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Lohsiriwat V, Wilson VG, Scholefield JH, Dashwood MR. Regional Distribution of Nitric Oxide Synthase in Human Anorectal Tissue: A Pilot Study on the Potential Role for Nitric Oxide in Haemorrhoids. Curr Vasc Pharmacol 2018; 18:43-49. [PMID: 30058493 DOI: 10.2174/1570161116666180730101532] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 07/25/2018] [Accepted: 07/26/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To study the distribution of nitric oxide synthase (NOS) isoforms and protein levels in human haemorrhoids and rectal tissue. METHODS Protein expression of NOS1, NOS2 and NOS3 was compared between haemorrhoids (n=14) and normal rectal submucosa (n=6) using Western blot analysis. The localisation of all NOS isoforms to specific structures was determined by immunohistochemistry. RESULTS Western blot analysis showed median (interquartile range) protein levels of all NOS isoforms were 1.5-2.4 times higher in haemorrhoids than rectal tissue; 121.4 (55.2-165.5) vs 50.0 (25.5-73.7) for NOS1 (p=0.020), 32.2 (23.8-140.6) vs 14.8 (9.6-34.0) for NOS2 (p=0.109), and 80.1 (62.0-139.5) vs 54.3 (48.7 -61.7) for NOS3 (p=0.015). Immunohistochemistry revealed a different distribution and location of all NOS isoforms in vascular and non-vascular structure of haemorrhoids and rectal tissues. The number of haemorrhoid specimens showing positive immunoreactivity of NOS in the vascular endothelium was significantly higher than that in rectal tissue for NOS1 (11/14 (79%) vs 1/6 (17%); p=0.018) and NOS3 (8/14 (57%) vs 0/6 (0%); p=0.042), but not for NOS2 (6/14 (43%) vs 4/6 (67%); p=0.63). CONCLUSION Haemorrhoids have significantly higher protein levels of NOS1 and NOS3 than rectal tissue. The vascular endothelium of haemorrhoids also has significantly higher positive immunoreactivity of NOS1 and NOS3 than rectal tissue suggesting that blood vessels in haemorrhoids are exposed to higher NO concentrations than those of rectal tissue. Since haemorrhoids exhibit marked vascular dilatation and present with bleeding or swelling, a reduction in NOS - by applying NOS inhibitors - may potentially improve the symptoms of haemorrhoids.
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Affiliation(s)
- Varut Lohsiriwat
- The University of Nottingham Medical School, Queen's Medical Centre, Nottingham, United Kingdom.,Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Vincent G Wilson
- The University of Nottingham Medical School, Queen's Medical Centre, Nottingham, United Kingdom
| | - John H Scholefield
- The University of Nottingham Medical School, Queen's Medical Centre, Nottingham, United Kingdom
| | - Michael R Dashwood
- Surgical and Interventional Sciences, Royal Free and University College Medical School, London, United Kingdom
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Abstract
In this review we aimed to evaluate quality of life after bile duct injury and the consequent medico-legal implications. A comprehensive English language literature search was performed on MEDLINE, Embase, Science Citation Index and Google™ Scholar databases for articles published between January 2000 and April 2016. The last date of search was 11 April 2016. Key search words included bile duct injury, iatrogenic, cholecystectomy, prevention, risks, outcomes, quality of life, litigation and were used in combination with the Boolean operators AND, OR and NOT. Long-term survival after bile duct injury is significantly impaired (all-cause long-term mortality approximately 21 %) along with the quality of life (especially psychological/mental state remains affected). Bile duct injury is associated with high rates of litigation. Monetary compensation varied from £2500 to £216,000 in the UK, €9826-€55,301 in the Netherlands and $628,138-$2,891,421 in the USA. Bile duct injuries have profound implications for patients, medical personnel and healthcare providers as they cause significant morbidity and mortality, high rates of litigation and raised healthcare expenditure.
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Affiliation(s)
- Deepak Hariharan
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre National Institute for Health Research Biomedical Research Unit, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Emmanouil Psaltis
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre National Institute for Health Research Biomedical Research Unit, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - John H Scholefield
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre National Institute for Health Research Biomedical Research Unit, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre National Institute for Health Research Biomedical Research Unit, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK.
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Kent C, Bessell EM, Scholefield JH, Chappell S, Marsh L, Mills J, Sayers I. Chemoradiotherapy with Brachytherapy or Electron Therapy Boost for Locally Advanced Squamous Cell Carcinoma of the Anus-Reducing the Colostomy Rate. J Gastrointest Cancer 2017; 48:1-7. [PMID: 27412395 PMCID: PMC5310557 DOI: 10.1007/s12029-016-9850-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Purpose The aim of this study is to determine overall survival, disease-specific survival and stoma-free survival after treatment of squamous cell carcinoma of the anus with chemoradiotherapy followed by brachytherapy or electron boost in a recent cohort of patients. Methods Fifty-two patients (median age 62 years) were treated with radical chemoradiotherapy (mitomycin C, infusional 5-fluorouracil concurrently with conformal radical radiotherapy 45 Gy in 25 fractions over 5 weeks) followed by a radiotherapy boost between 1 December 2000 and 30 April 2011. Follow-up was to 30 November 2014. Thirty-six patients received a boost (15–20 Gy) over 2 days with 192Ir needle brachytherapy for anal canal tumours, and 16 patients received electron beam therapy (20 Gy in 10 fractions in 2 weeks) for anal margin tumours. A defunctioning stoma was only created prior to chemoradiotherapy for fistula or severe anal pain. Results The overall survival for the 36 patients treated with chemoradiotherapy followed by brachytherapy was 75 % (95 % CI, 61–89) at 5 years, the disease-specific survival was 91 % (95 % CI, 81–101 %), and the stoma-free survival was 97 % (95 % CI, 91–103 %) all at 5 years. For the 16 patients treated with an electron boost for anal margin tumours, the 5-year overall survival, disease-specific survival and stoma-free survival were 68 % (95 % CI, 44–92 %), 78 % (95 % CI, 56–100 %) and 80 % (95 % CI, 60–100 %), respectively. Conclusions A very low stoma formation rate can be obtained with radical chemoradiotherapy followed by a brachytherapy boost for squamous cell carcinoma of the anal canal but not with an electron boost for anal margin tumours.
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Affiliation(s)
- C Kent
- Department of Clinical Oncology, Nottingham, UK
| | - E M Bessell
- Department of Clinical Oncology, Nottingham, UK.
| | | | - S Chappell
- School of Life Sciences, University of Nottingham, Nottingham, UK
| | - L Marsh
- Department of Clinical Oncology, Nottingham, UK
| | - J Mills
- Department of Clinical Oncology, Nottingham, UK
| | - I Sayers
- Department of Clinical Oncology, Nottingham, UK
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Lohsiriwat V, Scholefield JH, Wilson VG, Dashwood MR. Endothelin-1 and its receptors on haemorrhoidal tissue: a potential site for therapeutic intervention. Br J Pharmacol 2017; 174:569-579. [PMID: 28095606 DOI: 10.1111/bph.13719] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 06/15/2016] [Accepted: 07/10/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND AND PURPOSE Haemorrhoids is a common anorectal condition affecting millions worldwide. We have studied the effect of endothelin-1 (ET-1) and the role of endothelin ETA and ETB receptors in haemorrhoid tissue. EXPERIMENTAL APPROACH Protein expression of ET-1, ETA and ETB receptors were compared between haemorrhoids and normal rectal submucosa using Western blot analysis, with the localization of proteins determined by autoradiography and immunohistochemistry. Effects of ET-1 and sarafotoxin 6a on human colonic and rectal arteries and veins was assessed by wire myography and the involvement of receptor subtypes established by selective antagonists. KEY RESULTS Dense binding of [125 I]-ET-1 to haemorrhoidal sections was reduced by selective receptor antagonists. A higher density of ETB than ETA receptors was found in haemorrhoidal, than in control rectal tissue and confirmed by Western blot analysis. ETA and ETB receptors were localized to smooth muscle of haemorrhoidal arteries and veins, with ETB receptors on the endothelium. Human colonic and rectal arteries and veins were similarly sensitive to ET-1 and affected by the ETA selective antagonist, but sarafotoxin S6a-induced contractions were more pronounced in veins and antagonized by a selective ETB receptor antagonist. CONCLUSIONS AND IMPLICATIONS ETA and ETB receptors are present in human haemorrhoids with ETB receptors predominating. ETA receptors are activated by ET-1 to mediate a contraction in arteries and veins, but the latter are selectively activated by sarafotoxin S6a - a response that involves ETB receptors at low concentrations. Selective ETB agonists may have therapeutic potential to reduce congestion of the haemorrhoidal venous sinusoids.
