Complications and postoperative non-steroidal anti-inflammatory use of three extracapsular cruciate ligament repair techniques performed in a general practice clinic environment

OBJECTIVE

To report complications and postoperative non-steroidal anti-inflammatory use associated with fabellotibial suture, Tightrope and Ligafiba Isotoggle procedures performed on dogs of varying weights within a general practice setting.

MATERIALS AND METHODS

Clinical records of eligible patients from 2009 to 2018 were retrospectively extracted from five general practice clinics. Data for signalment, patient weight, surgery performed, complications, postoperative use of non-steroidal anti-inflammatory drugs, and timing thereof were extracted and analysed using multinomial logistic regression. Predicted probability tables were generated for complications and non-steroidal anti-inflammatory drug use.

RESULTS

The study included 370 surgeries, with 97 fabellotibial suture, 158 Tightrope and 42 Ligafiba Isotoggle procedures in patients less than 15 kg, and 43 fabellotibial suture, 16 Tightrope and 30 Ligafiba Isotoggle procedures in patients at least 15 kg. The proportion of patients that can be expected to have no complications was greatest for older dogs (9 years) weighing less than 15 kg (fabellotibial suture, 91%; Tightrope/Ligafiba Isotoggle, 88%), and the highest major medical and surgical complication risks were expected in young dogs (1 year) weighing over 15 kg (fabellotibial suture, 28%; Tightrope/Ligafiba Isotoggle, 59%). The predicted risk of requiring repeated non-steroidal anti-inflammatory drug prescriptions in the 18-month postoperative period for an 15 kg patient was 37% to 39%.

CONCLUSION

Weight and age were significant factors influencing complications and postoperative non-steroidal anti-inflammatory drug use in fabellotibial suture, Tightrope and Ligafiba Isotoggle surgical patients in a general practice setting.

CLINICAL SIGNIFICANCE

Clinicians should consider the possibility of complications and requirement for ongoing non-steroidal anti-inflammatory drug use before performing extracapsular procedures in patients weighing more than 15 kg.

Treatment of sacro-coccygeal intervertebral disc extrusion causing tail paresis and faecal incontinence in a dog

A 4-year 9-month-old beagle was presented for a 2-week history of acute onset of lowered tail carriage and faecal incontinence. Neurological examination was unremarkable except for an absent perineal reflex, there was no history of trauma. Blood work was unremarkable. Lumbosacral and coccygeal CT pre- and post-intravenous contrast revealed a large sacrococcygeal disc extrusion with mineralised material extending from the level of S2 and to midbody of Cd1. A dorsal laminectomy was performed from the cranial margin of S2 to the caudal margin of Cd1. A large volume of mineralised disc material was removed. The material was confirmed on histopathology to be consistent with extruded nucleus pulposus. The patient regained faecal continence within 3 days of hospital discharge. Based on a literature search this is the first report of a sacrococcygeal disc extrusion resulting in faecal incontinence, with successful surgical management.

Haemoglobin, Smoking and Peripheral Vascular Disease

One hundred and four patients with peripheral vascular disease requiring operation were reviewed retrospectively with respect to age, sex, preoperative haemoglobin, smoking habits and diabetic status. The preoperative haemoglobin levels and smoking status in 63 non-diabetic male patients with peripheral vascular disease were compared with a matched group of individuals treated for inguinal hernia. For all patients there was a significant correlation between smoking habits, preoperative haemoglobin level and the presence of peripheral vascular disease. The mechanisms by which smoking may damage the vascular tree are reviewed.

Clinical and in Vivo Response Following Surgery or Surgery Plus Adjuvant Chemotherapy or Immunotherapy for Colorectal Carcinoma in a Rat Model

Two cohorts of rats, 240 with colon cancer and 150 controls, were assessed clinically and immunologically for their response to tumour and its management which was either by surgical excision alone or by surgical excision combined with either adjuvant chemotherapy or immunotherapy. The histology and invasion characteristics were observed for similarity with those of human lesions. Metastases were found in liver, lymph nodes, the peritoneum or lungs in 27% of animals during follow up. Significantly fewer adjuvant-treated rats had metastases than those receiving surgery alone ( P < 0.05), and less total tumour weight was found in the adjuvant-treated rats at four ( P < 0.03) and six ( P < 0.001) weeks postoperatively. Animals in the adjuvant immunotherapy group survived longer than in either other group ( P < 0.001). The crude parameters of host response to tumour, body, spleen and mesenteric lymph node weight were recorded and the latter two indexed to body weight. The body weight of tumour and control rats increased significantly with time ( P < 0.04). The spleen and mesenteric node indices were significantly ( P < 0.04) greater in tumour than control rats and were varied by recurrent tumour growth and by the adjuvant treatment administered postoperatively.

Markers of angiogenesis associated with surgical attenuation of congenital portosystemic shunts in dogs

Background

Dogs with congenital portosystemic shunts (CPSS) have hypoplasia of the intrahepatic portal veins. Surgical CPSS attenuation results in the development of the intrahepatic portal vasculature, the precise mechanism for which is unknown, although new vessel formation by angiogenesis is suspected.

Hypothesis

That the degree of portal vascular development and the increase in portal vascularization after CPSS attenuation is significantly associated with hepatic vascular endothelial growth factor (VEGF) and VEGF receptor 2 (VEGFR2) gene expression and serum VEGF concentration.

Animals

Client‐owned dogs with CPSS undergoing surgical treatment. Forty‐nine dogs were included in the gene expression data and 35 in the serum VEGF data.

Materials and Methods

Dogs surgically treated by partial or complete CPSS attenuation were prospectively recruited. Relative gene expression of VEGF and VEGFR2 was measured in liver biopsy samples taken at initial and follow‐up surgery using quantitative polymerase chain reaction. Serum VEGF concentration was measured before and after CPSS attenuation using a canine specific ELISA. Statistical significance was set at the 5% level (P ≤ .05).

Results

There was a significant increase in the mRNA expression of VEGFR2 after partial attenuation (P = .006). Dogs that could tolerate complete attenuation had significantly greater VEGFR2 mRNA expression than those that only tolerated partial attenuation (P = .037). Serum VEGF concentration was significantly increased at 24 (P < .001) and 48 (P = .003) hours after attenuation.

Conclusions and Clinical Importance

These findings suggest that intrahepatic angiogenesis is likely to occur after the surgical attenuation of CPSS in dogs, and contributes to the development of the intrahepatic vasculature postoperatively.

Hepatic hepcidin gene expression in dogs with a congenital portosystemic shunt

Background

Microcytic anemia is common in dogs with a congenital portosystemic shunt (cPSS) and typically resolves after surgical attenuation of the anomalous vessel. However, the pathophysiology of the microcytic anemia remains poorly understood. Hepcidin has been a key role in controlling iron transport in both humans and animals and in mediating anemia of inflammatory disease in humans. The role of hepcidin in the development of microcytic anemia in dogs with a cPSS has not been examined.

