[Treatment strategy for early stage rectal cancer (T1 carcinoma)]. / Therapeutische Strategie bei Frühkarzinomen im Rektum (T1­Karzinom).

BACKROUND: A common consensus for the definition for early rectal cancer does not exist. This item is used in cases of histological findings including pTis, pT1 or pT2 tumors. The term early rectal cancer is not mentioned in the German S3 guidelines on colorectal cancer. The pTis tumors are located at the mucosa level of the intestinal wall and they have nearly no tendency to develop metastases but pT2 tumors have a high risk of local metastases; therefore, the term early rectal cancer is not adequate for pT2 tumors. OBJECTIVE: This focus of this article is exclusively on pT1 rectal cancer. Following the histological definition, pT1 tumors of the rectum are located at the level of the mucosa and submucosa of the intestinal wall. CONCLUSION: With respect to the nature of the tumor (e.g. size, grading, invasion of lymphatic and/or blood vessels, Kikuchi classification) local methods (endoscopic procedure, surgical techniques) or radical resections are recommended. Tumor budding is of increasing interest and importance. Depending on the severity of the tumor budding classification (bd1-bd3) there is an association with a more frequent occurrence of lymph node metastases and should therefore be taken into consideration in treatment decisions in the future.

Management of rectourinary fistula after urological interventions using biodesigned mesh: first experiences of an innovative technique.

PURPOSE: Rectourinary fistula (RUF) is an uncommon but devastating condition that usually occurs as a complication of surgical treatment or radiotherapy of prostate cancer. Although operative fistula repair remains the most successful treatment, there still is no consensus concerning the management of RUF. We present first experiences and transanal surgical technique using biological mesh for fistula repair after urological intervention. MATERIAL AND METHODS: From January 2009 to December 2013, four cases of RUF were reported at our university hospital. Fistula occurred after extraperitoneal laparoscopic radical prostatectomy, open radical prostatectomy, and high-intensity focused ultrasound, respectively. All patients were initially treated with transanal Cook Biodesign™ mesh, whereas two patients received reoperation with rectal mucosa advancement flap and gracilis muscle flap interposition, respectively. Mean follow-up was 36 months (range 9-62). RESULTS: Fistula diameters ranged from 0.6 to 3.0 cm and were located 5 to 6 cm of anocutaneous line. The time from diagnosis to fistula repair was 3 to 7 weeks. The median operative time for Cook Biodesing™ mesh procedure was 79 min (IQR 60, 98). The initial success rate for biological mesh was 50 % (2/4 patients). Larger fistulae were minimalized successfully and finally closed with reoperation mentioned above. No deterioration of continence was documented. CONCLUSIONS: Management of rectourinary fistula is still challenging. Using biomaterials for fistula closure seems to be a promising and minimally invasive transanal technique in future. Further analysis including more patients is needed to clarify its exact role in comparison to traditional surgical techniques.

[Memorandum 'Development of health services research in Bavaria from the perspective of the Bavarian State Working Group 'Health Services Research (LAGeV)': status quo - potential - strategies']. / Memorandum "Weiterentwicklung der Gesundheitsversorgungsforschung in Bayern aus Sicht der Landesarbeitsgemeinschaft Gesundheitsversorgungsforschung: Status quo - Entwicklungspotenziale - Strategien".

The aim of the memorandum on the development of health services research (HSR) in Bavaria is to operationalise the global objectives of the State Working Group "Health Services Research" (LAGeV) and to collectively define future topics, specific implementation steps, methods as well as ways of working for the future course of the LAGeV. The LAGeV is an expert committee that integrates and links the competencies of different actors from science, politics and health care regarding HSR and facilitates their cooperation. The memorandum is based on an explorative survey among the LAGeV members, which identified the status quo of health services research in Bavaria, potential for development, important constraints, promoting factors, specific recommendations as well as future topics for the further development of HSR in Bavaria. From the perspective of the LAGeV members, the 12 most important future topics are: 1) Interface and networking research, 2) Innovative health care concepts, 3) Health care for multimorbid patients, 4)Health care for chronically ill patients, 5) Evaluation of innovations, processes and technologies, 6) Patient orientation and user focus, 7) Social and regional inequalities in health care, 8) Health care for mentally ill patients, 9) Indicators of health care quality, 10) Regional needs planning, 11) Practical effectiveness of HSR and 12) Scientific use of routine data. Potential for development of HSR in Bavaria lies a) in the promotion of networking and sustainable structures, b) the establishment of an HSR information platform that bundles information and results in regard to current topics and aims to facilitate cooperation as well as c) in the initiation of measures and projects. The latter ought to pinpoint health care challenges and make recommendations regarding the improvement of health care and its quality. The cooperation and networking structures that were established with the LAGeV should be continuously expanded and be used to work on priority topics in order to achieve the global objectives of the LAGeV.

