The option of delayed reconstructive surgery following mastectomy for invasive breast cancer: why do so few patients embrace this offer?

BACKGROUND: Only a minority of patients who had undergone mastectomy for invasive breast cancer (BC) chose the option for delayed breast reconstruction (BR). We hypothesized that this might partly be (a) due to a lack of information, or (b) because many women cope well with their altered body. METHODS: A cross-sectional survey was completed by 101 early-stage BC survivors who had primary mastectomy. Twenty-six patients had delayed BR. The survey included measures to attitudes to BR and experiences/expectations about information related to BR. RESULTS: The percentage of patients who was informed regarding BR was high (97%). For 39.5% such information was not considered important, neither before mastectomy, nor during follow-up; advanced age was an important factor for the disinterest in information (odds ratio 1.81; 95% CI: 1.04-3.16; p = 0.033). For women without BR, the perception that mastectomy caused a serious damage to their body image changed over time to perceiving the operation as an acceptable alteration of the body (-1.10; 95% CI, -1.52, -0.64; p < 0.001); this process was similar to that in patients who had BR (paired t-test: -2.12; 95% CI, -2.82, -1.41; p > 0.001). From 63 patients who reported no intention to have a BR in the future, 28 (44.4%) responded with answers that showed a high satisfaction with their mastectomies without BR; 30 patients (47.6%) reported reasons, which might potentially be dispelled by information by an experienced reconstructive surgeon. CONCLUSIONS: We did not find any evidence that the low number of patients who chose delayed BR results from a lack of information regarding this procedure. The majority of patients overcome negative attitudes towards their mastectomy quickly and are uninterested in BR. Patients who are ambivalent must be identified; these women require particular attention and should receive intensive counseling.

Binding of STW 5 (Iberogast) and its components to intestinal 5-HT, muscarinic M3, and opioid receptors.

Clinical studies with the fixed herbal combination product STW 5 (Iberogast) have indicated an efficacy comparable to metoclopramide (5-HT(3) antagonist) and cisapride (5-HT(4) agonist) in functional gastro-intestinal diseases like functional dyspepsia (FD) and irritable bowel syndrome (IBS). Since serotonin (5-HT(3) and 5-HT(4)) and muscarinic M(3) receptors are known to play a central role in the etiology of FD and IBS, the extracts contained in STW 5 and several of their phytochemical components were studied in vitro for binding affinities to these receptors of the intestine. STW 5 inhibited the binding of (3)H-GR113808 and (3)H-4-DAMP to 5-HT(4) and M(3) receptors, respectively, about 10 times more potently than the binding of (3)H-GR65630 to 5-HT(3) receptors. IC(50) values for STW 5 did correspond to extract dilutions of 1:1000 (M(3) binding) and 1:2000 (5-HT(4) binding). In addition, STW 5 also potently inhibited the binding to opioid receptors with an IC(50) value of 1:2000. Of the nine herbal extracts contained in STW 5, the fresh plant extract of bitter candy tuft (Iberis amara) selectively inhibited binding to M(3) receptors, while ethanolic extracts of celandine herb and chamomile flower were selective to 5-HT(4), and liquorice root to 5-HT(3) receptors. Binding affinities to human recombinant 5-HT(3), 5-HT(4) and M(3) receptors were qualitatively similar to those of the corresponding intestinal receptors. The benzylisoquinoline alkaloid berberine had significant inhibitory action on 5-HT(4) and M(3) binding, showing IC(50) values of 40 ng/ml (100 nM) and 200 ng/ml (500 nM), respectively, but is present in the extract of celandine herb only in traces, so that also for the celandine extract a cooperative effect of several phytochemical constituents can be assumed. These in vitro data indicate that 5-HT(4) (to a lesser degree 5-HT(3)), muscarinic M(3), and opioid receptors represent target sites for the treatment of FD and IBS with STW 5 (Iberogast).

Recombinant Semliki Forest virus for over-expression and pharmacological characterisation of the histamine H(2) receptor in mammalian cells.

