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Background Pre-clinical studies indicate that dry-cold-carbon-dioxide (DC-CO2) insufflation leads to more peritoneal damage, inflammation and hypothermia compared with humidified-warm-CO2 (HW-CO2). Peritoneum and core temperature in patients undergoing colorectal cancer (CRC) surgery were compared. Methods Sixty-six patients were randomized into laparoscopic groups; those insufflated with DC-CO2 or HW-CO2. A separate group of nineteen patients undergoing laparotomy were randomised to conventional surgery or with the insertion of a device delivering HW-CO2. Temperatures were monitored and peritoneal biopsies and bloods were taken at the start of surgery, at 1 and 3 h. Further bloods were taken depending upon hospital length-of-stay (LOS). Peritoneal samples were subjected to scanning electron microscopy to evaluate mesothelial damage. Results Laparoscopic cases experienced a temperature drop despite Bair-HuggerTM use. HW-CO2 restored normothermia (≥ 36.5 °C) by 3 h, DC-CO2 did not. LOS was shorter for colon compared with rectal cancer cases and if insufflated with HW-CO2 compared with DC-CO2; 5.0 vs 7.2 days, colon and 11.6 vs 15.4 days rectum, respectively. Unexpectedly, one third of patients had pre-existing damage. Damage increased at 1 and 3 h to a greater extent in the DC-CO2 compared with the HW-CO2 laparoscopic cohort. C-reactive protein levels were higher in open than laparoscopic cases and lower in both matched HW-CO2 groups. Conclusions This prospective RCT is in accord with animal studies while highlighting pre-existing damage in some patients. Peritoneal mesothelium protection, reduced inflammation and restoration of core-body temperature data suggest benefit with the use of HW-CO2 in patients undergoing CRC surgery.

Purpose:The majority of deaths from breast cancer occur following the development of metastatic disease, a process inhibited by β-blockers in preclinical studies. This phase II randomized controlled trial evaluated the effect of preoperative β-blockade with propranolol on biomarkers of metastatic potential and the immune cell profile within the primary tumor of patients with breast cancer.Patients and Methods:In this triple-blind placebo-controlled clinical trial, 60 patients were randomly assigned to receive an escalating dose of oral propranolol (n = 30; 80–160 mg daily) or placebo (n = 30) for 7 days prior to surgery. The primary endpoint investigated the effect of propranolol on prometastatic and proinflammatory gene expression within the primary tumor.Results:Propranolol downregulated primary tumor expression of mesenchymal genes (P = 0.002) without affecting epithelial gene expression (P = 0.21). Bioinformatic analyses implicated downregulation of Snail/Slug (P = 0.03), NF-κB/Rel (P < 0.01), and AP-1 (P < 0.01) transcription factors in structuring the observed transcriptome alterations, and identified changes in intratumoral neutrophil, natural killer cell, and dendritic cell recruitment (all P < 0.01). Patients with clinical evidence of drug response (lowered heart rate and blood pressure) demonstrated elevated tumor infiltration of CD68+ macrophages and CD8+ T cells.Conclusions:One week of β-blockade with propranolol reduced intratumoral mesenchymal polarization and promoted immune cell infiltration in early-stage surgically-resectable breast cancer. These results show that β-blockade reduces biomarkers associated with metastatic potential, and support the need for larger phase III clinical trials powered to detect the impact of β-blockade on cancer recurrence and survival.See related commentary by Blaes et al., p. 1781

Supplementary Material

Purpose of review Surgery remains integral to treating solid cancers. However, the surgical stress response, characterized by physiologic perturbation of the adrenergic, inflammatory, and immune systems, may promote procancerous pathways. Anesthetic technique per se may attenuate/enhance these pathways and thereby could be implicated in long-term cancer outcomes. Recent findings To date, clinical studies have predominantly been retrospective and underpowered and, thus limit meaningful conclusions. More recently, prospective studies of regional anesthesia for breast and colorectal cancer surgery have failed to demonstrate long-term cancer outcome benefit. However, based on the consistent observation of protumorigenic effects of surgical stress and that of volatile anesthesia in preclinical studies, supported by in vivo models of tumor progression and metastasis, we await robust prospective clinical studies exploring the role of propofol-based total intravenous anesthesia (cf. inhalational volatiles). Additionally, anti-adrenergic/anti-inflammatory adjuncts, such as lidocaine, nonsteroidal anti-inflammatory drugs and the anti-adrenergic propranolol warrant ongoing research. Summary The biologic perturbation of the perioperative period, compounded by the effects of anesthetic agents, renders patients with cancer particularly vulnerable to enhanced viability of minimal residual disease, with long-term outcome consequences. However, low level and often conflicting clinical evidence equipoise currently exists with regards to optimal oncoanesthesia techniques. Large, prospective, randomized control trials are urgently needed to inform evidence-based clinical practice guidelines.

