The use of a negative pressure wound management system in perineal wound closure after extralevator abdominoperineal excision (ELAPE) for low rectal cancer

BACKGROUND

Perineal wound healing is a significant challenge after extralevator abdominoperineal excision (ELAPE) due to a high rate of wound breakdown. Negative pressure therapy has proven benefits in open wounds, and recently a negative pressure system has been developed for use on closed wounds at high risk of breakdown, such as apronectomy and hysterectomy. The aim of the present study was to determine whether negative pressure therapy applied to closed perineal wounds after ELAPE improved wound healing and compare outcomes to the published literature and outcomes from a historical cohort of patients who had undergone 'standard' abdominoperineal resection (APR) and primary closure of the perineal wounds.

METHODS

Prospective data on consecutive patients having ELAPE in the period from November 2012 to April 2015 were collected. The pelvic floor defect was reconstructed with biologic mesh. The adipose tissue layer was closed with vicryl sutures, a suction drain was left in the deep layer, the subcuticular layer and skin were closed, and the negative pressure system was applied. Any wound breakdown within the first 30 days postoperatively was recorded.

RESULTS

Of the 32 consecutive ELAPE patients whose perineal wounds were closed within 30 days with the use of the negative pressure system, there was 1 patient with major perineal wound breakdown and 2 patients with a 1 cm superficial wound defect, which needed no further treatment. In the remaining 29 (90 %) patients, the perineal wounds healed fully without complications. Twenty-five patients underwent standard APR in 2010-2011 with primary closure of their perineal wounds. Ten out of 25(40 %) of patients who had undergone standard APR and primary closure of perineal wounds had major wound complications (p = 0.01).

CONCLUSIONS

Our results suggest that after ELAPE the application of a negative pressure system to the perineal wound closed with biologic mesh may reduce perineal wound complications and may reduce the need for major perineal reconstruction.

Surgery in the older person: Training needs for the provision of multidisciplinary care

Introduction Many older surgical patients are exposed to high risks of morbidity and mortality when undergoing both elective and emergency surgery. Methods We provide an overview of perioperative care teams and the educational opportunities available to surgeons who undertake surgery in the older person. Findings The number of older people undergoing surgery is increasing at a rate faster than the proportion of older people in the overall population. Management of the older surgical patient throughout the surgical pathway forms part of the Specialty Training Curriculum for Geriatric Medicine. While 'surgery in childhood' continues to form part of the general surgical higher training syllabus, surgery in the later years of life does not. There are limited postgraduate courses and training opportunities currently available to surgeons in this field. There is clear societal need to address perioperative care for older surgical patients, which has proved successful in some centers. Moreover, surgical trainees support the inclusion of geriatric medicine issues into their training. Conclusions The ageing population requires a multidisciplinary perioperative approach, with dedicated and appropriately trained clinicians and allied health care professionals to improve outcomes.

Experience in implementing a quality management system in a tuberculosis laboratory, Kisumu, Kenya

We implemented a quality management system (QMS) and documented our improvements in a tuberculosis (TB) laboratory in Kisumu, Kenya. After implementation of the QMS, a sustained reduction in culture contamination rates for solid (from 15.4% to 5.3%) and liquid media (from 15.2% to 9.3%) was observed, and waste from product expiry was reduced significantly. External quality assurance (EQA) results were satisfactory before and after QMS implementation, and a client survey after implementation revealed 98% satisfaction. The laboratory attained ISO 15189 accreditation in October 2013. The implementation of QMS facilitated the attainment of target quality indicators, reduced waste due to expiry and led to high client satisfaction.

Systematic review and meta-analysis of risk factors for postoperative delirium among older patients undergoing gastrointestinal surgery

BACKGROUND

Postoperative delirium (POD) is common after surgery. As age is a known risk factor, the increased ageing of the population undergoing surgery emphasizes the importance of the subject. Knowledge of other potential risk factors in older patients with surgical gastrointestinal diseases is lacking. The aim here was to collate and synthesize the published literature on risk factors for delirium in this group.

METHODS

Five databases were searched (MEDLINE, Web of Science, Embase, CINAHL(®) and PSYCinfo(®) ) between January 1987 and November 2014. The Newcastle-Ottawa Scale was used to rate study quality. Pooled odds ratios or mean differences for individual risk factors were estimated using the Mantel-Haenszel and inverse-variance methods.

RESULTS

Eleven studies met the inclusion criteria; they provided a total of 1427 patients (318 with delirium and 1109 without), and predominantly included patients undergoing elective colorectal surgery. The incidence of POD ranged from 8·2 to 54·4 per cent. A total of 95 risk factors were investigated, illustrating wide heterogeneity in study design. Seven statistically significant risk factors were identified in pooled analysis: old age, American Society of Anesthesiologists (ASA) physical status grade at least III, body mass index, lower serum level of albumin, intraoperative hypotension, perioperative blood transfusion and history of alcohol excess. Patients with POD had a significantly increased duration of hospital stay and a higher mortality rate compared with those without delirium.

