A critical appraisal of endorectal ultrasound and transanal endoscopic microsurgery and decision-making in early rectal cancer

AIM

Transanal endoscopic microsurgery (TEM) for early rectal cancer (ERC) gives results similar to major surgery in selected cases. Endorectal ultrasound (ERUS) is an important part of the preoperative selection process. This study reports its accuracy and impact for patients entered on the UK TEM database.

METHOD

The UK TEM database comprises prospectively collected data on 494 patients. This data set was used to determine the prevalence of ERUS in preoperative staging and its accuracy by comparing preoperative T-stage with definitive pathological staging following TEM.

RESULTS

ERUS was performed in 165 of 494 patients who underwent TEM for rectal cancer. It inaccurately staged rectal cancer in 44.8% of tumours: 32.7% were understaged and 12.1% were overstaged. There was no significant difference in the depth of TEM excision or R1 rate between the patients who underwent ERUS before TEM and those who did not (P = 0.73).

CONCLUSION

The data show that ERUS is employed in a minority of patients with rectal cancers undergoing TEM in the UK and its accuracy in this 'Real World' practice is disappointing.

Lymphatic vessels in osteoarthritic human knees

OBJECTIVES

The distribution and function of lymphatic vessels in normal and diseased human knees are understood incompletely. This study aimed to investigate whether lymphatic density is associated with clinical, histological or radiographic parameters in osteoarthritis (OA).

METHODS

Sections of synovium from 60 knees from patients with OA were compared with 60 post mortem control knees (from 37 individuals). Lymphatic vessels were identified using immunohistochemistry for podoplanin, and quantified as lymphatic vessel density (LVD) and lymphatic endothelial cell (LEC) fractional area. Effusion status was determined by clinical examination, radiographs were scored for OA changes, and inflammation grading used haematoxylin and eosin stained sections of synovium.

RESULTS

Lymphatic vessels were present in synovia from both disease groups, but were not identified in subchondral bone. Synovial lymphatic densities were independent of radiological severity and age. Synovia from patients with OA displayed lower LVD (z=-3.4, P=0.001) and lower LEC fractional areas (z=-4.5, P<0.0005) than non-arthritic controls. In patients with OA, low LVD was associated with clinically detectable effusion (z=-2.2, P=0.027), but not with histological evidence of synovitis. The negative associations between lymphatics and OA/effusion appeared to be independent of other measured confounders.

CONCLUSION

Lymphatic vessels are present in lower densities in OA synovia. Abnormalities of synovial fluid drainage may confound the value of effusion as a clinical sign of synovitis in OA.

Intramedullary cervical spine germinoma: a case report

Primary intramedullary germinoma arising in the cervical spinal cord is a very rare entity. We present one such case arising in a young man who presented with radiculopathy and myelopathy, which was partially excised. Upon histological confirmation, he was treated successfully with radiotherapy alone. To our knowledge, this is only the second reported case worldwide which is histologically confirmed. Although extremely rare, differential diagnosis for intramedullary spinal cord tumor should include germinoma.

Metal organic chemical vapour deposition of vertically aligned ZnO nanowires using oxygen donor adducts

Vertically aligned zinc oxide (ZnO) nanowires (NWs) have been grown by liquid injection Metal Organic Chemical Vapour Deposition, using oxygen donor adducts of Me2Zn. The growth and characterisation of the nanowires grown using [Me2Zn(L)] where L = monodentate ethers, tetrahydrofuran (C4H8O) (1), tetrahydropyran (C5H10O) (2), furan (C4H4O) (3) and the bidentate ethers, 1,2-dimethoxyethane (C4H12O2,) (4) 1,4-dioxane (C4H8O2) (5) and 1,4-thioxane (C4H8SO) (6) is discussed. Single crystal X-ray structures of (4), (5), (6) have been established and are included here. The ZnO NWs were deposited in the absence of a seed catalyst on Si(111) and F-doped SnO2/glass substrates over the temperature range 350-600 degrees C. X-ray diffraction (XRD) data shows that the nanowires grown from all adduct precursors were deposited in the wurtzitic phase.