We describe the use of recombinant Semliki Forest virus (SFV) vectors for efficient expression of the rat histamine H(2) (rH(2)) receptor in COS-7 (African green monkey kidney cells) cells. Recombinant SFV-infected COS-7 cells express the histamine rH(2) receptor in a time-dependent fashion with a maximum expression level of 50 pmol mg(-1) after 40 h. SFV-mediated histamine rH(2) receptor expression shows similar pharmacological properties as the receptor expressed transiently or stably in mammalian cells. In addition, we demonstrate the pharmacological and functional characterisation of the D(115)N mutated histamine rH(2) receptor. It has been shown that the D(115)N mutation renders the receptor constitutively active and structurally unstable. The rapid onset of and high maximal expression levels obtained from SFV-infected COS-7 cells enabled us to characterise this mutant receptor. We prove that recombinant SFV vectors are powerful tools for heterologous expression of G-protein-coupled receptors and that one can achieve both the high-level gene expression described for baculovirus-infected insect cells and the use of mammalian cells as hosts.

Neurochemical studies with St. John's wort in vitro.

The effect of extracts and constituents of St. John's wort, Hypericum perforatum, at various CNS receptors were studied by radioligand binding techniques in order to determine a profile of pharmacological activity in vitro. Binding inhibition was examined for the G-protein coupled opioid, serotonin (5-HT), histamine, neurokinin and corticotropin releasing factor (CRF) receptors, for the steroid estrogen-alpha receptor and for the ligand-gated ionchannel GABA(A) receptor. Hypericin showed the most potent binding inhibiton of all tested constituents to human CRF1 receptor with an IC50 value of 300 nM. Preliminary GTPgamma35S binding studies to CRF1 coupled G-protein indicated an antagonistic action for hypericin. The acylphloroglucinole hyperforin failed to inhibit 125I-astressin binding to hCRF, receptor up to 10 microM. Hyperforin inhibited binding to opioid and serotonin (5-HT) receptors at IC50 values between 0.4 and 3 microM, while hypericin and pseudohypericin inhibited with weaker potency. The biflavonoid I3,II8-biapigenin inhibited 3H-estradiol binding to the estrogen-alpha receptor with an IC50 value of 1 microM. The inhibition of 3H-muscimol binding to the GABA(A) receptor is likely to be exclusively due to GABA present in the extract. We therefore hypothesize that additive or synergistic actions of several ditsinct compounds may be responsible for the beneficial antidepressant effect of St. John's wort.

Interaction of various Piper methysticum cultivars with CNS receptors in vitro.

Methanolic leaf and root extracts of the Hawaiian kava (Piper methysticum Forst.) cultivars, Mahakea, Nene, Purple Moi and PNG, were tested on binding affinities to CNS receptors including GABAA (GABA and benzodiazepine binding site), dopamine D2, opioid (mu and delta), serotonin (5-HT6 and 5-HT7) and histamine (H1 and H2). HPLC analysis was carried out in order to determine the amount of the main kavalactones kavain, 7,8-dihydrokavain, methysticin, 7,8-dihydromethysticin, yangonin and 5,6-demethoxyyangonin. The most potent binding inhibition was observed for leaf extracts to GABAA receptors (GABA binding site) with IC50 values of approximately 3 micrograms/ml, whereas root extracts were less active with IC50 values ranging from 5 micrograms/ml (Nene) to 87 micrograms/ml (Mahakea). Since the leaf extracts generally contained lower amounts of the kavalactones than the root extracts, there might exist additional substances responsible for these activities. Leaf extracts also inhibited binding to dopamine D2, opioid (mu and delta) and histamine (H1 and H2) receptors more potently than the corresponding root extracts with IC50 values ranging from 1 to 100 micrograms/ml vs. > or = 100 micrograms/l, respectively. Significant differences in the potential of binding inhibition were also observed between cultivars. Binding to serotonin (5-HT6 and 5-HT7) and benzodiazepine receptors was only weakly inhibited by both root and leaf extracts of all four cultivars. In conclusion, our investigation indicates that the GABAA, dopamine D2, opioid (mu and delta) and histamine (H1 and H2) receptors might be involved in the pharmacological action of kava extracts. Since the cultivars contained similar amounts of kavalactones, while their pharmacological activities differed markedly, other constituents may play a role in the observed activities. Additionally, leaves generally exhibited more potent binding inhibition than roots, therefore leaf of P. methysticum might be an interesting subject for further pharmacological studies.