CONCLUSION

Delirium is common in older patients undergoing gastrointestinal surgery. Several risk factors were consistently associated with POD.

A novel BRD4-NUT fusion in an undifferentiated sinonasal tumor highlights alternative splicing as a contributing oncogenic factor in NUT midline carcinoma

NUT midline carcinoma (NMC) is a fatal cancer that arises in various tissues along the upper midline of the body. The defining molecular feature of NMC is a chromosomal translocation that joins (in the majority of cases) the nuclear testis gene NUT (NUTM1) to the bromodomain protein family member 4 (BRD4) and thereby creating a fusion oncogene that disrupts cellular differentiation and drives the disease. In this study, we report the case of an adolescent NMC patient presenting with severe facial pain, proptosis and visual impairment due to a mass arising from the ethmoid sinus that invaded the right orbit and frontal lobe. Treatment involved radical resection, including exenteration of the affected eye with the view to consolidate treatment with radiation therapy; however, the patient experienced rapid tumor progression and passed away 79 days post resection. Molecular analysis of the tumor tissue identified a novel in-frame BRD4-NUT transcript, with BRD4 exon 15 fused to the last 124 nucleotides of NUT exon 2 (BRD4-NUT ex15:ex2_Δnt1–585). The partial deletion of NUT exon 2 was attributed to a mid-exonic genomic breakpoint and the subsequent activation of a cryptic splice site further downstream within the exon. Inhibition of the canonical 3′ acceptor splice site of NUT intron 1 in cell lines expressing the most common NMC fusion transcripts (PER-403, BRD4-NUT ex11:ex2; PER-624, BRD4-NUT ex15:ex2) induced alternative splicing from the same cryptic splice site as identified in the patient. Detection of low levels of an in-frame BRD4-NUT ex11:ex2_Δnt1–585 transcript in PER-403 confirmed endogenous splicing from this alternative exon 2 splice site. Although further studies are necessary to assess the clinical relevance of the increasing number of variant fusions described in NMC, the findings presented in this case identify alternative splicing as a mechanism that contributes to this pathogenic complexity.

Pooling sputum from multiple individuals for Xpert® MTB/RIF testing: a strategy for screening high-risk populations

SETTING

Symptom-based screening for tuberculosis (TB) disease is limited by poor performance of symptom screening in several key populations. We tested the hypothesis that pooling sputum from multiple individuals for Xpert(®) MTB/RIF testing would reduce the number of tests required while retaining an acceptable sensitivity, thus allowing the use of Xpert for TB screening.

METHODS

We compared pooling ratios that would require the least number of assays using Xpert and determined that for a population with a TB prevalence of approximately 3%, a 1:5 pooling ratio is optimal. To evaluate sensitivity, we generated pools of one specimen with known Mycobacterium tuberculosis culture positivity (smear microscopy-positive or -negative) with four culture-negative specimens.

RESULTS

All 20 of the pools generated from a smear- and culture-positive sputum sample were positive using Xpert. Of the 22 pools with a smear-negative, culture-positive sample, we included 17 in the analysis, of which 13 (76%) were Xpert-positive.

CONCLUSIONS

Pooling of sputum samples using Xpert achieved reasonable sensitivity and warrants further evaluation of the systematic screening of high TB prevalence populations.

Laparoscopic versus open surgery for colorectal cancer in the older person: A systematic review

Background

Laparoscopic surgery is being increasingly offered to the older person.

Objective

To systematically review the literature regarding laparoscopic colorectal cancer surgery in older people and compare to younger adult populations.

Study selection

We included randomized controlled trials that compared open to laparoscopic colorectal cancer surgery. Older people were defined as being 65 years and above.

Outcome measures

Overall survival and post-operative morbidity and mortality. Secondary endpoints were length of hospital stay, wound recurrence, disease-free survival and conversion rate.

Results

Seven trials included older people, average age of approximately 70 years. Two reported data specific to older patients (over 70 years): The ALCCaS study reported reduced length of stay and short-term complication rates in the laparoscopic group when compared to open surgery (8 versus 10 days, and 36.7% versus 50.6% respectively) and the CLASICC study reported equivalent 5 year survival between arms and a reduction of 2 days length of stay following laparoscopic surgery in older people. In trials which considered data on older and younger participants all five trials reported comparable overall survival and showed comparable or reduced complication rates; two demonstrated significantly shorter length of stay following laparoscopic surgery compared to open surgery.

Conclusion

Large numbers of older people have been included in well-conducted, multi-centre, randomized controlled trials for laparoscopic and open colorectal cancer surgery. This systematic review suggests that age itself should not be a factor when considering the best surgical option for older patients.

•

Seven well conducted randomised controlled trials of open versus laparoscopic colorectal cancer surgery have included older people.

•

Age alone should not be a barrier to laparoscopic colorectal cancer surgery.

•

The effect of comorbidity in older people undergoing laparoscopic surgery is less clear and warrants further study.

