Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Raman spectroscopy for cytopathology of exfoliated cervical cells

Cervical cancer is the fourth most common cancer affecting women worldwide but mortality can be decreased by early detection of pre-malignant lesions. The Pap smear test is the most commonly used method in cervical cancer screening programmes. Although specificity is high for this test, it is widely acknowledged that sensitivity can be poor mainly due to the subjective nature of the test. There is a need for new objective tests for the early detection of pre-malignant cervical lesions. Over the past two decades, Raman spectroscopy has emerged as a promising new technology for cancer screening and diagnosis. The aim of this study was to evaluate the potential of Raman spectroscopy for cervical cancer screening using both Cervical Intraepithelial Neoplasia (CIN) and Squamous Intraepithelial Lesion (SIL) classification terminology. ThinPrep® Pap samples were recruited from a cervical screening population. Raman spectra were recorded from single cell nuclei and subjected to multivariate statistical analysis. Normal and abnormal ThinPrep® samples were discriminated based on the biochemical fingerprint of the cells using Principal Component Analysis (PCA). Principal Component Analysis - Linear Discriminant Analysis (PCA-LDA) was employed to build classification models based on either CIN or SIL terminology. This study has shown that Raman spectroscopy can be successfully applied to the study of routine cervical cytology samples from a cervical screening programme and that the use of CIN terminology resulted in improved sensitivity for high grade cases.

Intra- and inter-observer reproducibility of CINtec® PLUS in ThinPrep® cytology preparations

BACKGROUND

This study evaluated the intra- and inter-observer reproducibility of the dual-stain biomarker, CINtec^® PLUS cytology in ThinPrep^® specimens, for improved specificity in the detection of cervical disease in women testing human papillomavirus (HPV) positive.

METHODS

A total of 972 cases of HPV-positive women from a triage and primary HPV screening population were selected from an ongoing study evaluating the clinical performance of CINtec^® PLUS cytology. For reproducibility analyses, three cytotechnologists rescreened sets of slides which they had previously reported themselves and which were previously reported by each of the other cytotechnologists. The original results of slides previously screened by each of the three cytotechnologists were also compared with the results of an expert reference evaluator.

RESULTS

Intra- and inter-observer agreement for paired evaluations between reviewers ranged from 82.8% to 94.9% (kappa 0.65-0.91) and 89.2% to 93% (kappa 0.83-0.88), respectively. Reproducibility analyses between the cytotechnologists and the reference evaluator revealed agreements ranging from 95.5% to 98% (kappa 0.89-0.96).

CONCLUSION

Evaluation of the dual-stain biomarker showed a high level of agreement across all evaluators suggesting that CINtec^® PLUS cytology will perform well in the hands of cytotechnologists and pathologist reviewers and could be introduced into cellular pathology laboratories that employ ThinPrep^® LBC with a minimum effort.

HPV16 and HPV18 genotyping triage in young women with borderline cytology or mild dyskaryosis: effect of age on genotype-specific risk of high-grade CIN

OBJECTIVE

Human papillomavirus (HPV) triage of borderline cytology or mild dyskaryosis is limited by the higher prevalence of HPV in women with these findings relative to those with high-grade cervical intraepithelial neoplasia (≥CIN2). This is particularly relevant in young women in whom HPV prevalence is discernible. In a previous analysis of HPV triage and colposcopy outcomes in Northern Ireland, we revealed a substantial amount of prevalent high-grade disease in women below 30 years of age. We explored the role of genotyping for HPV16/HPV18 in this population by assessing the risk of high-grade lesions associated with these genotypes and the effect of age on type-specific risk.

METHODS

Of the 866 women eligible for HPV triage, those who tested positive for HPV were referred to colposcopy. The relative risk of ≥CIN2 for HPV16, HPV18 and non-HPV16/18 high-risk genotype positivity was determined for cobas(®) HPV Test-positive results.

RESULTS

The relative risk of high-grade CIN was significantly greater in women infected with HPV16 and/or HPV18 compared with non-HPV16/18 infections, regardless of age (2.23 and 0.45, respectively). In women under 30 years of age, HPV16-associated risk of ≥CIN2 was significantly greater than that of HPV18 and the non-HPV16/18 genotypes (1.74 versus 1.03 and 0.58, respectively). In women aged ≥30 years, HPV18 infection presented the greatest risk of ≥CIN2 (3.03). The relative risk of ≥CIN2 associated with non-HPV16/18 genotypes was lower (range, 0.32-0.58) for both age groups.