Bisanthraquinone glycosides of Hypericum perforatum with binding inhibition to CRH-1 receptors.

Four new bisanthraquinone glycosides, S-(+)-skyrin-6-O-beta-glucopyranoside (1), R-(-)-skyrin-6-O-beta-glucopyranoside (2), S-(+)-skyrin-6-O-beta-xylopyranoside (3) and S-(+)-skyrin-6-O-beta-alpha-arabinofuranoside (4), have been isolated from an ethanol-water (1:1, v/v) dry extract of the aerial parts of Hypericum perforatum L. The structures were elucidated by spectroscopic methods, mainly NMR and mass spectrometry. Circular dichroism was used to determine their axial stereochemistry revealing 1 and 2 to be atropisomers. 1 and 2 inhibited [125I]sauvagine binding to corticotropin releasing hormone (CRH-1) receptors.

Extracts and constituents of Hypericum perforatum inhibit the binding of various ligands to recombinant receptors expressed with the Semliki Forest virus system.

Extracts, fractions and constituents of Hypericum perforatum were studied for in vitro receptor binding with various ligands to recombinant CNS receptors expressed with the Semliki Forest virus expression system. For this purpose we have prepared membranes of CHO cells with high density of several opioid, serotonin, estrogen, histamine, GABAA, neurokinin and metabotropic glutamate receptors, respectively. A lipophilic Hypericum fraction revealed relatively potent inhibition to the binding of the mu-, delta- and kappa-opioid and the 5-HT6 and 5-HT7 receptors. Moreover, Hypericum constituents such as the naphthodianthrones, hypericin and pseudohypericin, and the phloroglucinole hyperforin inhibited both binding to the opioid and serotonin receptors in the lower micromolar range. Estrogen binding was 50% inhibited by the biflavonoid I3,II8-biapigenin at micromolar concentration. The lipophilic Hypericum fraction provided a less potent inhibition of the neurokinin-1 receptor binding compared to the opioid and serotonin receptors. A total ethanolic Hypericum extract potently inhibited GABAA binding at approximately 3 micrograms/ml. This inhibition is however not specific to Hypericum, since extracts of plants like Valeriana officinalis and Passiflora incarnata showed similar inhibitions. Binding to neither histamine nor metabotropic glutamate receptors was affected by Hypericum extracts. These results support the hypothesis that several active constituents of Hypericum might in a synergistic way contribute to its antidepressant effect in the central nervous system.

Hypericum perforatum inhibits the binding of mu- and kappa-opioid receptor expressed with the Semliki Forest virus system.

The effects of Hypericum perforatum extracts on in vitro [3H]naloxone binding to the human mu- and rat kappa-opioid receptors were studied in chinese hamster ovary (CHO) cells using the Semliki Forest virus (SFV) expression system. Binding of [3H]naloxone to the mu- and kappa-opioid receptor was inhibited in the presence of Hypericum extracts showing IC50 values of approximately 25 and 90 micrograms/ml, respectively. In contrast, extracts of Valeriana officinalis did not inhibit binding to the mu-opioid receptor. Also, single constituents of H. perforatum like the flavonoids quercetin and kaempferol and the glycosilated flavonoid quercitrin did not inhibit [3H]naloxone binding to the mu-opioid receptor up to a concentration of 10 microM. The present in vitro data may suggest a new possible mechanism for the anti-depressant effect of H. perforatum.