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Affiliation(s)
- Varut Lohsiriwat
- Division of Gastrointestinal Surgery, Queen's Medical Centre, University of Nottingham, Nottingham, UK
| | - John H Scholefield
- Division of Gastrointestinal Surgery, Queen's Medical Centre, University of Nottingham, Nottingham, UK
| | - Vincent G Wilson
- School of Life Sciences, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Michael R Dashwood
- Royal Free Hospital Campus, University College Medical School, London, UK
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Albasri A, Fadhil W, Scholefield JH, Durrant LG, Ilyas M. Nuclear expression of phosphorylated focal adhesion kinase is associated with poor prognosis in human colorectal cancer. Anticancer Res 2014; 34:3969-3974. [PMID: 25075018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
AIM To determine whether phosphorylated focal adhesion kinase (P-FAK) has prognostic value in colorectal cancer (CRC) and to test whether it has any association with Tensin 4 (TNS4) expression. MATERIALS AND METHODS P-FAK expression was assessed using immunohistochemistry in 462 CRC cases arrayed on a tissue microarray. P-FAK and TNS4 expression were assessed by immunohistochemistry in 40 cases of paired primary colorectal cancer and corresponding hepatic metastases. RESULTS Nuclear P-FAK expression was observed in 44% of studied cases. Positive nuclear P-FAK expression was associated with shorter disease-specific survival in univariate (p=0.005) and multivariate analysis (p=0.016). P-FAK expression was greater in metastases than the primary tumours (p<0.001) and showed significant association with nuclear TNS4 (p<0.001) in metastases. CONCLUSION P-FAK expression is an independent prognostic marker in CRC. The present data suggest that the FAK signalling pathway may interact with TNS4, a known oncogene in CRC.
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Affiliation(s)
- Abdulkader Albasri
- Division of Pathology, School of Molecular Medical Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, U.K. Division of Pathology, Faculty of Medicine, University of Tibah, Medina, Saudi Arabia
| | - Wakkas Fadhil
- Division of Pathology, School of Molecular Medical Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, U.K
| | - John H Scholefield
- Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre NIHR Biomedical Research Unit, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, U.K
| | - Lindy G Durrant
- Academic Department of Clinical Oncology, School of Molecular Medical Sciences, City Hospital Campus, University of Nottingham, Nottingham, U.K
| | - Mohammad Ilyas
- Division of Pathology, School of Molecular Medical Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, U.K.
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Rayment SJ, Simpson JAD, Eames T, Acheson AG, Dashwood MR, Henry Y, Gruss H, Scholefield JH, Wilson VG. Dual effects of α2 -adrenoceptors in modulating myogenic tone in sheep isolated internal anal sphincter. Neurogastroenterol Motil 2014; 26:1095-103. [PMID: 24906134 DOI: 10.1111/nmo.12363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 04/17/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND The role of α-adrenoceptors in promoting continence through modulation of sphincter tone has focused primarily on the effects of α1 -adrenoceptors. We have used three clinically available agents, which are selective for α2 -adrenoceptors, to investigate their role in contractile and neurogenic responses on the internal anal sphincter (IAS). METHODS IAS strips, which had spontaneously generated tone, were used to investigate the contractile effect of lofexidine, brimonidine, and dexmedetomidine on muscle tone in the presence or absence of subtype selective antagonists. The effect of brimonidine on the magnitude and time course of neurogenic responses generated by electrical field stimulation (EFS) was also examined. The affinity of test compounds at α1 - and α2 -adrenoceptors was established by competition binding with [3H]-prazosin and [3H]-RX821002. KEY RESULTS All agonists caused concentration-dependent contraction of the IAS and lofexidine demonstrated an enantiomeric difference in potency with a 10-fold difference between the (-) and (+) isomers. Responses to lofexidine and dexmedetomidine were inhibited in the presence of the α1 -adrenoceptor selective antagonist prazosin, but not in the presence of RX811059 (α2 -adrenoceptor selective antagonist); brimonidine responses were inhibited by RX811059 and, to a lesser extent, by prazosin. Brimonidine affected both magnitude and duration of neurogenic responses, which was reversed in the presence of RX811059. CONCLUSIONS & INFERENCES We conclude that α2 -adrenoceptors can mediate contraction of IAS, although this effect is most evident with efficacious imidazoline agonists rather than the most selective ligand. In addition, this receptor subtype can directly inhibit noradrenergic contractile responses to EFS and, indirectly, enhance nitrergic relaxatory responses.
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Affiliation(s)
- S J Rayment
- Division of GI Surgery, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
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Siproudhis L, Jones D, Shing RNK, Walker D, Scholefield JH. Libertas: rationale and study design of a multicentre, Phase II, double-blind, randomised, placebo-controlled investigation to evaluate the efficacy, safety and tolerability of locally applied NRL001 in patients with faecal incontinence. Colorectal Dis 2014; 16 Suppl 1:59-66. [PMID: 24499497 DOI: 10.1111/codi.12546] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 12/29/2013] [Indexed: 12/27/2022]
Abstract
AIMS Faecal incontinence affects up to 8% of adults. Associated social isolation and subsequent depression can have devastating effects on quality of life (QoL). Faecal incontinence is an underreported health problem as the social isolation and stigma that patients experience makes it difficult for sufferers to discuss their condition with a physician. There have been few well-designed, placebo-controlled clinical trials of treatment for faecal incontinence and little clinical evidence is available to inform the most appropriate management strategies. Libertas, a robustly designed study will investigate the efficacy and safety of NRL001 (1R,2S-methoxamine), an α1 -adrenoceptor agonist, in the treatment of faecal incontinence. METHODS Libertas is a multicentre, Phase II, double-blind, randomised, placebo-controlled, parallel group study. Patient recruitment took place across 55 study centres in Europe. Patients suffering with faecal incontinence were randomised into four groups (approximately 110 each) to receive once daily self-administered doses of NRL001 (5, 7.5 or 10 mg or placebo in a suppository formulation) for 8 weeks. The primary objective of Libertas is to assess the impact of once daily administration of NRL001 on the severity and frequency of incontinence episodes as assessed by the Wexner score at 4 weeks, compared with placebo. Secondary outcomes include measures of efficacy of NRL001 compared with placebo following 8 weeks treatment; safety and tolerability; evaluation of plasma pharmacokinetics; establishment of any pharmacokinetic/pharmacodynamic relationship to adverse events; dose-response relationship; the efficacy of NRL001 therapy at 4 and 8 weeks assessed by the Vaizey score; and QoL using the Faecal Incontinence Quality of Life and the EQ-5D-5L Healthcare Questionnaires following 4 and 8 weeks NRL001 therapy. Overall patient satisfaction with the treatment will also be evaluated. DISCUSSION This is the first randomised controlled study to investigate the efficacy and safety of a selective α1 -adrenoceptor agonist for the treatment of faecal incontinence. Furthermore, this is the first time the impact of NRL001 on assessments of QoL, health outcomes and patient satisfaction will be assessed. Innovative strategies were developed to meet the challenge of recruiting patients for this study, for example, media advertising, posters and mailshots as allowed by each study centre.
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Affiliation(s)
- L Siproudhis
- Gastroenterology Unit, CHU Pontchaillou, Rennes, France
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8
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Simpson JAD, Bush D, Gruss HJ, Jacobs A, Pediconi C, Scholefield JH. A randomised, controlled, crossover study to investigate the safety and response of 1R,2S-methoxamine hydrochloride (NRL001) on anal function in healthy volunteers. Colorectal Dis 2014; 16 Suppl 1:5-15. [PMID: 24499492 DOI: 10.1111/codi.12541] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Accepted: 12/29/2013] [Indexed: 12/12/2022]
Abstract
AIMS This study aimed to assess the dose and volume effects of suppository preparations and safety of NRL001 (one of four possible stereoisomers of methoxamine hydrochloride) on anal sphincter tone using rectal suppositories in healthy adult volunteers. METHODS This was a Phase I, single-centre, randomised, double-blind, three-way crossover study during which subjects received three single doses of 1 g rectal suppositories (containing 5 or 10 mg NRL001 or matching placebo) or 2 g rectal suppositories (containing 10 or 15 mg NRL001 or matching placebo) on three separate dosing days. The outcome measures were mean anal resting pressure (MARP) variables (monitored continuously for 20-30 min before and up to 6 h after dosing), pharmacokinetics (PK) and safety assessments. RESULTS Twenty-six subjects were dosed with study medication. Two subjects were withdrawn prematurely and were not included in the main analysis. There was a dose-dependent increase in anal sphincter tone (MARP) when comparing the 5 and 10 mg doses of NRL001; however, the 15 mg dose did not have a significantly greater effect than the 10 mg dose. Suppository size (1 or 2 g) did not appear to have an effect on sphincter tone. There was no evidence against dose proportionality for the PK variables, but the mean maximum plasma concentration (Cmax ) for the 1 g suppository group was higher than for the 2 g group. Twenty-one adverse events were reported in 8 (30.8%) subjects. A dose dependent decrease in heart rate was noted; however, there were no adverse events reported that were related to this reduction in heart rate. CONCLUSIONS The increase in anal sphincter tone supports the potential therapeutic use of NRL001 in treating faecal incontinence, with further studies in patients required. NRL001 was well tolerated in single doses of up to 15 mg.