Impact of reduced hospitalisation on the cost of treatment for drug-resistant tuberculosis in South Africa

SETTING

The cost of multidrug-resistant tuberculosis (MDR-TB) treatment is a major barrier to treatment scale-up in South Africa.

OBJECTIVE

To estimate and compare the cost of treatment for rifampicin-resistant tuberculosis (RR-TB) in South Africa in different models of care in different settings.

DESIGN

We estimated the costs of different models of care with varying levels of hospitalisation. These costs were used to calculate the total cost of treating all diagnosed cases of RR-TB in South Africa, and to estimate the budget impact of adopting a fully or partially decentralised model vs. a fully hospitalised model.

RESULTS

The fully hospitalised model was 42% more costly than the fully decentralised model (US$13,432 vs. US$7753 per patient). A much shorter hospital stay in the decentralised models of care (44-57 days), compared to 128 days of hospitalisation in the fully hospitalised model, was the key contributor to the reduced cost of treatment. The annual total cost of treating all diagnosed cases ranged from US$110 million in the fully decentralised model to US$190 million in the fully hospitalised model.

CONCLUSION

Following a more decentralised approach for treating RR-TB patients could potentially improve the affordability of RR-TB treatment in South Africa.

Laparoscopic ventral mesh rectopexy in male patients with internal or external rectal prolapse

AIM

Laparoscopic ventral mesh rectopexy (LVMR) has been used to treat rectal prolapse, obstructed defaecation (OD), faecal incontinence (FI) and multicompartment pelvic floor dysfunction. Its value in treating men has been questioned. The aim of the present study was to assess the results in male patients.

METHOD

A password-protected electronic database of all LVMRs carried out in North Bristol NHS trust & Spire hospital between 2002 and 2013 was examined. In addition to the clinical outcome, quality of life (QoL), Cleveland Clinic Incontinence Score (CCIS), obstructed defecation syndrome (ODS) score, visual analogue score (VAS) for the severity of bowel and urinary symptoms and the numerical rating scale (NRS) for pain and patient-reported outcome measures were evaluated.

RESULTS

Sixty-eight men of median age 35 years and body mass index 26 kg/m(2) underwent LVMR for external rectal prolapse (18) or Grade III-V rectal intussusception (50) presenting with OD, FI and pelvic pain. Ten per cent had been labelled 'chronic idiopathic pelvic pain' and 60% had undergone previous haemorrhoidal surgery. Complications were minor and included urinary retention (10%). Eighty per cent of patients had an uncomplicated recovery with 24% being treated as day cases. There were no cases of impotence or retrograde ejaculation. Median follow-up was 42 (IQR 26-61) months. CCIS score improved from 4 (IQR 0-8) to 0 (IQR 0-0) (P < 0.001) and the ODS score from 18.5 (IQR 16-22) to 6 (IQR 5-8) (P < 0.001). Patients reported significant improvement in the NRS for pain and QoL (BBSQ-22) at 3 months (P = 0.000). The QoL and the VAS for bowel symptoms were maintained at 4 years. At the last follow-up 56 (82%) patients were asymptomatic and 6 (8.8%) had persisting symptoms. There was no case of recurrent external rectal prolapse.

CONCLUSION

LVMR is an effective treatment for external and symptomatic internal rectal prolapse in men, leading to significant improvement in QoL and function.

Psychosocial health conditions and HIV prevalence and incidence in a cohort of men who have sex with men in Bangkok, Thailand: evidence of a syndemic effect

Men who have sex with men (MSM) in Bangkok may experience multiple psychosocial health conditions, such as substance use, suicidality, and a history of sexual abuse. These factors may contribute to HIV vulnerability in a syndemic way. A syndemic is defined as a number of synergistically interacting health conditions producing excess disease in a population. The objective of this study is to examine whether psychosocial health conditions among MSM have a syndemic association with HIV prevalence and HIV incidence. To do this, we evaluated psychosocial health conditions and their associations with unprotected sex, HIV prevalence and HIV incidence in a cohort of Thai MSM (N = 1,292). There was a positive and significant association between the number of psychosocial health conditions and increased levels of unprotected sex and HIV prevalence at study baseline. The number of psychosocial health conditions at baseline was also associated with increased HIV incidence during follow-up (no conditions, HIV incidence = 15.3 %; one to three conditions, 23.7 %; four to five conditions, 33.2 %). The number of psychosocial health conditions was positively associated with HIV risk behavior and HIV prevalence and incidence. Prevention efforts among MSM need to address the existence of multiple psychosocial health conditions and their synergy to effectively decrease the spread of HIV infection.

Outcome of laparoscopic ventral mesh rectopexy for external rectal prolapse

AIM

The study assessed the efficacy of laparoscopic ventral mesh rectopexy (LVMR) for full thickness external rectal prolapse (ERP), including recurrent prolapse.

METHOD

A prospective database identified all patients undergoing LVMR for ERP over the 16-year period to December 2013. Clinical outcome, Cleveland Clinic Incontinence Score (CCIS), quality of life (QOL) and patient-reported outcome were evaluated.