Hypothesis

To determine whether hepatic hepcidin mRNA expression decreases, while red blood cell count (RBC) and mean corpuscular volume (MCV) increase in dogs after surgical attenuation of a cPSS.

Animals

Eighteen client‐owned dogs with confirmed cPSS undergoing surgical attenuation.

Method

Prospective study. Red blood cell count (RBC) and mean corpuscular volume (MCV), together with hepatic gene expression of hepcidin, were measured in dogs before and after partial attenuation of a cPSS.

Results

There was a significant increase in both RBC (median pre 6.17 × 10¹²/L, median post 7.08 × 10¹²/L, P < .001) and MCV (median pre 61.5fl, median post 65.5fl, P = .006) after partial surgical attenuation of the cPSS. Despite the increase in both measured red blood cell parameters, hepatic gene expression of hepcidin remained unchanged.

Conclusions and Clinical Importance

This study found no evidence that dysregulated production of hepcidin was associated with anemia in dogs with a cPSS.

Treatment of extrahepatic congenital portosystemic shunts in dogs - what is the evidence base?

A variety of surgical treatments and medical therapies are recommended for dogs with extrahepatic congenital portosystemic shunts (CPSS). The objective of this review was to assess the evidence base for the management of extrahepatic CPSS in dogs. An online bibliographic search was performed in November 2010 to identify articles relating to the question "Which of the treatment options for extrahepatic CPSS in dogs offers the best short- and long-term outcomes?" Articles were assigned a level of evidence based on a modified grading system. Thirty-eight articles were included in the review. Thirty-six articles were classified as grade 4 and two as grade 5. The timings and methods of assessment of short- and long-term outcomes varied widely between studies. One prospective study (grade 4a) showed that surgically treated dogs survived significantly longer than medically treated dogs. Four retrospective studies (grade 4b) compared the outcome of two surgical techniques but there were no statistically significant differences between treatment groups in terms of complications or outcome. The review found that the evidence base for the treatment of extrahepatic CPSS is weak. There is a lack of evidence of short- and long-term outcomes to recommend one treatment over another.

Vascular endothelial growth factor (VEGF) and VEGF receptor expression in biopsy samples of liver from dogs with congenital portosystemic shunts

Surgical attenuation of a congenital portosystemic shunt (CPSS) results in increased liver mass, development of intrahepatic portal vasculature and improved liver function. Vascular endothelial growth factor (VEGF) is a key regulator of angiogenesis. The aim of this study was to investigate the role of VEGF and its receptor in the hepatic response to CPSS surgery. The study included 99 dogs with CPSS treated with either partial or complete suture attenuation. Forty-four dogs with partial attenuation underwent a second surgery for complete attenuation. The expression of VEGF and VEGF receptor 2 (VEGFR2) in biopsy samples of liver was assessed by immunohistochemistry with rabbit anti-human VEGF polyclonal antibody and mouse anti-human VEGFR2 monoclonal antibody. Expression of these molecules was graded. The proportion of samples expressing VEGF was significantly greater in samples from dogs with CPSS compared with control samples (P=0.04) and the proportion of samples expressing VEGFR2 was significantly greater in control samples compared with samples from dogs with CPSS (P=0.04). VEGF labelling grade decreased significantly (P=0.038) and VEGFR2 increased significantly (P=0.046) between first and second surgery. The decrease in VEGF may reflect transient expression, preferential expression of other factors, reperfusion of existing vessels and/or increased angiogenesis before surgery in the form of arterialization and subsequent reduction due to improved portal blood flow. Partial suture attenuation was associated with a degree of 'normalization' of VEGF and VEGFR2 expression when compared with the control samples. Further investigation is needed to provide more information on the hepatic response to CPSS surgery.

Development and validation of a tissue cage model of acute inflammation in the cat

Four cylindrical silicon tissue cages (TC, internal volume: 6.7 ± 0.11 cm(3)) were inserted subcutaneously in 29 young healthy cats. A mild inflammatory reaction was induced by intracaveal injection of 1 mL of a 2%λ-carrageenan solution. TC exudate was subsequently sampled at predetermined times (up to 120 h) to measure exudate leucocyte counts and the concentrations of protein and eicosanoids. TC remained in situ for 9-10 months and were well tolerated. Leucocyte counts peaked at 34 h (50.1 ± 57.6 × 10(3) cells/mm(3) ) and returned towards baseline after 72 h. Protein concentration increased from 26.2 ± 2.7 g/L to a peak of 35.9 ± 6.0 g/L at 12 h before returning to baseline at 48 h. Exudate prostaglandin (PG)E(2) concentration peaked at 24 h (11.7 ± 13.7 ng/mL) and returned to baseline by 120 h. Repeated collection of fluid from noninjected cages did not increase transudate PGE(2). Ketoprofen (2 mg/kg, subcutaneously) suppressed exudate PGE(2) at 24 h. The carrageenan-stimulated TC model is an ethical and novel means of investigating soft tissue inflammation in the cat, in which exudate PGE(2) acts as surrogate marker of cyclooxygenase-2 activity. This model will facilitate the investigation of in vivo pharmacokinetics and pharmacodynamics of anti-inflammatory drugs in this species.

Expression of Toll-like receptor 2 in duodenal biopsies from dogs with inflammatory bowel disease is associated with severity of disease

There is growing evidence that aberrant innate immune responses towards the bacterial flora of the gut play a role in the pathogenesis of canine inflammatory bowel disease (IBD). Toll-like receptors (TLR) play an important role as primary sensors of invading pathogens and have gained significant attention in human IBD as differential expression and polymorphisms of certain TLR have been shown to occur in ulcerative colitis (UC) and Crohn's disease (CD). The aim of the current study was to evaluate the expression of two TLR important for recognition of commensals in the gut. TLR2 and TLR4 mRNA expression in duodenal biopsies from dogs with IBD was measured and correlated with clinical and histological disease severity. Endoscopic duodenal biopsies from 20 clinical cases and 7 healthy control dogs were used to extract mRNA. TLR2 and TLR4 mRNA expression was assessed using quantitative real-time PCR. TLR2 mRNA expression was significantly increased in the IBD dogs compared to controls, whereas TLR4 mRNA expression was similar in IBD and control cases. In addition, TLR2 mRNA expression was mildly correlated with clinical severity of disease, however, there was no correlation between TLR2 expression and histological severity of disease.