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Affiliation(s)
- J A D Simpson
- Division of Surgery, University of Nottingham, Nottingham, UK
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Affiliation(s)
- John H Scholefield
- Division of Surgery, Queen's Medical Centre, University Hospital Nottingham, Nottingham, UK
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Scholefield JH. Surgery for Anal Cancer. Colorectal Cancer 2014. [DOI: 10.1002/9781118337929.ch9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Maitra RK, Acheson AG, Gornall C, Scholefield JH, Williams JP, Maxwell-Armstrong CA. Results of laparoscopic colorectal surgery from a national training center. Asian J Surg 2014; 37:1-7. [DOI: 10.1016/j.asjsur.2013.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 01/24/2013] [Accepted: 07/09/2013] [Indexed: 02/07/2023] Open
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Abstract
Frameworks are in place to facilitate surgical trials
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Affiliation(s)
- J H Scholefield
- Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Biomedical Research Unit, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - D N Lobo
- Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Biomedical Research Unit, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, NG7 2UH, UK
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Abstract
BACKGROUND Three large randomised trials have shown that screening for colorectal cancer (CRC) using the faecal occult blood test (FOBt) can reduce the mortality from this disease. The largest of these trials, conducted in Nottingham since 1981, randomised 152,850 individuals between the ages of 45 and 74 years to an intervention arm receiving biennial Haemoccult (FOB) test kit or to a control arm. In 2006, the National Bowel Cancer Screening Programme was launched in England using the FOBt, with the expectation that it will reduce CRC mortality. AIMS To compare the CRC mortality and incidence in the intervention arm with the control arm after long-term follow-up. METHODS The 152,850 randomised individuals were followed up through local health records and central flagging (Office for National Statistics). RESULTS At a median follow-up of 19.5 years there was a 13% reduction in CRC mortality (95% CI 3% to 22%) in the intervention arm despite an uptake at first invitation of approximately 57%. The CRC mortality reduction in those accepting the first screening test, adjusted for the rate of non-compliers, was 18%. There was no significant difference in mortality from causes other than CRC between the intervention and control arms. Despite removing 615 adenomas >10 mm in size from the intervention arm, there was no significant difference in CRC incidence between the two arms. CONCLUSIONS Although the reduction in CRC mortality was sustained, further follow-up of the screened population has not shown a significant reduction in the CRC incidence. Moreover, despite the removal of many large adenomas there was no reduction in the incidence of invasive cancer which was independent of sex and site of the tumour.
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Affiliation(s)
- J H Scholefield
- Department of GI Surgery, University Hospital, Nottingham, UK.
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Humes DJ, Simpson J, Smith J, Sutton P, Zaitoun A, Bush D, Bennett A, Scholefield JH, Spiller RC. Visceral hypersensitivity in symptomatic diverticular disease and the role of neuropeptides and low grade inflammation. Neurogastroenterol Motil 2012; 24:318-e163. [PMID: 22276853 DOI: 10.1111/j.1365-2982.2011.01863.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Recurrent abdominal pain is reported by a third of patients with diverticulosis, particularly those with previous episodes of acute diverticulitis. The current understanding of the etiology of this pain is poor. Our aim was to assess visceral sensitivity in patients with diverticular disease and its association with markers of previous inflammation and neuropeptides. METHODS Patients with asymptomatic and symptomatic diverticular disease underwent a flexible sigmoidoscopy and biopsy followed 5-10 days later by visceral sensitivity testing with barostat-mediated rectal distension. Inflammation was assessed by staining of serotonin (5HT) and CD3 positive cells. mRNA levels of tumor necrosis factor alpha (TNF α) and interleukin-6 (IL-6) were quantitated using RT-PCR. Neuropeptide expression was assessed from percentage area staining with substance P (SP) and mRNA levels of the neurokinin 1 & 2 receptors (NK1 & NK2), and galanin 1 receptor (GALR1). KEY RESULTS Thirteen asymptomatic and 12 symptomatic patients were recruited. The symptomatic patients had a lower first reported threshold to pain (28.4 mmHg i.q.r 25.0-36.0) than the asymptomatic patients (47 mmHg i.q.r 36.0-52.5, P < 0.001). Symptomatic patients had a higher median overall pain rating for the stimuli than the asymptomatic patients (P < 0.02). Symptomatic patients had greater median relative expression of NK1 and TNF alpha mRNA compared with asymptomatic patients. There was a significant correlation between barostat VAS pain scores and NK 1 expression (Figure 4, r(2) 0.54, P < 0.02). CONCLUSIONS & INFERENCES Patients with symptomatic diverticular disease exhibit visceral hypersensitivity, and this may be mediated by ongoing low grade inflammation and upregulation of tachykinins.
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Affiliation(s)
- D J Humes
- Nottingham Digestive Disease Centre and Biomedical Research Unit, Nottingham University Hospital NHS Trust, Nottingham, UK.
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Affiliation(s)
- J A D Simpson
- Division of Gastrointestinal Surgery, Queens Medical Centre Campus, Nottingham University Hospital, Nottingham NG7 2UH, UK.
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Lohsiriwat V, Scholefield JH, Dashwood MR, Wilson VG. Pharmacological characteristics of endothelin receptors on sheep rectal blood vessels. Pharmacol Res 2011; 63:490-5. [PMID: 21382493 DOI: 10.1016/j.phrs.2011.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Revised: 02/25/2011] [Accepted: 02/27/2011] [Indexed: 12/23/2022]
Abstract
Haemorrhoids is associated with high blood flow of the anorectal region. The question of whether pharmacological manipulation of vascular supply can relieve the symptoms of haemorrhoids has been raised. In order to undertake this type of clinical investigation, it is first essential to gain a better understanding of the properties of vascular receptors that may regulate blood flow into anal cushions and haemorrhoids. Due to the limited availability of human anorectal specimens and the good reliability of sheep tissue as an experimental model of human anorectal diseases, we studied the properties of endothelin receptors in sheep rectal artery (SRA) and vein (SRV), the vessels contributing to the blood flow of haemorrhoidal plexus, using isometric tension recordings. We found that endothelin-1 and sarafotoxin 6a were very potent constrictor agents in both SRA and SRV. The selective ET(A) receptor antagonist PD156707 (100 nM) produced a parallel rightward displacement of ET-1-induced contractions in both vessels and abolished sarafotoxin 6a-induced contractions in the SRA. PD156707 (3 μM) practically abolished contractions to ET-1 in the SRA, suggesting that the response is entirely mediated by ET(A) receptors. While, the selective ET(B) receptor antagonist BQ788 (100 nM) caused no significant change in ET-1-induced contractions in both vessels, a minor role for ET(B) receptor subtype to responses to sarafotoxin 6a in the artery was suggested.
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Affiliation(s)
- Varut Lohsiriwat
- Division of Gastrointestinal Surgery, Queen's Medical Centre, University of Nottingham, UK.
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Affiliation(s)
- J H Scholefield
- University of Nottingham, Nottingham University Hospitals NHS Trust, Nottingham, UK.
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Affiliation(s)
- J H Scholefield
- University of Nottingham, Nottingham University Hospitals NHS Trust, Nottingham, UK.
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Abstract
Change is an everyday occurrence in the modern NHS and many new initiatives apparently conspire to make the surgeon's life ever more difficult. Many surgeons wish to take part in clinical research but either do not know how to get involved or lack support. This article describes recent developments that promise to make the participation of surgeons in clinical research easier.
