The Impact of Age in the Treatment of Non-comorbid Patients with Rectal Cancer: Survival Outcomes from the National Cancer Database.

BACKGROUND: Multimodal therapy has improved survival outcomes for rectal cancer (RC) significantly with an exemption for older patients. We sought to assess whether older non-comorbid patients receive substandard oncological treatment for localized RC referring to the National Comprehensive Cancer Network (NCCN) guidelines and whether it affects survival outcomes. METHODS: This is a retrospective study using patient data from the National Cancer Data Base (NCDB) for histologically confirmed RC from 2002 to 2014. Non-comorbid patients between ≥50 and ≤85 years and defined treatment for localized RC were included and assigned to a younger (<75 years) and an older group (≥75 years). Treatment approaches and their impact on relative survival (RS) were analyzed using loess regression models and compared between both groups. Furthermore, mediation analysis was performed to measure the independent relative effect on age and other variables on RS. Data were assessed using the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist. RESULTS: Of 59,769 included patients, 48,389 (81.0%) were assigned to the younger group (<75 years). Oncologic resection was performed in 79.6% of the younger patients compared to 67.2% of the older patients (p < 0.001). Chemotherapy (74.3% vs. 56.1%) and radiotherapy (72.0% vs. 58.1%) were provided less often in older patients, respectively (p < 0.001). Increasing age was associated with enhanced 30- and 90-day mortality with 0.6% and 1.1% in the younger and 2.0% and 4.1% in the elderly group (p < 0.001) and worse RS rates [multivariable adjusted HR: 1.93 (95% CI 1.87-2.00), p < 0.001]. Adherence to standard oncological therapy resulted in a significant increase in 5-year RS (multivariable adjusted HR: 0.80 (95% CI 0.74-0.86), p < 0.001). Mediation analysis revealed that RS was mainly affected by age itself (84%) rather than the choice of therapy. CONCLUSIONS: The likelihood to receive substandard oncological therapy increases in the older population and negatively affects RS. Since age itself has a major impact on RS, better patient selection should be performed to identify those that are potentially eligible for standard oncological care regardless of their age.

LARS is Associated with Lower Anastomoses, but not with the Transanal Approach in Patients Undergoing Rectal Cancer Resection.

BACKGROUND: Low anterior resection syndrome (LARS) is a defecation disorder that frequently occurs after a low anterior resection (LAR) with a total mesorectal excision (TME). The transanal (ta) TME for low rectal pathologies could potentially overcome some of the difficulties encountered with the abdominal approach in a narrow pelvis. However, the impact of the transanal approach on functional outcomes remains unknown. Here, we investigated the effect of the taTME approach on functional outcomes by comparing LARS scores between the LAR and taTME approaches in patients with colorectal cancer. METHODS: We conducted a retrospective cohort study including 80 patients (n = 40 LAR-TME, n = 40 taTME) with rectal adenocarcinoma. We reviewed medical charts to obtain LARS scores 6 months after the rectal resection or a reversal of the protective ileostomy. RESULTS: At the 6-month follow-up, 80% of patients exhibited LARS symptoms (44% minor LARS and 36% major LARS). LARS scores were not significantly associated with the T-stage, N-stage, or neo-adjuvant radiotherapy. The mean distance of the anastomosis from the anal verge was 4.0 ± 2.0 cm. The taTME group had significantly lower anastomoses compared with the LAR-TME group (median 4.0 cm [IQR1.8] vs. median 5.0 cm [IQR 2.0], p < 0.001). Univariable analysis revealed significantly higher LARS scores in the taTME group compared with the LAR-TME group (median LARS scores: 29 vs. 25, p = 0.040). However, multivariable regression analysis, adjusting for neo-adjuvant treatment, anastomosis distance from the anal verge, anastomotic leak rate, and body mass index, revealed no significant effect of taTME on the LARS score (adjusted regression coefficient: - 2.147, 95%CI: - 2.130 to 6.169, p = 0.359). We also found a significant correlation between LARS scores and the distance of the anastomosis from the anal verge (regression coefficient: - 1.145, 95%CI: - 2.149 to - 1.141, p = 0.026). CONCLUSION: Fifty percentage of patients in this cohort exhibited some LARS symptoms after a mid- or low-rectal cancer resection. As previously described, LARS scores were negatively correlated with the distance of the anastomosis from the anal verge. TaTME was after adjustment for the height of the anastomosis not associated with higher LARS at 6 months when compared with LAR-TME.