Isolation of a novel mutated strain of Xanthomonas campestris for xanthan production using whey as the sole substrate

This study was conducted to isolate novel lactose utilizing Xanthomonas campestris mutants. Such a mutant will assist the utilization of whey as the sole carbon source for xanthan gum production, lower costs of fermentation process and set a precise application for whey as a waste. In this study, a mutant strain (NA1) was isolated from Xanthomonas campestris cells exposed to nitrous acid mutagenesis Environmental conditions were optimized and maximum activity of the beta-galactosidase enzyme was obtained at pH 5.5 and 38 degrees C following which the beta-galactosidase activity in NA1 culture was increased 9.5 folds, compared to that of the wild type culture (336.1 U vs. 35.4 U). Xanthan gum production by NA1 using whey as carbon source was also studied. Using the experimental design of Plackett-Burman and statistical analysis, whey, as the main substrate and pH were the first factors affecting gum production among the seven parameters tested. Gum production using significant factors (such as substrate concentration and pH) was carried out in a lab-scale fermentor and 10 g L(-l) xanthan was obtained.

Colloid solutions for fluid resuscitation

BACKGROUND

Colloids are widely used in the replacement of fluid volume. However doubts remain as to which colloid is best. Different colloids vary in their molecular weight and therefore in the length of time they remain in the circulatory system. Because of this and their other characteristics, they may differ in their safety and efficacy.

OBJECTIVES

To compare the effects of different colloid solutions in patients thought to need volume replacement.

SEARCH STRATEGY

We searched the Cochrane Injuries Group specialised register, CENTRAL (2007, Issue 1), MEDLINE (1994 to March 2007), EMBASE (1974 to March 2007), and the National Research Register (2007, issue 1). Bibliographies of trials retrieved were searched, and drug companies manufacturing colloids were contacted for information. The search was last updated in March 2007.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing colloid solutions in critically ill and surgical patients thought to need volume replacement. The outcomes measured were death, amount of whole blood transfused, and incidence of adverse reactions.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data and assessed the quality of the trials.

MAIN RESULTS

Seventy trials, with a total of 4375 participants, met the inclusion criteria. Quality of allocation concealment was judged to be adequate in 24 trials and poor or uncertain in the rest. Deaths were obtained in 46 trials. For albumin or PPF versus hydroxyethyl starch (HES) 25 trials (n = 1234) reported mortality. The pooled relative risk (RR) was 1.14 (95% CI 0.91 to 1.43). For albumin or PPF versus gelatin, seven trials (n = 636) reported mortality. The RR was 0.97 (95% CI 0.68 to 1.39). For albumin or PPF versus Dextran four trials (n = 360) reported mortality. The RR was 3.75 (95% CI 0.42 to 33.09). For gelatin versus HES 18 trials (n = 1337) reported mortality and RR was 1.00 (95% CI 0.80 to 1.25). RR was not estimable in the gelatin versus dextran and HES versus dextran groups.Thirty-seven trials recorded the amount of blood transfused, however quantitative analysis was not possible due to skewness and variable reporting. Nineteen trials recorded adverse reactions, but none occurred.

AUTHORS' CONCLUSIONS

From this review, there is no evidence that one colloid solution is more effective or safe than any other, although the confidence intervals are wide and do not exclude clinically significant differences between colloids. Larger trials of fluid therapy are needed if clinically significant differences in mortality are to be detected or excluded.

Human islets derived from donors after cardiac death are fully biofunctional

Islets from brain-dead donors (BDDs) are being used in the treatment of Type 1 diabetes. However, both donor numbers and islet survival are limited. We explored the clinical potential for islets from non-heart-beating donors (NHBDs), who have lower circulating cytokines, by comparing islets from 10 NHBDs against 12 identically-isolated islets from BDDs over the same time period. The quantity and quality of islets from NHBDs was good. NHBD yielded approximately 12.6% more islets than those of BDDs (505,000 +/- 84,230 vs. 400,970 +/- 172,430 islet equivalent number [IEQ]/pancreas, p = 0.01) with comparable viability. ATP and GTP contents were lower (6.026 +/- 3.076 vs. 18.105 +/- 7.8 nM/mg protein, p = 0.01 and 1.52 +/- 0.87 vs. 3.378 +/- 0.83 nM/mg protein, p = 0.04) and correlated negatively to warm ischemia time (R(2)= 0.8022 and R(2)= 0.7996, respectively). Islets from NHBDs took longer to control hyperglycemia in diabetic mice, but were equally able to sustain euglycemia. With a warm ischemia time (WIT) of <or=25 min, islets from NHBDs are at least as competent as islets from BDDs and should be suitable for clinical use.