Insufflation with CO2 can employ continuous flow, recirculated gas and/or additional warming and humidification. The ability to compare these modes of delivery depends upon the assays employed and opportunities to minimize subject variation. The use of pigs to train colorectal surgeons provided an opportunity to compare three modes of CO2 delivery under controlled circumstances. Sixteen pigs were subjected to rectal resection, insufflated with dry-cold CO2 (DC-CO2) (n = 5), recirculated CO2 by an AirSeal device (n = 5) and humidification and warming (HW-CO2) by a HumiGard device (n = 6). Peritoneal biopsies were harvested from the same region of the peritoneum for fixation for immunohistochemistry for hypoxia-inducible factor 1 alpha (HIF-1α) and scanning electron microscopy (SEM) to evaluate hypoxia induction or tissue/cellular damage, respectively. DC-CO2 insufflation by both modes leads to significant damage to mesothelial cells as measured by cellular bulging and retraction as well as microvillus shortening compared with HW-CO2 at 1 to 1.5 h. DC-CO2 also leads to a rapid and significant induction of HIF-1α compared with HW-CO2. DC-CO2 insufflation induces substantive cellular damage and hypoxia responses within the first hour of application. The use of HW-CO2 insufflation ameliorates these processes for the first one to one and half hours in a large mammal used to replicate surgery in humans.

Solar light harvesting begins with electronic energy transfer in structurally complex light-harvesting antennae such as the peridinin chlorophyll-a protein from dinoflagellate algae. Peridinin chlorophyll-a protein is composed of a unique combination of chlorophylls sensitized by carotenoids in a 4:1 ratio, and ultrafast spectroscopic methods have previously been utilized in elucidating their energy-transfer pathways and timescales. However, due to overlapping signals from various chromophores and competing pathways and timescales, a consistent model of intraprotein electronic energy transfer has been elusive. Here, we used a broad-band two-dimensional electronic spectroscopy, which alleviates the spectral congestion by dispersing excitation and detection wavelengths. Interchromophoric couplings appeared as cross peaks in two-dimensional electronic spectra, and these spectral features were observed between the peridinin S2 states and chlorophyll-a Qx and Qy states. In addition, the inherently high time and frequency resolutions of two-dimensional electronic spectroscopy enabled accurate determination of the ultrafast energy-transfer dynamics. Kinetic analysis near the peridinin S1 excited-state absorption, which forms in 24 fs after optical excitation, reveals an ultrafast energy-transfer pathway from the peridinin S2 state to the chlorophyll-a Qx state, a hitherto unconfirmed pathway critical for fast interchromophoric transfer. We propose a model of ultrafast peridinin chlorophyll-a protein photophysics that includes (1) a conical intersection between peridinin S2 and S1 states to explain both the ultrafast peridinin S1 formation and the residual peridinin S2 population for energy transfer to chlorophyll-a, and (2) computationally and experimentally derived peridinin S2 site energies that support the observed ultrafast peridinin S2 to chlorophyll-a Qx energy transfer.

A 21-question survey was conducted among parents attending 4 pediatric outpatient practices to assess their knowledge, perceptions, and attitudes about fever. One hundred and ninety-seven surveys were included. Most commonly the participating parent was the mother. Parents used mainly axillary thermometers to measure child’s temperature and mentioned integers for their definition of fever, 100°F being the most frequent answer. Most parents would treat all fevers and would use alternating antipyretics. Parents had a generally negative perception of fever: only one third thought fever may have some benefit, and more than half thought there must be some risk. A positive perception of fever was associated with parental educational level but not with information by the pediatrician. There is much confusion about fever among our parents, a negative perception is prevalent, and parents seem to receive—or recall—little information from the pediatrician.

Cancer-related mortality, a leading cause of death worldwide, is often the result of metastatic disease recurrence. Anesthetic techniques have varying effects on innate and cellular immunity, activation of adrenergic-inflammatory pathways, and activation of cancer-promoting cellular signaling pathways; these effects may translate into an influence of anesthetic technique on long-term cancer outcomes. To further analyze the effects of propofol (intravenous) and volatile (inhalational gas) anesthesia on cancer recurrence and survival, we undertook a systematic review with meta-analysis. Databases were searched up to 14 November 2018. Comparative studies examining the effect of inhalational volatile anesthesia and propofol-based total intravenous anesthesia (TIVA) on cancer outcomes were included. The Newcastle Ottawa Scale (NOS) was used to assess methodological quality and bias. Reported hazard ratios (HRs) were pooled and 95% confidence intervals (CIs) calculated. Ten studies were included; six studies examined the effect of anesthetic agent type on recurrence-free survival following breast, esophageal, and non-small cell lung cancer (n = 7,866). The use of TIVA was associated with improved recurrence-free survival in all cancer types (pooled HR, 0.78; 95% CI, 0.65 to 0.94; P < 0.01). Eight studies (n = 18,778) explored the effect of anesthetic agent type on overall survival, with TIVA use associated with improved overall survival (pooled HR, 0.76; 95% CI, 0.63 to 0.92; P < 0.01). This meta-analysis suggests that propofol-TIVA use may be associated with improved recurrence-free survival and overall survival in patients having cancer surgery. This is especially evident where major cancer surgery was undertaken. Nevertheless, given the inherent limitations of studies included in this meta-analysis these findings necessitate prospective randomized trials to guide clinical practice. PROSPERO (CRD42018081478); registered 8 October, 2018.

