A multicentre, prospective, observational cohort study of variation in practice in perioperative analgesia strategies in elective laparoscopic colorectal surgery (the LapCoGesic study).

INTRODUCTION: Enhanced recovery programmes are established as an essential part of laparoscopic colorectal surgery. Optimal pain management is central to the success of an enhanced recovery programme and is acknowledged to be an important patient reported outcome measure. A variety of analgesia strategies are employed in elective laparoscopic colorectal surgery ranging from patient-controlled analgesia to local anaesthetic wound infiltration catheters. However, there is little evidence regarding the optimal analgesia strategy in this cohort of patients. The LapCoGesic study aimed to explore differences in analgesia strategies employed for patients undergoing elective laparoscopic colorectal surgery and to assess whether this variation in practice has an impact on patient-reported and clinical outcomes. MATERIALS AND METHODS: A prospective, multicentre, observational cohort study of consecutive patients undergoing elective laparoscopic colorectal resection was undertaken over a two-month period. The primary outcome measure was postoperative pain scores at 24 hours. Data analysis was conducted using SPSS version 22. RESULTS: A total of 103 patients undergoing elective laparoscopic colorectal surgery were included in the study. Thoracic epidural was used in 4 (3.9%) patients, spinal diamorphine in 56 (54.4%) patients and patient-controlled analgesia in 77 (74.8%) patients. The use of thoracic epidural and spinal diamorphine were associated with lower pain scores on day 1 postoperatively (P < 0.05). The use of patient-controlled analgesia was associated with significantly higher postoperative pain scores and pain severity. DISCUSSION: Postoperative pain is managed in a variable manner in patients undergoing elective colorectal surgery, which has an impact on patient reported outcomes of pain scores and pain severity.

Perforated diverticulitis: To anastomose or not to anastomose? A systematic review and meta-analysis.

BACKGROUND: No consensus has been reached in the management of perforated diverticulitis. Many surgeons opt for a Hartmann's procedure to avoid the risk of an anastomotic leak. We hypothesise that resection with primary anastomosis is a safe alternative in selected patients. We aim to conduct a systematic review and meta-analysis on the available literature. METHODS: Studies that compared emergency Hartmann's with primary anastomosis in perforated left sided colonic diverticulitis were systematically reviewed. The search strategy included all study types that compared primary anastomosis to Hartmann's in perforated diverticulitis and reported on morbidity and mortality. 5 databases (PubMed, MEDLINE via PubMed, OVID, EMBASE via OVID and The Cochrane Collaboration). The Cochrane's Bias Methods Group tool was used to assess the risk of bias and a meta-analysis of the relevant studies was conducted. RESULTS: The review retrieved 1933 abstracts of which 14 studies (2 RCTs, 4 prospective non-randomised and 8 retrospective non-randomised) with 765 patients in total, 482 in the Hartmann's group and 283 in the primary anastomosis group, met the inclusion criteria. This showed a significantly lower mortality with primary anastomosis (10.6%) compared to Hartmann's (20.7%) (p = 0.0003). Morbidity was also significantly lower (41.8% vs. 51.2%) (p = 0.0483). The RR for mortality was 0.92 in favour of primary anastomosis (p = 0.0019). The average anastomotic leak rate was 5.9%. CONCLUSION: Resection and primary anastomosis should be considered as a feasible and safe operative strategy in selected patients with perforated diverticulitis. There is however a paucity of high level evidence and further research is needed.

Inotropic agents use in patients hospitalized with acute decompensated heart failure: a retrospective analysis from a 22-year registry in a Middle-Eastern Country (1991-2013).