Pilot trial of a synthetic breakpoint peptide vaccine in patients with chronic myeloid leukemia (CML) and minimal disease

6514

Background: CML is characterized by a tumor-specific fusion oncoprotein, BCR-ABL. Peptides spanning the B3A2 breakpoint of BCR-ABL can elicit MHC restricted T cell responses and clinical responses. No such data have previously been reported for vaccines targeting B2A2. Methods: We initiated a clinical trial administering synthetic analog breakpoint specific peptide vaccines for either B3A2 or B2A2 breakpoints to CML patients with major or complete cytogenetic remission. Measurable minimal disease was determined by either quantitative polymerase chain reaction (RQ-PCR) or nested PCR for BCR-ABL. Vaccine was administered with GM-CSF and Montanide ISA 51 subcutaneously. Eleven vaccinations were planned over the course of 1 year with the first 5 doses administered bi-weekly. Results: Eleven of 20 planned patients have been accrued to the study. Eight had documented cytogenetic remission and 3 were BCR-ABL positive via FISH analysis. Seven of the 11 patients had measurable BCR-ABL transcript levels as determined by RQ-PCR and all 11 were positive using the nested technique. Of the 5 patients positive for BCR-ABL (by RQ-PCR) before vaccination, 3 converted from RQ-PCR positive to negative while the transcript levels in the other patients decreased by approximately 1 log after 5 doses. All 5 of these patients remained positive using the nested PCR technique. Vaccination was well tolerated with local skin reactions at the injection sites. Immunologic reactivity was assessed ex vivo by CD4 autologous proliferation assay and T cell interferon (IFN) secretion (ELISPOT) assay. Ten of 11 patients were immunologically unreactive to the peptides prior to the vaccinations. Following the 5th dose of vaccine, 8/8 patients (including 2 with B2A2) tested showed significant immunologic responses by one of the above assays. Conclusions: These preliminary results suggest vaccination with synthetic analog peptides derived from CML proteins results in immunologic responses and may be associated with molecular improvement. Clinical efficacy of these vaccines in reducing/ eliminating minimal disease has yet to be established.

[Table: see text]

Surgical resection for pancreatic cancer: Correlates of margin positivity

4097

Background: Positive surgical margins (PSMs) occur in 20–40% of pancreatic cancer cases treated surgically. PSMs are associated with local recurrence and poor survival. Objectives: Correlate clinicopathological parameters with PSMs in pancreatic cancer patients (pts) undergoing surgical resection. Methods: Clinicopathological data for 71 pts who underwent surgical resection for pancreatic cancer from 1999–2005 were obtained. Data including location, AJCC stage, tumor size, type of resection, use of neoadjuvant therapy, grade, morphology, perineural and angiolymphatic invasion were correlated with PSMs and survival using logistic regression, Fisher-exact test and log-rank test. Results: There were 29 males; median age was 65 years and median follow-up 14 months. Histologies were: adenocarcinoma (n = 67), sarcomatoid (n = 2), adenosquamous (n = 1) and mucinous cystadenocarcinoma (n = 1). Sites of disease were: head only (n = 56), head/uncinate (n = 7) and body/tail (n = 8). Surgical treatments included Whipple (n = 43), pylorus preserving Whipple (n = 18) distal pancreatectomy (n = 8) and total pancreatectomy (n = 2). Pathological AJCC stages were: ΙA (n = 4), ΙB (n = 2), ΙΙA (n = 14), ΙΙB (n = 48), and ΙΙΙ (n = 3). Neoadjuvant chemoradiation (CRT) was administered in 10 cases; 38 other pts received postoperative adjuvant therapy including CRT (n = 36)/chemotherapy only (n = 2). Overall median survival was 30 months and disease free survival 18.6 months. Nineteen cases (27%) had PSMs. PSMs were pancreatic transection line (n = 11), retroperitoneal margin (n = 9), bile duct (n = 1) and peripancreatic soft tissue (n = 2). On univariate analysis, PSM was associated with advanced AJCC stage (p = 0.02) and tumor location other than pancreatic head (p = 0.02). PSM rate was 10% (1/10) and 31% (18/61) for pts with/without neoadjuvant therapy, respectively (p = 0.27). On multivariate analysis, PSM correlated with AJCC stage (p = 0.04) and tumor location (p = 0.05). PSMs were not significantly related to survival or recurrence (p = 0.09). Conclusions: Advanced AJCC stage and tumor in pancreatic body/tail or uncinate are associated with PSMs following pancreatic cancer resection. Strategies to “downstage” with novel therapies prior to surgery should be investigated to facilitate a complete surgical resection.