Sucrose:Fructan 6-Fructosyltransferase, a Key Enzyme for Diverting Carbon from Sucrose to Fructan in Barley Leaves.

Sucrose:sucrose 6-fructosyltransferase, an enzyme activity recently identified in fructan-accumulating barley (Hordeum vulgare) leaves, was further characterized. The purified enzyme catalyzed the transfer of a fructosyl group from sucrose to various acceptors. It displayed some [beta]-fructosidase (invertase) activity, indicating that water could act as fructosyl acceptor. Moreover, it transferred the fructosyl residue of unlabeled sucrose to [U-14C]Glc, producing [U-14C]sucrose and unlabeled glucose. Most significantly for fructan synthesis, the enzyme used as acceptors but not as donors a variety of oligofructans containing [beta](2->1)- and [beta](2->6)-linked fructosyl moieties. Thus, it acted as a general sucrose:fructan fructosyltransferase. The products formed by the enzyme from sucrose and various purified, structurally characterized oligofructans were analyzed by liquid chromatography and identified by comparison with structurally characterized standards. The results showed that the enzyme formed exclusively [beta](2->6) fructosyl-fructose linkages, either initiating or elongating a fructan chain of the phlein type. We propose, therefore, to rename the purified enzyme sucrose:fructan 6-fructosyltransferase.

Purification and characterization of three soluble invertases from barley (Hordeum vulgare L.) leaves.

Three soluble isoforms of invertase (beta-fructofuranosidase; EC 3.2.1.26) were purified from 7-d-old primary leaves of barley (Hordeum vulgare L.). Invertase I, a monomeric protein of 64 kD, was purified to apparent homogeneity as shown by sodium dodecylsulfate-polyacrylamide gel electrophoresis. Invertases IIA and IIB, multimeric proteins with molecular masses of the 116 and 155 kD, were purified 780- and 1370-fold, respectively, but were not yet homogeneous. Extracts of epidermal strips of leaves contained only invertase IIB. The specific activity of invertase was more than 100-fold higher in the epidermis than in the mesophyll. All three isoforms were acidic invertases, with pH optima of around 5.0 and little activity in the alkaline range. Invertase I had a Km for sucrose of 8.1 mM, and invertases IIA and IIB had much lower values of 1.0 and 1.7 mM, respectively. Invertase I was more than 2-fold more resistant than the other two invertases to the inhibitors HgCl2 and pyridoxal. All three constitutive invertases were found to act also as sucrose-sucrose fructosyltransferases when supplied with high concentrations of sucrose, forming 1-kestose as principal product. However, the fructosyltransferase activity of all three enzymes was inhibited by pyridoxal in the same way as their invertase activity. This characteristic clearly differentiates them from the inducible sucrose-sucrose fructosyltransferase of barley leaves, the activity responsible for the initial steps of fructan biosynthesis, which has previously been shown to be insensitive to pyridoxal.

Fructan Synthesis in Excised Barley Leaves (Identification of Two Sucrose-Sucrose Fructosyltransferases Induced by Light and Their Separation from Constitutive Invertases).