[Update: Management of colonic diverticulitis]. / Update zum Management der Divertikulitis.

Update: Management of colonic diverticulitis Abstract. Several classification systems exist for diverticulosis and diverticulitis. We preferably use the "Classification of Diverticular Disease" (CDD) to grade the severity of disease. This classification is based on imaging by CT scan or ultrasound. The CDD system divides patients into categories with a common therapeutic strategy. Acute uncomplicated diverticulitis is treated by oral or intravenous antibiotics. For the majority of patients with uncomplicated diverticulitis, antibiotic therapy might be omitted in favor of a solely symptomatic therapy. Acute diverticulitis complicated by a relevant abscess or a perforation is treated by interventional drainage or surgical therapy. Resection with primary anastomosis replaces more and more resection with end colostomy (Hartmann's procedure). For patients with sepsis, the concept of damage control surgery has been introduced. The indication for elective surgery after conservative treatment of diverticulitis shall be dictated by the degree of the patient's symptoms, rather than the number of conservatively treated episodes of diverticulitis. Persisting complications, as fistulas and stenosis, represent an indication for elective colonic resection.

Validation of the International Tumor Budding Consensus Conference 2016 recommendations on tumor budding in stage I-IV colorectal cancer.

Tumor budding is a robust prognostic parameter in colorectal cancer and can be used as an additional factor to guide patient management. Although backed by large bodies of data, a standardized scoring method is essential for integrating tumor budding in reporting protocols. The International Tumor Budding Consensus Conference (ITBCC) 2016 has proposed such a scoring system. The aim of this study is to validate the ITBCC method of tumor budding assessment on a well-characterized colorectal cancer cohort. Three hundred seventy-nine patients with resected stage I-IV colorectal cancer were entered into the study. Tumor budding was scored by 2 pathologists according to the ITBCC recommendations on hematoxylin and eosin-stained slides and scored as BD1 (low grade), BD2 (intermediate grade), and BD3 (high grade). Analysis was performed using a 3-tier approach, a 2-tier approach (BD1 + 2 versus BD3) and budding as a continuous variable. High-grade tumor budding was associated with adverse clinicopathological features including higher pT, higher pN stage, and higher TNM stage (all P < .001) and poorer overall survival on univariate analysis (P = .0251 for BD1/2/3, P = .0106 for BD1 + 2 versus BD3, and P = .0195 for continuous scores; hazard ratio, 1.023 [95% confidence interval, 1.004-1.043 per bud]). In stage II cancers, BD3 was associated with poorer disease-free survival (P < .01). Tumor budding assessed by the method proposed by the ITBCC is applicable to colorectal cancer resection specimens and can be used for widespread reporting in routine.

CDX2 in colorectal cancer is an independent prognostic factor and regulated by promoter methylation and histone deacetylation in tumors of the serrated pathway.

BACKGROUND: In colorectal cancer, CDX2 expression is lost in approximately 20% of cases and associated with poor outcome. Here, we aim to validate the clinical impact of CDX2 and investigate the role of promoter methylation and histone deacetylation in CDX2 repression and restoration. METHODS: CDX2 immunohistochemistry was performed on multi-punch tissue microarrays (n = 637 patients). Promoter methylation and protein expression investigated on 11 colorectal cancer cell lines identified two CDX2 low expressors (SW620, COLO205) for treatment with decitabine (DNA methyltransferase inhibitor), trichostatin A (TSA) (general HDAC inhibitor), and LMK-235 (specific HDAC4 and HDAC5 inhibitor). RNA and protein levels were assessed. HDAC5 recruitment to the CDX2 gene promoter region was tested by chromatin immunoprecipitation. RESULTS: Sixty percent of tumors showed focal CDX2 loss; 5% were negative. Reduced CDX2 was associated with lymph node metastasis (p = 0.0167), distant metastasis (p = 0.0123), and unfavorable survival (multivariate analysis: p = 0.0008; HR (95%CI) 0.922 (0.988-0.997)) as well as BRAFV600E, mismatch repair deficiency, and CpG island methylator phenotype. Decitabine treatment alone induced CDX2 RNA and protein with values from 2- to 25-fold. TSA treatment ± decitabine also led to successful restoration of RNA and/or protein. Treatment with LMK-235 alone had marked effects on RNA and protein levels, mainly in COLO205 cells that responded less to decitabine. Lastly, decitabine co-treatment was more effective than LMK-235 alone at restoring CDX2. CONCLUSION: CDX2 loss is an adverse prognostic factor and linked to molecular features of the serrated pathway. RNA/protein expression is restored in CDX2 low-expressing CRC cell lines by demethylation and HDAC inhibition. Importantly, our data underline HDAC4 and HDAC5 as new epigenetic CDX2 regulators that warrant further investigation.