RESULTS

In total, 190 LVMRs (87% women) were performed during the study period, with a median active follow-up of 29 (1-196) months; 120 had a follow-up > 5 years and 16 > 10 years. The median time from surgery was 73 (1-196) months. The 60-day mortality, recurrence and mesh-related complication rates were 1%, 3% and 3.7%. The mean improvement in CCIS was 8 (P < 0.0001). Sixty-two patients returned a complete sequence of QOL scores (Birmingham Bowel and Urinary Symptoms Questionnaire 22), which had improved by 46% at year 1 and were sustained at a median of 4 years (P < 0.001). Mean patient-reported outcome measures for satisfaction at final review in 119 responders was 9.1/10. Thirty-nine patients underwent LVMR for recurrent ERP following perineal repair. Of these, full thickness recurrence occurred in one and there were no mesh complications. The same sustained improvement in QOL was observed.

CONCLUSION

LVMR for ERP is associated with low morbidity and recurrence and a long-term improvement in function and QOL. LVMR achieves the same benefits after a failed perineal procedure.

Anatomical characterisation of the cricothyroid membrane in females of childbearing age using computed tomography

BACKGROUND

In the event of failure to secure the airway by conventional means, it may be necessary to perform invasive airway access via the cricothyroid membrane. No studies have addressed anatomy of this structure in the obstetric population. We aimed to review the anatomical variation of this structure in a population of childbearing age.

METHODS

We searched the radiology database for computed tomography studies of the neck performed in a 13-month period in consecutive patients aged 15-55 years. Studies on 18 females and 22 males were reviewed. Male patients were included for comparison. Data were reconstructed using a high spatial frequency algorithm to optimise spatial resolution. Five parameters were measured: distance from the skin to the membrane, maximum midline height of the membrane in the vertical plane, maximum transverse diameter of the membrane, neck diameter and cartilaginous calcification.

RESULTS

The distance (mean range) from skin to the membrane was similar in females and males (16.2 [3-33] vs. 13.9 [3-37] mm, P = 0.42). The vertical height (9.9 [7-17] vs. 11.4 [8-15] mm, P = 0.04) and maximum width of the membrane (14.5 [10-17] mm vs. 12.5 [10-15] mm, P < 0.01) were greater in males. Cartilaginous calcification was low and did not differ between genders.

CONCLUSIONS

The cricothyroid membrane is not necessarily a superficial structure and consequently may be difficult to palpate. The smallest dimensions of the membrane indicate that smaller than recommended cricothyroidotomy devices may be required in some patients as the external diameter of commercial trocar devices and tracheal tubes may exceed 7 mm.

The acute abdomen in the older person

The acute abdomen is a common condition in older people. Half of all presentations to hospital require admission, with a third requiring immediate surgery. The Royal College of Surgeons of England have reported a worryingly high mortality rate in the over 80s undergoing emergency surgery, with a 3-fold difference in mortality throughout the England, Wales and Northern Ireland. The aim of this article is to highlight the issues that older people face in relation to acute abdominal pathology.

Impact of pulmonary hemodynamics on 6-min walk test in idiopathic pulmonary fibrosis

OBJECTIVES

Pulmonary hypertension (PH) has been associated with decreased functional capacity in patients with advanced idiopathic pulmonary fibrosis (IPF). We aimed to evaluate the true impact of altered pulmonary hemodynamics on functional capacity in a cohort of patients with IPF.

METHODS

Between January 1990 and December 2007, 124 patients [73M/51F; 111 Caucasians] with IPF underwent right heart catheterization and 6-min walk test (6MWT). Pulmonary arterial hypertension (PAH) was defined as mPAP≥25 and pulmonary artery occlusion pressure (PAOP)≤15mmHg, and Pre-PH as mPAP>20 and <25mmHg with PAOP<15mmHg. Demographic, hemodynamic, spirometric, and 6MWT data were collected.

RESULTS

Fifty four (44%) patients had PH. There were no significant differences between the PH and the non-PH groups in measures of pulmonary function other than PaO(2). Patients with PH and PAH had significantly lower 6-min walk distance (6MWD) (p=0.008 and p=0.03 respectively) and distance saturation product (DSP) (p=0.002 and p=0.006 respectively) compared to non-PH patients. Mean pulmonary arterial pressure (mPAP) was the best predictor of 6MWD by multivariate analysis (p=0.0006). Increasing mPAP was associated with a statistically significant decline in 6MWD (p=0.02) and DSP (p=0.01). Patients with 'Pre-PH' had lower 6MWD compared to patients with mPAP≤20mmHg (p=0.07).

CONCLUSIONS

Relative to measures of pulmonary function and hypoxia, altered pulmonary hemodynamics had a greater impact on 6MWD in patients with IPF. Higher mPAP was associated with more significant exercise impairment. Mild abnormalities in pulmonary hemodynamics (so called 'Pre-PH') were associated with reduced 6MWD.