Excised leaves of barley (Hordeum vulgare L.) exposed to continuous light accumulate large amounts of soluble carbohydrates. Carbohydrates were analyzed in deionized extracts by high-pressure liquid chromatography on an anion exchange column coupled with pulsed amperometric detection. During the first few hours of illumination, the main sugar to accumulate was sucrose. The levels of glucose and fructans (oligofructosylsucroses) increased later. The trisaccharide 1-kestose (1-kestotriose) predominated initially among the fructans. Later, 6-kestose (6-kestotriose) and tetra- and pentasaccharides accumulated also. Total extracts from barley leaves were chromatographed on a MonoQ column, and each fraction was assayed for enzymes of interest by incubation with 200 mM sucrose for 3 h, followed by carbohydrate analysis. Freshly excised leaves yielded two peaks of invertase, characterized by formation of fructose and glucose, but had almost no trisaccharide-forming activities. In leaves exposed to continuous light, two new enzyme activities appeared that generated fructan-related trisaccharides and glucose from sucrose. One of them was a sucrose-sucrose fructosyl-1-transferase (1-SST), producing 1-kestose exclusively: the peak fractions of this activity contained almost no invertase. The other was a sucrose-sucrose fructosyl-6-transferase (6-SST), producing 6-kestose. It comigrated with one of the constitutive invertases on MonoQ but was separated from it by subsequent chromatography on alkyl Superose. Nevertheless, the preparation retained invertase activity, suggesting that this enzyme may act both as fructosidase and fructosyltransferase. When incubated with 1-kestose in addition to sucrose, this enzyme formed less 6-kestose but instead produced large amounts of the tetrasaccharide bifurcose (1&6-kestotetraose), the main fructan tetrasaccharide accumulating in vivo. These results suggest that two inducible enzymes, 1-SST and 6-SST, act in concert to initiate fructan accumulation in barley leaves.

Regulation of sucrose-sucrose-fructosyltransferase in barley leaves.

The activity of sucrose-sucrose-fructosyltransferase (SST), a vacuolar enzyme strongly induced by light in excised leaves of barley (Hordeum vulgare L.), rapidly declined even in continuous light upon feeding of cycloheximide (CHI). The rate of decline was similar to that observed in light-treated leaves that were placed into darkness, in the presence or absence of CHI. The protease inhibitor leupeptin totally stopped the decline in SST activity in the dark and caused a substantial increase in the rate of induction of SST activity by light. Feeding of sucrose prevented or even reversed the SST activity decay induced by darkness in the absence of CHI but did not stabilize SST activity in the presence of CHI. The results suggest that SST is continuously subjected to rapid, constant proteolytic degradation in the vacuole, and that the enhancement of SST activity in the light or upon feeding sucrose in the dark is due exclusively to de novo protein synthesis.

Heat shock induces enzymes of trehalose metabolism, trehalose accumulation, and thermotolerance in Schizosaccharomyces pombe, even in the presence of cycloheximide.

Exponentially growing cells of the fission yeast, Schizosaccharomyces pombe, contained virtually no trehalose at 27 degrees C but rapidly accumulated large quantities during heat shock at 40 degrees C. Activities of trehalose-6-phosphate synthase and trehalase also increased upon heat shock. Thermotolerance of the cells, measured as survival at 52 degrees C, increased in parallel to trehalose accumulation and decreased in parallel to the trehalose levels when cells were shifted back to 27 degrees C. Trehalose levels, activities of enzymes of trehalose metabolism and thermotolerance strongly increased upon heat shock even in the presence of cycloheximide, indicating that none of these effects requires protein synthesis. The data support the hypothesis that trehalose acts as a thermoprotectant in Schizosaccharomyces pombe.

[Vaginal closure with resorbable clip in total abdominal hysterectomy]. / Vaginalverschluss mit resorbierbaren Klammern bei der abdominalen totalen Hysterektomie.

The latest type of clip stapler with resorbable clips for closure of the vaginal stump in abdominal hysterectomies was used by nineteen different surgeons on 80 patients at two university clinics, employing the same surgical procedure. Perioperative handling and the complication-free postoperative course were considered satisfactory. There was no dyspareunia, previously described in association with metal clips. Granular tissue requiring therapy and serosanguinous discharge were clearly reduced. On the basis of measurements of vaginal cuffs removed at the same time it can be said that there is no shortening of the vagina. The question of costs is discussed.

[Recto-vesical fistula (author's transl)]. / Les fitules entéro-vésicales.

23 cases of recto-vesical fistula are described; their diagnostic and therapeutic approach are discussed. The entero-vesical fistula result mainly from diverticular disease but may be secondary to tumor or Crohn's disease of the large bowel too. The treatment needs allways surgery: bowel resection and bladder extraperitonisation. Results and literature are compared.