Analysis of NOD1, NOD2, TLR1, TLR2, TLR4, TLR5, TLR6 and TLR9 genes in anal furunculosis of German shepherd dogs

Anal furunculosis (AF) primarily affects German shepherd dogs (GSD) and is characterised by inflammation and ulceration of the perianal tissues with development of cutaneous sinuses or rectocutaneous fistulae. Investigation of pattern recognition receptor (PRR) function has suggested that defective responses might occur in AF-affected GSD. The aim of the current study was to investigate whether canine PRR genes are involved in determining susceptibility to AF in this breed. Chromosomal location and coding sequences for NOD1, NOD2, TLR1, TLR2, TLR4, TLR5, TLR6 and TLR9 were determined and microsatellite markers identified for each gene. Microsatellite genotyping of 100 control GSD and 47 AF-affected GSD showed restricted allelic variation for AHT H91 (associated with TLR5) and REN216 NO5 (associated with both TLR1 and TLR6) compared with non-GSD dogs. Genotyping of single nucleotide polymorphisms identified in canine TLR1, TLR5, TLR6 and NOD2 genes failed to show any significant associations between PRR polymorphisms and AF. The highly restricted PRR genotypes seen in GSD are likely to have resulted from selective breeding and might influence innate immune responses in this breed.

Matrix metalloproteinase mRNA expression in canine anal furunculosis lesions

Although the aetiology of anal furunculosis (AF) in dogs is poorly understood, there is evidence for an underlying immune dysfunction. This is illustrated by the presence of a T helper type 1 cytokine mRNA profile in AF lesions and the clinical response to ciclosporin therapy. Expression of MMPs 2, 9 and 13 were evaluated in AF lesional biopsies by real-time quantitative RT-PCR. There was significantly increased expression of both MMP-9 and MMP-13 mRNA in AF biopsies compared to controls (p<0.001) but no significant difference in MMP-2 mRNA expression. Since MMP-9 and MMP-13 are primarily produced by macrophages, these data suggest that ulceration could be the result of aberrant activation of this cell type in the tissues. It is feasible that such pathological macrophage activity occurs in response to interferon-gamma secreted by T helper type 1 cells. This could explain why the lesions resolve following treatment with the immunosuppressive drug ciclosporin.

Unusual vascular ring anomaly associated with a persistent right aortic arch in two dogs

An unusual vascular ring anomaly consisting of a persistent right aortic arch and a left ligamentum arteriosum extending from the main pulmonary artery to an aberrant left subclavian artery and left aortic arch remnant complex was identified in a German shepherd dog and a great Dane. The left subclavian artery and left aortic arch remnant complex originated at the junction between the right distal aortic arch and the descending aorta and coursed dorsal to the oesophagus in a cranial direction. The attachment of the ligamentum arteriosum to the aberrant left subclavian artery was approximately 5 cm cranial to the point of origin of the aberrant left subclavian artery and left aortic arch remnant complex from the descending aorta in both dogs. This anomaly observed in both dogs is similar to an anomaly reported in humans, in which a persistent right aortic arch is found in conjunction with an aberrant left subclavian artery and a left aortic arch remnant (Kommerell's diverticulum). Surgical ligation and division of the left ligamentum arteriosum in both dogs, along with division of the left subclavian artery in the great Dane, resulted in resolution of clinical signs in both of the dogs in this report.

Localised mid-jejunal volvulus following intussusception and enteroplication in a dog

Ileocolic intussusception was successfully treated surgically by partial enterectomy and enteroplication in an 11-month-old, male neutered German shepherd dog. Segmental intestinal volvulus was identified in the same dog two months later and was managed successfully by a second partial enterectomy. The dog made an uneventful recovery and was free of clinical disease six months after the second surgery. Both conditions are reviewed in this case report and a possible relationship between these two episodes in this dog is discussed.

Aciclovir or ganciclovir universal prophylaxis of cytomegalovirus infection in liver transplantation: an economic analysis

BACKGROUND

Cytomegalovirus (CMV) following orthotopic liver transplantation can result in significant morbidity and mortality. Prophylaxis with oral aciclovir (ACV) or ganciclovir (GCV) for all transplant recipients (universal prophylaxis) may be beneficial, but which agent is more cost-effective is unknown.

METHODS

A single centre, retrospective study of all patients who had OLT at the Western Australian Liver Transplantation Service was performed. Patients received ACV from 1992 to 1998, and GCV from 1999 to 2001. A comparative cost-effectiveness analysis for the two groups was performed based on the mean total cost of the number of cases of CMV infection and disease as the clinical end-point.

RESULTS

The ACV group comprised of 55 patients and there were 24 in the GCV group. The incidence of CMV disease was 7% and 4% for the ACV and GCV groups, respectively (P > 0.05). For CMV infection it was 16% and 8%, respectively (P > 0.05). GCV prevented more cases of CMV infection and disease than ACV but at an incremental cost of dollars A20,000 (dollars US10,172) per case prevented. Overall, ACV was more cost-effective than GCV by dollars A2200 (dollars US1119) per person. The cost benefit of ACV was derived principally through a reduced pharmaceutical cost. Both agents were well tolerated without development of antiviral resistance.

CONCLUSIONS

Universal prophylaxis of CMV infection-following liver transplantation with aciclovir is more cost-effective than with ganciclovir.

Rural residents' utilisation of health and visiting specialist health services

INTRODUCTION AND OBJECTIVES

The purpose of the study was to identify the demographic and health service characteristics impacting on rural residents' utilisation of health and visiting specialist services in Western Australia.

METHOD

Focus group discussions were held with an age-stratified, randomly selected group of forty-eight residents in four rural Western Australian towns between May and June 2000.

RESULTS

Discussions revealed a preference to use local health services for basic care and to travel for the treatment of major or severe illnesses. The focus group participants supported visiting specialist services, indicating a willingness to use them for consultations, diagnostic and minor procedures. Utilisation of visiting services was conditional on the provision of information on specialist reputation, service outcomes, integration of the service into local facilities, and recommendation by the local general practitioner.

CONCLUSION

Numerous factors influence the service-seeking behaviour of rural patients. These factors need to be recognised and considered in the design and promotion of resident and visiting specialist services if the migration for health care is to be rationalised.

Costs of accessing surgical specialists by rural and remote residents

INTRODUCTION

Access to surgical specialist services by rural and remote residents in Australia is limited. Little information is available on the cost to rural residents of accessing specialist treatment. The aim of the present study was to define the personal costs incurred by country patients in Western Australia when accessing specialist surgical services in a rural or metropolitan setting.

METHODS

A random sample of 50 patients who attended a visiting rural surgical service between December 1998 and February 1999 inclusive was recruited. In a structured telephone interview patients were asked 40 non-clinical questions relating to their recent specialist consultation. The cost of accessing these services was determined from time lost from work, distance and travel expenses. The same formula was then applied to estimate the cost of attending a base metropolitan hospital. The need for an accompanying person was determined from a subset of 16 patients who had transferred to metropolitan specialist consultation in the previous 12 months. Average waiting list times for consultations and common surgical procedures for the visiting service were compared with those for a metropolitan-based service.

RESULTS

An estimated saving of AU$1,077 was made per specialist consultation when accessing a local rather than a metropolitan service. Savings were observed in travel time, distance travelled, lost income, provision of an escort and waiting time.