A sustaining rod increases necrosis of loop ileostomies: a randomized controlled trial.

PURPOSE: Defunctioning loop ileostomies (LI) are commonly used in colorectal surgery to reduce the potentially detrimental consequences of anastomotic leakages. However, stoma-related morbidity is high with up to 75% of patients having local complications. The aim of this study was to investigate the effect of a sustaining rod on the local complication rate. METHODS: In this prospective, multi-center, randomized controlled trial, subjects were allocated to either a rod or a rod-less protocol (NCT00959738). The primary outcome was local morbidity as measured by a stoma specific morbidity score (SSMS) during the first 3 months postoperatively. RESULTS: Between August 2008 and July 2014, a total of 122 patients were enrolled in the study, of which 78 (63.8%) completed the study [44 (56.4%) rod, 34 (43.6%) rod-less]. There was no significant difference in the SSMS between the two groups. The incidence of necrosis or partial necrosis, however, was significantly increased in the rod group: 13 (29.5%) vs. 1 (2.9%) in the rod-less group (p < 0.01). The retraction rate did not differ significantly between the groups: two (4.5%) in the rod vs. five (14.7%) in the rod-less group (p = 0.13). High body mass index (BMI > 26) was associated with an odds ratio of 5 (p < 0.01) for severe stoma complications. CONCLUSIONS: A rod-less technique for loop ileostomies reduces the risk of stomal necrosis, with a high BMI being an independent risk factor for stomal complications.

Risk factors for fatal outcome in surgical patients with postoperative aspiration pneumonia.

INTRODUCTION: Aspiration pneumonia in hospitalized surgical patients has been associated with a mortality of approximately 30%. The aim of this study was to assess pre-, intra- and postoperative risk factors for mortality in patients suffering aspiration pneumonia after abdominal surgery. METHODS: Retrospective study from 01/2006-12/2012 of patients with clinically and radiologically confirmed aspiration pneumonia after abdominal surgery. RESULTS: A total of 70 patients undergoing abdominal surgery and postoperative aspiration pneumonia were identified. There were 53 (76%) male patients, the mean age was 71 ± 12 years and the mean ASA score was 3 ± 1. The surgical procedures included 32 colorectal or small bowel resections, 10 partial liver resections, 9 gastric surgeries, 8 esophageal resections, 5 pancreatic surgeries, and 6 hernia repairs. Aspiration pneumonia occurred at mean postoperative day 7 ± 10. Overall, 53% (n = 37) of patients required re-intubation, with 4 ± 5 days of additional mechanical ventilation. Mean hospital and ICU length of stay was 32 ± 25 days and 6 ± 9 days, respectively. Overall mortality was 27% (n = 19). Forward logistic regression revealed older age [OR 7.41 (95% CI: 1.29-42.62)], bilateral aspiration pneumonia [OR 7.39 (95% CI: 1.86-29.29)] and intraoperative requirement of blood component transfusion [OR 5.09 (95% CI: 1.34-19.38)] as independent risk factors for mortality (overall R(2) = 0.336). CONCLUSION: Postoperative aspiration pneumonia remains a severe complication with significant mortality. Increasing age, the need for intraoperative blood component transfusion and bilateral pulmonary infiltrates are independent risk factors for fatal outcome after aspiration pneumonia. Therefore, these patients suffering aspiration pneumonia require special attention and increased monitoring.