Time-resolved multi-pulse methods were applied to investigate the excited state dynamics, the interstate couplings, and the excited state energy transfer pathways between the light-harvesting pigments in peridinin-chlorophyll a-protein (PCP). The utilized pump-dump-probe techniques are based on perturbation of the regular PCP energy transfer pathway. The PCP complexes were initially excited with an ultrashort pulse, resonant to the S0 → S2 transition of the carotenoid peridinin. A portion of the peridinin-based emissive intramolecular charge transfer (ICT) state was then depopulated by applying an ultrashort NIR pulse that perturbed the interaction between S1 and ICT states and the energy flow from the carotenoids to the chlorophylls. The presented data indicate that the peridinin S1 and ICT states are spectrally distinct and coexist in an excited state equilibrium in the PCP complex. Moreover, numeric analysis of the experimental data asserts ICT → Chl-a as the main energy transfer pathway in the photoexcited PCP systems.

Background Patients with an impaired renal function show a high incidence of bone and mineral disturbances. These ‘chronic kidney disease – mineral and bone disorders’ (CKD-MBD) range from high turnover osteoporosis to adynamic bone disease. Currently, the histomorphometric analysis of a bone biopsy taken from the iliac crest is viewed as the gold standard for CKD-MBD subtype differentiation. However, the clinical relevance of such a biopsy is questionable since iliac crest fractures are an extremely rare finding. Therefore, we aimed to elucidate if the histomorphometric parameter ‘trabecular bone volume (BV/TV)’ from the iliac crest is representative for other biopsy locations. We chose two skeletal sites of higher fracture risk for testing, namely, the tibial bone and the lumbar spine, to examine if the current gold standard of bone biopsy is indeed golden. Methods Bone biopsies were taken from 12 embalmed body donors at the iliac crest, the proximal tibia, and the lumbar vertebral body, respectively. Masson-Goldner stained sections of methyl methacrylate embedded biopsies were used for trabecular bone volume calculation. Furthermore, exemplary μ-computed tomography (XtremeCT) scans with subsequent analysis were performed. Results Median values of trabecular bone volume were comparable between all body donors with median (interquartile range, IQR) 18.3% (10.9–22.9%) at the iliac crest, 21.5% (9.5–40.1%) at the proximal tibia, and 16.3% (11.4–25.0%) at the lumbar spine. However, single values showed extensive intra-individual variation, which were also confirmed by XtremeCT imaging. Conclusions Distinct intra-individual heterogeneity of trabecular bone volume elucidate why a bone biopsy from one site does not necessarily predict patient relevant endpoints like hip or spine fractures. Physicians interpreting bone biopsy results should know this limitation of the current gold standard for CKD-MBD diagnostic, especially, when systemic therapeutic decisions should be based on it.

Purpose: The majority of deaths from breast cancer occur following the development of metastatic disease, a process inhibited by β-blockers in preclinical studies. This phase II randomized controlled trial evaluated the effect of preoperative β-blockade with propranolol on biomarkers of metastatic potential and the immune cell profile within the primary tumor of patients with breast cancer. Patients and Methods: In this triple-blind placebo-controlled clinical trial, 60 patients were randomly assigned to receive an escalating dose of oral propranolol (n = 30; 80–160 mg daily) or placebo (n = 30) for 7 days prior to surgery. The primary endpoint investigated the effect of propranolol on prometastatic and proinflammatory gene expression within the primary tumor. Results: Propranolol downregulated primary tumor expression of mesenchymal genes (P = 0.002) without affecting epithelial gene expression (P = 0.21). Bioinformatic analyses implicated downregulation of Snail/Slug (P = 0.03), NF-κB/Rel (P < 0.01), and AP-1 (P < 0.01) transcription factors in structuring the observed transcriptome alterations, and identified changes in intratumoral neutrophil, natural killer cell, and dendritic cell recruitment (all P < 0.01). Patients with clinical evidence of drug response (lowered heart rate and blood pressure) demonstrated elevated tumor infiltration of CD68+ macrophages and CD8+ T cells. Conclusions: One week of β-blockade with propranolol reduced intratumoral mesenchymal polarization and promoted immune cell infiltration in early-stage surgically-resectable breast cancer. These results show that β-blockade reduces biomarkers associated with metastatic potential, and support the need for larger phase III clinical trials powered to detect the impact of β-blockade on cancer recurrence and survival. See related commentary by Blaes et al., p. 1781

Solar light harvesting begins with electronic energy transfer in structurally complex light-harvesting antennae such as the peridinin chlorophyll