BACKGROUND: Data about the use of positive inotropic agents in patients hospitalized with acute decompensated heart failure (ADHF) is limited. METHODS: The records of 8066 patients with ADHF who were hospitalized at Hamad Medical Corporation, Qatar from 1991 to 2013 were analyzed to explore demographics and clinical characteristics of the patients according to inotropic agents use. RESULTS: Eight hundred fifty eight patients [10.6%, 95% CI (10 to 11.3%)] received intravenous inotropic support. Patients receiving inotropes were more likely to be female and have preserved ejection fraction when compared to those not receiving inotropic agents. Comorbidities associated with higher likelihood of receiving inotropic treatment included acute myocardial infarction, chronic renal impairment, dyslipidemia, hypertension, obesity and hyperglycemia. Patient on inotropes were more likely to undergone percutaneous coronary intervention (PCI), intra-aortic balloon pump support and intubation. There were no differences in the mean plasma BNP and CK-MB levels between the 2 groups. Heart failure patients receiving inotropes also were more likely to have complications including ventricular tachycardia (2.0% vs. 0.9%, p = 0.003), prolonged hospital stay (8.0 vs. 5.0 days, p = 0.001), cardiac arrest (14.6% vs. 3.2%, p = 0.001) and in-hospital mortality (30.8% vs. 9.1 %, p = 0.001). Over the study period there was an increase use of inotropic agents and decreased mortality rates. CONCLUSION: Inotropic use increased over the period whereas; female gender and conventional cardiac risk factors were predictors of inotropic agents use in the study.

Pre-operative gastric emptying time correlates with clinical response to gastric electrical stimulation in the treatment of gastroparesis.

BACKGROUND: Gastric electrical stimulation (GES) may be of benefit in cases of gastroparesis that fail to respond to standard medical therapy. Response to this treatment is varied and prediction of clinical improvement is difficult. METHODS: This was a retrospective review and symptom questionnaire survey for all patients who underwent GES insertion in a single institution from November 2008 until May 2010 using the gastroparesis cardinal symptom index (GCSI). RESULTS: 14 out of 17 patients who had GES insertion responded to telephone or postal questionnaire. Mean pre-operative gastric emptying time was 151 min (median 146 min, range 18-318). Median follow up was 14 months (range 7-25 months). The mean reduction in GCSI score after GES insertion was 51% (13.4 vs 6.4, Z = 0.0013). Percentage reduction in GCSI correlated with pre-operative solid gastric emptying time (p = 0.0086). Two patients who responded to questionnaire required device removal, one due to a gastric perforation and the other for discomfort related to the implant and a poor clinical response. CONCLUSIONS: GES significantly improves symptoms of gastroparesis on the GCSI score. Not all patients respond equally to GES, and response may be predicted by pre-operative solid gastric emptying times.

The case of the forgotten toothbrush.

INTRODUCTION: Although foreign body ingestion is relatively common, toothbrush swallowing is rare. A diagnosis of small-bowel perforation, caused by a sharp or pointed foreign body, is rarely made preoperatively because the clinical symptoms are usually nonspecific and can mimic other surgical conditions, such as appendicitis and diverticulitis. PRESENTATION OF CASE: We report a case of a swallowed toothbrush which passed past the pylorus and perforated the terminal ileum. The patient however presented with a fluctuant mass in the left iliac fossa, pyrexia and generalised tenderness mimicking a diverticular abscess. DISCUSSION: Ingestion of a foreign body is commonly encountered in the clinic among children, adults with intellectual impairment, psychiatric illness or alcoholism, and dental prosthetic-wearing elderly subjects. However, toothbrush swallowing is rare, with only approximately 40 reported cases. CONCLUSION: Bowel perforation by foreign bodies can mimic acute appendicitis and should be considered in differential diagnoses. Clinically, patients often do not recall ingesting the foreign body, which makes the clinical diagnosis more challenging, and a correct diagnosis is frequently delayed. Several radiological investigations, such as small-bowel series, ultrasonography, and computed tomography scans, may lead to the correct diagnosis, but in most patients, the diagnosis is not confirmed until the surgical intervention has been performed.

Human Th1 cell lines recognize the Mycobacterium tuberculosis ESAT-6 antigen and its peptides in association with frequently expressed HLA class II molecules.