CONCLUSION

This analysis demonstrates the value of genotyping for HPV16/HPV18 and age stratification to improve the specificity of HPV triage and to tailor management relative to the risk of high-grade CIN and cancer.

Effect of glacial acetic acid treatment of cervical ThinPrep specimens on HPV DNA detection with the cobas 4800 HPV test

BACKGROUND

Cytology laboratories in the UK routinely treat unsatisfactory cervical liquid-based cytology (LBC) specimens with glacial acetic acid (GAA) to reduce the unsatisfactory rate. However, there is limited published data on the effect of GAA reprocessing on the molecular detection of human papillomavirus (HPV). The aim of this study was to assess the impact of GAA treatment of cervical ThinPrep(®) samples on HPV detection with the cobas(®) 4800 HPV Test (Roche Molecular Systems, Pleasanton, CA, USA).

METHODS

Residual ThinPrep samples (n = 121) were selected to provide a range of typical cytology results and enrich the study samples for HPV positivity. Specimens were equally split into two fractions: one part treated with 10% GAA and the other part left untreated. All samples were HPV tested using the cobas 4800 HPV Test, which simultaneously detects a total of 14 high-risk HPV (hrHPV) genotypes and individually identifies HPV16 and HPV18. The HPV positive/negative status of tested samples determined the level of agreement between treated and untreated fractions; one sample failed owing to detection of a clot by the instrument during pipetting, leaving 120 samples in the study. Statistical analysis was performed using an unweighted kappa.

RESULTS

Analysis of overall HPV positivity showed 97.5% (117/120) agreement between the treated and untreated fractions with a kappa value of 0.95. There were 63/65 (96.9%) concordant HPV positive and 54/55 (98.2%) concordant HPV negative results. In addition to the three discordant results for overall HPV positivity, there were three HPV type-specific discrepancies giving a total of 114/120 concordant HPV results (95% agreement).

CONCLUSIONS

Glacial acetic acid (GAA) treatment of cervical ThinPrep specimens does not have significant adverse affects on HPV detection with the cobas 4800 HPV Test.

The untold truth about "bath salt" highs: A case series demonstrating local tissue injury

The epidemic of injecting cathinone derivatives, marketed as "bath salts", by intravenous drug users among inner city Dubliners led to an associated rise in soft tissue complications. The spectrum of the cases encountered, ranging from self-limiting cellulitis to extensive abscess formation, at a single institution is described.

Rising rates of caesarean deliveries at full cervical dilatation: a concerning trend

OBJECTIVES

To audit caesarean sections performed at full cervical dilatation over a three year period in a tertiary referral centre in Ireland. To evaluate (i) the rate of caesarean deliveries in the second stage of labour, (ii) the indication for delivery and (iii) the associated fetal and maternal morbidity in this cohort of women.

STUDY DESIGN

This cohort study was carried out in the University Hospital Galway (UHG). Medical records of 136 consecutive women with singleton cephalic pregnancies at term, identified from the hospital database, who underwent a second stage caesarean section (CS) between 1 January 2006 and 31 December 2008, were reviewed retrospectively and demographic and outcome data were collected.

RESULTS

During the study period 2801/10,202 (27.5%) babies were delivered by CS. One hundred and thirty six CS (4.8%) were performed at full dilatation. The rate of CS during the second stage increased from 0.9% in 2006 to 1.8% in 2008. The majority of women were nulliparous (76.5%) and in spontaneous labour (64%). 44.1% of women had a second stage CS without a trial of instrumental delivery. 41.3% of public deliveries were attended by a consultant. The majority of babies (54%) were delivered because of a prolonged second stage with a mean duration of 146 min from full dilatation to delivery. Twenty-four of 59 primiparous women (40.7%), who underwent CS because of a prolonged second stage, did not receive oxytocin. 13.2% of babies were admitted to the neonatal intensive care unit. Estimated blood loss was documented in 67% of cases (n=91); 14.3% of women (n=13) had a postpartum haemorrhage greater than or equal to 1000 mls. 23% of these women (n=3) required a blood transfusion. The overall blood transfusion rate was 2.2%. 50% of women had a hospital stay of greater than four days.

CONCLUSIONS

There is a worrying rise in the overall rate of CS at full dilatation. Audit of the second stage CS rate is a useful measure of clinical standards. Strategies for improved care include increased consultant presence, meticulous documentation and ongoing training of junior obstetric staff to ensure safe intrapartum care.

