Indications and outcomes for repeat cytoreductive surgery and heated intra-peritoneal chemotherapy in peritoneal surface malignancy

INTRODUCTION

Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) is offered in specialist centres as a treatment for peritoneal surface tumours. Despite its demonstrated efficacy, intra-abdominal recurrence occurs in 31-57% of patients. The aim of this study is to review the early and long-term outcomes in patients who undergo repeat CRS/HIPEC.

MATERIALS AND METHODS

A retrospective review of a prospectively maintained database of patients who had undergone repeat CRS/HIPEC for appendiceal neoplasms and colorectal peritoneal metastases (CRPM) from 2003 to 2019 was performed at a single specialist centre. Data pertaining to both short term outcomes and survival were evaluated.

RESULTS

Of 1259 patients who had undergone CRS/HIPEC, 84(6.7%) underwent repeat surgery: 45(53.6%) had pseudomyxoma peritonei (PMP) secondary to low grade appendiceal mucinous neoplasms (LAMN), 21(25.0%) had appendix carcinoma and 18(21.4%) had CRPM. Demographics, intra-operative findings and short-term outcomes were comparable across tumour types and between procedures. Median (95% CI) interval between procedures was 22.7(18.9-26.6) months and was comparable between tumour types. Median (95%CI) overall survival was not reached for the cohort overall or for those with PMP, but was 61.0(32.6-89.4) months for those with appendix cancer and 76.9(47.4-106.4) months for CRPM (p=<0.001). Survival was favourable in the PMP group (HR [95%CI] 0.044 [0.008-0.262]; p = 0.000) and unfavourable in the CC2-3 at index CRS procedure group (HR [95%CI] 25.612 [2.703-242.703]; p = 0.005).

CONCLUSION

Our findings demonstrate that repeat cytoredutive surgery with HIPEC can result in favourable survival, especially for patients with PMP when complete cytoreduction is achieved at index operation. We recommend that detailed patient assessment is performed through an expert multidisciplinary team meeting (MDT).

Discovery of Acyl-sulfonamide Nav1.7 Inhibitors GDC-0276 and GDC-0310

Nav1.7 is an extensively investigated target for pain with a strong genetic link in humans, yet in spite of this effort, it remains challenging to identify efficacious, selective, and safe inhibitors. Here, we disclose the discovery and preclinical profile of GDC-0276 (1) and GDC-0310 (2), selective Nav1.7 inhibitors that have completed Phase 1 trials. Our initial search focused on close-in analogues to early compound 3. This resulted in the discovery of GDC-0276 (1), which possessed improved metabolic stability and an acceptable overall pharmacokinetics profile. To further derisk the predicted human pharmacokinetics and enable QD dosing, additional optimization of the scaffold was conducted, resulting in the discovery of a novel series of N-benzyl piperidine Nav1.7 inhibitors. Improvement of the metabolic stability by blocking the labile benzylic position led to the discovery of GDC-0310 (2), which possesses improved Nav selectivity and pharmacokinetic profile over 1.

Long-term outcomes for patients with peritoneal acellular mucinosis secondary to low grade appendiceal mucinous neoplasms

INTRODUCTION

Low grade appendiceal mucinous neoplasms (LAMN) are known to metastasise to the peritoneum resulting in pseudomyxoma peritonei (PMP). Literature suggests that the long-term outcome is dependent on the cellular grade of the peritoneal histology, less is known about the risk to patients with acellular mucinosis (AM) alone. This study aims to review long-term outcomes in patients with PMP treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC), whose peritoneal histology was AM secondary to LAMN.

METHODS

Pathological and treatment outcomes were collected from a prospectively maintained database between 2005 and 2019. Data was collected on patients with LAMN and AM diagnosed following CRS/HIPEC. A single institution performed the surgery and pathology reporting, samples reported by three different pathologists.