[Scientific evidence for laparoscopic rectal cancer surgery]. / Evidenzlage der laparoskopischen Chirurgie beim Rektumkarzinom.

BACKGROUND: Innovative surgical techniques in colorectal surgery aim to provide diminished surgical injury and at least equivalent or even improved quality of treatment and oncological results. High level clinical studies are mandatory to examine the feasibility and advantages (or disadvantages) of new operative techniques. OBJECTIVES: Laparoscopic colonic resection for cancer has been investigated with respect to safety and oncological quality in various prospective randomized studies (COST study, COLOR-I and CLASICC). The minimally invasive procedure is feasible and safe which was demonstrated in many studies but can these results be extrapolated to laparoscopic rectal cancer surgery? RESULTS: The short term outcomes of the COLOR-II trial were published recently and laparoscopic resection for rectal cancer was not found to be inferior compared to open resection. Recovery after laparoscopic surgery was better than after open surgery. Laparoscopic surgery was found to have significant advantages with respect to blood loss, operating time, use of pain medication, early restoration of bowel function and reduction of hospital stay as well as the lateral safety margins in the distal third of the rectum. The long-term results focussing on local recurrence showed a positive trend in favor of laparoscopic rectal surgery and will be published shortly. CONCLUSION: Laparoscopic total mesorectal excision (TME) appears to have clinically measurable short-term advantages in patients with primary rectal cancer based on the evidence of randomized studies. Laparoscopic rectal cancer resection may become the gold standard in the future.

Endothelial lipase releases saturated and unsaturated fatty acids of high density lipoprotein phosphatidylcholine.

We assessed the ability of endothelial lipase (EL) to hydrolyze the sn-1 and sn-2 fatty acids (FAs) from HDL phosphatidylcholine. For this purpose, reconstituted discoidal HDLs (rHDLs) that contained free cholesterol, apolipoprotein A-I, and either 1-palmitoyl-2-oleoylphosphatidylcholine, 1-palmitoyl-2-linoleoylphosphatidylcholine, or 1-palmitoyl-2-arachidonylphosphatidylcholine were incubated with EL- and control (LacZ)-conditioned media. Gas chromatography analysis of the reaction mixtures revealed that both the sn-1 (16:0) and sn-2 (18:1, 18:2, and 20:4) FAs were liberated by EL. The higher rate of sn-1 FA cleavage compared with sn-2 FA release generated corresponding sn-2 acyl lyso-species as determined by MS analysis. EL failed to release sn-2 FA from rHDLs containing 1-O-1'-hexadecenyl-2-arachidonoylphosphatidylcholine, whose sn-1 position contained a nonhydrolyzable alkyl ether linkage. The lack of phospholipase A(2) activity of EL and its ability to liberate [(14)C]FA from [(14)C]lysophosphatidylcholine (lyso-PC) led us to conclude that EL-mediated deacylation of phosphatidylcholine (PC) is initiated at the sn-1 position, followed by the release of the remaining FA from the lyso-PC intermediate. Thin-layer chromatography analysis of cellular lipids obtained from EL-overexpressing cells revealed a pronounced accumulation of [(14)C]phospholipid and [(14)C]triglyceride upon incubation with 1-palmitoyl-2-[1-(14)C]linoleoyl-PC-labeled HDL(3), indicating the ability of EL to supply cells with unsaturated FAs.

Intracellular distribution and mobilization of unesterified cholesterol in adipocytes: triglyceride droplets are surrounded by cholesterol-rich ER-like surface layer structures.