[Table: see text]

Detection of antibodies against serotypes 1 and 2 infectious bursal disease virus by commercial ELISA kits

Two distinct serotypes of infectious bursal disease virus (IBDV) are recognized in chicken and turkey flocks in the United States. Serologic testing of chicken flocks for serotype 1 viruses is routinely performed to monitor disease status and vaccination. Earlier studies indicated that enzyme-linked immunosorbent assay (ELISA) test detects antibodies to both serotypes of the virus, while the virus neutralization (VN) test is serotype specific. It is useful to evaluate currently available commercial ELISA kits for their ability to differentiate between antibodies elicited by the two serotypes. Three trials were performed in which chickens were orally inoculated with either a high or a low dose of serotype 1 STC or serotype 2 OH strains of IBDV. Sera collected at 0, 7, 14, and 21 days from these chickens and antisera procured from naturally infected broiler (n=20) and layer (n=30) flocks were tested with five different commercial ELISA kits and by VN. All ELISA kits detected different levels of antibodies elicited against serotype 1 of the virus and moderate and high levels of antibodies against serotype 2 virus. A correlation existed between the ELISA and the VN titers of experimentally infected chickens. All serum samples tested from the commercial layer flocks and 65% of the broiler flocks had antibodies against the OH strain. However, no correlation between the VN titers and ELISA titers was observed for the commercial broilers and layers sera by the majority of the kits. The results indicated that currently available commercial ELISA kits detect antibodies elicited by the two serotypes of IBDV. Hence, the prevalence of serotype 2 antibodies in the flocks should be considered while determining antibody profiles of the flocks against serotype 1 viruses.

Interference Between Mild and Pathogenic Strains of Infectious Bursal Disease Virus in Chickens

Infectious bursal disease virus is a contagious, immunosuppressive disease of young chickens that is controlled by vaccination. Cross-protection occurs between different strains of the virus as a result of shared neutralizing epitopes. However, interactions between two antigenically similar strains (a mild and a pathogenic) coinfecting the same host have not been investigated. Groups of specific-pathogen-free chickens were inoculated with a mild strain followed by a pathogenic strain at 0, 16, 24, or 48 hr postinoculation (PI) with a mild strain. Virus persistence and the predominant strain of the virus were determined by reverse transcriptase-polymerase chain reaction and restriction fragment length polymorphism analysis, respectively, in bursas at 2, 4, 8, 14, and 21 days PI with the pathogenic strain. Severity of infection was assessed by the bursa/body weight ratios and histopathologic lesion scores. The mild virus interfered with replication of the pathogenic virus. The greatest interference was observed when the pathogenic strain was inoculated 24 hr PI with the mild strain. The interference phenomenon observed might be due to competition for host receptor sites or production of cytokine(s). This interference phenomenon could have practical implications for vaccine usage and protection.

Neonatal sepsis: an etiological study

OBJECTIVE

A periodic review of neonatal sepsis to asses any change in the infecting organism.

METHOD

A prospective study was conducted at HMC and ASH, Karachi. The babies suspected to have or developed sepsis any time during hospitalization were investigated to establish the diagnosis and isolate the causative organism. Blood culture was taken at the time of admission or when sepsis was suspected.