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Affiliation(s)
- JH Scholefield
- Professor of Surgery, Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre National Institute for Health Research Biomedical Research Unit, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham
| | - DN Lobo
- Reader in Gastrointestinal Surgery, Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre National Institute for Health Research Biomedical Research Unit, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham
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Rayment SJ, Eames T, Simpson JAD, Dashwood MR, Henry Y, Gruss H, Acheson AG, Scholefield JH, Wilson VG. Investigation of the distribution and function of alpha-adrenoceptors in the sheep isolated internal anal sphincter. Br J Pharmacol 2010; 160:1727-40. [PMID: 20649575 DOI: 10.1111/j.1476-5381.2010.00842.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE We have investigated the distribution of alpha-adrenoceptors in sheep internal anal sphincter (IAS), as a model for the human tissue, and evaluated various imidazoline derivatives for potential treatment of faecal incontinence. EXPERIMENTAL APPROACH Saturation and competition binding with (3)H-prazosin and (3)H-RX821002 were used to confirm the presence and density of alpha-adrenoceptors in sheep IAS, and the affinity of imidazoline compounds at these receptors. A combination of in vitro receptor autoradiography and immunohistochemistry was used to investigate the regional distribution of binding sites. Contractile activity of imidazoline-based compounds on sheep IAS was assessed by isometric tension recording. KEY RESULTS Saturation binding confirmed the presence of both alpha(1)- and alpha(2)-adrenoceptors, and subsequent characterization with sub-type-selective agents, identified them as alpha(1A)- and alpha(2D)-adrenoceptor sub-types. Autoradiographic studies with (3)H-prazosin showed a positive association of alpha(1)-adrenoceptors with immunohistochemically identified smooth muscle fibres. Anti-alpha(1)-adrenoceptor immunohistochemistry revealed similar distributions of the receptor in sheep and human IAS. The imidazoline compounds caused concentration-dependent contractions of the anal sphincter, but the maximum responses were less than those elicited by l-erythro-methoxamine, a standard non-imidazoline alpha(1)-adrenoceptor agonist. Prazosin (selective alpha(1)-adrenoceptor antagonist) significantly reduced the magnitude of contraction to l-erythro-methoxamine at the highest concentration used. Both prazosin and RX811059 (a selective alpha(2)-adrenoceptor antagonist) reduced the potency (pEC(50)) of clonidine. CONCLUSIONS AND IMPLICATIONS This study shows that both alpha(1)- and alpha(2)-adrenoceptors are expressed in the sheep IAS, and contribute (perhaps synergistically) to contractions elicited by various imidazoline derivatives. These agents may prove useful in the treatment of faecal incontinence.
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Affiliation(s)
- S J Rayment
- Centre for Integrated Systems Biology and Medicine, Department of Surgery, The University of Nottingham Medical School, Queen's Medical Centre, Clifton Boulevard, Nottingham, UK
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Whynes DK, Mangham CM, Balfour TW, Scholefield JH. Analysis of deaths occurring within the Nottingham trial of faecal occult blood screening for colorectal cancer. Gut 2010; 59:1088-93. [PMID: 20639252 DOI: 10.1136/gut.2009.192971] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
OBJECTIVE To report the causes of, and ages at, death of subjects in an English colorectal cancer screening trial. DESIGN AND SETTING Analysis of 78 708 deaths occurring between 1981 and 2008, within the Nottingham randomised controlled trial of biennial faecal occult blood testing. MAIN OUTCOME MEASURES Cause of death, age at death by sex and by cause. RESULTS Significantly more subjects died from verified colorectal cancer in the trial's control group than in the intervention group (3.2% vs 2.9%). For no other major cause of death was the difference in proportion across the two groups statistically significant. Age at death was lower for cancer than for other principal causes, except for ischaemic heart disease among women. However, mean age at death was higher for colorectal cancer than for other cancers, except for prostate cancer among men. Increasing levels of material deprivation significantly lowered the expected ages at death, independently of cause. For both men and women, the mean age at death from all causes for screening participants was higher than that of controls and non-participants. Mean deprivation was lowest among participants. Of those participating in screening, and dying from colorectal cancer, subjects receiving negative test results lived significantly longer than those who received positive test results. However, if dying from other causes, they died at an earlier age. CONCLUSIONS The age at death from colorectal cancer is higher than that of most other cancers. Those accepting a screening invitation live longer than non-participants. In part, this difference is explained by relative deprivation. Among screening participants, the receipt of a positive, as opposed to a negative, test result is associated with a later age at death.
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Affiliation(s)
- D K Whynes
- School of Economics, University of Nottingham, Nottingham NG7 2RD, UK.
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Simpson JAD, Al-Attar A, Watson NFS, Scholefield JH, Ilyas M, Durrant LG. Intratumoral T cell infiltration, MHC class I and STAT1 as biomarkers of good prognosis in colorectal cancer. Gut 2010; 59:926-33. [PMID: 20581241 DOI: 10.1136/gut.2009.194472] [Citation(s) in RCA: 124] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate immunosurveillance/editing in colorectal cancer. DESIGN Transformation stimulates the production of interferon gamma (IFNgamma) which signals via the IFNgamma receptor (IFNGR1) on tumours. This results in stimulation of nuclear STAT1 (nSTAT1), inhibition of tumour growth and upregulation of major histocompatibility complex (MHC) while promoting T cell extravasation. In contrast, downregulation of MHC class I by allele loss results in loss of T cell recognition. A tissue microarray of 462 colorectal tumours with mean follow-up of 42 months (range 1-116) was stained by immunohistochemistry for markers which predict immunosurveillance/editing. RESULTS The presence of a high level of intratumoral T cells (ITTC) correlated with improved survival compared with a low level of ITTC, with a mean difference in survival of 16.3 months (p=0.006). There was a direct correlation between nSTAT1 expression and ITTC (p<0.001). Patients whose tumours had a high level of ITTC and nSTAT1 survived 20 months longer than those whose tumours had a low level of ITTC and no nSTAT1. A strong correlation was seen between ITTC and MHC class I expression (p=0.0002). A mean survival advantage of 26.1 months was seen in patients whose tumours had strong MHC I expression and high levels of ITTC over those who had weak MHC I and low levels of ITTC (log-rank test=12.023, p=0.034). Both MHC I and ITTC are independent predictors of good survival. CONCLUSIONS ITTC, nSTAT1 and strong MHC class I expression on tumours identify patients with improved survival and an intact tumour immune system that may benefit from immunotherapy. Conversely, loss of these markers identifies patients whose tumours have escaped immunosurveillance and are unlikely to benefit from immunotherapy.
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Affiliation(s)
- Jonathan A D Simpson
- Academic Department of Clinical Oncology, Institute of Immunology, Infections and Immunity, University of Nottingham, City Hospital Campus, Nottingham, UK.
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Cairns SR, Scholefield JH, Steele RJ, Dunlop MG, Thomas HJW, Evans GD, Eaden JA, Rutter MD, Atkin WP, Saunders BP, Lucassen A, Jenkins P, Fairclough PD, Woodhouse CRJ. Guidelines for colorectal cancer screening and surveillance in moderate and high risk groups (update from 2002). Gut 2010; 59:666-89. [PMID: 20427401 DOI: 10.1136/gut.2009.179804] [Citation(s) in RCA: 769] [Impact Index Per Article: 54.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The British Society of Gastroenterology (BSG) and the Association of Coloproctology for Great Britain and Ireland (ACPGBI) commissioned this update of the 2002 guidance. The aim, as before, is to provide guidance on the appropriateness, method and frequency of screening for people at moderate and high risk from colorectal cancer. This guidance provides some new recommendations for those with inflammatory bowel disease and for those at moderate risk resulting from a family history of colorectal cancer. In other areas guidance is relatively unchanged, but the recent literature was reviewed and is included where appropriate.
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Affiliation(s)
- Stuart R Cairns
- Digestive Diseases Centre, Brighton and Sussex University Hospitals, Royal Sussex County Hospital, Eastern Road, Brighton, UK.
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Ahmed MAH, Al-Attar A, Kim J, Watson NFS, Scholefield JH, Durrant LG, Ilyas M. CD24 shows early upregulation and nuclear expression but is not a prognostic marker in colorectal cancer. J Clin Pathol 2010; 62:1117-22. [PMID: 19946098 DOI: 10.1136/jcp.2009.069310] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND AIMS The putative stem cell marker CD24 is a small, heavily glycosylated, cell surface molecule which was originally associated with tumour metastasis. Recently it has been reported to be upregulated and of prognostic importance in colorectal tumours. The study aims to study the prognostic value of CD24 in a large series of colorectal cancer (CRC). METHODS CD24 protein expression was examined by immunohistochemistry. A total of 10 whole tissue sections (WTS) of adenoma and 345 CRCs arranged as tissue microarrays (TMAs) were evaluated. For comparison with non-neoplastic tissue, 10 WTS containing tumour with associated non-neoplastic tissue were also studied. RESULTS None of the samples of normal tissue (adjacent to tumour) showed CD24 expression. In the tumours, CD24 expression was seen on the luminal surface of the cells, within the cytoplasm and, unexpectedly, also within the nucleus. Positive immunostaining was seen in 9/10 (90%) adenomas and 313/345 (91%) of CRCs. Weak statistical associations were found between CD24 expression and some clinicopathological features. In contrast to other published studies, however, the analysis did not show any association between CD24 expression and poor prognosis-if anything it was found that loss of CD24 expression appeared to be more related to poor outcome. CONCLUSION Upregulation of CD24 is an early and common event during the development of CRC and it may be expressed in any cellular compartment, including the nucleus. CD24 is not, however, a good prognostic marker in CRC.