The value of serial serum lactate measurements in predicting the extent of ischemic bowel and outcome of patients suffering acute mesenteric ischemia.

BACKGROUND: Acute mesenteric ischemia (AMI) is an emergency with a mortality rate up to 50%. Detecting AMI continues to be a major challenge. This study assed the correlation of repeated preoperative serum lactate with bowel necrosis and to identify risk factors for a lethal outcome in patients with AMI. METHODS: A retrospective study of 91 patients with clinically and pathologically confirmed AMI from January 2006 to December 2012 was performed. RESULTS: In-hospital mortality rate was 42.9%. Two hundred nine preoperative lactate measurements were analyzed (2.3 ± 1.1 values per patient). Less than or equal to six hours prior to surgery, the mean serum lactate level was significantly higher (4.97 ± 4.21 vs. 3.24 ± 3.05 mmol/L, p = 0.006) and the mean pH significantly lower (7.28 ± 0.12 vs. 7.37 ± 0.08, p = 0.001) compared to >6 h before surgery. Thirty-four patients had at least two lactate measurements within 24 h prior to surgery. In this subgroup, 17 patients (50%) exhibited an increase, 17 patients (50%) a decrease in lactate levels. Forward logistic regression analysis showed that length of necrotic bowel and the highest lactate value 24 h prior to surgery were independent risk factors for mortality (r2 = 0.329). CONCLUSION: The value of serial lactate and pH measurements to predict the length of necrotic bowel is very limited. Length of necrotic bowel and lactate values are independent risk factors for mortality.

A20--an omnipotent protein in the liver: prometheus myth resolved?

Contribution of NF-kappaB inhibitory and ubiquitin-editing A20 (tnfaip3) to the liver's protective response to injury, particularly to its anti-inflammatory armamentarium, is exemplified by the dramatic phenotype of A20 knockout mice that die prematurely of unfettered inflammation predominantly in the liver. A number of additional studies originating from our laboratory and others clearly demonstrate that A20 is part of the liver response to injury and resection. Upregulation of A20 in hepatocytes serves a broad hepatoprotective goal through combined anti-inflammatory, anti-apoptotic, anti-oxidant and pro-regenerative functions. The molecular basis for A20's hepatoprotective functions were partially resolved and include blockade of NF-kappaB activation in support of its anti-inflammatory function, inhibition of pro-caspase 8 cleavage in support of its anti-apoptotic function, increasing Peroxisome Proliferator Activated Receptor alpha (PPARalpha) expression in support of its anti-oxidant function, and decreasing Cyclin Dependent Kinase Inhibitor p21 while boosting IL-6/STAT3 proliferative signals as part of its pro-regenerative function. In experimental animal models, overexpression of A20 in the liver protects from radical acute fulminant toxic hepatitis, lethal hepatectomy, and severe liver ischemia reperfusion injury (IRI), and allows successful engraftment of marginal liver grafts. Conversely, partial loss of A20, as in A20 heterozygote mice, significantly impairs liver regeneration and damage, which confers high lethality to an otherwise safe procedure i.e., 2/3 partial hepatectomy. This is the ultimate proof of the physiologic role of A20 in liver regeneration and repair. In recent work, A20's functions in the liver have expanded to encompass regulation of lipid and glucose metabolism, unlocking a whole new set of metabolic diseases that could be affected by A20. In this chapter we review all available data regarding A20's physiologic role in the liver, and Reflect on the clinical implication of these findings with regard to A20-based therapies in the context of liver transplantation, resection of large liver tumors, liver fibrosis, and metabolic liver diseases.

[Focused surgical bedside ultrasound: E-FAST (focused assessment with sonography in trauma) - abdominal aortic aneurysm - cholecystolithiasis - acute appendicitis]. / Fokussierte Chirurgische Bedside Sonographie: E-FAST - Abdominales Aortenaneurysma - Cholezystolithiasis - Appendizitis acuta.

Ultrasound is an easy to learn and highly efficient diagnostic tool to complete the clinical examination and improve bedside decision-making. In the trauma room, surgeons are often required to make a quick decision as to whether or not a patient needs an emergency intervention or whether further diagnostics are required. For this reason, education of surgeons in performing focused emergency ultrasound is pivotal. The goal of ICAN is to improve and expand the education of surgeons in Switzerland. This article provides a short review of the most frequent surgical pathologies encountered in the emergency room.