We have used a synthetic-peptide approach to map epitope regions of the Mycobacterium tuberculosis ESAT-6 antigen recognized by human T cells in relation to major histocompatibility complex (MHC) restriction. ESAT-6-specific CD4+ T-cell lines were established by stimulating peripheral blood mononuclear cells from 25 HLA-DR-typed tuberculosis patients with complete antigen in vitro. The established T-cell lines were then screened for proliferation and interferon-gamma (IFN-gamma) secretion in response to eight overlapping 20-mer peptides covering the ESAT-6 sequence. The response of the T-cell lines to ESAT-6 and peptides from a human leucocyte antigen (HLA)-heterogeneous group of donors suggested the presence of multiple epitopes and promiscuous recognition of the antigen. Analysis of antigen and peptide recognition in the presence of anti-HLA class I and class II antibodies suggested that the T-cell lines recognized ESAT-6 in association with HLA-DR and -DQ molecules. Furthermore, testing of selected T-cell lines with ESAT-6 and the peptides in the presence of autologous and allogeneic HLA-DR- and -DQ-typed antigen-presenting cells identified HLA-DR2, -DR52 and -DQ2 amongst the HLA molecules involved in the presentation of ESAT-6 and its peptides to human Th1 cells. In addition, the T-cell lines were cytotoxic for monocytes and macrophages pulsed with ESAT-6 and peptides. In conclusion, the recognition of ESAT-6 by IFN-gamma-secreting and cytotoxic CD4+ T cells in association with frequently expressed HLA class II molecules supports the application of this antigen to either specific diagnosis or subunit vaccine design.

Immunogenicity of Mycobacterium tuberculosis RD1 region gene products in infected cattle.

Current immuno-diagnostic tests for the detection of Mycobacterium bovis infection in cattle rely on the use of tuberculin PPD as antigens. However, the use of a cattle vaccine is effectively prohibited because BCG, the only potentially available cattle TB vaccine, compromises the current tuberculin test. The main objective of this study was to identify specific antigens, which could increase the test sensitivity to levels achieved with tuberculin. Our approach utilized the availability of the genome sequences of Mycobacterium tuberculosis and BCG by applying principles of comparative genomics to the identification of species-specific antigens. Eight open-reading frames (Rv3871 to Rv3878) encoding for putative antigens in the RD1 region of the M. tuberculosis genome, which is deleted in all strains of BCG, were selected and screened in the form of pools of synthetic peptides for immunological reactivity (antigen induced proliferation and IFN-gamma secretion) with peripheral blood mononuclear cells from cattle experimentally infected with M. bovis. Our results confirm the immunodominant role of two RD1 region products, CFP-10 (Rv3874) and ESAT-6 (Rv3875). In addition, we were able to identify 3 more antigens (Rv3871, Rv3872 and Rv3873), which induced immunological reactivity in PBMC from more than 50%M. bovis of infected cattle.

Identification and HLA restriction of naturally derived Th1-cell epitopes from the secreted Mycobacterium tuberculosis antigen 85B recognized by antigen-specific human CD4(+) T-cell lines.