CONCLUSION

The present study shows that the personal costs and difficulties incurred by rural and remote residents when accessing specialist treatment can be reduced if a visiting specialist service is available.

Adult-to-adult living donor liver transplantation for fulminant hepatic failure

The outcome of fulminant hepatic failure without timely liver transplantation is poor. We describe a 19-year-old woman with fulminant hepatic failure due to acute hepatitis B infection who received a living donor liver transplant from her sister. The donor's recovery was uneventful, allowing hospital discharge on Day 6. Two months after transplantation the recipient developed a biliary stricture requiring surgery. One year after transplantation, her liver function was normal.

Improving basic surgical skills for final year medical students: the value of a rural weekend

BACKGROUND

Hospitals employing medical graduates often express concern at the inexperience of new interns in basic surgical skills. In self assessment questionnaires, our senior medical students reported little clinical procedural experience. A practical skills workshop was staged in order to set learning goals for the final study year. This gave the students an opportunity to learn, revise and practice basic surgical techniques.

METHOD

The Bruce Rock rural community sponsored a surgical camp at the beginning of the academic year. Ninety-five (80%) of the class registered at the workshop, which rotated them through teaching modules, with private study opportunities and the capacity to cater for varied skill levels. Eight teaching stations with multiple access points were provided, and ten mock trauma scenarios were staged to augment the learning process.

RESULTS

The teaching weekend was rated by students on an evaluative entrance and exit questionnaire. Sixty-five (73%) students returned questionnaires. They recorded significant improvement (P < 0.05) in their ability to handle the teaching stations. All students had inserted intravenous lines in practice prior to the camp, so the rating change in intravenous line insertion ability was not statistically significant.

CONCLUSIONS

The weekend retreat offers students a chance to focus on surgical skills, free from the pressures of a clinical setting or the classroom. The emphasis was on the value of practice and primary skills learning. Students endorsed the camp as relevant, practical and an enjoyable learning experience for basic surgical skills.

TP53 gene mutation status in pretreatment biopsies of oesophageal adenocarcinoma has no prognostic value

Identification of markers which help to predict response to treatment and overall survival at the time of diagnosis would assist in the management of patients with oesophageal adenocarcinoma. In the present study we investigated the prognostic significance of mutations to the TP53 tumour suppressor gene in a large, consecutive series of oesophageal adenocarcinomas. The incidence of TP53 mutation determined by molecular analysis of endoscopic biopsy specimens was 36% (49/135). No statistically significant difference was observed in patient survival according to the TP53 status of the tumour biopsy. The median survival time for patients with mutation was 12 +/- 1 months compared with 14 +/- 2 months for patients with TP53. These results demonstrate that mutation of the TP53 gene is not a useful predictive marker for patient survival in oesophageal adenocarcinoma.

Management of biliary tract complications following liver transplantation

BACKGROUND

A review of biliary tract complications was performed in 32 patients who underwent liver transplantation by the Western Australian Liver Transplantation Service during a 2-year period.

METHODS

A review was made of patient data collected prospectively, and confirmed by retrospective casenote review.

RESULTS

A total of 30 patients (31 grafts) survived more than 2 days after transplantation, and of these 28 had an end-to-end biliary anastomosis. Analysis of these 28 patients found that eight of 17 patients with T-tubes had complications: three leaks at T-tube removal; two strictures and leaks; and three strictures. Six of 11 patients without a T-tube had complications: one leak; three strictures and leaks; and two strictures. Predisposing factors were present in eight of the 14 patients with biliary tract complications: hepatic artery stenosis in three; and one each with hepatic artery thrombosis; biliary calculi; donor-recipient bile duct mismatch; severe cellular rejection: and prolonged postoperative hypotension. Acute rejection, steroid-resistant rejection and cytomegalovirus infection were all significantly more common in those patients with biliary tract complications compared with those without. There was no difference in cold ischaemic time or donor age. Twelve of the 14 patients with biliary complications required endoscopic stenting with or without balloon dilation, and eight patients required radiological percutaneous drainage of bile collections. Only one patient required biliary reconstruction and two patients required re-transplantation. One patient died of uncontrolled infection. Of three patients who underwent choledochojejunostomy, biliary leak developed in two patients, both of whom required operative biliary and hepatic repair. One of the three patients died from disseminated Aspergillus infection. The median total hospital stay of patients with biliary complications was 61 days (range: 30-180 days) compared with 33.5 days (range: 22-70 days) for patients without. Of patients with end-to-end biliary anastomosis, 50% had biliary tract complications and more than half of these had predisposing factors. The majority of biliary complications were managed without the need for surgery.

CONCLUSION

A total of 50% of patients with end-to-end biliary anastomosis had biliary tract complications. Biliary strictures presented later than leaks, and the majority of these complications were managed without the need for surgery.

The changes seen in balloon-injured porcine femoral arteries following sympathectomy

On the basis that vasoconstriction may contribute to restenosis following angioplasty, the influence of lumbar sympathectomy on the morphometry of femoral arteries after balloon injury was examined in a pig model. Twenty-six juvenile pigs underwent balloon de-endothelialization of the right femoral artery followed by an open bilateral lumbar sympathectomy (n = 14) or a sham sympathectomy (n = 12). Four weeks later flow was measured in femoral arteries. Animals were then killed and the femoral arteries were perfusion-fixed and harvested. Sympathectomy resulted in a significant (P = 0.04) increase in flow in both the injured (right) and uninjured (left) femoral arteries. Sympathectomy did not inhibit intimal thickening following balloon injury: median (interquartile range) intimal area was 0.4 mm2 (0.3-0.9) in the sympathectomy group versus 0.5 mm2 (0.4-0.9) in the sham group. Sympathectomy did, however, result in a significant (P = 0.02) increase in the lumen area: 1.1 mm2 (0.8-1.8) versus 0.7 mm2 (0.6-0.9). Sympathectomy may reduce vasospasm following angioplasty with the potential for clinical benefit.

Banff schema for grading liver allograft rejection: utility in clinical practice

An accurate and functional system for grading acute liver allograft rejection is important for patient management, research, and communication. The Banff schema is a consensus document designed to provide an internationally accepted standard for this purpose. The aim of this study is to determine if application of the Banff schema would significantly alter the grading of acute liver allograft rejection compared with the Birmingham system. One hundred twenty-four post-liver transplantation biopsies performed by the Western Australian Liver Transplantation Service between 1992 and 1997 were retrospectively analyzed by a pathologist and a hepatologist. Each was supplied with a brief clinical history before applying the Banff and Birmingham criteria. Results were compared with each other and to the diagnosis made at the time of the biopsy, which was based on the European grading system. Rejection was diagnosed by the reviewers in 61 of 124 biopsy specimens according to the criteria of Snover. The Banff schema and Birmingham system agreed on the grade of rejection in 22 of the 61 biopsy specimens. The Banff schema elevated the grade of rejection in 39 specimens by an increment of one. In no instance did the Banff schema reduce the grade. Comparison between the Banff schema and diagnosis made at the time of biopsy showed agreement in 39 specimens, whereas the Banff schema elevated the grade in 15 specimens and reduced the grade in 23 specimens. In comparison to the Birmingham system, the Banff schema elevated the grade of liver allograft rejection in the majority of biopsy specimens, and this has the potential to alter clinical management with the adoption of the Banff schema or if the systems are used interchangeably.