RESULTS

Of the 2079 patients with any appendiceal neoplasm referred between 2005 and 2019, 809 underwent CRS/HIPEC, 67 (8%) of those had PMP with purely AM secondary to a LAMN. In the AM group the median age was 59, 37 (55%) were female, follow up was for a median 39 (2-145) months. Inpatient mortality occurred in 1 patient (1.5%), disease specific mortality in 2 (3%), recurrence in 2 (3%) and disease progression in 1 (1.5%).

CONCLUSION

This study has identified AM secondary to LAMN as a low risk group for recurrence following CRS/HIPEC compared with epithelial pathology. Given such a low rate of recurrence we would recommend low intensity surveillance post CRS/HIPEC. Agreed standardised pathological assessment is required to exclude cellular material in specimens and diagnose AM.

MicroRNA-mediated regulation of immune responses to intestinal helminth infections

Intestinal helminth infections are highly prevalent in the developing world, often resulting in chronic infection and inflicting high host morbidity. With the emergence of drug-resistant parasites, a limited number of chemotherapeutic drugs available and stalling vaccine efforts, an increased understanding of antihelminth immunity is essential to provide new avenues to therapeutic intervention. MicroRNAs are a class of small, nonprotein coding RNAs which negatively regulate mRNA translation, thus providing finite control over gene expression in a plethora of biological settings. The miRNA-mediated coordinated control of gene expression has been shown to be essential in infection and immunity, in promoting and fine-tuning the appropriate immune response. This review gathers together and discusses observations of miRNA-mediated effects on the immune system and the subsequent impact on our understanding of antihelminth immunity.

CD4+ Th2 cells are directly regulated by IL-10 during allergic airway inflammation

Interleukin-10 (IL-10) is an important regulatory cytokine required to control allergy and asthma. IL-10-mediated regulation of T cell-mediated responses was previously thought to occur indirectly via antigen-presenting cells. However, IL-10 can act directly on regulatory T cells and T helper type 17 (Th17) cells. In the context of allergy, it is therefore unclear whether IL-10 can directly regulate T helper type 2 (Th2) cells and whether this is an important regulatory axis during allergic responses. We sought to determine whether IL-10 signaling in CD4⁺ Th2 cells was an important mechanism of immune regulation during airway allergy. We demonstrate that IL-10 directly limits Th2 cell differentiation and survival in vitro and in vivo. Ablation of IL-10 signaling in Th2 cells led to enhanced Th2 cell survival and exacerbated pulmonary inflammation in a murine model of house dust mite allergy. Mechanistically, IL-10R signaling regulated the expression of several genes in Th2 cells, including granzyme B. Indeed, IL-10 increased granzyme B expression in Th2 cells and led to increased Th2 cell death, identifying an IL-10-regulated granzyme B axis in Th2 cells controlling Th2 cell survival. This study provides clear evidence that IL-10 exerts direct effects on Th2 cells, regulating the survival of Th2 cells and severity of Th2-mediated allergic airway inflammation.

Giant condylomata acuminata of Buschke and Lowenstein: A peristomal variant

INTRODUCTION

Giant condylomata acuminata (GCA) is a rare, locally invasive tumour that may undergo malignant transformation. It was first described a HPV-induced penile tumour which clinically resembled both a squamous cell carcinoma and condyloma acuminatum, often arising from a pre-existing warty lesion. We describe a case of peri-stomal GCA transformation into invasive squamous cell carcinoma (SCC), which is, to our knowledge, the first report of this in the literature.

PRESENTATION OF CASE

A 74 year old gentleman developed an acuminate, papillomatous peristomal eruption around a fifty year old ileostomy, with biopsies of the eruption showing reactive changes. Two years later, he developed ulcerating plaques affecting the previously papillomatous areas and an erythematous nodular lesion involving the superior part of the ileostomy and adjacent skin. Histological examination of the ileostomy lesion showed focal small islands of atypical squamous epithelium, and moderately differentiated invasive squamous cell carcinoma was shown in the excised tissue subsequently. Human papillomavirus (HPV type 16), p16 and p53 tumour suppressors were positive in the peri-stomal skin sample.