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Affiliation(s)
- M A H Ahmed
- Division of Pathology, School of Molecular Medical Sciences, Queen's Medical Centre Campus, University of Nottingham, Nottingham NG7 2UH, UK
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Simpson J, Sundler F, Humes DJ, Jenkins D, Scholefield JH, Spiller RC. Post inflammatory damage to the enteric nervous system in diverticular disease and its relationship to symptoms. Neurogastroenterol Motil 2009; 21:847-e58. [PMID: 19453515 DOI: 10.1111/j.1365-2982.2009.01308.x] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Some patients with colonic diverticula suffer recurrent abdominal pain and exhibit visceral hypersensitivity, though the mechanism is unclear. Prior diverticulitis increases the risk of being symptomatic while experimental colitis in animals increases expression of neuropeptides within the enteric nervous system (ENS) which may mediate visceral hypersensitivity. Our aim was to determine the expression of neuropeptides within the ENS in diverticulitis (study 1) and in patients with symptomatic disease (study 2). Study 1 - Nerves in colonic resection specimens with either acute diverticulitis (AD, n = 16) or chronic diverticulitis (CD, n = 16) were assessed for neuropeptide expression recording % area staining with protein gene product (PGP9.5), substance P (SP), neuropeptide K (NPK), pituitary adenylate cyclase activating polypeptide (PACAP), vasoactive intestinal polypeptide (VIP) and galanin. Study 2 - Seventeen symptomatic and 15 asymptomatic patients with colonic diverticula underwent flexible sigmoidoscopy and multiple peridiverticular mucosal biopsies. Study 1- Neural tissue, as assessed by PGP staining was increased to a similar degree in circular muscle in both AD and CD. The CD specimens showed significant increases in the immunoreactivity of SP, NPK and galanin in both mucosal and circular muscle layer compared with controls. Study 2 - Mucosal histology was normal and PGP9.5 staining was similar between groups however patients with symptomatic diverticular disease demonstrated significantly higher levels of SP, NPK, VIP, PACAP and galanin within the mucosal plexus. Patients with symptomatic diverticular disease exhibit increased neuropeptides in mucosal biopsies which may reflect resolved prior inflammation, as it parallels the changes seen in acute and chronic diverticulitis.
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Affiliation(s)
- J Simpson
- Department of General Surgery, Wolfson Digestive Diseases Centre, University Hospital, Nottingham, UK.
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Abstract
Objective: In a hospital based setting, identify factors which influence the cost of colorectal cancer care? Design: Retrospective case note review Setting: Nottingham, United Kingdom Participants: 227 patients treated for colorectal cancer Methods: Retrospective review of the hospital records provided the primary data for the costing study and included all CRC related resource consumption over the study period. Results: Of 700 people identified, 227 (32%) sets of hospital notes were reviewed. The median age of the study group was 70.3 (IQR 11.3) years and there were 128 (56%) males. At two years, there was a significant difference in costs between Dukes D cancers (£3641) and the other stages (£3776 Dukes A; £4921 Dukes B). Using univariate and multivariate regression, the year of diagnosis, Dukes stage of disease, intensive nursing care, stoma requirements and recurrent disease all significantly affected the total cost of care. Conclusions: CRC remains costly with no significant difference in costs if diagnosed before compared to after 1992. Very early and very late stage cancers remain the least costly stage of cancers to treat. Other significant effectors of hospital costs were the site of cancer (rectal), intensive nursing care, recurrent disease and the need for a stoma.
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Affiliation(s)
- D A L Macafee
- Division of GI Surgery, Queen's Medical Centre, Nottingham
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Macafee DAL, West J, Scholefield JH, Whynes DK. Treated Colorectal Cancer: What is the Cost to Primary Care? Clin Med Oncol 2008; 3:1-7. [PMID: 20689603 PMCID: PMC2872599 DOI: 10.4137/cmo.s877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Colorectal cancer is the second commonest cause of cancer death and the cost to primary care has not been estimated. Aim: To determine the direct primary care costs of colorectal cancer care. Design: Retrospective case note review. Setting: Nottingham, United Kingdom. Methods: We identified people with colorectal cancer between 1995 and 1998, from computerised pathology records. Colorectal cancer related resources consumed in primary care, from hospital discharge to death, were identified from retrospective notes review. Outcome measures were costs incurred by the General Practitioner (GP) and the total cost to primary care. We used multiple linear regression to identify predictors of cost. Results: Of 416 people identified from pathology records, the median age at primary operation of the 135 (33%) people we selected was 74.2 (IQR 14.4) years, 75 (56%) were male. The median GP cost was: Dukes A £61.0 (IQR 516.2) and Dukes D £936.2 (1196.2) p < 0.01. The geometric mean ratio found Dukes D cancers to be 10 times as costly as Dukes A. The median total cost was: Dukes A £1038.3 (IQR 5090.6) and Dukes D £1815.2 (2092.5) p = 0.06. Using multivariate analysis, Dukes stage was the most important predictor of GP costs. For total costs, the presence of a permanent stoma was the most predictive variable, followed by adjuvant therapy and advanced Dukes stage (Dukes C and D). Conclusions: Contrary to hospital based care costs, late stage disease (Dukes D) costs substantially more to general practice than any other stage. Stoma care products are the most costly prescribable item. Costs savings may be realised in primary care by screening detection of early stage colorectal cancers.
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Affiliation(s)
- D A L Macafee
- Specialist Registrar in General Surgery, Department of Paediatric Surgery, Royal Victoria Infirmary, Newcastle upon Tyne
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Abstract
Population screening for colorectal cancer (CRC) has recently commenced in the United Kingdom supported by the evidence of a number of randomised trials and pilot studies. Certain factors are known to influence screening cost-effectiveness (e.g. compliance), but it remains unclear whether an ageing population (i.e. demographic change) might also have an effect. The aim of this study was to simulate a population-based screening setting using a Markov model and assess the effect of increasing life expectancy on CRC screening cost-effectiveness. A Markov model was constructed that aimed, using a cohort simulation, to estimate the cost-effectiveness of CRC screening in an England and Wales population for two timescales: 2003 (early cohort) and 2033 (late cohort). Four model outcomes were calculated; screened and non-screened cohorts in 2003 and 2033. The screened cohort of men and women aged 60 years were offered biennial unhydrated faecal occult blood testing until the age of 69 years. Life expectancy was assumed to increase by 2.5 years per decade. There were 407 552 fewer people entering the model in the 2033 model due to a lower birth cohort, and population screening saw 30 345 fewer CRC-related deaths over the 50 years of the model. Screening the 2033 cohort cost £96 million with cost savings of £43 million in terms of detection and treatment and £28 million in palliative care costs. After 30 years of follow-up, the cost per life year saved was £1544. An identical screening programme in an early cohort (2003) saw a cost per life year saved of £1651. Population screening for CRC is costly but enables cost savings in certain areas and a considerable reduction in mortality from CRC. This Markov simulation suggests that the cost-effectiveness of population screening for CRC in the United Kingdom may actually be improved by rising life expectancies.
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Affiliation(s)
- D A L Macafee
- Department of Surgery, Royal Victoria Infirmary, Newcastle-upon, Tyne NE1 4LP, UK.