ResumenObjetivoEl manejo de la isquemia crítica de los miembros inferiores representa un reto para el cirujano vascular debido a la alta tasa de amputaciones y mortalidad. Las opciones de manejo actuales: puente femorodistal, angioplastia con o sin la colocación de Stents y la resección de la placa con láser o de manera mecánica, presentan a largo plazo una tasa de éxito muy baja y un número de amputaciones supracondíleas que continúa siendo elevado.MétodosPara este estudio prospectivo se reclutaron 173 pacientes con diagnóstico de estadio avanzado, con isquemia crítica de miembro inferior quienes fueron tratados con alprostadil (60 – 120 mcgr/día) por vía intravenosa sistémica por 28 días. La respuesta se midió clínicamente por mejoría del llenado capilar y con el uso de la escala análoga visual del dolor.ResultadosAl momento del alta hospitalaria el 94.3% de los pacientes mejoró el puntaje en la escala análoga visual del dolor (p < 0.0001). El seguimiento a más de un año del tratamiento con alprostadil mostró que el 97% de los pacientes mejoró significativamente su estadio de isquemia, evitándose así una amputación mayor. No se observó respuesta al tratamiento en pacientes previamente intervenidos por vía endovascular (5 pacientes).ConclusionesEl tratamiento de pacientes con isquemia crítica de miembro inferior con alpostadil por infusión intravenosa, con bolos diarios de entre 60 y 120 mcg durante 28 días, este medicamento es seguro y presenta mínimos efectos secundarios. Esta terapia mejora sustancialmente el estadio funcional de Rutherford en estos pacientes y evita amputaciones mayores.AbstractObjetiveManagement of critical lower limb ischemia represents a challenge for the vascular surgeon due to the high rate of amputations and mortality. Current management options include femorodistal bypass, angioplasty with or without stent and laser or mechanical resection of the plaque. They present a low success rate in the long run and a number of supracondylar amputations that still remains high.MethodsThis prospective study included 173 patients diagnosed with advanced stage critical lower limb ischemia who were treated with systemic intravenous alprostadil (60 - 120 mcg/day) during 8 days. Response was measured clinically with improvement of capillary refill and using the visual analog scale for pain.ResultsUpon discharge 94.3% of patients improved their visual analogue scale score for pain (p < 0.0001). Follow-up for more than a year of alprostadil treatment revealed that 97% of patients significantly improved their ischemia status, thus avoiding further amputation. No response to treatment was observed in patients who had previously undergone endovascular surgery (5 patients).ConclusionsTreating patients with critical lower limb ischemia with intravenous alprostadil, administering daily doses of between 60 and 120 mcg during 28 days shows that this drug is safe and causes minimal secondary effects. This therapy significantly improves Rutherford's function state in these patients and avoids further amputations.

Photochromic [Pd

This introduction considers the alarming growth in extent and population of London in the Industrial Revolution and its social consequences, an increase not just in size but in diversity, thanks to the arrival of immigrants drawn by Britain’s religious toleration, its political liberties and its economic opportunities. Jewish immigrants from Eastern Europe, for example, were beginning late in the eighteenth century to supplement those who had come earlier from Western Europe. Among the crowds Wordsworth observes on the streets of London in the 1790s are not just “The Frenchman and the Spaniard,” or even “The Swede, the Russian”, but also American Indians, “Moors, / Malays, Lascars, the Tartar and Chinese, / And Negro Ladies in white muslin gowns” (The Prelude 1805, 7.235–43). The introduction looks at the railways, and their enablement of suburbanisation, and at the beginnings of social and political reform, including the expanding base of education and the consequent creation of a broad reading public.

This Introduction looks at the growth of London and Westminster from the accession of Queen Elizabeth I (when it was already a busy port and a diverse and cosmopolitan city) to the Restoration of Charles II. It pays particular attention to the lay-out of Elizabethan London, and follows in detail an imaginary time-traveller on her journey from Bedlam, north of the City, down Bishopsgate, southwards past the Royal Exchange and Lombard St, and over London Bridge to Shakespeare’s Globe, with some consequent consideration of Elizabethan theatre.

This introduction develops the theme of London’s rapid expansion and transformation into a modern city, with improved transportation by Underground Railway, electric trams and the omnibus, and unimaginably fast communication via the telegraph and (later) the telephone. It considers the dissemination of literature through the development of periodical publication and the ‘railway novel’, and the rise of free public libraries established through the Public Libraries Act of 1850. The introduction also contemplates London’s morally ambivalent role as the capital of an empire covering a quarter of the globe (as highlighted by the Diamond Jubilee of 1897), and social developments such as the ‘scandalous’ rise of the ‘New Woman’ and the struggle for female suffrage.

This Introduction, dealing inevitably with the Restoration, the Great Plague and the Great Fire (and the subsequent rebuilding of the City), considers this period as the beginning of the transformation of London into the great commercial, financial and imperial capital it became in the nineteenth century, with the development of great public buildings like new St Paul’s Cathedral and the rebuilt Royal Exchange, the establishment of broad thoroughfares, public parks and fashionable districts such as Mayfair, and the foundation of the Royal Society and (later) the British Museum. It was the new Royal Exchange and the unprecedented founding of the Bank of England that marked the emergence of London as the hub of global capitalism that it still is, generating a flood of money into the economy that seemed to some contemporaries to be a channel of moral corruption, as exemplified by the South Sea Bubble, an early manifestation of what has recently been termed “irrational exuberance” in the stock market. It is no coincidence that this period saw a rapid growth in legislative concern with crimes of property, and the introduction ends with a consideration of crime and punishment in Georgian London, and its somewhat ambivalent treatment in the literature of the time.

There was an isolated error relating to the Oh et al. study (1) within our recurrence-free survival analysis. When the reported estimates for Oh et al. are corrected, the pooled hazard ratio (HR) is now 0.87; 95% confidence interval (CI), 0.66 to 1.15; P=0.32.

