La unión y formación de poros de las actinoporinas están determinadas por las propiedades fisicoquímicas de la membrana

Introducción. Las actinoporinas (AP) son proteínas formadoras de poro (PFP) que se asocian a membranas conduciendo a la muerte celular. Sticholysinas I y II (St, StI/II) se encuentran entre las AP más potentes descritas en la naturaleza. El objetivo del presente trabajo fue estudiar la influencia de la composición lipídica y dinámica de la membrana en la unión y formación de poros por StI/II y nigrelysina (Ngr), una nueva AP aquí descrita. Métodos. La unión y formación de poros se estudiaron mediante membranas modelo combinadas con espectroscopía de fluorescencia y microscopía. Resultados y discusión. St y Ngr se unen y permeabilizan preferencialmente membranas que contienen esfingomielina (SM) cuando se compara con fosfatidilcolina (PC), debido a la presencia, en SM, de la unidad de fosfocolina de PC más la unidad ceramida (Cer). StI reconoce a Cer y a gangliósidos, aunque en menor extensión. En términos de propiedades dinámicas, StI penetra preferencialmente membranas con elevada movilidad lateral y adecuado nivel de SM. StI permeabiliza más eficientemente membranas con esteroles además de SM. Los bordes de la coexistencia de dominios lipídicos no constituyen un factor determinante para su unión y actividad. La heterogeneidad molecular de las membranas, más allá de la presencia de dominios, favorece la actividad de AP. Conclusiones. Estos estudios explican la relevancia de SM, otros lípidos de base Cer y esteroles a la actividad de St, Ngr, y por extensión, a las AP. Desde una perspectiva dinámica, una fase altamente fluida y moderadamente enriquecida en SM y esteroles constituye una plataforma ideal para la formación de poros por AP.Introduction. Actinoporins (AP) are pore-forming proteins (PFPs) that readily bind to membranes leading to cell death. Sticholysins I and II (St, StI/II) are among the most potent AP described in nature. This proposal aimed to characterize the influence of lipid composition and dynamic properties of membranes on binding and pore-formation by StI/II and nigrelysin (Ngr), a novel AP here described. Methods. Binding and pore-formation were studied using model membranes such as liposomes and lipidic monolayers combined with fluorescence spectroscopy and microscopic techniques. Results and Discussion. St and Ngr bind and preferentially permeabilize membranes containing sphingomyelin (SM) over phosphatidylcholine (PC). This is explained by the presence of the PC phosphocholine unit plus a ceramide moiety (Cer) in SM. StI also recognizes Cer and gangliosides although to a lesser extent. In terms of dynamic properties, StI penetrates preferentially membranes with high lateral mobility and moderately enriched in SM. Also, StI permeabilizes more efficiently membranes containing sterols, in addition to SM. The appearance of borders resulting from lipidic domains coexistence is not a determining factor for binding or activity in membranes. Indeed, the activity is enhanced by membrane molecular heterogeneity beyond the presence of lipidic domains. As a conclusion these studies explain the relevance of SM and sterols for St, Ngr, and by extension, to APs binding to membrane and explain the contribution of other Cer-based lipids to their activity. In dynamic terms, a highly fluid phase, and moderately enriched in SM and sterols, is an ideal platform for the formation of pores in the membrane for AP.Universidad Nacional, Costa RicaAcademia de Ciencias de Cuba, CubaEscuela de Ciencias Biológica

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background: Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods: The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results: A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion: Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)

The impact of surgical delay on resectability of colorectal cancer: An international prospective cohort study

AimThe SARS-CoV-2 pandemic has provided a unique opportunity to explore the impact of surgical delays on cancer resectability. This study aimed to compare resectability for colorectal cancer patients undergoing delayed versus non-delayed surgery.MethodsThis was an international prospective cohort study of consecutive colorectal cancer patients with a decision for curative surgery (January-April 2020). Surgical delay was defined as an operation taking place more than 4 weeks after treatment decision, in a patient who did not receive neoadjuvant therapy. A subgroup analysis explored the effects of delay in elective patients only. The impact of longer delays was explored in a sensitivity analysis. The primary outcome was complete resection, defined as curative resection with an R0 margin.ResultsOverall, 5453 patients from 304 hospitals in 47 countries were included, of whom 6.6% (358/5453) did not receive their planned operation. Of the 4304 operated patients without neoadjuvant therapy, 40.5% (1744/4304) were delayed beyond 4 weeks. Delayed patients were more likely to be older, men, more comorbid, have higher body mass index and have rectal cancer and early stage disease. Delayed patients had higher unadjusted rates of complete resection (93.7% vs. 91.9%, P = 0.032) and lower rates of emergency surgery (4.5% vs. 22.5%, P ConclusionOne in 15 colorectal cancer patients did not receive their planned operation during the first wave of COVID-19. Surgical delay did not appear to compromise resectability, raising the hypothesis that any reduction in long-term survival attributable to delays is likely to be due to micro-metastatic disease

Stoma-free survival after anastomotic leak following rectal cancer resection: worldwide cohort of 2470 patients

Background: The optimal treatment of anastomotic leak after rectal cancer resection is unclear. This worldwide cohort study aimed to provide an overview of four treatment strategies applied. Methods: Patients from 216 centres and 45 countries with anastomotic leak after rectal cancer resection between 2014 and 2018 were included. Treatment was categorized as salvage surgery, faecal diversion with passive or active (vacuum) drainage, and no primary/secondary faecal diversion. The primary outcome was 1-year stoma-free survival. In addition, passive and active drainage were compared using propensity score matching (2: 1). Results: Of 2470 evaluable patients, 388 (16.0 per cent) underwent salvage surgery, 1524 (62.0 per cent) passive drainage, 278 (11.0 per cent) active drainage, and 280 (11.0 per cent) had no faecal diversion. One-year stoma-free survival rates were 13.7, 48.3, 48.2, and 65.4 per cent respectively. Propensity score matching resulted in 556 patients with passive and 278 with active drainage. There was no statistically significant difference between these groups in 1-year stoma-free survival (OR 0.95, 95 per cent c.i. 0.66 to 1.33), with a risk difference of -1.1 (95 per cent c.i. -9.0 to 7.0) per cent. After active drainage, more patients required secondary salvage surgery (OR 2.32, 1.49 to 3.59), prolonged hospital admission (an additional 6 (95 per cent c.i. 2 to 10) days), and ICU admission (OR 1.41, 1.02 to 1.94). Mean duration of leak healing did not differ significantly (an additional 12 (-28 to 52) days). Conclusion: Primary salvage surgery or omission of faecal diversion likely correspond to the most severe and least severe leaks respectively. In patients with diverted leaks, stoma-free survival did not differ statistically between passive and active drainage, although the increased risk of secondary salvage surgery and ICU admission suggests residual confounding