DISCUSSION AND CONCLUSIONS

Recurring, changing papillomatous lesions in the peristomal area should be reviewed with a high index of suspicion in relation to GCA tumours as they can progress to invasive squamous cell carcinomas.

Microbial biogeochemistry of Boiling Springs Lake: a physically dynamic, oligotrophic, low-pH geothermal ecosystem

Boiling Springs Lake (BSL) in Lassen Volcanic National Park, California, is North America's largest hot spring, but little is known about the physical, chemical, and biological features of the system. Using a remotely operated vessel, we characterized the bathymetry and near-surface temperatures at sub-meter resolution. The majority of the 1.2 ha, pH 2.2 lake is 10 m deep and 50-52 °C, but temperatures reach 93 °C locally. We extracted DNA from water and sediments collected from warm (52 °C) and hot (73-83 °C) sites separated by 180 m. Gene clone libraries and functional gene microarray (GeoChip 3.0) were used to investigate the BSL community, and uptake of radiolabeled carbon sources was used to assess the relative importance of heterotrophic vs. autotrophic production. Microbial assemblages are similar in both sites despite the strong temperature differential, supporting observations of a dynamic, convectively mixed system. Bacteria in the Actinobacteria and Aquificales phyla are abundant in the water column, and Archaea distantly related to known taxa are abundant in sediments. The functional potential appears similar across a 5-year time span, indicating a stable community with little inter-annual variation, despite the documented seasonal temperature cycle. BSL water-derived DNA contains genes for complete C, N, and S cycles, and low hybridization to probes for N and S oxidation suggests that reductive processes dominate. Many of the detected genes for these processes were from uncultivated bacteria, suggesting novel organisms are responsible for key ecosystem services. Selection imposed by low nutrients, low pH, and high temperature appear to result in low diversity and evenness of genes for key functions involved in C, N, and S cycling. Conversely, organic degradation genes appear to be functionally redundant, and the rapid assimilation of radiolabeled organic carbon into BSL cells suggests the importance of allochthonous C fueling heterotrophic production in the BSL C cycle.

Classification of and cytoreductive surgery for low-grade appendiceal mucinous neoplasms

BACKGROUND

Low-grade appendiceal mucinous neoplasm (LAMN) is a precursor lesion for pseudomyxoma peritonei (PMP), which, if treated suboptimally, may later disseminate throughout the abdominal cavity. The role of cytoreductive surgery for these relatively early lesions is unclear.

METHODS

Clinicopathological details and treatment outcomes of patients with a LAMN and disease limited to the appendix or immediate periappendiceal tissues, referred to a national treatment centre between 2002 and 2009, were evaluated prospectively.

RESULTS

Of 379 patients with a diagnosis of PMP, 43 (median age 49 years) had LAMNs localized to the appendix and periappendiceal tissue. Thirty-two patients initially presented with symptoms of acute appendicitis or right iliac fossa pain. Two distinct lesions were identified: type I (disease confined to the appendiceal lumen) and type II (mucin and/or neoplastic epithelium in the appendiceal submucosa, wall and/or periappendiceal tissue, with or without perforation). Type I lesions were managed by a watch-and-wait surveillance policy with serial measurement of tumour markers and computed tomography in 14 of 16 patients. Seventeen of 27 patients with type II lesions underwent risk-reducing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy with low morbidity. After a median follow-up of 40 months, there was no disease progression in either treatment pathway.

CONCLUSION

This study identified two LAMN subtypes. Type II lesions have pathological features of increased risk for dissemination and should be considered for risk-reducing cytoreductive surgery.