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Simpson J, Sundler F, Humes DJ, Jenkins D, Wakelin D, Scholefield JH, Spiller RC. Prolonged elevation of galanin and tachykinin expression in mucosal and myenteric enteric nerves in trinitrobenzene sulphonic acid colitis. Neurogastroenterol Motil 2008; 20:392-406. [PMID: 18208479 DOI: 10.1111/j.1365-2982.2007.01037.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Diverticulitis causes recurrent abdominal pain associated with increased mucosal expression of mucosal galanin and substance P (SP). We studied changes in mucosal and myenteric plexus neuropeptides in adult rats using a model of colonic inflammation, trinitrobenzenesulphonic acid colitis. We assessed the effects on the pan-neuronal markers protein gene product 9.5 (PGP9.5) and neurofilament protein, as well as specific neuropeptides at 1, 2, 3, 4, 6, 8, 10 and 14 weeks. Following the acute injury there was macroscopic resolution of inflammation but minor microscopic abnormalities persisted. Percent area stained of mucosal PGP9.5 fell initially but average levels on days 21 and 28 levels were significantly elevated (P < 0.001), returning to normal by day 42. Percent area staining of PGP9.5 in the muscle rose immediately and remained significantly elevated at 70 days (P < 0.001). SP, neuropeptide K and galanin followed a similar overall pattern. SP to PGP9.5 ratio was significantly increased in the muscle both acutely (days 1-28) and in the long term (days 70 and 98), whereas the galanin to PGP9.5 ratio was significantly increased in the mucosa throughout the study. Low-grade chronic inflammation after an acute initial insult causes a persistent increase in the expression of galanin in the mucosa and SP in muscle layer.
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Affiliation(s)
- J Simpson
- Wolfson Digestive Diseases Centre, University of Nottingham, Nottingham, UK
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Abstract
OBJECTIVE Intensive follow-up post surgery for colorectal cancer (CRC) is thought to improve long-term survival principally through the earlier detection of recurrent disease. This paper aims to calculate the additional resource and cost implications of intensive follow up post-CRC resection, examine the possibility of risk-stratifying this follow up to those at highest risk of recurrence and investigating the impact that population screening might have on the future cost and outcomes of follow up. METHOD Two follow-up regimens were constructed: the 'standard' follow-up protocol used the principles of the British Society of Gastroenterology (BSG) guidelines whilst the 'intensive' follow-up protocol used the most intensive arm of the follow up after colorectal surgery (FACS) trial. Using ONS data, the number of CRC diagnosed in a given year was calculated for 2003 and projected for 2016 based on the population of England and Wales. The resource requirements and costs of follow up over a 5-year period were then calculated for the two time periods. Risk stratifying entry to follow up and the introduction of population CRC screening were then considered. RESULTS For the 2003 cohort, an intensive follow-up program would detect 853 additional resectable recurrences over 5 years with 795 fewer subjects requiring palliative care. An additional 26 302 outpatient appointments, 181 352 CEA tests and 79 695 CT scans over 5 years would be required to achieve this. The cost of investigating subjects who would never develop detectable recurrences was pound15.6 million. The cost per additional resectable recurrence was pound18 077, a figure also found for a nonscreened population in 2016. An identical intensive follow-up policy with biennial FOBT screening in 2016 saw the cost per additional resectable recurrence rise to pound36 255. CONCLUSION Intensive follow up will detect considerably more resectable recurrences but at considerable cost and it is unclear if such follow up will be achievable in an already over-stretched NHS. If population-based CRC screening increases the number of Dukes A cancers this may offer the possibility of risk-stratifying future follow up to those at highest risk of recurrence; minimizing tests on those who will never have recurrent disease and better utilizing our scarce resources.
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Affiliation(s)
- D A L Macafee
- Department of Surgery, James Cook University Hospital, Middlesborough, Cleveland, UK.
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Affiliation(s)
- Austin G Acheson
- Section of Gastrointestinal Surgery, University Hospital, Queen's Medical Centre, Nottingham NG7 2UH.
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Abstract
BACKGROUND The importance of psychological factors in symptom expression in diverticulosis is unknown. This follow-up study assessed the relative importance of colonic and psychological factors in symptom expression. METHODS Patients with barium enema-proven diverticula were sent a bowel symptom questionnaire in 1999 and again in 2006 with additional psychological questionnaires included. RESULTS Some 170 of 261 initial responders were eligible for follow-up and 124 (72.9 per cent) provided complete replies. Forty-two (33.9 per cent) of 124 respondents experienced recurrent abdominal pain a median of 3.5 (interquartile range (i.q.r.) 2.00-9.25) days per month, with a median duration of 1 (i.q.r. 0.7-2) h. Multivariable analysis identified a history of acute diverticulitis (odds ratio 3.98; P = 0.010) and a raised score on the Hospital Anxiety and Depression Scale (odds ratio 2.53; P = 0.030) as the best predictors of recurrent pain. CONCLUSION Psychological and colonic factors are important in symptom expression in diverticulosis.
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Affiliation(s)
- D J Humes
- Wolfson Digestive Diseases Centre, University of Nottingham, Nottingham, UK
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Ullenhag GJ, Mukherjee A, Watson NFS, Al-Attar AH, Scholefield JH, Durrant LG. Overexpression of FLIPL is an independent marker of poor prognosis in colorectal cancer patients. Clin Cancer Res 2007; 13:5070-5. [PMID: 17785559 DOI: 10.1158/1078-0432.ccr-06-2547] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Colorectal cancer is one of the most common cancers. The tumor necrosis factor-related apoptosis inducing ligand (TRAIL) pathway transmits apoptotic signals and anticancer agents that activate this system, which are in clinical development. We sought to determine the prognostic value of the clinically most relevant members of this pathway in colorectal cancer patients. EXPERIMENTAL DESIGN We used an arrayed panel of colorectal cancer tissue to assess the protein expression of the functional TRAIL receptors (TRAIL-R1 and TRAIL-R2) and both the long and short forms of FLICE inhibitory protein (FLIP(L) and FLIP(S)). Disease-free survival was examined by Kaplan-Meier estimates and the log-rank test. Prognostic factors were determined by Cox multivariate analysis. RESULTS The TRAIL receptors and FLIP(S) were not associated with survival. On univariate analysis, strong FLIP(L) expression was associated with a significantly higher survival (P = 0.0082). On multivariate analysis using the Cox proportional hazards model, FLIP(L) phenotype was significantly associated with a poor prognosis in this series (hazard ratio, 2.04; 95% confidence interval, 1.18-3.56; P = 0.011). CONCLUSIONS Overexpression of FLIP(L), but not TRAIL-R1 or TRAIL-R2, provides stage-independent prognostic information in colorectal cancer patients. This may indicate a clinically more aggressive phenotype and a subset of patients for whom more extensive adjuvant treatment would be appropriate.
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Affiliation(s)
- Gustave J Ullenhag
- Section of Gastrointestinal Surgery, University Hospital Nottingham, United Kingdom
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Nisar PJ, Gruss HJ, Bush D, Acheson AG, Scholefield JH. Intra-anal application of l-erythro methoxamine gel increases anal resting pressure in patients with incontinence. Br J Surg 2007; 94:1155-61. [PMID: 17542041 DOI: 10.1002/bjs.5821] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background
This study examined the effects of a single dose of intra-anal l-erythro methoxamine on mean anal resting pressure (MARP) and cardiovascular variables in patients with faecal incontinence.
Methods
Patients had anorectal physiology tests and ultrasonography before participating. Six patients received 0·3 and 1 per cent gels on separate days, two patients received 0·3 per cent gel, and two patients received 1 per cent gel. MARP, blood pressure, pulse rate and plasma drug concentrations were measured for 6 h after application.
Results
Intra-anal 0·3 per cent gel caused a rapid, significant rise in MARP lasting 2 h (P = 0·036). In four of these patients, the response was sufficient to increase MARP to within the normal range at 2 h. Application of 1 per cent gel caused a significant rise in MARP for 4 h after application (P = 0·028). There was a significant decrease in pulse at 2 and 1 h respectively after application of 0·3 and 1 per cent gels.
Conclusion
Intra-anal application of l-erythro methoxamine can be used to increase MARP in patients with faecal incontinence. Application of 1 per cent l-erythro methoxamine gel produced a rapid, sustained rise in MARP, which raises the possibility of therapeutic application.
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Affiliation(s)
- P J Nisar
- Section of Surgery, University Hospital, Queen's Medical Centre, Nottingham, UK.
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Watson NFS, Spendlove I, Madjd Z, McGilvray R, Green AR, Ellis IO, Scholefield JH, Durrant LG. Expression of the stress-related MHC class I chain-related protein MICA is an indicator of good prognosis in colorectal cancer patients. Int J Cancer 2007; 118:1445-52. [PMID: 16184547 DOI: 10.1002/ijc.21510] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The realization of targeted cancer therapy has driven the need to improve selection of patients with colorectal cancer for adjuvant therapy, leading to a search for potential new prognostic markers. There is accumulating evidence that immunosurveillance acts as an extrinsic tumor suppressor. As genetic instability is an early event in colorectal cancer, this can lead to altered expression of molecules conferring resistance to immune attack. Hence, molecules up or downregulated in this process may impact on patient survival. In our study, 449 colorectal tumors were screened for expression of the stress-related protein MICA, which functions as a ligand for the NKG2D receptor and whose expression confers susceptibility to both T- and NK-cell attack. Intensity of MICA expression was quantified using automated image analysis and MICA expression showed no correlation with conventional clinicopathological variables. In contrast, survival analysis showed a significant correlation between higher levels of MICA expression and improved disease-specific survival, with independent prognostic significance in multivariate analysis. Thus, patients with low levels of MICA and a poor prognosis may be good candidates for aggressive chemotherapy. In contrast, patients with high expression of MICA may be candidates for the antibody therapies, as they should be susceptible to NK killing by antibody dependent cellular cytotoxicity.