CONDENSATION

The increase of second stage caesarean sections requires urgent strategies for improved care including increased consultant presence, meticulous documentation and training of junior obstetric staff.

Increased cholecystectomy rate in the laparoscopic era: a study of the potential causative factors

BACKGROUND

It has been suggested that an increased cholecystectomy rate in the laparoscopic era may be due to a reduced threshold for surgery or diagnostic confusion with irritable bowel syndrome (IBS). This study aims to determine the validity of these suggestions.

METHODS

Questionnaires were sent to patients who had undergone cholecystectomy between 1988-1990 (open) and 1998-2000 (laparoscopic). Patients were asked about abdominal pain, fatty food intolerance, jaundice, and indigestion pre- and postoperatively. Questionnaires included Rome II criteria for the diagnosis of IBS and SF-36 quality-of-life data. Histological severity of gallbladder disease was assessed using a standard scoring system.

RESULTS

A total of 124 of 196 patients in the open group and 264 of 400 patients in the laparoscopic group replied. There was no difference between the groups in gender, age at surgery, IBS incidence, or quality-of-life scores. The laparoscopic group reported a lower incidence of preoperative fat intolerance (45.8 vs 58.1%, p < 0.05) and a higher incidence of persistent postoperative abdominal pain (27.3 vs 17.7%, p < 0.05). Mean histopathology severity scores were higher in the open group (4.42 vs 3.95, p < 0.01).

CONCLUSIONS

Increased cholecystectomy rate in the laparoscopic era cannot be attributed to diagnostic confusion with IBS. However, a reduction in the threshold for surgery may have contributed to the increased rate of cholecystectomy.

Absence of Epstein-Barr virus encoded RNA and latent membrane protein (LMP1) in salivary gland neoplasms

A series of 55 (42 benign and 13 malignant) salivary gland tumours were investigated by immunohistochemistry, to detect Epstein-Barr virus (EBV) latent membrane protein (LMP1) and by in situ hybridization for EBV-encoded RNA. Non-neoplastic gland from all the patients with tumours and 15 control glands were also examined. All cases, both neoplastic and non-neoplastic were negative for LMP1 and failed to show any positive signal by in situ hybridization for EBV RNA. One undifferentiated carcinoma from a European patient was included in the group. These results confirm previous reports of an ethnic association between EBV and undifferentiated carcinomas of the salivary gland. They do not support an aetiological role for EBV in other salivary gland tumours.

Cavernous hemangioma in the submandibular gland masquerading as sialadenitis: case report

This report describes a case of cavernous hemangioma in the submandibular gland of a 37-year-old Irish woman. The lesion clinically and radiologically (as shown both by plain radiographs and computed tomography imaging) resembled salivary calculous disease. Numerous phleboliths were present in the hemangioma. The rarity of a cavernous hemangioma in such a location and its simulation of salivary calculous disease stimulated us to report the case.

Phospholipase A2 is activated by tumor necrosis factor-alpha in primary hepatocytes stimulated by a deleted form of hepatocyte growth factor

Several factors are released in the liver microenvironment immediately after injury. Among these factors TNF alpha is implicated as a regulator of hepatocyte proliferation. Hepatocytes in the intact liver are mostly in the G0 phase of the cell cycle and after injury (including collagenase perfusion) display a constitutive expression of the growth-regulated c-myc oncogene. TNF alpha co-added with dHGF in hepatocyte cultures, superinduced the DNA synthetic response observed at all time points. In parallel, TNF alpha/dHGF-treated hepatocytes have shown increased expression of the c-myc oncogene at times corresponding to the in vitro G1 phase of the cell cycle. TNF alpha activated PLA2 in hepatocytes and it is believed that the subsequent production of PGE2 plays a role in the "priming" process in these cells and at the same time amplifies the proliferating signals induced by hepatocyte-specific growth factors.