Central electron temperature estimations of TJ-II neutral beam injection heated plasmas based on the soft x ray multi-foil technique

The core electron temperature (T(e0)) of neutral beam heated plasmas is determined in TJ-II stellarator by using soft x ray detectors with beryllium filters of different thickness, based on the method known as the foil absorption technique. T(e0) estimations are done with the impurity code IONEQ, making use of complementary information from the TJ-II soft x ray tomography and the VUV survey diagnostics. When considering the actual electron density and temperature profile shapes, an acceptable agreement is found with Thomson scattering measurements for 8 different magnetic configurations. The impact of the use of both neutral beam injectors on the T(e0) measurements is addressed. Also, the behaviour of T(e0) during spontaneous profile transitions is presented.

Long-term follow-up and survival of antiretroviral-naive patients with cryptococcal meningitis in the pre-antiretroviral therapy era, Gauteng Province, South Africa

Cryptococcal meningitis (CM) is a major cause of death among HIV-infected persons in sub-Saharan Africa. We conducted a study to describe the long-term outcomes during the pre-antiretroviral post-ART therapy period. Enrolled cases were those detected through population-based surveillance in Gauteng Province, South Africa, and diagnosed during March-November 2002 and July-September 2003 from eight large hospitals representing academic, provincial and rural settings. Of 1089 case-patients diagnosed with CM, 721 (70%) survived to discharge. Among the 256 with follow-up information, 154 (60%) were established to have died, 44% of whom died as outpatients. Overall, the 14- and 90-day survival post-diagnosis was 68% and 41%, respectively. On Cox proportional hazards multivariable analysis, severe disease was associated with shorter survival time; having received any antifungal treatment for the cryptococcal episode was associated with increased survival time at follow-up. Although most patients in this cohort survived the initial hospitalization, only 41% were still alive three months after diagnosis, with nearly half of deaths occurring outside a hospital. These data are an important baseline from which to measure effectiveness of public health management of CM in South Africa.

The impact of uterine leiomyomas on reproductive outcomes

Uterine leiomyomas (fibroids, myomas) are a common benign disease of the uterus with a prevalence of 8-18%. Prevalence rates vary with race, and fibroids are most common in African American women. Uterine leiomyomas can also be present during pregnancy, which may occur more frequently than previously suspected, with prevalence rates reported of up to 10%. Recent evidence has emerged to clarify the relationship of uterine fibroids on fertility and obstetrical outcomes. In this paper we review evidence that uterine fibroids, specifically submucosal and intramural myomas, negatively impact fertility and are associated with adverse obstetrical outcomes such as: pain, preterm labor, placental abruption, malpresentation, postpartum hemorrhage, and cesarean section. Myomectomy performed for submucosal and intramural fibroids significantly improves fertility outcome, and current evidence suggests myomectomy is the treatment of choice in women desiring to conceive. For women that do not desire surgery, medical management of myomas is available. Treatment with GnRH agonists may be considered, however newer medications with fewer side effects give practitioners and patients more options. Progesterone antagonists, selective progesterone receptor modulators, and aromatase inhibitors have all shown promise as effective therapies. Non-pharmacologic treatments such as uterine artery embolization and MRI-guided ultrasound have also emerged as effective treatments for uterine fibroids. With such a wide range of new and emerging treatment options, it is important for providers to understand which fibroids are likely to respond optimally to a specific treatment, in order to individualize appropriate and effective management for patients.

Good treatment outcomes among foreigners receiving antiretroviral therapy in Johannesburg, South Africa

Foreigners, including displaced persons, often have limited health-care access, especially to HIV services. Outcomes of antiretroviral therapy (ART) in South Africans and foreigners were compared at a Johannesburg non-governmental clinic. Records were reviewed of 1297 adults enrolled between April 2004 and March 2007 (568 self-identified foreigners, 431 South Africans citizens and 298 with unknown origin). Compared with citizens, foreigners had fewer hospital admissions (39%, 90/303 versus 51%, 126/244; P < 0.001), less missed appointments for ART initiation (20%, 39/200 versus 25%, 51/206; P < 0.001), faster median time to ART initiation (14 versus 21 days, P = 0.008), better retention in care (88%, 325/369 versus 69%, 155/226; P < 0.001) and lower mortality (2.5%, 14/568 versus 10%, 44/431; P < 0.001) after 426 person-years. In logistic regression, after controlling for baseline CD4 count and tuberculosis status, foreigners were 55% less likely to fail ART than citizens (95% CI = 0.23–0.87). These findings support United Nations High Commissioner for Refugees recommendations that ART should not be withheld from displaced persons.