Gastric carcinomas with microsatellite instability: clinical features and mutations to the TGF-beta type II receptor, IGFII receptor, and BAX genes

The replication error phenotype (RER+) represents an important new form of genetic alteration characterized by widespread instability in repetitive nucleotide sequences. The aim of this study was to compare the features of RER+ gastric tumours with those of RER+ colonic tumours. RER status was determined by analysis of size alterations in the BAT-26 mononucleotide repeat microsatellite. Twelve of 121 (10 per cent) gastric carcinomas from a low-incidence region were found to be RER+. BAT-26 instability was associated with tumours showing an absence of nodal invasion ( p=0.009) and with a trend for improved prognosis. These tumours were more frequent in older, female patients. Frameshift mutations in mononucleotide repeat sequences within the transforming growth factor-beta receptor II (RII), insulin-like growth factor II receptor (IGFIIR), and BAX genes were observed in 83, 33, and 25 per cent, respectively, of RER+ tumours. Only 1/12 (8 per cent) RER+ tumours contained a p53 gene mutation compared with 29/109 (27 per cent) RER- tumours. RER+ gastric carcinomas therefore share several important features with RER+ colonic tumours, including less frequent nodal invasion, improved prognosis, a similar frequency of mutation in growth control genes containing repetitive nucleotide sequences, and a low frequency of mutation of the p53 tumour suppressor gene.

Asymptomatic carotid artery stenosis associated with peripheral vascular disease: a prospective study

This study aimed to determine the prevalence of symptomless internal carotid artery stenosis in consecutive patients presenting with peripheral vascular disease. Duplex ultrasound screening of the carotid arteries was used to determine the degree of stenosis. Co-morbidities were recorded together with age, sex and tobacco use. Internal carotid artery stenosis of > 50% was found in 35% of patients. Among these there was > or = 70% stenosis in 18% of patients and of this group 5% had an occluded carotid vessel at first presentation. Males presented with peripheral vascular disease and associated carotid stenoses at a younger age than females. Male smokers had a higher prevalence of stenosis (P = 0.036) but all smokers had developed stenoses 3-5 years before non-smokers. Females with abdominal aortic aneurysms had a greater prevalence of carotid stenosis (P = 0.037), and male aneurysmal disease diminished stenosis prevalence (P = 0.023). Men with an elevated serum creatinine were more likely to have a stenosis (P = 0.019), but not women. The other co-morbidities were not specifically associated with carotid artery stenosis.

Developing visiting surgical services for rural and remote Australian communities

The University Department of Surgery at Queen Elizabeth II Medical Centre (Perth, Western Australia) has undertaken a pilot project to provide surgical services to country communities where no such service exists. Three surgeons undertake a regular schedule of appointments, and are accompanied by final-year medical students to give them experience with common conditions rarely managed in teaching hospitals. The service is supported by a central administrative office and coordinated by a general practitioner, who negotiates with the regional healthcare providers. Patients are referred by their general practitioner, who may work with the surgeon as anaesthetist or surgical assistant.

Mutation of the transforming growth factor-beta type II receptor gene in right-sided colorectal cancer: relationship to clinicopathological features and genetic alterations

The presence of inactivating mutations in the transforming growth factor-beta (TGF-beta) type II receptor (RII) gene in the colon cancer suggests that it may behave like a tumour suppressor gene. RII is mutated in the majority of colon tumours exhibiting widespread microsatellite instability, a characteristic generally referred to as the replication error phenotype (RER+). We investigated the association between RII mutations and various clinicopathological variables and genetic alterations in a large series of sporadic adenocarcinomas arising in the proximal colon. RII mutations were found in 17 per cent (36/210) of right-sided tumours and in 86 per cent (32/37) of those displaying RER+. They were associated with the absence of lymph node invasion (P = 0.04), poor histological differentiation (P = 0.006), and with a trend for improved patient survival. Tumours with an RII mutation also showed non-significant trends for a lower incidence of p53 protein overexpression and of p53, K-ras, and APC gene mutation compared with tumours with normal RII. These results indicate that right-sided colorectal tumours containing RII mutations resemble those with the RER+ phenotype in terms of their clinicopathological features and genetic alterations.

Prognostic factors in elective aortic reconstructive surgery

BACKGROUND

The present study was carried out to determine the risk factors associated with peri-operative mortality and long-term survival in patients undergoing abdominal aortic reconstructive surgery (ARS).

METHODS

A retrospective review was performed of the case notes of all patients having ARS at a university teaching hospital during a 5.5-year period, and their details entered onto a pro forma.

RESULTS

A total of 252 patients underwent ARS between July 1989 and December 1994. The peri-operative mortality was 7.5%. The most frequent adverse events were cardiac events, accounting for 8 (42%) of the peri-operative deaths. The risk of a peri-operative cerebrovascular accident was low (n = 3, 1.2%) as was the risk of peri-operative renal failure requiring dialysis (n = 3, 1.2%). Factors independently linked to increased peri-operative mortality included moderate-to-severe hypertension (P = 0.05, odds ratio = 3.54), those with renal impairment (P = 0.05, odds ratio = 2.69), and blood transfusion requirements (P < 0.001, odds ratio = 1.26). Long-term survival was independently shortened by occlusive disease (P = 0.004, hazard ratio = 2.78) and ischaemic heart disease (P < 0.001, hazard ratio = 3.58).

CONCLUSIONS

The risks of ARS were significantly increased in patients with severe hypertension, those with renal impairment and those requiring blood transfusion. Long-term survival was shortened for those patients with occlusive aortic disease and ischaemic heart disease. These risk factors should be carefully assessed in each patient before performing elective ARS.

Liver transplantation in Western Australia: improved services to an isolated population

OBJECTIVE

To assess performance of the Western Australian Liver Transplantation Service in the light of debate about whether small transplant centres can produce optimal outcomes.

DESIGN

Review of patient data collected prospectively and confirmed by retrospective casenote review.

SUBJECTS

All patients referred to the Western Australian Liver Transplantation Assessment Panel. Those who underwent transplantation at the Western Australian Liver Transplantation Service (to June 1996) were compared with those referred to other transplant centres before the elective service was established in July 1994.

OUTCOME MEASURES

Numbers of referrals and transplants; characteristics of the transplantation procedure; and patient outcomes.