On the Ground•Rangelands in Indian Country are unique. Legal and historical realities present challenges to range and natural resources management not seen outside of Indian Country.•Cooperative Extension educational programs are highly valued for their important impact on Agriculture and Natural Resources in counties. These programs exist on less then 10% of America’s Indian Reservations. Federally Recognized Tribal Extension Program (FRTEP) personnel, in the few places where they are funded, are a sought after resource to tribal individuals and communities in Indian Country.

The perioperative period of cancer surgery and its impact on patients’ long-term cancer outcomes is of increasing research interest. The physiological changes coincident with surgery are characterized by a stress response manifesting as activation of inflammatory pathways and immunosuppression. These changes are potentially deleterious to a patient’s capacity to control residual or released tumor cells. Of particular relevance to anesthesiologists is the role of available adjuncts that may offset these changes to improve patients' recovery from surgery and their long-term cancer outcomes. Animal and human evidence indicates a potential therapeutic benefit for β-adrenergic receptor antagonists, selective cyclooxygenase inhibitors, and anti-fibrinolytics administered through the perioperative period. In addition to reducing the surgical stress response, these agents may effect the cancer-host tissue interface to reduce cancer invasion and dissemination. Future research will focus on defining the role of these agents as integral perioperative adjuncts for cancer surgery.

Dilation of lymphatic vessels may contribute to iatrogenic dissemination of cancer cells during surgery. We sought to determine whether neuraxial anesthesia reduces regional lymphatic flow. Using nuclear lymphoscintigraphy, 5 participants receiving spinal anesthesia for brachytherapy had lower extremity lymph flow at rest compared with flow under conditions of spinal anesthesia. Six limbs were analyzed. Four limbs were excluded because of failure to demonstrate lymph flow (1 patient, 2 limbs), colloid injection error (1 limb), and undiagnosed deep vein thrombosis (1 limb). All analyzed limbs showed reduced lymph flow washout from the pedal injection site (range 62%-100%) due to neuraxial anesthesia. Lymph flow was abolished in 3 limbs. We report proof-of-concept that neuraxial anesthesia reduces lymphatic flow through a likely mechanism of sympathectomy.

Surgery is a mainstay treatment for patients with solid tumours. However, despite surgical resection with a curative intent and numerous advances in the effectiveness of (neo)adjuvant therapies, metastatic disease remains common and carries a high risk of mortality. The biological perturbations that accompany the surgical stress response and the pharmacological effects of anaesthetic drugs, paradoxically, might also promote disease recurrence or the progression of metastatic disease. When cancer cells persist after surgery, either locally or at undiagnosed distant sites, neuroendocrine, immune, and metabolic pathways activated in response to surgery and/or anaesthesia might promote their survival and proliferation. A consequence of this effect is that minimal residual disease might then escape equilibrium and progress to metastatic disease. Herein, we discuss the most promising proposals for the refinement of perioperative care that might address these challenges. We outline the rationale and early evidence for the adaptation of anaesthetic techniques and the strategic use of anti-adrenergic, anti-inflammatory, and/or antithrombotic therapies. Many of these strategies are currently under evaluation in large-cohort trials and hold promise as affordable, readily available interventions that will improve the postoperative recurrence-free survival of patients with cancer.

Background The biological perturbation associated with psychological and surgical stress is implicated in cancer recurrence. Preclinical evidence suggests that beta-blockers can be protective against cancer progression. We undertook a meta-analysis of epidemiological and perioperative clinical studies to investigate the association between beta-blocker use and cancer recurrence (CR), disease-free survival (DFS), and overall survival (OS). Methods Databases were searched until September 2017, reported hazard ratios (HRs) pooled, and 95% confidence intervals (CIs) calculated. Comparative studies examining the effect of beta-blockers (selective and non-selective) on cancer outcomes were included. The Newcastle Ottawa Scale was used to assess methodological quality and bias. Results Of the 27 included studies, nine evaluated the incidental use of non-selective beta-blockers, and ten were perioperative studies. Beta-blocker use had no effect on CR. Within subgroups of cancer, melanoma was associated with improved DFS (HR 0.03, 95% CI 0.01–0.17) and OS (HR 0.04, 95% CI 0.00–0.38), while endometrial cancer had an associated reduction in DFS (HR 1.40, 95% CI 1.10–1.80) and OS (HR 1.50, 95% CI 1.12–2.00). There was also reduced OS seen with head and neck and prostate cancer. Non-selective beta-blocker use was associated with improved DFS and OS in ovarian cancer, improved DFS in melanoma, but reduced OS in lung cancer. Perioperative studies showed similar variable effects across cancer types, albeit from a limited data pool. Conclusion Beta-blocker use had no evident effect on CR. The beneficial effect of beta-blockers on DFS and OS in the epidemiological or perioperative setting remains variable, tumour-specific, and of low-level evidence at present.