The expression and function of IGFBP-3 in normal and malignant breast tissue

The mitogenic and anti-apoptotic effects of insulin-like growth factor-I (IGF-I) are regulated by a family of insulin-like growth factor binding proteins (IGFBPs), particularly IGFBP-3. Little is known about the IGF-independent role of IGFBP-3 in breast cancer and the mechanisms regulating its production. The expression of IGFBP-3 in paired malignant and adjacent normal (n=53), and healthy normal (n=17) breast tissue samples was investigated using RT-PCR, immunohistochemistry and ELISA. We compared IGFBP-3 expression with other members of the IGF-I axis, other known tumorigenic genes and clinicopathological parameters. We also developed a novel tissue explant system using fresh normal and malignant breast tissue, with which we examined the in vitro effects of IGFBP-3 alone and in combination with known apoptotic agent, doxorubicin (n=6), on tissue viability and apoptosis. We demonstrated a high level of expression of IGFBP-3 mRNA in all samples. 96% of samples also expressed IGFBP-3 protein. No significant correlation was seen between IGFBP-3 expression and other clinicopathological parameters. The in vitro tissue explant system demonstrated that IGFBP-3 had little effect by itself on apoptosis. However, when used in combination with doxorubicin, increased apoptosis was seen in tumours. In contrast, less apoptosis was seen in normal tissue suggesting a protective effect. These divergent effects suggest a potential novel chemotherapeutic approach in the treatment of breast cancer. These findings suggest that IGFBP-3 may play a role in tumorigenesis, and that IGFBP-3 levels could be used in the future in cancer risk assessment/prevention or as markers of response to cancer treatments.

Association of primary mediastinal B-cell lymphoma (PMBL) in children (C) and adolescents (A) with a significantly inferior prognosis: Final results of the FAB/LMB 96 trial

10001

Background: Single pediatric cooperative group studies have demonstrated an EFS ranging from 65 - 75% in C & A with large cell lymphomas arising in the mediastinum (Lones/Cairo et al, J Clin Oncol, 2000; Burkhardt/Reiter et al, Br J Haematol, 2005; Seidman/Reiter et al, J Clin Oncol, 2003). Recently, Staudt and Shipp have independently demonstrated that following gene expression profiling by oligonucleotide microarray that PMBL resembles more like classical Hodgkin lymphoma than diffuse large B-cell lymphoma with enhanced NF-κB pathway gene expression (Rosenwald et al, J Exp Med, 2003; Abramson et al, Blood, 2005). It remains to be determined what the optimal therapy for C & A with PMBL is and if poor outcome subgroups can be identified. Methods: We analyzed the results of C & A with PMBL treated with group B therapy on FAB/LMB 96 (Patte/Cairo et al, Blood, 2007). Results: There were 528 patients with stage III/IV disease treated on group B therapy on FAB/LMB 96 resulting in a 2 yr EFS of 84% (CI95: 82–86%). Forty-two of these patients had PMBL; M/F: 26/16; 10 - 14 vs 15 -19 yrs: 28/14; and LDH < 2 vs ≥ 2 upper normal: 20/22. Response to COP reduction: 1 CR (100%), 33 IR (20–99%) and 7 NR (< 20%). There was no significant difference in EFS with respect to age, gender, COP response and initial LDH. 5 yr EFS and OS were 54% (CI95: 38–68%) and 73% (CI95: 56–84%), respectively. 5 yr EFS was significantly inferior compared to the remainder of the other patients with stage III disease treated on group B therapy (54%: CI95 38–68% vs 85%: CI95 81–88%) (p < 0.001). Conclusions: PMBL in C & A is associated with a significantly inferior EFS compared to other histological forms of stage III/IV mature B-NHL. Alternate treatment strategies including consideration of underlying biological differences need to be developed to improve EFS in C & A with this poor-risk sub-group of mature B-NHL.

No significant financial relationships to disclose.

Advanced stage, elevated LDH, primary sites, but not adolescent (A) age (≥ 15 years) as risk factors for disease progression in childhood (C) and adolescent (A) mature B-NHL: Report of the FAB/LMB 96 international trial

10032

Background: We recently reported the results in C & A with low risk (group A), intermediate risk (group B) and high risk (group C) mature B-NHL treated on FAB/LMB 96 (Gerrard et al, Br J Haematol, 2008; Patte et al, Blood, 2007; Cairo et al, Blood, 2007, respectively). Adolescent age (15–21 yrs) has historically been considered to be an independent risk factor for poor outcome in subsets of mature B-NHL (Hochberg/Cairo et al, Br J Haematol, 2008; Burkhardt et al, Br J Haematol 2005; Cairo et al, Br J Haematol, 2003). Methods: We analyzed the EFS of all pts treated on FAB/LMB 96 and the following risk factors were significant in a univariate and Cox multivariate analysis: age (<15 vs ≥15 yrs), stage I/II vs III/IV, primary sites, LDH <2 vs ≥2 NL and histology (DLBCL vs BL/BLL). Results: 1111 pts (15%, 15–21 years) were treated with group A (N = 132), group B (N = 744), and group C (N = 235) therapy. Five year EFS (CI95) for all, A, B, C pts was 86% (84%,88%), 98% (93%, 100%), 87%% (84%, 89%), and 79%% (73%,84%), respectively. Age (≥15 yrs), LDH ≥2NL, stage III/IV, and BM+/CNS+ and histology were significant univariate risk factors for decreased EFS (P<0.045, <0.0001, <0.0001, <0.0001, and <0.0001 respectively). Multivariate analysis demonstrated age ≥15 yrs and DLBCL histology were no longer independent significant risk factors (p = .82 and 0.08, respectively), but LDH (RR 2.0, p = .001), stage III/IV (RR 3.8, p<0.001), and primary sites including PMBL (RR 4.0, p<.001) and BM+/CNS+ (RR 2.8, p<0.001) were independent significant risk factors for poorer outcome. Conclusions: With the use of modern short but intense FAB-LMB 96 therapy, adolescent age is no longer a poor risk factor in children with mature B-NHL. The independent risk factors identified in this study (stage, LDH, primary site) for decreased EFS in C & A mature B-NHL will form the basis of the next risk adapted international pediatric mature B-NHL trial.