L'ultrasonographie medicale représente un apport diagnostique important et facile à apprendre. Il aide à poser en peu de temps un diagnostic correct au lit du patient. Les chirurgiens sont souvent appelés à prendre en salle de réanimation des décisions concernant un geste opératoire immédiat ou une mesure diagnostique supplémentaire. Dans beaucoup de pays les chirurgiens sont bien formés à la pratique de l'ultrasonographie. Il y a un grand interêt en Suisse à suivre cette direction. La section ICAN de la Société Suisse d'Ultrasonographie Médicale élargit grandement l'éventail des cours de formation. Cet article donne un bref tour d'horizon sur les applications les plus importantes de l'ultrasonographie chirurgicale au service des urgences.

Laparoscopic versus open end colostomy closure: a single-center experience.

The aim of this study was to review our experience with laparoscopic end colostomy closure. A retrospective review of a prospectively entered database was performed. Proportions and continuous variables were compared using the Fisher's exact and the Mann-Whitney U tests, respectively. Within the study period, 53 patients underwent closure of end colostomies. The main reasons for the colonic resections were perforated diverticulitis (52.7%) and neoplasms (20.8%). In 28 patients (53%), laparoscopic closure (LC) was attempted. Demographics did not differ between the attempted LC and the primary open closure (OC) group. The conversion rate from an LC to an OC was 50 per cent (14 of 28), mostly as a result of adhesions (71.4%). Hospital length of stay (HLOS) was significantly longer for the OC than with the attempted LC group (15.4 ± 11.9 days vs 11.3 ± 8.5 days, P = 0.046). The overall complication rate was not different between the completed LC and the OC groups (43 vs 56%, P = 0.634). The majority of complications detected (91.1%) were minor and could be treated conservatively. The role of laparoscopy to close end colostomies is questionable, because the conversion rate is high. However, a shorter HLOS can be expected when laparoscopy is successful. To reduce morbidity resulting from prolonged operation times, it is crucial to convert early and pre-emptively if hostile adhesions are found.

Transdiaphragmatic resuscitative open cardiac massage: description of the technique and a first case-series of an alternative approach to the heart.

BACKGROUND: The purpose of this paper is to describe the transdiaphragmatic approach to the heart for open CPR in patients that arrest at laparotomy and to present a first case series of patients that have undergone this procedure. METHODS: All patients who had undergone intraperitoneal transdiaphragmatic open CPR between January 1, 2002 and December 31, 2012 were retrieved from the operation registry at Bern University Hospital, Switzerland. Transdiaphragmatic access to the heart is initiated with a 10-cm-long anterocaudal incision in the central tendon of the diaphragm--approximately at 2 o'clock. Internal cardiac compression through the diaphragmatic incision can be performed from both sides of the patient. From the right side of the patient, cardiac massage is performed with the right hand and vice versa. RESULTS: A total of six patients were identified that suffered cardiac arrest during laparotomy with open CPR performed through the transdiaphragmatic approach. Four patients suffered cardiac arrest during orthotopic liver transplantation and two trauma patients suffered cardiac arrest during damage control laparotomy. In three patients, cardiac activity was never reestablished. However, three patients regained a perfusion heart rhythm and two of these survived to the ICU. One patient ultimately survived to discharge. CONCLUSIONS: In patients suffering cardiac arrest during laparotomy, the transdiaphragmatic approach allows for a rapid, technically easy, and almost atraumatic access to the heart, with excellent CPR performance. After this potentially life-saving procedure, pulmonary or surgical site complications are expected to occur much less compared with the conventionally performed emergency department left-sided thoracotomy.

The sensitivity of an interferon-γ release assay in microbiologically confirmed pediatric tuberculosis.