RESULTS

Out of 109 episodes of blood culture proven sepsis 68 presented as early onset (within 48 hours of birth) and 41 as late onset sepsis (after 48 hours of birth). In early onset group Gram -ve and Gram +ve organisms were almost equal, i.e. 33 and 35 respectively. Among the gram -ve organism most of the cases were due to Klebsiella sp, and Enterococcus was the commonest Gram +ve organism. In late onset group majority of infections were due to gram +ve organisms, i.e. 30 out of 41. Staph. aureus and Staph. epidermidis were commonest. The organisms were least sensitive to Ampicillin (< 20%) and highly sensitive to Amikacin (90% to 100%), Cefotaxime was also seen as a good choice of antibiotic with sensitivity of (84%-89%).

CONCLUSION

Gram +ve organisms were the main cause of neonatal sepsis. Klebsiella sp. is still the commonest organism causing early onset sepsis. The data must be periodically reviewed and antibiotic policy revised accordingly.

Banff criteria as predictors of outcome following acute renal allograft rejection

BACKGROUND

The Banff classification of renal allograft rejection grades acute tubulointerstitial rejection (AIR) by severity of tubulitis and acute vascular rejection (AVR) by severity of arteritis. The intensity of tubulitis has not, however, been demonstrated to be of prognostic value and other features such as glomerulitis and eosinophil infiltration are of uncertain significance. This study was performed in order to determine the clinical value of this pathological classification.

METHODS

Banff criteria were correlated with outcome in 134 consecutive graft recipients transplanted in our unit over a 3-year period (1994 1996) who experienced at least one biopsy-confirmed acute rejection episode. Of 197 biopsies performed for the diagnosis of rejection, 177 contained at least one artery and were suitable for Banff grading. Tissue eosinophil counts were available for 101 biopsies. Clinical severity of rejection was classified as mild (fully responsive to pulse steroid therapy), moderate (partially steroid responsive) and severe (steroid unresponsive/requiring ATG therapy).

RESULTS

Graft failure ensued in 18 of 58 patients with AVR compared with 10 of 65 patients with AIR (P= < 0.05). Clinical severity of rejection correlated with the presence of arteritis, but not severity of tubulitis; rejections graded I, IIA and IIB according to the Banff' 93 classification were clinically severe in 3/68 (4%), 2/28 (7%) and 15/67 (22%) respectively (P= <0.05). The presence of glomerulitis showed no correlation with clinical severity or graft loss. Tissue eosinophilia (>10 eosinophils/mm2) was present in 18 of 33 patients who had at least one episode of AVR (v1/2), compared with 11 of 45 patients who suffered only AIR (P= <0.02).

CONCLUSIONS

We conclude that: arteritis, but not severe tubulitis or glomerulitis, is an adverse prognostic factor in acute rejection and that tissue eosinophilia is associated with vascular rejection. Our findings support the 1997 revision of the Banff classification, replacing grades with types of acute rejection.

Cytokine gene polymorphisms predict acute graft rejection following renal transplantation

BACKGROUND

The proinflammatory cytokine tumor necrosis factor-alpha (TNF-alpha) has been implicated in the pathogenesis of acute rejection, while animal models suggest a role for interleukin-10 (IL-10) in promoting graft survival. It has also been shown that polymorphisms in the TNFA gene promoter (position -308) and in the IL-10 gene promoter (position -1082) correlate with differential production of these cytokines in vitro. The aim of this study was to determine whether TNF-alpha and IL-10 gene polymorphisms influence the incidence and severity of acute rejection in the first six months following renal transplantation.

METHODS

The cytokine genotypes of 115 consecutive first cadaveric kidney allograft recipients and their donors were screened. The rejection episodes (REs) were defined clinically and confirmed histologically where possible and further classified according to severity (RS), namely steroid-resistant or responsive REs. The genotypes were then correlated with the REs and RS.

RESULTS

The recipient TNF-alpha high producer genotype and IL-10 high producer genotype were significantly associated with multiple REs (>/=2) in human leukocyte antigen (HLA)-DR mismatched transplants (P = 0.0047 and P = 0.045, respectively), whereas only the TNF-alpha high producer genotype was associated with steroid-resistant REs (P = 0.025). When recipient cytokines were analyzed together, the TNF-alpha high/IL-10 high producer genotype had the worst prognosis, whereas TNF-alpha low/IL-10 low producer genotype was protective.