In addition to their central role in triglyceride storage, fat cells are a primary depot of unesterified cholesterol (FC) in the body. In comparison, peripheral cells contain very little FC. This difference in adipocytes versus peripheral tissues is inconsistent with the current theory of cholesterol homeostasis. Attempting to resolve this discrepancy, we examined intracellular storage sites of FC in murine 3T3-F442A adipocytes. Using the cholesterol-binding antibiotic, filipin, in combination with high resolution fluorescence microscopy, intense fluorescent staining characteristically decorated the periphery of triglyceride droplets (TGD) as well as the plasma membrane (PM) of fat cells. Filipin-staining was not visible inside the lipid droplets. Purification of TGD by subcellular fractionation demonstrated that the rise in total FC content of adipocytes upon differentiation was attributable to an increase in TGD-FC, which contributed up to one third of the total cellular FC. The protein component of purified TGD from cultured adipocytes as well as from murine adipocytes obtained from fresh tissues contained the lumenal endoplasmic reticulum (ER) immunoglobulin binding protein (BiP) and the integral ER membrane protein calnexin. Efflux experiments using the extracellular FC acceptors (&bgr;)-cyclodextrin or apolipoprotein A-I demonstrated that TGD-associated FC was releasable from TGD. Whereas FC efflux from adipocytes was unaffected in the presence of brefeldin A or monensin, the secretion of a control protein, lipoprotein lipase, was effectively reduced. In summary, our findings identify the TGD surface layer as primary intracellular storage site for FC within adipocytes. We suggest that the structural role of ER-resident proteins in this adipocyte TGD envelope has been previously neglected. Our findings support the suggestion that an ER-like structure, albeit of modified lipid composition, constitutes the lipid droplets' surface layer. Finally, the efflux process of FC from adipocytes upon extracellular stimulation with (beta)-cyclodextrin provides evidence for an energy-dependent intracellular trafficking route between the TGD-FC pool and the PM-FC sites which is distinct from the secretory pathway of proteins.

A single G to A nucleotide transition in exon IV of the lecithin: cholesterol acyltransferase (LCAT) gene results in an Arg140 to His substitution and causes LCAT-deficiency.

We have characterized the molecular defect causing lecithin:cholesterol acyltransferase (LCAT)-deficiency (LCAT-D) in the LCAT gene in three siblings of Austrian descent. The patients presented with typical symptoms including corneal opacity, hemolytic anemia, and kidney dysfunction. LCAT activities in the plasma of these three patients were undetectable. DNA sequence analysis of polymerase chain reaction (PCR)-amplified DNA of all six LCAT exons revealed a new point mutation in exon IV of the LCAT gene, i.e., a G to A substitution in codon 140 converting Arg to His. This mutation caused the loss of a cutting site for the restriction endonuclease HhaI within exon IV: Upon digestion of a 629-bp exon IV PCR product with HhaI, the patients were found to be homozygous for the mutation. Eight of 11 family members were identified as heterozygotes. Transfection studies of COS-7 cells with plasmids containing a wild-type or a mutant LCAT cDNA revealed that, in contrast to the cell medium containing wild-type enzyme, no enzyme activity was detectable upon expression of the mutant protein. This represents strong evidence for the causative nature of the observed mutation for LCAT deficiency in affected individuals and supports the conclusion that Arg140 is crucial for the structure of an enzymatically active LCAT protein.

A novel missense mutation in the gene for lipoprotein lipase resulting in a highly conservative amino acid substitution (Asp180-->Glu) causes familial chylomicronemia (type I hyperlipoproteinemia).

A previously undescribed single missense mutation (C-->G) was detected within exon 5 of the LPL gene in two members of an Italian family affected with type I hyperlipoproteinemia. This mutation causes a highly conservative amino acid replacement (Asp-->Glu) at position 180 of the mature LPL protein resulting in a virtual absence of LPL enzyme activity and LPL enzyme mass in postheparin plasma. Adipose tissue mRNA concentrations and mRNA sizes were not affected. Both patients were homozygous for the mutation, whereas the parents were heterozygous. Comparison of the expression of the mutated cDNA and the wildtype cDNA in cos-7 cells revealed proper transcription and translation of the mutated clone into an immunologically detectable protein. The mutated LPL protein was secreted from the cells in a manner similar to that of wild-type LPL and bound to heparin-Sepharose with identical properties. However, the mutated enzyme, in contrast to wildtype LPL, exhibited no detectable lipolytic activity against a triglyceride substrate. Our results demonstrate that even a highly conservative amino acid replacement outside the proposed active site of LPL is incompatible with proper enzyme function.

Bactericidal kinetics of various dosages of fleroxacin simulated in bacterial cultures.