UNLABELLED: This study aimed at determining the sensitivity of a whole blood interferon-γ release assay (IGRA) among children with microbiologically confirmed tuberculosis in a high-burden country. Children with a diagnosis of tuberculosis based on clinical and radiographic assessment were tested with an IGRA in addition to microbiologic examination of appropriate specimens for acid-fast bacilli, mycobacterial rRNA, and observation for growth of Mycobacterium tuberculosis on appropriate culture media. Of the 405 children with a clinical diagnosis of tuberculosis, 91 (22.5 %) had microbiologically confirmed tuberculosis, of whom 81 were tested with an IGRA. A positive result was obtained in 43 (sensitivity 53.1 %, 95 % confidence interval 42.3 to 63.6 %), uninfluenced by age, sex, or disease manifestation. CONCLUSIONS: The sensitivity of a whole blood interferon-γ release assay in microbiologically confirmed pediatric tuberculosis was low. An IGRA cannot, thus, be used as rule-in test, but it might be useful to rule in tuberculosis among children in whom tuberculosis is notoriously difficult to confirm microbiologically.

A20 promotes liver regeneration by decreasing SOCS3 expression to enhance IL-6/STAT3 proliferative signals.

UNLABELLED: Liver regeneration is of major clinical importance in the setting of liver injury, resection, and transplantation. A20, a potent antiinflammatory and nuclear factor kappa B (NF-κB) inhibitory protein, has established pro-proliferative properties in hepatocytes, in part through decreasing expression of the cyclin dependent kinase inhibitor, p21. Both C-terminal (7-zinc fingers; 7Zn) and N-terminal (Nter) domains of A20 were required to decrease p21 and inhibit NF-κB. However, both independently increased hepatocyte proliferation, suggesting that additional mechanisms contributed to the pro-proliferative function of A20 in hepatocytes. We ascribed one of A20's pro-proliferative mechanisms to increased and sustained interleukin (IL)-6-induced signal transducer and activator of transcription 3 (STAT3) phosphorylation, as a result of decreased hepatocyte expression of the negative regulator of IL-6 signaling, suppressor of cytokine signaling 3 (SOCS3). This novel A20 function segregates with its 7Zn not Nter domain. Conversely, total and partial loss of A20 in hepatocytes increased SOCS3 expression, hampering IL-6-induced STAT3 phosphorylation. Following liver resection in mice pro-proliferative targets downstream of IL-6/STAT3 signaling were increased by A20 overexpression and decreased by A20 knockdown. In contrast, IL-6/STAT3 proinflammatory targets were increased in A20-deficient livers, and decreased or unchanged in A20 overexpressing livers. Upstream of SOCS3, levels of its microRNA regulator miR203 were significantly decreased in A20-deficient livers. CONCLUSION: A20 enhances IL-6/STAT3 pro-proliferative signals in hepatocytes by down-regulating SOCS3, likely through a miR203-dependent manner. This finding together with A20 reducing the levels of the potent cell cycle brake p21 establishes its pro-proliferative properties in hepatocytes and prompts the pursuit of A20-based therapies to promote liver regeneration and repair.

Bioactive polyacrylamide hydrogels with gradients in mechanical stiffness.

We propose a novel, single step method for the production of polyacrylamide hydrogels with a gradient in mechanical properties. In contrast to already existing techniques such as UV photo-polymerization with photomasks (limited penetration depth) or microfluidic gradient mixers (complex microfluidic chip), this technique is not suffering such limitations. Young's modulus of the hydrogels was varied by changing the total monomer concentration of the hydrogel precursor solution. Using programmable syringe pumps, the total monomer concentration in the solution fed to the hydrogel mold was varied from 16 wt% down to 5 wt% over the feeding time to obtain a gradient in compliance ranging from 150 kPa down to 20 kPa over a length of 10 mm down to 2.5 mm. Polymerization was achieved with the dual initiation system composed of ammonium persulfate and N,N,N',N'-tetramethylethylenediamine, which were both fed through separate capillaries to avoid premature polymerization. Functionalized with the model ligand collagen I, the substrates were bioactive and supported the attachment of human foreskin fibroblasts (around 30% of the cells seeded attached after 1 h). A kinetic morphology study on homogeneous hydrogels of different stiffness's indicated that fibroblasts tend to spread to their final size within 2 h on stiff substrates, while the spreading time was much longer (ca. 4-5 h) on soft substrates. These trends were confirmed on hydrogels with compliance gradients, showing well spread fibroblasts on the stiff end of the hydrogel after 2 h, while the cells on the soft end still had small area and rounded morphology.