Antigen 85B (Ag85B/MPT59) is a major secreted protein from Mycobacterium tuberculosis which is a promising candidate antigen for inclusion in novel subunit vaccines against tuberculosis (TB). The present study was undertaken to map naturally derived T-cell epitopes from M. tuberculosis Ag85B in relation to major histocompatibility complex (MHC) class II restriction. Antigen-specific CD4(+) T-cell lines were established from HLA-typed TB patients and Mycobacterium bovis BCG vaccinees by stimulation of peripheral blood mononuclear cells with purified Ag85B in vitro. The established T-cell lines were then tested for proliferation and gamma interferon (IFN-gamma) secretion in response to 31 overlapping synthetic peptides (18-mers) covering the entire sequence of the mature protein. The results showed that the epitopes recognized by T-cell lines from TB patients were scattered throughout the Ag85B sequence whereas the epitopes recognized by T-cell lines from BCG vaccinees were located toward the N-terminal part of the antigen. The T-cell epitopes represented by peptides p2 (amino acids [aa] 10 to 27), p3 (aa 19 to 36), and p11 (aa 91 to 108) were frequently recognized by antigen-specific T-cell lines from BCG vaccinees in both proliferation and IFN-gamma assays. MHC restriction analysis demonstrated that individual T-cell lines specifically recognized the complete Ag85B either in association with one of the self HLA-DRB1, DRB3, or DRB4 gene products or nonspecifically in a promiscuous manner. At the epitope level, panel studies showed that peptides p2, p3, and p11 were presented to T cells by HLA-DR-matched as well as mismatched allogeneic antigen-presenting cells, thus representing promiscuous epitopes. The identification of naturally derived peptide epitopes from the M. tuberculosis Ag85B presented to Th1 cells in the context of multiple HLA-DR molecules strongly supports the relevance of this antigen to subunit vaccine design.

Multiple epitopes from the Mycobacterium tuberculosis ESAT-6 antigen are recognized by antigen-specific human T cell lines.

A synthetic-peptide approach was used to map epitope regions of the Mycobacterium tuberculosis 6-kDa early secreted antigen target (ESAT-6) by testing human CD4(+) T cell lines for secretion of IFN-gamma in response to recombinant ESAT-6 (rESAT-6) and overlapping 20-mer peptides covering the antigen sequence. The results demonstrate that all of the ESAT-6 peptides screened were able to induce IFN-gamma secretion from one or more of the T cell lines tested. Some of the individual T cell lines showed the capacity to respond to all peptides. Human leukocyte antigen (HLA-DR) typing of the donors showed that rESAT-6 was presented to T cells in association with multiple HLA-DR molecules. The results suggest that frequent recognition of the M. tuberculosis ESAT-6 antigen by T cells from patients with tuberculosis is due to the presence of multiple epitopes scattered throughout the ESAT-6 sequence.

In vitro inhibition of human malignant brain tumour cell line proliferation by anti-urokinase-type plasminogen activator monoclonal antibodies.

A brain tumour-associated marker, urokinase (UK), was investigated using rabbit anti-UK polyclonal and murine anti-UK monoclonal antibodies, which were prepared by immunization with low molecular weight UK (LMW-UK) and high molecular weight urokinase (HMW-UK) synthetic peptide respectively. The polyclonal antibody cross-reacted with both LMW-UK and HMW-UK, whereas the murine MAbs were specific for HMW-UK. These immunological probes were used to study urokinase in glioma extracts, tissues, sera and cell lines that had been prepared from primary cultures of freshly dissected gliomas. Radioimmunoassays showed that glioma extracts had much higher level (5- to 44-fold) of UK than normal human brain extracts. This result was confirmed by immunoblotting of electrophoresis gels of glioma and human brain extracts. Immunohistochemical study using anti-UK MAb demonstrated much higher levels of UK in glioma tissue than normal brain tissue. Immunohistochemical study using anti-UK MAbs localized UK on the cell surface of glioma cells. Anti-UK MAbs inhibited the proliferation of AA cell lines and GB cell lines (50% to > 90%) and exerted minor effects (< or = 20%) on normal human liver, intestine and lymphocyte cell lines. Taken together, these results suggest that anti-UK MAbs may have therapeutic potential for human gliomas and cancer metastasis.

Human glioma associated intermediate filament proteins: over-expression, co-localization and cross-reactivity.