CONCLUSIONS

We conclude that recipient TNF-alpha and IL-10 gene polymorphisms are determinants of REs and RS following kidney transplantation. Routine screening of these gene polymorphisms may have a clinical role in identifying patients at risk of multiple REs and severe rejections.

Cytokine and S100B levels in paediatric patients undergoing corrective cardiac surgery with or without total circulatory arrest

OBJECTIVES

Neurological damage following cardiopulmonary bypass (CPB) is difficult to objectively evaluate in infants. In adults, serum elevations of astroglial S100B correlate with proven brain injury independent of operative temperature. The deleterious effects of inflammatory cytokines, generated during CPB, on the brain have not been studied in infants using S100B as a marker for cerebral injury.

METHODS

Twelve neonates, weighing 3.3 +/- 0.2 kg (total circulatory arrest group (TCA)) and 12 infants weighing 7.0 +/- 1.0 kg (cardiopulmonary bypass group (CPB)) underwent corrective cardiac surgery for various pathologies. Serial blood samples on induction, at the end of CPB, 30 min, 2 h and 24 h after the administration of protamine, were taken. The resultant plasma was frozen to -80 degrees C and stored for batch analysis. Cytokines were measured using ELISAs and S100B using a luminometric assay.

RESULTS

The TCA group were younger and experienced a longer perfusion time than the CPB group (137 +/- 8 vs. 113 +/- 7, P = 0.04). The mean TCA time was 23 +/- 4 min. The TCA group had significantly higher levels of IL-6 (P = 0.001), IL-8 (P = 0.005) and S100B (P = 0.002) at 24 h. C5b-9 levels were significantly lower in the TCA group: end of CPB (P = 0.001), 30 min (P < 0.001), 2 h (P = 0.002). There was a weak, but significant correlation between IL-6 levels at the end of CPB and S100B levels 2 h later (r = 0.55, P = 0.03). Long extubation times were associated with high 24-h S100B levels (r = 0.52, P = 0.01).

CONCLUSIONS

(1) The TCA group have prolonged rises of IL-6, IL-8 and S100B. (2) The TCA group generates significantly lower complement. (3) Astroglial injury, seen after surgery, may, in part, be cytokine mediated.

Carcinoma gall bladder presenting as hemobilia

A 60-year-old man presented with recurrent bouts of melena, requiring multiple transfusions. Upper GI endoscopic evaluation demonstrated fresh bleeding from the ampulla of Vater. Ultrasonography and CT scan suggested a gall bladder mass without evidence of metastases. Laparotomy confirmed a mass confined to the lumen of the gall bladder. The patient underwent cholecystectomy. Histological examination showed papillary adenocarcinoma of the gall bladder extending up to the muscularis propria.

Serum S100beta release after coronary artery bypass grafting: roller versus centrifugal pump

BACKGROUND

Microemboli generated during cardiopulmonary bypass (CPB) are implicated in the cerebral injury seen after coronary artery bypass grafting. Centrifugal pumps generate fewer microemboli than roller pumps. Increased S100beta levels have been reported after coronary artery bypass grafting, with levels greater than 1 ng/mL resulting in poorer neuropsychologic outcome. This study investigated the potential neurologic benefits of centrifugal pumps, by using S100beta as a marker for cerebral injury.

METHODS

Thirty-two patients who had coronary artery bypass grafting were randomly assigned to two groups. Serial blood samples (preoperative, end of bypass, 30 minutes, and 2 and 24 hours after cardiopulmonary bypass) were taken and the serum analyzed for S100beta using a new immunoluminometric assay.

RESULTS

Both groups were matched for age, number of grafts, and cardiopulmonary bypass and cross-clamp times. Postoperative serum S100beta levels were significantly higher in both groups than preoperative levels. Peak S100beta levels did not correlate with cardiopulmonary bypass time; however, 24-hour S100beta levels correlated with intubation time r = 0.40, p = 0.04). Th ere was no significant difference in S100beta levels between the groups at any of the time points.

CONCLUSIONS

S100beta levels increased after coronary artery bypass grafting. Centrifugal pumps do not significantly decrease S100beta release. Persistently increased S100beta levels are associated with longer intubation times.