Full-thickness pouch prolapse after restorative proctocolectomy: a potential future problem treated by the new technique of external pelvic neorectal suspension (the Express procedure)

Full thickness pouch prolapse following restroative proctocolectomy is an uncommon complication but likely to become more frequent as this population of patients grows older. Conventional procedures to correct the prolapse may be impossible or significantly risk permanent ileostomy formation. The Express technique which is relatively minimally invasive, is a perineal procedure which elevates and suspends the antero-lateral walls of the prolapsing pouch to the external surface of the pelvis, utilizing strips of long lasting collagen.

Letter 1: Safety lessons taken from the airlines (Br J Surg 2004; 91: 393–394)

The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses can be sent electronically via the BJS website (www.bjs.co.uk) or by post. All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length. Letters submitted by post should be typed on A4-sized paper in double spacing and should be accompanied by a disk.

Increased serum transforming growth factor-beta1 in human colorectal cancer correlates with reduced circulating dendritic cells and increased colonic Langerhans cell infiltration

Cancer-related cytokines may interfere with the differentiation and migration of dendritic cells (DCs) and with the associated up-regulation of co-stimulatory molecules in vitro. We determined whether cytokines affected the distribution and activation of DCs in patients with colorectal cancer by measuring the levels of serum cytokines [transforming growth factor (TGF)-beta1 and vascular endothelial growth factor (VEGF)], DC numbers and phenotype from peripheral blood and mesenteric lymph nodes draining the cancer, and the infiltration of DCs into colorectal cancer. A significant increase in the serum level of TGF-beta1 correlated with a significant reduction in the level of circulating DCs in cancer patients that was associated with an increased infiltration of Langerhans cells into colorectal mucosa. The prevalence but not intensity of co-stimulatory molecule expression in circulating and mesenteric lymph node DCs was reduced in patients with colorectal cancer compared to patients with inflammatory bowel conditions. There was no correlation between co-stimulatory molecule expression and serum TGF-beta1. Thus the circulating DC depletion in colorectal cancer could be explained by a TGF-beta1-related DC redistribution from the circulation into the colorectal cancer and adjacent mucosa where DC levels were increased. There was an impairment of DC activation within colorectal cancer that was not related to serum level of cytokines.

Central nervous system tumours in adolescents

Adolescents with brain tumours have been, and in most cases still are, haphazardly assigned, on referral, to either 'paediatric' or 'adult'-based treatment centres. In this age group, there is therefore a history of inconsistent treatment, delivery of inappropriate 'maturity-related' care and a reduced chance of gathering vital biological, clinical and treatment-related information germane to this group of patients and their tumours. These days, adolescents with brain tumours should be actively targeted for recruitment into clinical trials and admission into dedicated neuro-oncology centres or programmes that can deliver the necessary and age appropriate multidisciplinary management.

Identification of novel HLA class I alleles using single allele sequencing

Three new HLA-A and five HLA-B alleles reported in this paper have been characterized by direct sequencing of PCR product obtained by group-specific amplification of potential new alleles. Four new alleles, B*5133, B*5134, B*1574 and B*5807, carry motifs observed in previously identified HLA-B alleles and may have evolved via gene conversion. Four alleles, A*2438, A*3405, A*2437 and B*520104, display polymorphisms at positions previously considered constant. All new alleles were identified either by an unexpected sequence specific oligonucleotide probe hybridization pattern or by sequence-based typing, and later confirmed by single allele sequencing.

Transferrin regulates transcription of the MBP gene and its action synergizes with IGF-1 to enhance myelinogenesis in the md rat

Myelin-deficient (md) rats and their unaffected littermates were injected at postnatal day 4 either with a single dose of transferrin (Tf) or insulin-like growth factor one (IGF-1) singly or combined. Two weeks later, their brains were perfused and coronal sections were analyzed for MBP by in situ hybridization and for transferrin and myelin basic protein (Tf and MBP) by double immunofluorescence. Each of the factors separately had an effect on mutant animals as seen by both increased OL maturation, and MBP mRNA and protein synthesis. The combination of factors resulted in a profound enhancement of the myelinogenic properties of oligodendrocytes (OL) with a consequent increase in the number of MBP-labeled fibers. The brains of unaffected littermates also responded to growth factor(s) injection either by increasing myelination in some brain areas or by regulating the synthesis of MBP in OL. Using rat OL cultures we studied the site of transferrin action for the expression of MBP gene. We found by run off transcription that the MBP mRNA was significantly increased at the nuclear level but the PLP message was unaffected. Thus, transferrin selectively regulates MBP at the transcriptional level and together with IGF-1 synergizes to increase both the maturation and myelinogenic properties of md and normal OL.