RESULTS

Annual referrals for liver transplant in Western Australia (WA) increased from 12 (1985-1993) to 41 (July 1994-June 1996), with five deaths on the "activated" list before July 1994, but none after. To June 1996, 30 patients had received 31 transplants by the Western Australian Liver Transplantation Service (two emergency transplants in 1992 and 1993, respectively, and 28 elective transplants and one retransplant after June 1994), with median operation time of 5.5 hours (range, 3-10.5), median red cell transfusion of 4 units (range, 0-55) and median hospital stay of 24 days (range, 12-128). There was no severe primary graft dysfunction. Major complications included hepatic artery thrombosis or stenosis (5 patients, one requiring retransplant), biliary stricture not associated with hepatic artery pathology, bile leak and perihepatic abscess (4 each), and cytomegalovirus infection (3). Patient survival was 83% and graft survival 81% at a mean follow-up of 13 months, compared with 86% and 83%, respectively, at one year for WA patients who received transplants elsewhere before July 1994.

CONCLUSIONS

Performance of the Western Australian Liver Transplantation Service compares favourably with national and international standards, and WA patients receiving liver transplants have increased dramatically since the service was established. This supports the viability of committed liver transplantation centres with only 10-15 patients a year and argues the need for nationally decentralised services.

Hypothermic ischaemia of the liver: a re-perfusion phenomenon

BACKGROUND

The effects of hypothermic injury to the liver were investigated on an isolated perfusion circuit by comparing porcine livers with varying degrees of preservation injury.

METHODS

A group of unstored livers (n = 5) were compared to livers stored in University of Wisconsin (UW) solution for 18 h (n = 5), and a group of livers stored in Hartmann's solution for 18 h (n = 5).

RESULTS

We observed that the degree of platelet sequestration was directly related to the severity of the preservation injury. After 2 h of isolated liver perfusion, the perfusate platelet count fell from 148 +/- 14 x 10(9)/L to 84 +/- 13 x 10(9)/L for control livers. In comparison for livers stored in UW solution, the platelet count fell from 173 +/- 43 x 10(9)/L to 61 +/- 14 x 10(9)/L representing a 64.8% fall, while for those stored in Hartmann's solution, an even more profound fall from 152 +/- 36 x 10(9)/L to 19 +/- 9 x 10(9)/L (87.5% fall) was observed. The difference between the UW-stored and Hartmann's-stored livers was significant (P < 0.05). However, using this model, the degree of leukocyte sequestration did not differentiate the groups. Both histological and ultrastructural examination of liver biopsies taken immediately following revascularization demonstrated that for mild degrees of preservation injury following hypothermic storage, changes occur to the sinusoidal lining cells well before changes to the parenchymal elements.

CONCLUSIONS

These findings substantiate the hypothesis that the primary injury associated with hypothermia involves the sinusoidal lining cells (non-parenchymal elements), that it is predominantly a reperfusion phenomenon and that efforts at improving preservation should therefore be targeted primarily at these cells and not the hepatocytes.

Intra-abdominal fluid collections after liver transplantation

Fluid collections are commonly seen following orthotopic liver transplantation. The majority of these collections are not infected and resolve spontaneously. However, infected collections are associated with significant morbidity and mortality and usually require drainage. Clinical signs of infection are frequently masked following transplantation due to immunosuppression. Intrahepatic collections usually represent abscesses or bilomas and invariably require intervention. Altered anatomical relationships result in signs that frequently help to differentiate these from loculated fluid within hepatic fissures. Other imaging features indicating infection include the presence of gas where none was seen previously, the development of a discrete wall and changes in the surrounding liver.

Hypermethylation of the Myf-3 gene in human colorectal cancer

Abnormal methylation of DNA is one of the earliest detectable changes in human tumors. We investigated hypermethylation of the Myf-3 gene, the human homolog of the mouse myogenic gene Myo-D1, in colorectal adenomas and adenocarcinomas. Histologically normal gut mucosa from colorectal cancer patients showed moderately higher levels of methylation than in other normal tissues. Varying degrees of Myf-3 hypermethylation were found in all five adenomas and eight adenocarcinomas examined. Carcinomas arising from within adenomas generally showed a decrease in both the heterogeneity and intensity of Myf-3 methylation. Regional hypermethylation of this gene therefore appears to be an early event in human colorectal neoplasia.

Morphometric changes seen in balloon-injured porcine iliac arteries: the influence of sympathectomy on intimal hyperplasia and remodelling

OBJECTIVES

To assess the influence of lumbar sympathectomy on intimal thickening and arterial remodelling following balloon de-endothelialisation.

DESIGN

Experimental animal model with control and treated (sympathectomy) groups.

METHODS

Unilateral common iliac artery de-endothelialisation was performed in 36 male pigs using a 5F balloon catheter introduced via the profunda femoris artery. Bilateral lumbar sympathectomies were performed in 18 animals. Both iliac arteries were perfusion-fixed and harvested 4 weeks later. Arterial morphometry was assessed using computer image analysis.

RESULTS

Area measurements are expressed as median (interquartile range) in mm2. Balloon injury resulted in significant intimal thickening but no loss of lumen due to compensatory enlargement of the injured artery. Sympathectomy resulted in significant lumen enlargement (4.8 (2.6-6.3) vs. 1.9 (1.7-2.9)) in balloon-injured arteries. Although intimal thickening was reduced (0.9 (0.6-1.7) vs. 1.5 (0.9-2.0)), this was not statistically significant.

CONCLUSIONS

Sympathectomy increases lumen area 4 weeks after balloon injury to porcine iliac arteries. This effect is due to a combination of reduced arterial wall thickening and increased arterial size.

Concordance between p53 protein overexpression and gene mutation in a large series of common human carcinomas

Immunohistochemical (IHC) detection of p53 protein was compared with the presence of p53 gene mutation in many colorectal (n = 100), breast (n = 92), endometrial (n = 122), and gastric (n = 116) carcinomas. Two commercially available antibodies, DO7 and CM1, were used for IHC analysis of paraffin-embedded tissue sections. Screening for gene mutations in frozen and paraffin-embedded tumor samples was carried out using polymerase chain reaction-single-strand conformation polymorphism (PCR-SSCP). The frequency of nuclear staining with DO7 or CM1 for each tumor type, respectively, was colorectal (36%, 23%); breast (15%, 19%); endometrial (21%, 33%); and gastric (23%,-). Overall correlation between the two antibodies for nuclear staining was 90% for the 314 tumors analyzed. Cytoplasmic staining was observed with DO7 in 7% of breast and 5% of gastric carcinomas and with CM1 in 17% of breast and 54% of endometrial carcinomas. p53 gene mutation was found in 39% of colorectal, 28% of breast, 13% of endometrial, and 25% of gastric cancers. The concordance between p53 nuclear overexpression and gene mutation (both positive or both negative) was 68% for colorectal, 79% for breast, 76% for endometrial, and 73% for gastric carcinomas. This study provides further evidence that IHC detection of p53 protein accumulation does not always indicate the presence of a gene mutation and vice versa. Discordant results were observed in approximately 20% to 30% of the tumors studied, highlighting the need for careful characterization of both p53 gene and protein alterations when assessing the relationship between p53 status and tumor behavior.

