PATIENTS AND METHODS

Full-thickness surgical intestinal samples were obtained from 144 subjects (38 normal controls, 32 inflammatory controls, 38 Crohn's disease, 36 ulcerative colitis) and tested for kallikrein and kallistatin by immunoperoxidase techniques.

RESULTS

Compared with controls, kallikrein immunoreactivity was significantly weaker in goblet cells (p=0.0001) and significantly stronger in interstitium (p=0.0001) of the Crohn's disease and ulcerative colitis samples. Kallistatin colocalised with kallikrein, with almost no reactivity in goblet cells but strong reactivity in interstitium of inflammatory bowel disease patients (p=0.0001 versus controls). The kallikrein and kallistatin depletion of goblet cells and the increased interstitial kallikrein and kallistatin reactivity correlated with the degree of tissue inflammation (p=0.0001). Disease-free samples had normal kallikrein and kallistatin patterns.

CONCLUSIONS

Kallikrein-kinin system is actively involved in inflammatory bowel disease as a result of the release of kallikrein in the intestinal extracellular space; this involvement correlates with the degree of tissue inflammation. The normal pattern observed in the disease-free samples seems to rule out a genetic defect of kallikrein and kallistatin in inflammatory bowel diseases.

Relationship between the regulatory region polymorphism of human tissue kallikrein gene and essential hypertension

Ten alleles with length and nucleotide sequence variations were identified in the regulatory region of human tissue kallikrein gene. This present study aimed to study the polymorphisms of the regulatory region of human tissue kallikrein gene of the Chinese and investigate the relationship of the polymorphisms with essential hypertension. A case-control study was conducted in 200 hypertensive and 200 normotensive subjects of unrelated Chinese Han origin. All subjects were aged from 30 to 70 years and had no history of diabetes mellitus, kidney failure, or thyroid gland disease. The alleles were detected by polymerase chain reaction (PCR) and genotyping was performed with allele-specific oligonucleotide analysis (ASO). Data from the essential hypertensive and control subjects were statistically analysed by the Student's t-test and chi2-test. The age- and gender-matching of the groups were accurate. The case group and the control group were in Hardy-Weinberg equilibrium at this locus (cases, P=0.313; control subjects, P=0.457). There were nine alleles among the case and control groups, and the allele frequencies were found to be significantly different between cases and controls (chi2=25.701, P<0.001). The genotype frequencies were also significantly different (chi2=70.100, P<0.001) between these two groups. In conclusion, there are polymorphisms in the regulatory region of human tissue kallikrein gene in the Chinese Han people. Differences in both allele frequencies and genotype frequencies between these two groups have provided evidence towards the association of hypertension with the polymorphisms in this studied site.

Recombinant adeno-associated virus-mediated kallikrein gene therapy reduces hypertension and attenuates its cardiovascular injuries

Gene therapy of hypertension requires long-term expression of a therapeutic gene to achieve stable reduction of blood pressure. Human tissue kallikrein (HK) cleaves kininogen to produce a potent vasoactive peptide kinin, which plays an important role in the regulation of the cardiovascular and renal functions. In the present study, we have delivered human kallikrein cDNA with an rAAV vector to explore the potential therapeutic effects of kallikrein on hypertension and related secondary complications. A single tail vein injection of the rAAV-HK vector into the adult spontaneously hypertensive rats resulted in a significant reduction (12.0+/-2.55 mmHg, P<0.05, n=6, ANOVA) of the systolic blood pressure from 2 weeks after vector injection, when compared with the control rAAV-lacZ vector-injected rats. Weekly blood pressure monitoring showed stable hypertension-reduction effect throughout the course of the 20-week experiments. In addition, total urine microalbumin contents decreased as a result of rAAV-HK treatment. Histological analysis of various tissues showed remarkable amelioration of cardiovascular hypertrophy, renal injury and collagen depositions in the rAAV-treated group. Finally, persistent expression of the transgene product HK was confirmed by the enzyme-linked immunosorbent assay and reverse transcription-polymerase chain reaction. We conclude that rAAV-mediated HK delivery rendered a long-term and stable reduction of hypertension and protected against renal injury, cardiac remodeling in the spontaneously hypertensive rat model. Further studies are warranted for the development of a gene therapy strategy for human hypertension.