Evaluation of standardized tasks for primary care physicians using the MOXXI electronic prescribing and integrated drug management system

The Medical Office for the Twenty First Century (MOXXI) is a research project testing the potential benefits of an electronic prescription and drug management system for primary care physicians. This system includes a dynamic electronic pad for prescription entry with fields for treatment indications; a drug profiler with a graphic representation of the list of prescription medications purchased in the last year; a refill compliance calculator; dates of emergency room visits and hospital admissions; cost of drugs dispensed; and an alert system that detects interactions among drugs, treatment duplications, and contraindications with certain allergies or specific diseases. One concern expressed by physicians that could influence uptake and acceptability is the increased time that may be required to use the system. User abilities are a factor in this process, as well as user interface, user training and system speed.

Flow cytometry correlates with RT-PCR for detection of spiked but not circulating colorectal cancer cells

The aim of this study was to determine whether flow cytometry (FACS) could detect spiked or circulating colorectal cancer cells. A flow cytometric assay was developed and its sensitivity compared with the reverse transcription polymerase-chain reaction (RT-PCR), using carcinoembryonic antigen (CEA) and cytokeratin (CK) 20 mRNA as target markers. Sensitivity limits for RT-PCR and flow cytometry (FACS) were established using spiked blood, and pre-operative blood samples from 20 colorectal cancer patients and 16 healthy no-cancer controls were analysed for circulating tumour cells (CTC) using both methods. Blood samples for FACS analysis were immuno-magnetically enriched using ferrofluid particles. CTC were defined as positive for pan-cytokeratin and negative for CD45 pan-leucocyte antigen (CK+/CD45- events). There was a significant (P < 0.0001) correlation between the number of spiked cancer cells and their recovery using FACS. The lowest detectable concentration was 20 spiked cancer cells in 14 ml blood for both RT-PCR and FACS. A positive FACS result significantly (P < 0.05) concurred with a positive RT-PCR result in spiked blood. The number of CK+/CD45- events detected in the blood of colorectal cancer patients was not significantly greater (P = 0.07) than in blood taken from 'no cancer' controls and furthermore there was no concordance (P = 1) between RT-PCR and FACS positivity in cancer patients' blood. FACS detection of tumour cells was feasible in vitro, and correlated with RT-PCR. However, its sensitivity in vivo was poor and did not correlate with RT-PCR detection of CTC. Uncertainties about antigen expression on normal circulating cells and about CTC phenotype need to be resolved, before FACS can be developed for detection of tumour cells within the circulation.

Serum tryptophan decrease correlates with immune activation and impaired quality of life in colorectal cancer

Cancer-related indoleamine (2,3)-dioxygenase up-regulation by interferon-gamma might influence quality of life by depleting serum tryptophan. We correlated serum tryptophan levels with immune activation and quality of life in patients with colorectal liver metastases. Venous blood was sampled from patients with primary colorectal cancer and from patients with metachronous colorectal liver metastases who completed quality of life and psychological questionnaires. Serum tryptophan, kynurenine, neopterin, interleukin 2 soluble receptor alpha (IL-2 sRalpha), soluble tumour necrosis factor receptor I (sTNF RI), interleukin 6, and C-reactive protein were measured. Liver metastasis volume was estimated by computerised tomography, and survival from blood sampling was noted. Sixty-six patients with colorectal cancer were studied (39 males; median age 66 years) of whom 25 had colorectal liver metastases only (17 males; median age 62 years; median liver metastasis volume 208 ml; median survival 234 days). Reduced serum tryptophan was significantly associated with Rotterdam Symptom Checklist physical symptom (r=-0.51, P=0.01) and Sickness Impact Profile (r=-0.42, P=0.04) scores, and correlated with increased serum neopterin (r=-0.36, P=0.003), IL-2 sRalpha (r=-0.51, P=0.01) and sTNF RI (r=-0.45, P=0.02) levels. Stepwise regression analyses suggested that serum tryptophan was an independent predictor of Rotterdam Symptom Checklist physical symptom (regression coefficient -20.78, P=0.01) and Sickness Impact Profile (regression coefficient -109.09, P=0.04) scores. The results supported a role for interferon-gamma-mediated serum tryptophan decrease in cancer-induced quality of life deterioration.