From in-vitro data, recommendations for dosing with fleroxacin are presented. Serum pharmacokinetics of 250, 400, 500, 800, 1000 and 1500 mg once daily dosages were simulated in bacterial cultures. The bactericidal kinetics of clinical isolates of Escherichia coli, Pseudomonas aeruginosa and Staphylococcus aureus with MICs for fleroxacin similar to MIC90 or above were investigated. Bacterial populations of all strains with MICs equal to or below 2 mg/l were reduced by at least 99% by a once daily dosage of 400 mg of fleroxacin. 500 mg once per day was high enough to induce a two log reduction of P. aeruginosa MIC 4 mg/l. At a 250 mg dosing mutants with MICs four times above the MICs of the initial strains were selected. The increased concentrations of fleroxacin after multiple dosing enhanced bactericidal activity. Once daily dosing increased the initial rate of killing but reduced the extent of inactivation in comparison with twice daily dosing of the same total amount. From our in-vitro investigation a once daily dosage of 400 mg of fleroxacin should be effective against causative organisms with an MIC of up to 2 mg/l, both in the rate and extent of killing and to minimize the risk for selection of resistant mutants.

Microbiologic and therapeutic aspects of Staphylococcus aureus in cystic fibrosis patients.

Staphylococcus aureus was the most frequent (28.8%) gram-positive organism in 149 cystic fibrosis patients. Next to Pseudomonas aeruginosa, S. aureus was the most persistent bacterial pathogen as well. Persistence was not correlated to the age or sex of our patients. Colonization by S. aureus was not prevented completely by oral antibiotics like cotrimoxazole or oral cephalosporins. Persisting staphylococci were less susceptible to the antibiotic substances used than strains detectable only sporadically. Increase of sputum concentrations of P. aeruginosa was observed in episodes of treatment with purely antistaphylococcal compounds. Improvement of effectiveness of antibacterial therapy may be achievable by antibiotics more active against staphylococci, active both against staphylococci and P. aeruginosa, or adequate drug combinations.

Selective pressure of antistaphylococcal chemotherapeutics in favour of Pseudomonas aeruginosa in cystic fibrosis.

Pseudomonas aeruginosa is insensitive against the majority of oral chemotherapeutics active against staphylococci. During application of such compounds in patients colonized by P. aeruginosa the concentration of P. aeruginosa increased in the majority of treatment episodes by factors between 2.5 and 50000. So, from a microbiological point of view the application of purely antistaphylococcal drugs should not be used prophylactically against staphylococci.

Novel R-factor borne beta-lactamase of Escherichia coli confering resistance to cephalosporins.

Strains of Escherichia coli resistant to ceftazidime but susceptible to other third generation cephalosporins were detected in three patients at two different locations (München, Bremen). The resistance was self-transmissible to other E. coli strains. Resistance against ampicillin, kanamycin, chloramphenicol and sulfonamide was co-transferred. The isoelectric point (pI) of the beta-lactamase was similar to the pI of the AER-1 and LCR-1 beta-lactamases. These enzymes, however, do not confer resistance to ceftazidime. Therefore the beta-lactamase described is the first example for a ceftazidimase.

Serologic response to Candida albicans and Aspergillus fumigatus in cystic fibrosis.

In order to evaluate the role of fungi in patients with cystic fibrosis, we determined serum IgG antibodies against Candida albicans and Aspergillus fumigatus using an indirect ELISA in patients with or without fungi in the sputum and in sera of healthy individuals. For both C. albicans and A. fumigatus the antibody levels were significantly higher in the CF groups than in the control group, regardless of whether these fungi could be isolated during the observation time or not. In contrast to A. fumigatus, we found that in the majority of cases antibody levels increase significantly with the isolation of C. albicans from sputum. Therefore, we conclude that one has to pay more attention to C. albicans in CF patients. One must also particularly reevaluate long-term antibiotic treatment and look for means to prevent fungal recolonization and reinfection.

Qualitative and quantitative microbiological analysis of sputa of 102 patients with cystic fibrosis.