No significant financial relationships to disclose.

Observation of WZ production

We report the first observation of the associated production of a W boson and a Z boson. This result is based on 1.1 fb;-1 of integrated luminosity from pp collisions at sqrt[s]=1.96 TeV collected with the CDF II detector at the Fermilab Tevatron. We observe 16 WZ candidates passing our event selection with an expected background of 2.7+/-0.4 events. A fit to the missing transverse energy distribution indicates an excess of events compared to the background expectation corresponding to a significance equivalent to 6 standard deviations. The measured cross section is sigma(pp-->WZ)=5.0(-1.6)(+1.8) pb, consistent with the standard model expectation.

Deciphering cancer complexities in genetically engineered mice

Because the pRb pathway is disrupted in most solid human cancers, we have generated genetically engineered mouse cancer models by inactivating pRb function in several cell types, including astrocytes and mammary, prostate, ovarian, and brain choroid plexus epithelia. In every case, proliferation and apoptosis are acutely induced, predisposing to malignancy. Cell type dictates the pathways involved in tumor progression. In the astrocytoma model, we developed strategies to induce events in the adult brain, either throughout the tissue or focally. Both K-Ras activation and Pten inactivation play significant roles in progression. In the prostate model, adenocarcinoma progression depends on Pten inactivation. However, nonautonomous induction of p53 in the mesenchyme leads to evolution of both compartments, with p53 loss occurring in the mesenchyme. Thus, studies in these models continue to identify key tumorigenesis mechanisms. Furthermore, we are hopeful that the models will provide useful preclinical systems for diagnostic and therapeutic development.

Cyclo-oxygenase-2 (COX-2) mRNA expression and hormone receptor status in breast cancer

AIMS

The purpose of this study was to evaluate COX-2 mRNA expression with known clinical prognostic features of breast cancer, oestrogen/progesterone receptor status, tumour size and grade.

METHODS

Total RNA was extracted from 45 frozen breast tumour (invasive) and 22 normal breast tissue samples. COX-2 mRNA transcription was quantified using a real time RT-PCR assay and expressed as copy number/microg total RNA. All specimens were assessed for tumour grade, size, nodal status and presence of vascular invasion and oestrogen and progesterone receptor status.

RESULTS

COX-2 mRNA was detected in all samples with a median copy number of 1.15 x 10(7) for tumours and 6.5 x 10(6) for normal samples. Expression was significantly higher in oestrogen receptor negative tumours compared to the receptor positive group. There was no correlation between COX-2 mRNA levels and tumour size, grade, nodal status and presence of vascular invasion.

CONCLUSIONS

COX-2 mRNA expression is increased in oestrogen and progesterone receptor negative breast cancers.

Differential expression of IGF-binding protein-3 in normal and malignant colon and its influence on apoptosis

IGF-binding protein-3 (IGFBP-3) has been reported to exert a protective influence on the pathogenesis of colorectal cancer. This may reflect its modulation of IGF-I bioactivity as well as IGF-I-independent effects on cell proliferation and apoptosis. Although local expression of IGF-I in the colon is increasingly recognised as having important regulatory consequences, the role of locally expressed IGFBP-3 remains unknown. The aims of the present study were: (i) to quantify and localise the expression of IGFBP-3 in human normal and malignant colon; (ii) to relate this expression to that of other components of the IGF-I axis; and (iii) to investigate the effects of IGFBP-3 on colonic epithelial cell proliferation and apoptosis. RNA was extracted from 46 paired samples of normal and malignant colonic tissue. IGFBP-3, IGF-I, IGF-I receptor and GH receptor mRNA levels were quantified using real-time RT-PCR. Laser-capture microdissection of the same samples was used to isolate mRNA from epithelium and stromal components and localise mRNA expression. Expression was confirmed at a protein level by immunohistochemistry. Human colorectal cancer HT-29 and CaCo-2 cells were cultured with IGFBP-3 (200 ng/ml), +/- IGF-I (20 ng/ml), +/- sodium butyrate (5 mM). Cell number was assessed by an MTS assay (a modification of the MTT assay), and apoptosis assessed by cell morphology and FACS analysis using both annexin and propidium iodide staining. UO146, a MAP kinase inhibitor, and wortmannin, an inhibitor of the phosphatidylinositol 3-kinase (PI-3K) pathway, were used to determine the contribution of these signalling pathways on the effects of IGFBP-3. IGFBP-3 mRNA was detected in all samples (mean copy number/mug total RNA in normal colon, 2.6 x 10(6) compared with 1.3 x 10(7) in the cancers; P < 0.0001). Immunohistochemistry confirmed the expression and showed it to be equally distributed between epithelial and stromal components in normal tissue, but to be mainly restricted to the stromal component of malignant tissue. This differential expression was confirmed by RT-PCR of RNA from laser-capture microdissected samples. IGF-I mRNA was detected in 31 samples of normal colon; mean IGFBP-3 copy number was higher in the IGF-I-positive samples compared with IGF-I-negative samples. IGFBP-3 on its own induced apoptosis in HT-29 cells (P < 0.001). Co-incubation of 200 ng/ml IGFBP-3 with butyrate (5 mM) resulted in the potentiation of its apoptosis (P < 0.0001), which was not rescued by co-incubation with IGF-I (P < 0.0001). The addition of UO126 caused a decrease in cell number and increased the effects of IGFBP-3. IGFBP-3 is differentially expressed between stromal and epithelial components of normal and malignant colon, which may reflect its pro-apoptotic, IGF-I-independent effect on colonic epithelial cells. These effects are mediated in part by the PI-3K pathway in contrast to the MAP kinase pathway used by IGF-I.