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Affiliation(s)
- Nicholas F S Watson
- Academic Department of Clinical Oncology, University of Nottingham, City Hospital, Nottingham, United Kingdom.
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Duncan TJ, Watson NFS, Al-Attar AH, Scholefield JH, Durrant LG. The role of MUC1 and MUC3 in the biology and prognosis of colorectal cancer. World J Surg Oncol 2007; 5:31. [PMID: 17349047 PMCID: PMC1828734 DOI: 10.1186/1477-7819-5-31] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2006] [Accepted: 03/09/2007] [Indexed: 12/18/2022] Open
Abstract
Background MUC1 and MUC3 are from a large family of glycoproteins with an aberrant expression profile in various malignancies. Much interest has been focused on the role of these proteins in the development and progression of colorectal cancer; however, no previous studies have included the highly confounding variable of vascular invasion in their survival analysis. Using high throughput tissue microarray technology we assessed the prognostic value of MUC1 and MUC3 expression in the largest cohort of colorectal cancer patients to date. We propose that tumours lacking expression of MUC1 and MUC3 will be more likely to metastasise, due to previously observed loss of cell-cell adhesion, and this will therefore lead to more aggressive cancers with poorer prognosis. Methods A tissue micro-array was prepared from tumour samples of 462 consecutive patients undergoing resection of a primary colorectal cancer. A comprehensive prospectively recorded data base with mean follow up of 75 months was collected and included common clinicopathological variables and disease specific survival. Immunohistochemical analysis of MUC1 and MUC3 expression was performed using antibodies NCL-MUC1 and 1143/B7 respectively, results were correlated with the variables within the database. Results Positive expression of MUC1 and MUC3 was seen in 32% and 74% of tumours respectively. On univariate analysis no correlation was seen with either MUC1 or MUC3 and any of the clinicopathological variables including tumour grade and stage, vascular invasion and tumour type. Kaplan-Meier analysis demonstrated a significant reduction in disease specific survival with MUC1 positive tumours (p = 0.038), this was not seen with MUC3 (p = 0.552). On multivariate analysis, using Cox proportional hazards model, MUC1 expression was shown to be an independent marker of prognosis (HR 1.339, 95%CI 1.002–1.790, p = 0.048). Conclusion MUC1 expression in colorectal cancer is an independent marker of poor prognosis, even when vascular invasion is included in the analysis. These results support previous studies suggesting a role for MUC1 in colorectal cancer development possibly through its effects on cell adhesion.
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Affiliation(s)
- Timothy J Duncan
- Academic Department of Clinical Oncology, Institute of Immunology, Infections and Immunity, University of Nottingham, City Hospital, Nottingham, UK
| | - Nicholas FS Watson
- Academic Department of Clinical Oncology, Institute of Immunology, Infections and Immunity, University of Nottingham, City Hospital, Nottingham, UK
- Section of Gastrointestinal Surgery, Queen's Medical Centre, Nottingham, UK
| | - Ahmad H Al-Attar
- Academic Department of Clinical Oncology, Institute of Immunology, Infections and Immunity, University of Nottingham, City Hospital, Nottingham, UK
| | - John H Scholefield
- Section of Gastrointestinal Surgery, Queen's Medical Centre, Nottingham, UK
| | - Lindy G Durrant
- Academic Department of Clinical Oncology, Institute of Immunology, Infections and Immunity, University of Nottingham, City Hospital, Nottingham, UK
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Ullenhag GJ, Spendlove I, Watson NFS, Indar AA, Dube M, Robins RA, Maxwell-Armstrong C, Scholefield JH, Durrant LG. A Neoadjuvant/Adjuvant Randomized Trial of Colorectal Cancer Patients Vaccinated with an Anti-Idiotypic Antibody, 105AD7, Mimicking CD55. Clin Cancer Res 2006; 12:7389-96. [PMID: 17121873 DOI: 10.1158/1078-0432.ccr-06-1003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To assess the tolerability and effectiveness of 105AD7 vaccination in colorectal cancer patients. 105AD7 is a human anti-idiotypic antibody mimicking CD55, a glycoprotein, which is more than expressed on colorectal cancer cells and protects them from attack by complement. EXPERIMENTAL DESIGN Colorectal cancer patients (n = 67) eligible for primary surgery were randomized to receive the anti-idiotypic antibody 105AD7+/-Bacillus Calmette-Guerin/alum or to no treatment (control group). The immunizations were given i.d./i.m. before surgery and continued for a period of 2 years. The patients were monitored in enzyme-linked immunospot (ELISPOT; gamma-IFN), proliferation assay, and Luminex cytokine assays. RESULTS No serious adverse events were recorded. Of the 32 investigated immunized patients, 14 (44%) were considered to be responders in the ELISPOT assay. Induced proliferative responses were noted in 17 of 40 (43%) monitored patients. There was no correlation between the ELISPOT and proliferation assays. Luminex analyses revealed tumor necrosis factor-alpha and granulocyte macrophage colony-stimulating factor responses not only to the vaccine but also toward the native antigen CD55 in 9 of 13 (69%) patients. CONCLUSIONS Immune responses to vaccination were induced in a majority of monitored patients measured by ELISPOT and proliferation assay. The lack of correlation between the ELISPOT and proliferation assays may reflect the fact that the two methods measure different T-cell responses and highlights the importance of multiple readouts in evaluating a potential cancer vaccine. Responses to both the anti-idiotype and the CD55 antigen were measurable, adding support to the use of CD55 as a target in cancer treatment.
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Affiliation(s)
- Gustav J Ullenhag
- Academic Department of Clinical Oncology, Nottingham City Hospital, Nottingham, United Kingdom
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Watson NFS, Durrant LG, Scholefield JH, Madjd Z, Scrimgeour D, Spendlove I, Ellis IO, Patel PM. Cytoplasmic expression of p27 kip1 is associated with a favourable prognosis in colorectal cancer patients. World J Gastroenterol 2006; 12:6299-304. [PMID: 17072952 PMCID: PMC4088137 DOI: 10.3748/wjg.v12.i39.6299] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the prognostic significance of p27kip1 in colorectal cancer patients.
METHODS: Cytoplasmic and nuclear p27kip1 expression was evaluated in 418 colorectal cancers using tissue microarrays. Data were associated with known patient and tumor variables and long-term patient outcomes, providing further insight into the mechanisms by which p27kip1 may influence tumor development.
RESULTS: Nuclear and cytoplasmic p27Kip1 expressions were detected in 59% and 19% of tumors respectively. Cytoplasmic p27Kip1 was almost invariably associated with positive nuclear p27Kip1 expression. Neither case correlated with known clinical or pathological variables, including tumor stage, grade or extramural vascular invasion. Furthermore, nuclear p27kip1 expression had no impact on survival. However, we identified a significant correlation between expression of cytoplasmic p27kip1 and longer disease-specific survival times. On multivariate analysis, TNM stage and extramural vascular invasion were highly significant independent prognostic factors, with positive cytoplasmic p27 expression showing a trend towards improved patient survival (P = 0.059).
CONCLUSION: These findings support the recent evidence that cytoplasmic p27kip1 has a distinct and important biological role that can influence tumor outcome.
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Affiliation(s)
- Nicholas F S Watson
- Section of Gastrointestinal Surgery, University of Nottingham, E Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH, United Kingdom.