Transforming growth factor-alpha-induced DNA synthesis and c-myc expression in primary rat hepatocyte cultures is modulated by indomethacin

Primary hepatocytes stimulated with epidermal growth factor (EGF) secrete prostaglandins into the culture medium as soon as 1 h after the addition of the EGF. Transforming growth factor-alpha (TGF alpha), a potent hepatocyte mitogen, shares the same receptor with EGF, and its expression is increased after partial hepatectomy. TGF alpha is also secreted in culture. We have observed that TGF alpha induced hepatocyte DNA synthesis (30 h after addition) and at the same time stimulated the production of prostaglandins E2 and F2 alpha by the cultured hepatocytes. Indomethacin at 20-100 microM inhibited the TGF alpha-induced hepatocyte DNA synthesis, and this effect was specifically due to the inhibition of prostaglandin formation. Indomethacin also inhibited a TGF-alpha-induced increase in hepatocyte c-myc expression, indicating that prostaglandins mediate this increase, as previously shown for EGF. TGF alpha increased the expression of the EGF receptor gene, and this was prevented by the presence of an antibody against TGF alpha in the culture medium. We therefore suggest that TGF alpha induces hepatocyte proliferation either through coupling with its receptor (i.e. the EGF receptor) or by subsequent phosphorylation of lipocortin I. This leads to activation of phospholipase. A2, which seems to regulate the metabolism of arachidonic acid and the formation of prostaglandins. Thus hepatocyte proliferation in vitro appears to be controlled by a self-regulatory autocrine pathway involving activation of phospholipase A2 and secretion of prostaglandins and TGF alpha.

[Plasmid analysis of antibiotic resistant Shigella isolates]

A correlation between the multiple drug resistance patterns and the plasmid profiles given by 70 clinical isolates of Shigella sonnei and Shigella flexneri was investigated in this study. The most common plasmids were purified from different isolates by electroelution and characterized via restriction endonuclease digestions.

Uncontrolled nuclear division in normal x transformed somatic cell hybrids

Uncontrolled nuclear division (UND), as indicated by progressive multinucleation when cell division is inhibited by cytochalasin B, is a very characteristic property of transformed cells growing in vitro. In an attempt to determine the genetic basis for this transformation phenotype we have produced a series of somatic cell hybrids between different transformed and normal cells. In all hybrids there was suppression of UND but in some this was only transient. In hybrids between transformed human cells and mouse 3T3 cells, UND was only re-expressed when the human parental cell line had been transformed by SV40 virus. The results lend tentative support to the suggestion that cellular mechanisms involved in the induction and suppression of UND may not be the same in all cell lines.

Human bronchial epithelial cells with integrated SV40 virus T antigen genes retain the ability to undergo squamous differentiation

Human bronchial epithelial cells transformed by either DNA virus infection (SV40 or Adenovirus 12-SV40 hybrid virus) or transfection with the SV40 large T antigen gene were studied for their ability to undergo squamous differentiation when exposed to 12-O-tetradecanoylphorbol-13 acetate (TPA), transforming growth factor-beta 1 (TGF-beta 1), or fetal bovine serum (FBS), agents that induce the squamous differentiation of normal human bronchial epithelial cells. Squamous differentiation occurred in all ten T-antigen-positive cell cultures when they were exposed to either FBS or TGF-beta 1, but none differentiated when exposed to TPA. From one cell line, designated BEAS-2B, two subclones were isolated, one of which was induced to undergo squamous differentiation by FBS, and a second that failed to undergo squamous differentiation and was mitogenically stimulated when exposed to serum. These phenotypically different subclones provide a new in vitro cellular system for delineating the mechanism(s) of human bronchial epithelial cell squamous differentiation in response to FBS or TGF-beta 1.

A new experimental metastasis model in athymic nude mice, the human malignant melanoma LOX

The human tumor line LOX was established as an s.c. xenograft in nude mice from a lymph-node metastasis of a patient with malignant melanoma. I.v. injection into adult nude mice of single-cell suspensions prepared from xenografts resulted in progressively growing lung tumor colonies that killed the animals. No difference in colony formation was seen between cells taken from lung colonies and s.c. xenografts. An in vitro cell line, LOX-L, was established from lung colonies, and the monolayer cells, detached with EDTA, retained the same ability to form experimental lung metastases. In a total of 14 experiments, 82 of 89 mice receiving 1 X 10(6) viable tumor cells died with a mean survival time of 34.1 +/- 4.8 days. Long-term passaging in vivo and in vitro did not result in any alteration of the lung-colonizing potential of the LOX cells, whereas trypsinization of the cells before i.v. injection reduced lung colony formation. The life span was inversely related to the number of LOX cells injected, permitting estimation of the cell kill caused by chemotherapy. Mice injected i.v. with the LOX cells showed the same relative response to cis-diamminedichloroplatinum (CDDP) and mitozolomide (MZA) as did animals carrying s.c. xenografts. The LOX cells have shown a remarkable stability and similarity to the cells of the patient's tumor with respect to morphology, karyotype and chemosensitivity. The LOX model may be useful for testing effects of therapy on lung micro- and macrometastases, and the activity of antimetastatic agents, as well as for studying mechanisms involved in the metastatic process.