Monocyte chemoattractant protein-1 gene expression in injured pig artery coincides with early appearance of infiltrating monocyte/macrophages

Monocyte chemoattractant protein-1 (MCP-1) and interleukin-8 (IL-8) are potent chemokines which attract circulating monocytes and neutrophils respectively to inflamed tissues. JE/MCP-1 gene expression has been previously studied in rabbit aortae after endothelial denudation and the rapid appearance of this transcript was thought to precede emigration of phagocytes. We now report MCP-1 gene expression following de-endothelialization of iliac arteries in the pig, a species which can develop spontaneous atherosclerosis. Using Northern blot analysis, we demonstrated that MCP-1 mRNA was rapidly induced in pig arteries at 2 h and continued to increase to reach a maximum at 8 h before returning to low levels at 16-24 h after injury. The increase seen for MCP-1 mRNA at 8 h was also observed for IL-8 mRNA but was not apparent for growth-related gene expressions, urokinase-type plasminogen activator (u-PA), and plasminogen activator inhibitor-1 (PAI-1). Since smooth muscle cells, endothelial cells, and phagocytes are all capable of expressing MCP-1, we examined pig arteries for immunostaining using a monoclonal antibody to human MCP-1 (5D3-F7). At 8 h after injury, the predominant cell type staining positive for MCP-1 was the monocyte/macrophage. Staining was also observed in occasional scattered neutrophils, but MCP-1 protein could not be detected in smooth muscle cells or on extracellular matrix within the sensitivity constraints posed by our methodology. Our results are consistent with invading monocyte/macrophages having a major input into the production of this chemokine in the arterial wall following injury. The fact that MCP-1 expression accompanied monocyte/macrophage presence in damaged artery, rather than preceding it, is suggestive that continued MCP-1 expression is required for functions other than chemoattraction.

Vitamin D3 exacerbates intimal hyperplasia in balloon-injured arteries

Although a high dose of vitamin D3 is known to cause arterial calcification and degeneration, its effect on intimal hyperplasia has never been studied. The aim of this study was to examine the influence of a moderate supplement of vitamin D3 on intimal hyperplasia in the balloon-injured rat carotid artery. Forty-four rats had balloon injury to the carotid artery; 22 were given oral vitamin D3 supplementation (0.25 microgram kg-1 day-1). Animals were killed at 4 weeks and the carotid arteries were perfusion fixed and assessed morphometrically by means of computerized image analysis of transverse sections. Mean (s.e.m.) intimal area was significantly greater in the vitamin D3-treated animals than in controls: 0.92(0.05) versus 0.71(0.07) mm2 (P = 0.02). The area of the media of both injured and uninjured arteries was not influenced by vitamin D3 administration. A small dose of vitamin D3 resulted in significant exacerbation of intimal hyperplasia in this rat carotid artery model and raises the question of the role of dietary vitamin D3 in restenosis following vascular intervention.

p53 accumulation and mutation are prognostic indicators of poor survival in human gastric carcinoma

The aim of our study was to examine the prognostic significance of p53 protein accumulation and gene mutation in a series of 116 gastric carcinomas from a low incidence population. Formalin-fixed, paraffin-embedded tumour sections were used to investigate p53 protein accumulation by immunostaining with monoclonal antibody (MAb) DO-7 and p53 gene mutation by single-strand conformation polymorphism analysis of exons 5-8. Nuclear p53 accumulation was detected in 23% of tumours and mutation in 28%. Concordance between the 2 alterations was observed in 73% of cases. p53 protein accumulation was more frequent in tumours with lymph node metastasis, while p53 mutations were more frequent in tumours from older patients. The histopathological parameters of depth of invasion, grade and histological type showed no significant associations with either p53 alteration. In univariate analysis, both alterations were associated with significantly shortened patient survival. The 5-year survival rate for patients with a p53 mutation was 9% compared to 42% for those without a mutation. In multivariate analysis adjusted for the other histopathological parameters, p53 gene mutation but not immunohistochemically-detected p53 protein accumulation was an independent prognostic indicator of poor survival in gastric carcinoma.

Expression of transforming growth factor-beta1 (TGF-beta1) and urokinase-type plasminogen activator (u-PA) genes during arterial repair in the pig

OBJECTIVE

The transition from quiescence to proliferation in vitro is accompanied by early expression of proliferation-associated genes encoding products including cytokines and enzymes. We aimed to investigate TGF-beta1, u-PA and PAI-1 gene expressions in relation to proliferation and extracellular matrix (ECM) protein gene expressions in porcine arteries following injury.

METHODS

Right iliac arteries of juvenile pigs were de-endothelialised and harvested at fixed times after injury. RNA was then extracted and analysed by Northern blot analysis. RNA transcripts in thickened neointima of arteries were examined by in situ hybridisation using digoxygenin-labelled cDNA probes.

RESULTS

TGF-beta1, u-PA and PAI-1 transcripts were rapidly elevated (2-8h) and preceded a peak in histone mRNA at 24h after arterial injury. A second prolonged rise in TGF-beta1 mRNA at 4d coincided with elevated ECM protein gene expression. TGF-beta1 gene expression was detected in neointimal cells lining the arterial lumen at 4wk after injury.

CONCLUSIONS

The timings of increases in TGF-beta1, u-PA and PAI-1 mRNAs in injured arteries are consistent with contributions to processes prior to proliferation. The observation of a second protracted elevation in TGF-beta1 expression is supportive of an additional role in stimulation of ECM protein synthesis. Functional specialisation exists within the thickened intima of arteries late in repair.

Role of cimetidine in the prevention of intimal hyperplasia in rat carotid artery

In vitro studies have revealed that histamine increases smooth muscle cell proliferation and migration, an effect abolished by the H2 antagonist cimetidine. This study examined the effect of cimetidine on intimal hyperplasia in vivo. Thirty male Wistar rats underwent endothelial denudation of the left carotid artery; 15 received cimetidine 350 mg per kg per day for four weeks and 15 received vehicle only. Four weeks after injury the left carotid arteries were perfusion fixed and harvested. Morphometric analysis revealed that there was no significant difference between the intima:media ratio of rats treated with cimetidine (median (interquartile range (i.q.r.)) 1.69 (0.59)) and those treated with vehicle (median (i.q.r.) 1.59 (0.59), P = 0.28). Similarly, the percentage luminal reduction was not significantly different between the groups (median (i.q.r.) 54.7 (19.9) per cent and 45.8 (13.4) per cent respectively, P = 0.30). It is concluded that treatment with cimetidine does not reduce the formation of intimal hyperplasia in rat carotid arteries de-endothelialized with a balloon catheter.