Background: Recent interest has focused on the role of perioperative epidural analgesia in improving cancer outcomes. The heterogeneity of studies (tumour type, stage and outcome endpoints) has produced inconsistent results. Clinical practice also highlights the variability in epidural effectiveness. We considered the novel hypothesis that effective epidural analgesia improves cancer outcomes following gastro-oesophageal cancer surgery in patients with grouped pathological staging. Methods: Following institutional approval, a database analysis identified 140 patients, with 2-year minimum follow-up after gastro-oesophageal cancer surgery. All patients were operated on by a single surgeon (2005‐2010). Information pertaining to cancer and survival outcomes was extracted. Results: Univariate analysis demonstrated a 1-year 14% vs. 33% (P = 0.01) and 2-year 27% vs. 40% [hazard ratio (HR)=0.59; 95% CI, 0.32‐1.09, P = 0.087] incidence of cancer recurrence in patients with (vs. without) effective (> 36 h duration) epidural analgesia, respectively. Multivariate analysis demonstrated increased time to cancer recurrence (HR = 0.33; 95% CI: 0.17‐ 0.63, P < 0.0001) and overall survival benefit (HR = 0.42; 95% CI: 0.21‐0.83, P < 0.0001) at 2-year follow-up following effective epidural analgesia. Subgroup analysis identified epidural-related cancer recurrence benefit in patients with oesophageal cancer (HR = 0.34; 95% CI: 0.16‐0.75, P = 0.005) and in patients with tumour lymphovascular space infiltration (LVSI), (HR = 0.49; 95% CI: 0.26‐0.94, P = 0.03). Effective epidural analgesia improved estimated median time to death (2.9 vs. 1.8 years, P = 0.029) in patients with tumour LVSI. Conclusions: This study found an association between effective post-operative epidural analgesia and medium-term benefit on cancer recurrence and survival following oesophageal surgery. A prospective study that controls for disease type, stage and epidural effectiveness is warranted.

Over the last decade, vacuum carburising in combination with high pressure gas quenching (HPGQ) has become a preferred technology in gear industry mainly in Europe and North America. Driven by cost savings in manufacturing of gears and shafts, the heat treatment process has gone into the focus of the manufacturers. The potential of savings in heat treatment is huge because the new technology allows the integration into the manufacturing chain of gears and shafts. With vacuum heat treatment furnaces is it possible to implement this integration into manufacturing. The advantages of vacuum technology are in particular: the absence of surface oxidation, the cold wall technology, the gas quenching technology, the reduced logistics, flexible reaction on the needs of production and the control of distortion. In parallel to the development of the new heat treat process, a second point came into the focus of manufacturers: the choice of material. The industry recognised that by choosing a slightly higher a...

Many of the physiological responses that comprise the surgical stress response are known to promote cancer-signaling pathways. Tissue resection and exposure to the pharmaco-physiological stressors of anesthesia required for surgery activate local and systemic inflammatory cytokines, up-regulate cyclooxygenase with increased prostaglandin production, and increase adrenergic activity. The activation of neuro-hormonal pathways is increasingly linked with cancer propagation. Retrospective evidence suggests that the use of anesthetic techniques and adjuncts that modulate these pathways and commonly available to practicing anesthesiologists may benefit patients scheduled for cancer surgery. Minimising the inflammatory response, preventing perioperative immunosuppression, and optimizing fluid delivery may have oncological benefits (improved disease free survival, reduced postoperative complications with timely delivery of adjuvant therapies) that extend beyond enhanced postoperative recovery. This review will consider key components of local and systemic inflammatory response, relevant immune cell mediators, perioperative endothelial dysfunction, and relevant perioperative therapies specific to the care of the patient receiving cancer surgery.

During cancer surgery, prostaglandin-mediated inflammation may promote and activate micrometastatic disease with a consequent increase in long-term cancer recurrence. Cyclooxygenase-2 inhibitors, known to have anti-proliferative properties, may offset such perioperative perturbation. We investigated the effectiveness of these agents to minimize inflammatory changes during cancer surgery.Following ethics approval, 32 patients who were to undergo major intracavity cancer surgery were enrolled in this prospective, randomized, clinical trial. The treatment group received 400 mg celecoxib preoperatively followed by five 200 mg 12-hourly doses. The control group received no anti-inflammatory agents. Inflammatory and immunomodulatory end points were measured serially. The primary end points were the measured plasma and urinary prostaglandin E metabolite (PGENo differences in the 48-hr plasma or urinary PGEStandard dosing of the cyclooxygenase-2 inhibitor celecoxib slightly reduced perioperative cyclooxygenase activity during cancer surgery. Given cyclooxygenase's role in cancer pathways, we recommend dose-finding studies be undertaken before prospective clinical trials are conducted testing the currently unsubstantiated hypothesis that perioperative anti-inflammatory administration improves long-term cancer outcomes. This trial was registered at: Australian New Zealand Clinical Trial Registry: ACTRN12615000041550; www.anzctr.org.au.

A model for the third order optical response of carotenoids is used to analyse transient grating and pump-probe data of peridinin in solution and bound in the peridinin-chlorophyll protein (PCP). For peridinin in solution, the transient grating signal detected at 505 nm exhibits a bi-exponential recovery whose fast phase is assigned to relaxation from the S-2 state that has a lifetime of 75 +/- 25 fs. The slower, solvent-dependent rise component is assigned to equilibration of the (S-1/ICT) state, taking place on a time scale of 0.6 and similar to 2.5 ps in acetontrile and benzene, respectively. These dynamics match those obtained from pump-probe measured in the spectral region of the ICT state, implying that the ICT state contributes to the signal at 505 nm. In PCP, the transient grating signal shows distinctly different kinetics, and the signal shows no recovery. This difference is explained by energy transfer from peridinin to chlorophyll-a. (C) 2009 Elsevier B. V. All rights reserved. (Less)