Psychosocial needs of boys in secure care for serious or persistent offending

BACKGROUND

The mental health of child offenders who are detained in secure settings is a matter of great public and professional concern but there has been little systematic longitudinal research on the outcomes of these problems once the young person has returned to the community. The aims of the present study were to describe the psychosocial outcomes of boys in secure care and to establish if these outcomes were correlated with criminal outcomes.

METHOD

Prospective cohort study of 97 boys whose average age was 14 years when they were admitted to secure units in the North West of England. The boys were followed up on average 2 years later, when outcome data were obtained on 81/97 (83%) cases. The main outcome measure was a standardised assessment of mental health, social and educational needs obtained by interview with the young person and corroborated in most cases by information from informants. All data were then reviewed by experienced clinicians who made best-estimate ratings of need 'blind' to the findings from the first phase of the study.

RESULTS

The average number of needs requiring an intervention at follow-up (mean=3.4, sd=3.0) was much lower than before admission to secure care (mean=8.2, sd=2.5) (mean difference 4.9 needs, 95% CI 4.0 to 5.7). Educational and occupational needs were particularly well dealt with. However, many mental health problems persisted or worsened. For example, 31% had a need for treatment of substance abuse, a significant increase compared with when they were in secure care (percentage difference 21%, 95% CL 9.0% to 32.7%). No mental disorder predicted subsequent offending.

CONCLUSIONS

Boys who have been in secure care continue to have a high rate of mental health problems. The mental health needs of this group are not, however, static but change over time and with changing circumstances. Services need to be designed to meet these changing needs.

Reversal of brain dysfunction with UV-A1 irradiation in a patient with systemic lupus

Low-dose ultraviolet A-1 (UV-A1; 340-400 nm) bodily irradiation significantly reduces clinical manifestations of systemic lupus erythematosus (SLE). As neuropsychiatric-like symptoms respond prominently, a single patient was selected to undergo positron emission tomography (PET) before and after therapy to determine the effects of the therapy on the brain. The functional changes in 18F-deoxyglucose uptake as determined by PET imaging in this SLE patient indicated that improvement in brain function paralleled the reversal of cognitive deficits noted after the administration 160 kJ of bodily UV-A1 irradiation administered three times a week. Also of interest is that the UV-A1 irradiation, for the first time, ameliorated discoid lupus rashes, presumably due to a systemic action, as the lesions were for the first time covered during therapy.

Pharmacokinetics of recombinant factor IX after intravenous and subcutaneous administration in dogs and cynomolgus monkeys

Hemophilia B therapy requires intravenous (IV) infusions of large volumes of factor IX due to the low concentration of factor IX in concentrates (approximately 100 IU/mL). High concentration recombinant factor IX (rFIX) could be a significant advance since it would reduce the large volumes necessary for IV dosing and allow for low-volume subcutaneous (SC) administration. To evaluate high concentration factor IX, we produced formulations with either 2,000 or 4,000 IU/mL and studied the SC bioavailability in beagle dogs, cynomolgus monkeys and hemophilia B dogs along with efficacy in hemophilia B dogs. Beagle dog SC bioavailability was 86.4% using a 2000 IU/mL formulation and 77.0% using a 4000 IU/mL formulation. Monkey bioavailability of a 4000 IU/mL formulation of rFIX was 34.8%. A single SC administration of 200 IU/kg (4000 IU/mL) of rFIX to hemophilia B dogs, produced factor IX clotting activity above 5% for 5 days with a bioavailability of 48.6%. High concentration SC rFIX has an acceptable pharmacokinetic profile in monkeys and dogs, and produces a sustained FIX activity in hemophilic dogs.