Does sentinel lymph node biopsy have a role in colorectal cancer?

Sentinel lymph node (SLN) biopsy in colorectal cancer is feasible, and may offer a means of reducing histopathology workload while maintaining staging accuracy. Although SLN biopsy allows use of sensitive molecular markers that can identify isolated tumour cells and micrometastases, these findings require more extensive clinical evaluation before they can be used to guide patient management. The application of molecular markers to identification of minimal residual disease after primary tumour resection, shows promise as a means of indicating patients requiring chemotherapy.

NMR analysis of helix I from the 5S RNA of Escherichia coli

The structure of helix I of the 5S rRNA from Escherichia coli has been determined using a nucleolytic digest fragment of the intact molecule. The fragment analyzed, which corresponds to bases (-1)-11 and 108-120 of intact 5S rRNA, contains a G-U pair and has unpaired bases at its termini. Its proton resonances were assigned by two-dimensional NMR methods, and both NOE distance and coupling constant information have been used to calculate structural models for it using the full relaxation matrix algorithm of the molecular dynamics program XPLOR. Helix I has A-type helical geometry, as expected. Its most striking departure from regular helical geometry occurs at its G-U, which stacks on the base pair to the 5' side of its G but not on the base pair to its 3' side. This stacking pattern maximizes interstrand guanine-guanine interactions and explains why the G-U in question fails to give imino proton NOE's to the base pair to 5' side of its G. These results are consistent with the crystal structures that have been obtained for wobble base pairs in tRNAPhe [Mizuno, H., & Sundaralingam, M. (1978) Nucleic Acids Res. 5, 4451-4461] and A-form DNA [Rabbinovich, D., Haran, T., Eisenstein, M., & Shakked, Z. (1988) J. Mol. Biol. 200, 151-161]. The conformations of the terminal residues of helix I, which corresponds to bases (-1)-11 and 108-120 of native 5S RNA, are less well-determined, and their sugar puckers are intermediate between C2' and C3'-endo, on average.

Phase I study of percutaneous cryotherapy for colorectal liver metastasis

BACKGROUND

The aim was to determine the safety and feasibility of percutaneous cryotherapy for treating irresectable colorectal liver metastases.

METHODS

Liquid nitrogen cryoprobes were inserted percutaneously into metastases using the Seldinger technique under computed tomographic guidance. Single-probe treatments were performed with either 3.6- or 6.3-mm cryoprobes (ice-ball volumes 18 and 59 cm3 respectively), or dual-probe treatments with two adjacent 6.3-mm probes (ice-ball volume 205 cm3). Treatment involved a single freeze--thaw cycle.

RESULTS

Fifteen patients received 25 single-probe treatments and seven patients received 14 dual-probe treatments. The treatment-related mortality rate was zero and complications occurred after six of 39 treatments. Liver metastasis growth was significantly delayed for 2 months after dual-probe but not single-probe treatment. Metastasis cryotherapy stimulated an immediate rise, followed by a fall, in serum carcinoembryonic antigen (CEA) level, associated with immune upregulation that was significantly greater after dual-probe treatments.

CONCLUSION

Ablation zones that were approximately four times larger than those produced by previously described percutaneous techniques delayed the growth of metastases, reduced serum CEA concentration, and induced detectable inflammatory and T-lymphocyte responses. Percutaneous cryotherapy for treatment of colorectal liver metastases is feasible and may have a place in conjunction with chemotherapy.

Description of fourteen new DRB alleles found in a stem cell donor registry

Fourteen DRB alleles, DRB1*0705, DRB1*11014, DRB1*1134, DRB1*1136, DRB1*1141, DRB1*1335, DRB1*1337, DRB1*1338, DRB1*1342, DRB1*1343, DRB1*1349, DRB1*1510, DRB3*0105, and DRB5*0103, are described. Among them, eleven are variants which differ by only one nucleotide from previously described alleles, including one silent variant (DRB1*11014). Alleles, DRB1*0705, DRB1*1335 and DRB3*0105, display unique sequence motifs that have never been observed in DRB alleles.