Killing of Friend erythroleukaemia cells by cytochalasin B is cell cycle specific

Exposure to 2.0 micrograms/ml cytochalasin B causes loss of viability in Friend erythroleukaemia cells. This effect is only observed however in cells undergoing mitosis.

Effect of cytochalasin B on somatic cell hybrids between normal and transformed cells

Cytochalasin B (CB) prevents cytokinesis in animal cells. In normal cells nuclear division and DNA synthesis are also blocked and the cells, held in the G1 phase of the cell cycle, remain either mononucleate or binucleate. In transformed cell lines DNA synthesis and nuclear division continue and the cells become multinucleate. We have examined the response to CB in two sets of somatic cell hybrids made between cells that display multinucleation after CB treatment and cells that do not. In a cross between transformed mouse LMTK cells and normal rat embryo lung cells, very little multinucleation was observed after treatment with CB for 7 days. The ability of the LMTK cells to form clones in soft agar was also significantly reduced in these hybrids. Segregant sub-clones that re-expressed both of these transformation phenotypes were isolated. These had reduced chromosome numbers. A second cross was made between two variants of the BHK cell line, one of which displayed a high level of multinucleation in CB while the other did not. Again the hybrids showed a response similar to that of the non-multinucleating parent. From the results obtained with these two hybrids we conclude that the multinucleation induced in transformed cells by CB behaves as a recessive character in crosses with normal cells.

Synthesis of alpha (immediate-early) proteins in Vero cells infected with pseudorabies virus

The synthesis of alpha (immediate-early) polypeptides in Vero cells infected with pseudorabies virus was studied. Cycloheximide was added at the beginning of infection and removed several hours later. The accumulated alpha mRNA was translated either in vivo in the presence of actinomycin D to prevent further mRNA synthesis, or in vitro. In intact cells three electrophoretically distinct virus-specific proteins were synthesized, with apparent molecular weights of approximately 180 000 (A), 190 000 (B) and 200 000 (C). The accumulation of B and C was prevented by the proline analogue azetidine. Only protein A was detected in vitro. Proteins B and C were not detected in normally infected cells. All three were associated with the nuclear fraction of cell homogenates and A and B were phosphorylated. The radioactivity of B and C declined during a chase period while that of A increased. This change was prevented by adding cycloheximide during the chase. The pattern of chymotrypsin digestion products suggested that A and B at least were similar proteins. It is presumed that protein A is the single immediate-early protein previously described and analogous to ICP 4 of herpes simplex virus. The significance and function, if any, of proteins B and C is not known but it is possible that they represent stages in the formation or transport of A within the cell and that the progression depends on an unstable protein which is depleted in cells treated with cycloheximide.

New storage procedure for human tumor biopsies prior to estrogen receptor measurement

Breast tumor biopsies required for steroid receptor determination are normally frozen in liquid nitrogen and stored until assay. However, some limitations of this type of storage exist. To try to both eliminate the need for liquid nitrogen and as part of a study of serial assays on a single tumor biopsy, alternative storage media were investigated. This study shows that storage of breast tumor biopsies at -20 degrees in sucrose buffer made 50% in glycerol prevented the tissues from freezing, yet retained the specific estrogen receptor content both quantitatively and in terms of molecular form (8S:4S ratio). Receptor was stable for up to 100 days, and individual samples could be successfully reassayed throughout this period. Forty-four biopsies from 40 patients were halved, and one section from each was stored in liquid nitrogen, while the other was stored in sucrose:glycerol. Overall, the correlation of receptor content between the two storage methods was good. Using a clinical cutoff value of 20 fmol/mg cytosol protein, only one sample of the 44 would have been classified differently after storage in the two media. Progesterone receptor in biopsies stored in sucrose:glycerol also appears to be stable for at least a limited period.

Cytochalasin B induces abnormal chromosome segregation in Friend erythroleukaemia cells

Friend erythroleukaemia cells were made binucleate by brief exposure to cytochalasin B (CB). The binucleate cells were then allowed to grow in the absence of the CB. They produced pseudotetraploid derivatives which subsequently showed considerable variation in chromosome number. Cells with abnormal chromosome numbers failed to form clones, and disappeared from the culture. This is in marked contrast to previously reported stable pseudotetraploid cells arising in baby hamster kidney (BHK) cells after CB treatment.