The identification of human brain tumor-associated markers could facilitate the development of new diagnostic and therapeutic strategies for these malignancies. The type III intermediate filament proteins (IFPs): vimentin, desmin and glial fibrillary acidic protein (GFAP) were studied in human glioma tissue extracts, in sera from glioma patients and in low passage glioma cell lines prepared from primary cultures of freshly dissected tumors. Radioimmunoassay (RIA) studies, using anti-GFAP, anti-desmin and anti-vimentin mAbs, showed high levels of these proteins in glioma extracts. Binding studies with authentic IFPs indicated the absence of circulating antibodies against these proteins in the sera of glioma patients. On the other hand, these sera showed high levels of vimentin. Binding studies with these antibodies using RIAs and western immunoblotting, showed that while anti-GFAF mAbs were specific to GFAP, anti-desmin mAb cross-reacted completely with GFAP, anti-vimentin mAb cross-reacted substantially with desmin and GFAP. Immunofluorescence staining of frozen sections revealed high levels of neurofilaments in gliomas and strikingly low levels in normal brain tissue. Double immunofluorescence staining showed co-occurrence of all three IFPs in the same filaments. This suggests either co-expression or cross-reactivity of these proteins due to their high degree of homology. Thus, caution should be exercised in the use and interpretation of immunohistochemical data using antibodies to IFs.

Paucity of humoral response in patients to glioma-associated antigen(s): antigen localization by immunofluorescence.

Xenogeneic immunization of freshly-prepared human glioma extracts into goats has yielded a polyclonal antiserum, which after multiple absorptions specifically identifies antigenic entities only in glioma extracts, and not in appropriate controls, both by radioimmunoassays (RIAs) and Western immunoblots. The results from the absorbed polyclonal antiserum have been confirmed by the successful generation of six stable murine monoclonal antibodies (MAbs) which recognize a subset of the same antigens with high specificity on immunoblots and with no apparent cross-reactivities by RIA to normal brain, serum, liver, muscle, kidney, spleen, or melanoma tissues. Moreover, the tested murine MAbs (B12C4) reveal a striking and abundant glial filament protein, possibly related to glial fibrillary acidic protein (GFAP) or other intermediate filament proteins, by frozen-section immunofluorescence. This is seen only in gliomas and is absent, or dramatically reduced, in normal human cortex. Use of potent immortalizing strain (FF41) of Epstein-Barr virus (EBV) to establish antibody-secreting human lymphoblastoid lines, and the generation of mouse-human chimeric fusions, have yielded lines possessing variable supernatant human antibody secretion. Radioimmunoassays using culture supernatants, and sera from glioma patients and an normal individual, have demonstrated surprisingly similar reactivity profiles, even after a sensitive sandwich RIA employing the B6C6 murine MAb. These results suggest that, although human glioma-associated antigens, including possibly the up-regulation of GFAP expression, clearly exist, there seems to be a muted humoral response as evidenced by a paucity of tumor-specific B-cells. This may be due to antigenic shielding by the blood-brain barrier, or due to a form of immunological compromise in patients harboring these malignancies.

Biochemical studies on the lipid content of Tilapia nilotica and Sparus auratus.

Seasonal variations of total lipids, free fatty acids, triglycerides, phospholipids and cholesterol content of the freshwater fish Tilapia nilotica and the marine fish Sparus auratus were investigated. Male fish of S. auratus showed higher muscular and hepatic total lipids and hepatic free fatty acids than those of T. nilotica (P less than 0.05). The mean differences in gonadal male lipids of the two species were not significant. Tilapia nilotica female fish showed a significantly higher content of hepatic free fatty acids, phospholipids and cholesterol (P less than 0.01, 0.01, 0.05 respectively) and gonadal total lipids, triglycerides, and cholesterol (P less than 0.05) than those of S. auratus females. In contrast S. auratus females exhibited higher muscular total lipids, triglycerides, phospholipids and cholesterol content (P less than 0.01, 0.05, 0.02, 0.05, respectively) and gonadal phospholipids (P less than 0.05) than those of the T. nilotica females. In general hepatic and gonadal lipids of freshwater fish T. nilotica were higher than those of the marine fish S. auratus, and in contrast the marine fish contained higher muscular lipids than the freshwater fish.