The peridinin-chlorophyll a -protein (PCP) of dinoflagellates is unique among the large variety of natural photosynthetic light-harvesting systems. In contrast to other chlorophyll protein complexes, the soluble PCP is located in the thylakoid lumen, and the carotenoid pigments outnumber the chlorophylls. The structure of the PCP complex consists of two symmetric domains, each with a central chlorophyll a (Chl- a ) surrounded by four peridinin molecules. The protein provides distinctive surroundings for the pigment molecules, and in PCP, the specific environment around each peridinin results in overlapping spectral line shapes, suggestive of different functions within the protein. One particular Per, Per-614, is hypothesized to show the strongest electronic interaction with the central Chl- a . We have performed an in vitro reconstitution of pigments into recombinant PCP apo-protein (RFPCP) and into a mutated protein with an altered environment near Per-614. Steady-state and transient optical spectroscopic experiments comparing the RFPCP complex with the reconstituted mutant protein identify specific amino acid-induced spectral shifts. The spectroscopic assignments are reinforced by a determination of the structures of both RFPCP and the mutant by x-ray crystallography to a resolution better than 1.5 Å. RFPCP and mutated RFPCP are unique in representing crystal structures of in vitro reconstituted light-harvesting pigment-protein complexes.

The triplet state of the carotenoid peridinin, populated by triplet-triplet energy transfer from photoexcited chlorophyll triplet state, in the reconstituted Peridinin-Chlorophyll a-protein, has been investigated by ODMR (Optically detected magnetic resonance), and pulse EPR spectroscopies. The properties of peridinins associated with the triplet state formation in complexes reconstituted with Chl a and Chl d have been compared to those of the main-form peridinin-chlorophyll protein (MFPCP) isolated from Amphidinium carterae. In the reconstituted samples no signals due to the presence of chlorophyll triplet states have been detected, during either steady state illumination or laser-pulse excitation. This demonstrates that reconstituted complexes conserve total quenching of chlorophyll triplet states, despite the biochemical treatment and reconstitution with the non-native Chl d pigment. Zero field splitting parameters of the peridinin triplet states are the same in the two reconstituted samples and slightly smaller than in native MFPCP. Analysis of the initial polarization of the photoinduced Electron-Spin-Echo detected spectra and their time evolution, shows that, in the reconstituted complexes, the triplet state is probably localized on the same peridinin as in native MFPCP although, when Chl d replaces Chl a, a local rearrangement of the pigments is likely to occur. Substitution of Chl d for Chl a identifies previously unassigned bands at approximately 620 and approximately 640 nm in the Triplet-minus-Singlet (T-S) spectrum of PCP detected at cryogenic temperature, as belonging to peridinin.

We present infrared and visible transient absorption measurements of the first excited singlet state (S 1 and S1/ICT) of peridinin in methanol, isopropanol, and chloroform solution following one-photon excitation, using 490 nm light, to excite the S2 state that populates S1 via rapid (~50 fs in methanol) internal conversion. This technique enables the study of subsequent structural dynamics in S1 involved in the formation of the charge transfer state. The S1 lifetime of peridinin in methanol, isopropanol, and chloroform is found to be 12, 54, and 65 ps, respectively, as deter- mined by infrared transient absorption. We observe two formation timescales in the S1 state. We attribute the shortest timescale to relaxation following internal conver- sion and the longer timescale to formation of the S1/ICT state.

Peridinin-chlorophyll-protein (PCP), containing differently absorbing chlorophyll derivatives, are good models with which to study energy transfer among monomeric chlorophylls (Chls) by both bulk and single-molecule spectroscopy. They can be obtained by reconstituting the N-terminal domain of the protein (N-PCP) with peridinin and chlorophyll mixtures. Upon dimerization of these "half-mers", homo- and heterochlorophyllous complexes are generated, that correspond structurally to monomeric protomers of native PCP from Amphidinium carterae. Heterochlorophyllous complexes contain two different Chls in the two halves of the complete structure. Here, we report reconstitution of N-PCP with binary mixtures of Chl a, Chl b, and [3-acetyl]-Chl a. The ratios of the pigments were varied in the reconstitution mixture, and relative binding constants were determined from quantification of these pigments in the reconstituted PCPs. We find higher affinities for both Chl b and [3-acetyl]-Chl a than for the native pigment, Chl a.

We combine ensemble and single-molecule spectroscopy to gain insight into the energy transfer between chlorophylls (Chls) in peridinin-chlorophyll-protein (PCP) complexes reconstituted with Chl a, Chl b, as well as both Chl a and Chl b. The main focus is the heterochlorophyllous system (Chl a/b-N-PCP), and reference information essential to interpret experimental observations is obtained from homochlorophyllous complexes. Energy transfer between Chls in Chl a/b-N-PCP takes place from Chl b to Chl a and also from Chl a to Chl b with comparable Förster energy transfer rates of 0.0324 and 0.0215ps−1, respectively. Monte Carlo simulations yield the ratio of 39:61 for the excitation distribution between Chl a and Chl b, which is larger than the equilibrium distribution of 34:66. An average Chl a/Chl b fluorescence intensity ratio of 66:34 is measured, however, for single Chl a/b-N-PCP complexes excited into the peridinin (Per) absorption. This difference is attributed to almost three times more efficient energy transfer from Per to Chl a than to Chl b. The results indicate also that due to bilateral energy transfer, the Chl system equilibrates only partially during the excited state lifetimes.