[Gene cloning and expression of outer membrane protein of Helicobacter pylori]

OBJECTIVE

To construct a recombinant vector which expresses the 18 kDa outer membrane protein (OMP) from Helicobacter pylori (Hp), and exploit the possibility of obtaining Hp vaccine and diagnostic reagent kit for rapid diagnosis of Hp infection.

METHODS

The gene encoding the structural 18 kDa outer membrane protein of Hp was amplified from Hp chromosomal DNA by PCR. The purified PCR product and identified plasmid pQE30 underwent restriction enzyme (Hind III, BamHI, BgLI) digestion and purified by PCR purification reagent kit, and then linked in the proportion of 4:1 (molar weight). The recombinant vector was sequenced with T7 as seqiencing primer. Homology of the determined DNA sequence was analyzed by DNA analysis software. The recombinant vector was selected and identified by restriction enzyme digestion, and then transformed into DH5 a (PREP4) Escherichia coli strain which was cultured and induced by isopropylthio-beta-D-galactosideso as to determine its expressed products.

RESULTS

The gene segment inserted into the recombinant vector was identified as the gene experssing the OMP of HP with a molecular mass of 18 fDa. As compared with previously reports, 2% of the gene was mutated, 1.68% of the amino acid residues was changed, and the homogeneity was about 98%. The level of soluble expression products was about 18% of total cellular protein. ELISA results showed that this objective protein could be recognized by anti-serum against Hp.

CONCLUSION

The product expressed by Hp OMP gene clone has good antigenicity. The recombinant vector expressing 18 kDa OMP may be a potential source for effective protein vaccine against Hp infection and reagent kit of Hp infection diagnosis.

Effect of estrogen on flow-induced dilation in NO deficiency: role of prostaglandins and EDHF

To investigate the role of estrogen in flow-induced dilation (FiD) in nitric oxide (NO) deficiency, FiD was examined in isolated gracilis arterioles of ovariectomized (OVX) and OVX rats with estrogen replacement (OVE). Both groups of rats were treated chronically with N(omega)-nitro-L-arginine methyl ester. Plasma concentration of NO(2)/NO(3) was reduced in both groups. Plasma concentration of estradiol was lower in OVX than in OVE rats. FiD was similar in vessels of the two groups; calculated wall shear stress and basal tone were significantly greater in OVX vs. OVE rats. Indomethacin did not affect FiD in vessels from OVE rats but abolished dilation in vessels from OVX rats. Valeryl salicylate or NS-398 inhibited FiD by approximately 50%, whereas their simultaneous administration eliminated the response in arterioles from OVX rats. In vessels from OVE rats, miconazole or charybdotoxin eliminated FiD. Thus, in NO deficiency, prostaglandins derived from both cyclooxygenase isoforms mediate FiD in gracilis arterioles of OVX rats. Estrogen replacement switches the mediation, showing dependence on endothelium-derived hyperpolarizing factor in the arterioles of OVE rats.

Treatment and outcome of Taiwanese patients with 6-pyruvoyltetrahydropterin synthase gene mutations

Ten cases of tetrahydrobiopterin (BH4) deficiency were identified in 1,337,490 newborns screened in a Chinese population in Taiwan. The high incidence of BH4 deficiency in the Taiwanese population may be explained by a founder effect, since all of the patients revealed 6-pyruvoyltetrahydropterin synthase gene mutations, and grouping N52S and P87S mutations together constituted 88.9% of the disease alleles. BH4 supplementation with restriction of high-protein foods gave control of plasma phenylalanine within normal range, and levodopa itself prevented seizure. However, the average intelligence quotient (IQ) score of these patients was only 76 +/- 14 (56-98). Statistically, the age of starting medication, including 5-hydroxytryptophan (5-HTP), was inversely correlated to IQ scores of these patients. We suggest the combination of BH4, levodopa and 5-HTP as the standard protocol to commence the treatment of BH4 deficiency as early as possible, although prenatal brain damage could have existed.