A microbiological analysis of 102 patients suffering from cystic fibrosis was conducted over a 22 month period. 20 microbial species with the following incidence were identified: Pseudomonas aeruginosa: 83.4%; Candida albicans: 29.4%; Staphylococcus aureus: 24.5%; Staphylococcus epidermidis: 11.8%; Haemophilus influenzae: 11.8%; Streptococcus pneumoniae; 6.9%; Pseudomonas maltophilia: 6.8%; Aspergillus fumigatus: 5.9%. Other species were present in less than 5% of the patients. In the majority of specimens with P. aeruginosa, more than one type (up to six) was detectable. These strains were identical in colony appearance, O-serotype and pyocin-type. Quantitative analysis revealed concentrations of colony-forming units of 10(7) to 10(9) for P. aeruginosa, 10(6) to 10(8) for P. maltophilia, 10(4) to 10(7) for S. aureus, 10(4) to 10(6) for S. epidermidis and 10(4) to 10(7) for C. albicans in the majority of specimens. Significant differences were observed in the time periods during which the pathogens persisted in the patients. Maximum persistence was observed for P. aeruginosa. P. maltophilia and A. fumigatus had about similar persistence rates, which were lower than those for P. aeruginosa but above those for S. aureus and H. influenzae. S. epidermidis was eliminated within shorter periods than S. aureus. C. albicans, although the second most frequent microorganism identified, showed a very low persistence rate. The microbiological analysis confirms results from other research centers (high incidence of P. aeruginosa), but reveals significant regional differences as well (Pseudomonas cepacia not detectable, higher incidence of P. maltophilia and C. albicans). This underlines the necessity for detailed qualitative and quantitative microbiological analysis of sputa from cystic fibrosis patients as a prerequisite for rational analysis of etiological, epidemiological and therapeutical aspects of cystic fibrosis.

Microbiological perspectives of co-trimoxazole.

Trimethoprim-sulfamethoxazole in vitro activity was compared with ampicillin, tetracycline, sulfonamide and trimethoprim against isolates of 24 gram-negative and 11 gram-positive species. The incidence of more than 10% of strains with minimal inhibitory concentrations above 32 mg/l was restricted to Escherichia coli, Shigella spp., Klebsiella pneumoniae, Providencia rettgeri, Morganella morganii, methicillin-resistant Staphylococcus aureus and Staphylococcus epidermidis. Occasionally, Streptococcus pneumoniae and Haemophilus influenzae strains with MICs above 32 mg/l were identified. Co-trimoxazole in vitro activity was superior to the comparative drugs for the majority of species. Co-trimoxazole remains an active combination against major pathogens of infections of the upper and lower respiratory, urinary tract and enteric infections with a still low incidence of resistant organisms.

Bacteriological effects of anti-Pseudomonas aeruginosa chemotherapy in cystic fibrosis.

Strains of Pseudomonas aeruginosa resistant to clinically relevant antibiotics (beta-lactams, quinolones, aminoglycosides) were detectable in sputa of cystic fibrosis patients. Correlations between in vitro susceptibility and bacteriological results in vivo were demonstrated at a quantitative level. P. aeruginosa strains susceptible prior to antibiotic therapy were observed to become resistant towards each of the compounds used for treatment. We conclude that antibiotic therapy in cystic fibrosis has to be optimized by culture specific selection of the drugs and consecutive bacteriological follow-ups.

[Imipenem resistance in Pseudomonas aeruginosa]. / Imipenem-Resistenz bei Pseudomonas aeruginosa.

Mutants of P. aeruginosa resistant to imipenem can be selected at high frequency in vitro. They remain susceptible to other beta-lactams. Strains resistant both against imipenem and other beta-lactams are, however, detectable in vitro and in vivo. Imipenem-resistant strains appeared in blood cultures and emergence of IMI-resistance during therapy has been observed. The activity of other beta-lactams against P. aeruginosa is antagonized in the presence of IMI, because of beta-lactamase induction by imipenem. In addition to the risk of emergence of IMI-resistance of P. aeruginosa during therapy, there is an increasing incidence of IMI-resistant strains already existing prior to therapy. In the treatment of infections caused by P. aeruginosa combination therapy including a non-beta-lactam antibiotic active against the pathogen is indicated.

Changes in microbial ecology by therapeutic use of aminoglycosides.

Alterations in microbial ecology caused by the usage of aminoglycosides for therapy of human infections are due to their selective pressure favouring insensitive or resistant species or strains. There is a positive correlation between aminoglycoside consumption and the incidence of resistance to aminoglycosides. This correlation is, however, modified by measures of infection control. At the present time, the overall incidence of resistance to aminoglycosides does not show major changes. The ecological impacts of aminoglycoside consumption appear to be less significant as compared to other antibiotics due to factors specific for the aminoglycoside group.