A20-mediated modulation of inflammatory and immune responses in aortic allografts and development of transplant arteriosclerosis.

BACKGROUND: Transplant arteriosclerosis (TA) is the pathognomonic feature of chronic rejection, the primary cause of allograft failure. We have shown that the NF-κB inhibitory protein A20 exerts vasculoprotective effects in endothelial and smooth muscle cells (SMC), and hence is a candidate to prevent TA. We sought direct proof for this hypothesis. METHODS: Fully mismatched, C57BL/6 (H2) into BALB/c (H2), aorta to carotid allografts were preperfused with saline, recombinant A20 adenovirus (rAd.A20) or rAd.ß-galactosidase (ß-gal), implanted, harvested 4 weeks after transplantation, and analyzed by histology, immunohistochemistry, and immunofluorescence staining. We measured indoleamine 2,3-dioxygenase, interleukin-6, and transforming growth factor-ß mRNA and protein levels in nontransduced, and rAd.A20 or rAd.ß-gal-transduced human SMC cultures after cytokine treatment. RESULTS: Vascular overexpression of A20 significantly reduced TA lesions. This correlated with decreased graft inflammation and increased apoptosis of neointimal SMC. Paradoxically, T-cell infiltrates increased in A20-expressing allografts, including the immunoprivileged media, which related to A20 preventing indoleamine 2,3-dioxygenase upregulation in SMC. However, infiltrating T cells were predominantly T-regulatory cells (CD25+/Forkhead Box P3 [FoxP3+]). This agrees with A20 inhibiting interleukin-6 and promoting transforming growth factor-ß production by medial SMC and in SMC cultures exposed to cytokines, which favors differentiation of regulatory over pathogenic T cells. CONCLUSIONS: In summary, A20 prevents immune-mediated remodeling of vascular allografts, therefore reduces TA lesions by affecting apoptotic and inflammatory signals and modifying the local cytokine milieu to promote an immunoregulatory response within the vessel wall. This highlights a novel function for A20 in local immunosurveillance, which added to its vasculoprotective effects, supports its therapeutic promise in TA.

[Adhesions and abdominal pain]. / Adhäsionen und Bauchschmerzen.

Adhesions occur with a high incidence after intra-abdominal surgery but can also develop due to infections, radiation or for idiopathic reasons. The formation of adhesions is initiated by tissue damage and is the result of peritoneal tissue repair involving the activation of the inflammatory system and the coagulation cascade. Acute small bowel obstruction is one of the most common complications and should be diagnosed rapidly using clinical examination and radiological imaging. A complete obstruction is life threatening and in a high percentage of patients requires rapid surgical intervention by laparotomy or laparoscopy depending on the clinical situation and the patients history. Despite numerous investigations, there is no reliable, commonly used method to prevent intra-abdominal adhesions. Minimizing tissue damage and foreign body exposure, avoiding spillage of intestinal and biliary contents as well as a laparoscopic approach seem to have a beneficial effect on the formation of intra-abdominal adhesions.

A20 modulates lipid metabolism and energy production to promote liver regeneration.

BACKGROUND: Liver regeneration is clinically of major importance in the setting of liver injury, resection or transplantation. We have demonstrated that the NF-κB inhibitory protein A20 significantly improves recovery of liver function and mass following extended liver resection (LR) in mice. In this study, we explored the Systems Biology modulated by A20 following extended LR in mice. METHODOLOGY AND PRINCIPAL FINDINGS: We performed transcriptional profiling using Affymetrix-Mouse 430.2 arrays on liver mRNA retrieved from recombinant adenovirus A20 (rAd.A20) and rAd.ßgalactosidase treated livers, before and 24 hours after 78% LR. A20 overexpression impacted 1595 genes that were enriched for biological processes related to inflammatory and immune responses, cellular proliferation, energy production, oxidoreductase activity, and lipid and fatty acid metabolism. These pathways were modulated by A20 in a manner that favored decreased inflammation, heightened proliferation, and optimized metabolic control and energy production. Promoter analysis identified several transcriptional factors that implemented the effects of A20, including NF-κB, CEBPA, OCT-1, OCT-4 and EGR1. Interactive scale-free network analysis captured the key genes that delivered the specific functions of A20. Most of these genes were affected at basal level and after resection. We validated a number of A20's target genes by real-time PCR, including p21, the mitochondrial solute carriers SLC25a10 and SLC25a13, and the fatty acid metabolism regulator, peroxisome proliferator activated receptor alpha. This resulted in greater energy production in A20-expressing livers following LR, as demonstrated by increased enzymatic activity of cytochrome c oxidase, or mitochondrial complex IV. CONCLUSION: This Systems Biology-based analysis unravels novel mechanisms supporting the pro-regenerative function of A20 in the liver, by optimizing energy production through improved lipid/fatty acid metabolism, and down-regulated inflammation. These findings support pursuit of A20-based therapies to improve patients' outcomes in the context of extreme liver injury and extensive LR for tumor treatment or donation.