Single molecule spectroscopy experiments are reported for native peridinin–chlorophyll a–protein (PCP) complexes, and three reconstituted light-harvesting systems, where an N-terminal construct of native PCP from Amphidinium carterae has been reconstituted with chlorophyll (Chl) mixtures: with Chl a, with Chl b and with both Chl a and Chl b. Using laser excitation into peridinin (Per) absorption band we take advantage of sub-picosecond energy transfer from Per to Chl that is order of magnitude faster than the Forster energy transfer between the Chl molecules to independently populate each Chl in the complex. The results indicate that reconstituted PCP complexes contain only two Chl molecules, so that they are spectroscopically equivalent to monomers of native-trimeric-PCP and do not aggregate further. Through removal of ensemble averaging we are able to observe for single reconstituted PCP complexes two clear steps in fluorescence intensity timetraces attributed to subsequent bleaching of the two Chl molecules. Importantly, the bleaching of the first Chl affects neither the energy nor the intensity of the emission of the second one. Since in strongly interacting systems Chl is a very efficient quencher of the fluorescence, this behavior implies that the two fluorescing Chls within a PCP monomer interact very weakly with each other which makes it possible to independently monitor the fluorescence of each individual chromophore in the complex. We apply this property, which distinguishes PCP from other light-harvesting systems, to measure the distribution of the energy splitting between two chemically identical Chl a molecules contained in the PCP monomer that reaches 280 cm− 1. In agreement with this interpretation, stepwise bleaching of fluorescence is also observed for native PCP complexes, which contain six Chls. Most PCP complexes reconstituted with both Chl a and Chl b show two emission lines, whose wavelengths correspond to the fluorescence of Chl a and Chl b. This is a clear proof that these two different chromophores are present in a single PCP monomer. Single molecule fluorescence studies of PCP complexes, both native and artificially reconstituted with chlorophyll mixtures, provide new and detailed information necessary to fully understand the energy transfer in this unique light-harvesting system.

This work investigates the interaction of carotenoid and chlorophyll triplet states in the peridinin-chlorophyll-a-protein (PCP) of Amphidinium carterae using step-scan Fourier transform infrared spectroscopy. We identify two carotenoid triplet state lifetimes of approximately 13 and approximately 42 mus in the spectral region between 1800 and 1100 cm(-1) after excitation of the 'blue' and 'red' peridinin (Per) conformers and the Q(y) of chlorophyll-a (Chl-a). The fast and slow decaying triplets exhibit different spectral signatures in the carbonyl region. The fast component generated at all excitation wavelengths is from a major conformer with a lactone stretching mode bleach at 1745 cm(-1). One (1720 cm(-1)) and two (1720 cm(-1) and 1741 cm(-1)) different Per conformers are observed for the slow component upon 670- and 530-480-nm excitation, respectively. The above result implies that (3)Per triplets are formed via two different pathways, corroborating and complementing visible triplet-singlet (T-S) spectra (Kleima et al., Biochemistry (2000), 39, 5184). Surprisingly, all difference spectra show that Per and Chl-a modes are simultaneously present during the (3)Per decay, implying significant involvement of (3)Chl-a in the (3)Per state. We suggest that this Per-Chl-a interaction via a delocalized triplet state lowers the (3)Per energy and thus provides a general, photoprotection mechanism for light-harvesting antenna complexes.

International audience; The structures and environments of the protein-bound peridinins (Pers) and chlorophylls (Chls) a/c2 in the membrane-intrinsic major light-harvesting complex of the dinoflagellate Amphidinium carterae (LHCAmph) are characterised using resonance Raman (RR) spectroscopy with 11 excitation wavelengths, at 77K. The excitation-dependent variation in the CC stretching mode (ν1) suggests the presence of three Pers with conjugation lengths over 8 double bonds (dBs), and one diadinoxanthin, between 413.7 and 528.7nm. Two Perred species are revealed on excitation at 550 and 560nm. These Perred species exhibit anomalously low ν1 values, together with notable resonant enhancement of lactone ring-breathing and -deformation modes. To discern protein-specific effects, the RR spectra are compared to that of Per in polar (acetonitrile), polarisable (toluene) and polar-protic (ethanol) solvents. Resonantly enhanced lactone, ring-breathing (942cm(-1)) and ring-deformation (~650cm(-1)), modes are identified both in solution, and in the protein, and discussed in the context of the mixing of the S1 and S2 states, and formation of the intramolecular charge-transfer (ICT) state. In the Chl-absorbing region, two sets of Chl c2's, and (at least) six Chl a's can be differentiated. With a pigment ratio of 5-6 (Chl a):2 (Chl c2):5-6 (Per):1 Ddx determined from the fit to the RT absorption and 77K RR spectra, sequence comparison of LHCAmp to LHCII, and the diatom LHC, fucoxanthin-chlorophyll-a/c-protein (FCP), a template for the conserved pigment binding sites is proposed, to fill the paucity of structural information in the absence of a crystal structure for LHCAmph.