Clonal analysis of colorectal tumors using K-ras and p53 gene mutations as markers

Mutations to the K-ras oncogene and p53 tumor suppressor gene are two of the most common genetic lesions in human cancers. In the present study we examined the clonality of colorectal tumors with respect to each of these genetic alterations. Screening for mutations was carried out using the polymerase chain reaction-based technique of single-strand conformation polymorphism. Eleven primary colorectal adenocarcinomas and two secondary adenocarcinomas were analyzed at four different sites within the tumor. Involved pericolic lymph nodes were collected from nine of these cases, a metastatic deposit in the liver was obtained in one case, and adjacent adenomatous lesions were collected in two cases. Seven tumors contained mutations in either the K-ras or p53 genes. In all cases, DNA derived from multiple sites within an individual tumor or metastatic deposits arising from that tumor showed the same pattern of gene mutation. Immunohistochemical staining for p53 protein overexpression also showed similar patterns of reactivity within individual tumors and their metastatic deposits. These results suggest that the major clonal expansion of colorectal carcinomas occurs after the acquisition of mutations in these genes. Our results also indicate that sampling errors are unlikely to occur in molecular studies aimed at defining the role of these genes in colorectal cancer progression.

Radiological predictors of response to renovascular reconstructive surgery

The aim of this study was to identify preoperative angiographic criteria which could be used to predict the response to renovascular reconstruction. A cohort of 49 patients who survived for more than 6 months after renovascular reconstruction was studied. All preoperative angiograms were reviewed independently and the renal size, degree of stenosis and the length of the lesion recorded. The response of blood pressure and renal function to surgery were correlated with the angiographic findings. We found that 58% of patients had long-term improvement in blood pressure control, though the response was significantly better where both kidneys were >12 cm in size (82%) compared with when both kidneys were < 12 cm (25%), P < 0.02. The degree of stenosis, while showing a trend towards a better blood pressure response with increasing stenosis, was not a statistically significant factor. None of the angiographic criteria examined could be used to predict the response in renal function. We have shown that the preoperative renal size is the only angiographic factor that may have some role in predicting the response of blood pressure to renovascular reconstruction.

A method for the treatment of ureteric complications following renal transplantation

Over an 8-year period, 117 renal transplants (97 cadaveric and 20 living related) were performed at the Sir Charles Gairdner Hospital, Perth, Western Australia, Australia. Ureteric complications following renal transplantation occurred following seven transplants (6%). The technique of using a multiply fenestrated vesicocutaneous stent/drain to manage this problem is described. This was uncomplicated in all cases with the exception of one case in which the stent/drain was removed early because of blockage and sepsis, but most importantly on no occasion was the graft lost. We therefore recommend this technique for the management of this complication, whether early or late. We observed a disproportionate number of ureteric complications in living related transplants, a feature not described previously.

Short-term and long-term outcome following renovascular reconstruction

Experience with renovascular reconstruction at the authors' institution over the past 16 years has been reviewed. A total of 76 patients underwent surgical intervention for renovascular disease during that time. This included 62 patients with atherosclerosis and 11 with fibromuscular hyperplasia. Indications for intervention were uncontrolled hypertension in 42 patients and to restore renal impairment in eight. The procedure was performed for both indications in 26 patients. Ten patients (13%) died in the perioperative interval, which correlated strongly with comorbidity. With the exception of one patient, all deaths occurred in the elderly (> 65 years). While an increased mortality rate (P < 0.05) was observed in those undergoing concomitant surgical procedures (20%) as opposed to those undergoing renovascular reconstruction alone (6%), this was not an independent risk factor. Both the short term and long term response of hypertension control to renovascular reconstruction were favourable, with age < 60 years, shorter duration of hypertension (< 5 years) and diagnosis of fibromuscular hyperplasia predictive of a better response. Renovascular reconstruction, while successful in stabilizing or even improving renal function in the short term, was poor at restoring function long term, especially in the subgroup of patients whose serum creatinine was > 200 mumol/l at the time of reconstruction.

Effects of epidermal growth factor and mitogenic pathway inhibitors on rat colon cancer proliferation in vitro

The proliferative responses of two rat colon cancer cell lines (Per192NR and Per237) to concentrations of epidermal growth factor (EGF) were assessed alone, or in combination with calcium sequestration or inhibitors of protein kinase A, C (PKA and PKC). Up to 160nM of EGF stimulated cell proliferation in Per237 cells, but was ineffective in Per192NR cells. In both cell lines all inhibitors failed to alter basal proliferation. In Per192NR cells the combination of 5 to 20nM EGF and inhibitor resulted in a biphasic reduction in basal proliferation which was lost by 20nM. In the Per237 cells only 10nM EGF and PKA inhibitor reduced proliferation. Tumours derived from the same origin respond differently to EGF-induced mitogenesis.

The common molecular genetic alterations in Dukes' B and C colorectal carcinomas are not short-term prognostic indicators of survival

Our study was undertaken to determine the prognostic significance of several common genetic alterations observed in colorectal carcinomas. We have previously analysed loss of heterozygosity of the MCC, APC, p53 and DCC tumour suppressor gene loci as well as p53 gene mutations and protein over-expression in a series of 100 Dukes' stage B and C colorectal tumours obtained at surgery. To extend our observations of alterations that may occur in these tumours, mutations to the c-Ki-ras oncogene and APC tumour suppressor gene were detected by PCR single-strand conformation polymorphism analysis. Short-term follow-up revealed no significant association between overall patient survival and any single, or combination of, genetic alteration(s). Surprisingly, patients whose tumours showed evidence of p53 protein over-expression/accumulation by immunocytochemistry (ICC) had a significantly better prognosis (p = 0.039) than those whose tumours had no p53 ICC reactivity.

A comparison of flushing solutions for liver procurement using an isolated perfused porcine model

There is no agreement on the best technique of in situ flushing of livers prior to storage. In order to study this, porcine livers were stored in the University of Wisconsin (UW) solution for 18 h and then assessed using an isolated perfused porcine model. Livers flushed in situ with UW solution were compared to livers flushed with a non-preservation solution (Hartmann's solution). No statistically significant differences could be found in bile production (18.7 +/- 4.4 vs 17.9 +/- 3.8mL/1000 g per 2 h), aspartate amino-transferase (AST) levels in the perfusate after 2 h of isolated perfusion (687 +/- 101 vs 724 +/- 114 U/L), potassium levels in the perfusate after 2 h on the circuit (5.4 +/- 1.5 vs 5.5 +/- 2.3 mmol/L), weight gain (15.2 +/- 3.7 vs 17.1 +/- 4.0%) or platelet sequestration (41.6 +/- 11.7 vs 37.4 +/- 9.8%) between livers flushed with UW solution as opposed to those flushed with Hartmann's solution, respectively. Of overriding importance was the solution in which the liver was stored, reconfirming the superiority of UW solution over an extracellular solution for preservation. If extrapolated to the clinical situation, these findings would have substantial cost-saving implications.