O-glycosylation regulates ubiquitination and degradation of the anti-inflammatory protein A20 to accelerate atherosclerosis in diabetic ApoE-null mice.

BACKGROUND: Accelerated atherosclerosis is the leading cause of morbidity and mortality in diabetic patients. Hyperglycemia is a recognized independent risk factor for heightened atherogenesis in diabetes mellitus (DM). However, our understanding of the mechanisms underlying glucose damage to the vasculature remains incomplete. METHODOLOGY/PRINCIPAL FINDINGS: High glucose and hyperglycemia reduced upregulation of the NF-κB inhibitory and atheroprotective protein A20 in human coronary endothelial (EC) and smooth muscle cell (SMC) cultures challenged with Tumor Necrosis Factor alpha (TNF), aortae of diabetic mice following Lipopolysaccharide (LPS) injection used as an inflammatory insult and in failed vein-grafts of diabetic patients. Decreased vascular expression of A20 did not relate to defective transcription, as A20 mRNA levels were similar or even higher in EC/SMC cultured in high glucose, in vessels of diabetic C57BL/6 and FBV/N mice, and in failed vein grafts of diabetic patients, when compared to controls. Rather, decreased A20 expression correlated with post-translational O-Glucosamine-N-Acetylation (O-GlcNAcylation) and ubiquitination of A20, targeting it for proteasomal degradation. Restoring A20 levels by inhibiting O-GlcNAcylation, blocking proteasome activity, or overexpressing A20, blocked upregulation of the receptor for advanced glycation end-products (RAGE) and phosphorylation of PKCßII, two prime atherogenic signals triggered by high glucose in EC/SMC. A20 gene transfer to the aortic arch of diabetic ApoE null mice that develop accelerated atherosclerosis, attenuated vascular expression of RAGE and phospho-PKCßII, significantly reducing atherosclerosis. CONCLUSIONS: High glucose/hyperglycemia regulate vascular A20 expression via O-GlcNAcylation-dependent ubiquitination and proteasomal degradation. This could be key to the pathogenesis of accelerated atherosclerosis in diabetes.

A20 inhibits post-angioplasty restenosis by blocking macrophage trafficking and decreasing adventitial neovascularization.

OBJECTIVE: Neointimal hyperplasia is an inflammatory and proliferative process that occurs as a result of injury to the vessel wall. We have shown that the homeostatic protein A20 prevents neointimal hyperplasia by affecting endothelial cell (EC) and smooth muscle cell (SMC) responses to injury. In this work, we questioned whether A20 impacts other pathogenic effectors of neointimal hyperplasia including homing of monocyte/macrophages and EC/SMC precursors to the site of vascular injury, vascular endothelial growth factor (VEGF) secretion, and adventitial neovascularization. METHODS AND RESULTS: Carotid balloon angioplasty was performed on rat recipients of a bone marrow transplant from green fluorescent rats. Adenoviral delivery of A20 prevented neointimal hyperplasia and decreased macrophage infiltration. This was associated with decreased ICAM-1 and MCP-1 expression in vitro. Additionally, A20 reduced neovascularization in the adventitia of balloon injured carotid arteries, which correlated with fewer VEGF positive cells. CONCLUSIONS: A20 downregulates adhesion markers, chemokine production, and adventitial angiogenesis, all of which are required for macrophage trafficking to sites of vascular injury. This, in turn, diminishes the inflammatory milieu to prevent neointimal hyperplasia.