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Watson NFS, Durrant LG, Madjd Z, Ellis IO, Scholefield JH, Spendlove I. Expression of the membrane complement regulatory protein CD59 (protectin) is associated with reduced survival in colorectal cancer patients. Cancer Immunol Immunother 2006; 55:973-80. [PMID: 16151805 PMCID: PMC11030621 DOI: 10.1007/s00262-005-0055-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2005] [Accepted: 07/20/2005] [Indexed: 10/25/2022]
Abstract
It has been known for some time that the immune system can recognise growing tumours, and that tumours may respond by modulation of molecules, which make them resistant to further attack. Expression, over-expression, or loss of these molecules may function as markers of tumour progression and prognosis. Among such molecules are the membrane-bound complement regulatory proteins (mCRP), which protect cells from bystander attack by autologous complement. These include CD59 (protectin), which prevents formation of the MAC complex in the terminal stages of complement activation. In the present study, we evaluated immunohistochemical expression of CD59 in a series of over 460 well-characterised colorectal cancers using tissue microarrays (TMA), and related this information to known tumour and patient variables and to survival. The CD59 expression was observed in 69 (15%) of cases overall, and was significantly associated with tumour grade. In contrast, no associations were noted with tumour site, stage or histological type. On survival analysis, a further correlation was observed between expression of CD59 by the colorectal tumours and a reduction in disease-specific patient survival. This observation was strongest for patients with early stage disease. However, a negative impact on survival was also seen in those patients with late stage disease. These results indicate that TMA linked to good clinicopathological databases with good long term follow up are useful tools for determining new prognostic indicators that can be used in future patient management. Immune surveillance may result in immune-editing that induces variable expression of a range of target antigens, and these may be useful prognostic markers. This study has identified CD59 expression as a marker of poor prognosis in colorectal cancer patients.
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Affiliation(s)
- Nicholas F. S. Watson
- Academic Department of Clinical Oncology, City Hospital, University of Nottingham, Hucknall Road, Nottingham NG5 1PB , UK
- Section of Gastrointestinal Surgery, Queen’s Medical Centre, University Hospital, Derby Road, Nottingham NG7 2UH , UK
| | - Lindy G. Durrant
- Academic Department of Clinical Oncology, City Hospital, University of Nottingham, Hucknall Road, Nottingham NG5 1PB , UK
| | - Zahra Madjd
- Academic Department of Clinical Oncology, City Hospital, University of Nottingham, Hucknall Road, Nottingham NG5 1PB , UK
| | - Ian O. Ellis
- Department of Histopathology, Nottingham City Hospital, Nottingham , UK
| | - John H. Scholefield
- Section of Gastrointestinal Surgery, Queen’s Medical Centre, University Hospital, Derby Road, Nottingham NG7 2UH , UK
| | - Ian Spendlove
- Academic Department of Clinical Oncology, City Hospital, University of Nottingham, Hucknall Road, Nottingham NG5 1PB , UK
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Watson NFS, Ramage JM, Madjd Z, Spendlove I, Ellis IO, Scholefield JH, Durrant LG. Immunosurveillance is active in colorectal cancer as downregulation but not complete loss of MHC class I expression correlates with a poor prognosis. Int J Cancer 2005; 118:6-10. [PMID: 16003753 DOI: 10.1002/ijc.21303] [Citation(s) in RCA: 175] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Many colorectal tumors lose or downregulate cell surface expression of MHC class I molecules conferring resistance to T-cell-mediated attack. It has been suggested that this phenomenon is due to in vivo immune-tumor interactions. However, evidence of the impact of MHC class I loss on outcomes from colorectal cancer is scarce. In our study of more than 450 colorectal cancers in tissue microarray format, we have shown that both high levels of MHC class I expression and absent MHC class I expression are associated with similar disease-specific survival times, possibly due to natural killer cell-mediated clearance of MHC class I-negative tumor cells. However, tumors with low level expression of MHC class I were found to confer a significantly poorer prognosis, retaining independent significance on multivariate analysis. The existence of these poor prognosis tumors, which may avoid both NK- and T-cell-mediated immune surveillance, has important implications for the design of immunotherapeutic strategies in colorectal cancer.
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Affiliation(s)
- Nicholas F S Watson
- Academic Department of Clinical Oncology, University of Nottingham, City Hospital, Nottingham, United Kingdom
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Benson EA, Narayanan K, Rogers K, Scholefield JH, Duncan JL. Breast abscesses. Br J Surg 2005. [DOI: 10.1002/bjs.1800740942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | | | - K Rogers
- Clinical Sciences Centre, Northern General Hospital, Sheffield, UK
| | - J H Scholefield
- Clinical Sciences Centre, Northern General Hospital, Sheffield, UK
| | - J L Duncan
- Clinical Sciences Centre, Northern General Hospital, Sheffield, UK
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Scholefield JH, Duncan JL, Rogers K. Mammary duct ectasia. Br J Surg 2005. [DOI: 10.1002/bjs.1800731034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | - J L Duncan
- Northern General Hospital, Sheffield S5 7AU, UK
| | - K Rogers
- Northern General Hospital, Sheffield S5 7AU, UK
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Abstract
Chronic anal fissure is a tear in the lining of the anal canal that, if not treated appropriately at an early stage, causes considerable anal pain during defaecation. Surgery is no longer considered the first-line treatment of this common condition, as recent advancements in medical treatment has produced promising results in the healing of fissures, thus avoiding the unwanted complications that frequently occur following operative treatment. This review looks at those pharmacological agents used commonly in the treatment of chronic anal fissures and explores alternative therapies that may be of benefit in the future.
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Affiliation(s)
- Austin G Acheson
- Division of Gastrointestinal Surgery, Queen's Medical Centre, Nottingham, NG7 2UH, UK.
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Jonas-Obichere M, Scholefield JH, Acheson A, Mundey M, Tyler H, Wilson VG. Comparison of the effects of nitric oxide donors and calcium channel blockers on the intrinsic myogenic tone of sheep isolated internal anal sphincter. Br J Surg 2005; 92:1263-9. [PMID: 16044408 DOI: 10.1002/bjs.5070] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Chronic anal fissure is associated with considerable pain and anal hypertonia. Numerous clinical studies attest to the effectiveness of individual nitro-containing drugs and organic calcium channel blockers in this condition but there are few comparative studies. METHODS Isolated segments of sheep internal anal sphincter were prepared for isometric tension recording. The effect of various drugs on myogenic tone was examined in the absence or presence of sodium orthovanadate (SOV), an agent used to mimic anal hypertonia by increasing myogenic tone. RESULTS All the drugs tested produced concentration-dependent inhibition of myogenic tone, with the maximum effect ranging from 66.4 per cent (verapamil) to 100 per cent (sodium nitroprusside). Sodium nitroprusside and diltiazem were the most potent, followed by glyceryl trinitrate (GTN), nifedipine and verapamil, which had similar potency, and finally nicorandil. The potency of GTN and diltiazem was reduced threefold in the presence of 1 mmol/l SOV. The combined effect of GTN and diltiazem was greater than the effect of either agent alone, even in the presence of 3 mmol/l SOV. CONCLUSION Nitro-containing drugs and organic calcium channel blockers are potent inhibitors of anal sphincter myogenic tone that may be used in combination to treat chronic anal fissure.
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Affiliation(s)
- M Jonas-Obichere
- Centre of Integrated Systems Biology and Medicine, Department of Surgery, Queen's Medical Centre, Nottingham, UK
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Nisar PJ, Gruss HJ, Bush D, Barras N, Acheson AG, Scholefield JH. Intra-anal and rectal application of l-erythro methoxamine gel increases anal resting pressure in healthy volunteers. Br J Surg 2005; 92:1539-45. [PMID: 16231282 DOI: 10.1002/bjs.5171] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Background
This study examined the effect of a single local application of l-erythro methoxamine, an α1-adrenoceptor agonist, on mean anal resting pressure (MARP) and cardiovascular variables in healthy volunteers.
Methods
l-Erythro methoxamine gel was administered in a single-blind manner; 0·3–3 per cent gels were applied perianally (n = 12), 1–3 per cent gels intra-anally (n = 16) and 1 per cent gel rectally (n = 8). MARP, systolic blood pressure, diastolic blood pressure and pulse rate were measured before application and for up to 6 h afterwards. Blood samples were taken to estimate plasma drug levels.
Results
Perianal gel produced no increase in MARP. Intra-anal 1 per cent and 3 per cent gel produced a significant rapid rise in MARP for 4 and 5 h respectively after application (P = 0·012 and P = 0·017 respectively). Rectal 1 per cent gel increased MARP for 2 h after application (P = 0·036). Intra-anal gel resulted in an increase in systolic blood pressure (1 per cent gel at 2 h, P = 0·042; 3 per cent gel at 4 h, P = 0·017). One per cent intra-anal and rectal gels caused a decrease in the pulse rate for 2 h after application (P = 0·012 and P = 0·018 respectively). Six subjects complained of nausea and three of headache after gel application.
Conclusion
Intra-anal and rectal gel produced a sustained rise in MARP with rapid onset in volunteers. This raises the possibility of a therapeutic application for l-erythro methoxamine in patients with passive incontinence and internal anal sphincter dysfunction.
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Affiliation(s)
- P J Nisar
- Section of Surgery, University Hospital, Queen's Medical Centre, Nottingham NG7 2UH, UK.
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