Neurons in the human hippocampus and amygdala respond to both low- and high-level image properties

A large number of studies have demonstrated that structures within the medial temporal lobe, such as the hippocampus, are intimately involved in declarative memory for objects and people. Although these items are abstractions of the visual scene, specific visual details can change the speed and accuracy of their recall. By recording from 415 neurons in the hippocampus and amygdala of human epilepsy patients as they viewed images drawn from 10 image categories, we showed that the firing rates of 8% of these neurons encode image illuminance and contrast, low-level properties not directly pertinent to task performance, whereas in 7% of the neurons, firing rates encode the category of the item depicted in the image, a high-level property pertinent to the task. This simultaneous representation of high- and low-level image properties within the same brain areas may serve to bind separate aspects of visual objects into a coherent percept and allow episodic details of objects to influence mnemonic performance.

Blind outcome assessment: the development and use of procedures to maintain and describe blinding in a pragmatic physiotherapy rehabilitation trial

Objectives: (1) To develop trial protocols which promote the achievement of blind outcome assessment. (2) To report outcome assessor beliefs regarding group allocation at follow-up assessments. (3) To document and describe instances of unblinding occurring during the trial to assist and inform rehabilitation researchers and clinicians.

Design: Prospective longitudinal observational study.

Setting: An NHS Hospital Trust specializing in orthopaedic surgery.

Subjects: One hundred and seven patients participating in a prospective pragmatic randomized controlled trial investigating physiotherapy rehabilitation following total knee arthroplasty, plus three outcome assessors.

Interventions: A protocol was developed using available research and designed to minimize instances of unblinding during a physiotherapy rehabilitation trial. Administrative, office, patient and research staff procedures were included.

Main measures: Trial questionnaires measured blind outcome assessment responses at 3 and 12 months post surgery. The outcome assessor kept a field diary recording the events surrounding instances of unblinding. Data underwent descriptive and content analysis.

Results: Blind outcome assessment was believed successful for n = 74 (81.32%) assessments at 3-month follow-up, and n = 83 (91.21%) at 12 months. Forty instances ( n = 28 participants) of unblinding were described in the field diary. While the main cause of unblinding was participants telling the outcome assessor, in 12.5% of events the assessor drew the wrong conclusion regarding group allocation. Not all unblinding events were remembered at subsequent assessments, even in this relatively small trial.

Conclusions: Blind outcome assessment was considered achievable in this trial. Specific trial protocols enabled blinding beliefs to be reported and instances of unblinding to be described.

Treatments and outcomes of peritoneal surface tumors through a centralized national service (United kingdom)

PURPOSE

Treatment of peritoneal surface malignancies with combined cytoreductive surgery and heated intraperitoneal chemotherapy may improve oncologic outcome. To better define treatment pathways, five-year results in patients referred to one of two centralized national treatment centers in the United Kingdom were analyzed.

METHODS

A prospective database of patients referred to the Manchester Peritoneal Tumor Service, established in 2002, was analyzed. Outcomes were evaluated using Kaplan-Meier life tables and Cox models.

RESULTS

Two hundred seventy-eight patients (median age, 56.9 (range, 16-86) years) were considered by a dedicated multidisciplinary team and tracked on seven clinical pathways. Among the 118 surgically treated, the most common diagnosis was pseudomyxoma peritonei (101 patients, 86%). Major complications occurred in 11 patients (9%); there was no 30-day mortality. Where complete cytoreduction was achieved, three-year and five-year tumor-related survival rates were 94% and 86%, respectively. In the Cox model, incompleteness of cytoreduction (P = 0.001) and high-grade tumor (P < 0.0001) were independent prognosticators of poor outcome.

CONCLUSION

The establishment of a national treatment center has allowed refinement of techniques to achieve internationally recognized results. Having achieved low levels of morbidity and mortality in the treatment of mainly pseudomyxoma peritonei of appendiceal origin, the technique of cytoreductive surgery and heated intraperitoneal chemotherapy may be considered for peritoneal carcinomatosis of colorectal origin.

A phase II study evaluating the use of concurrent mitomycin C and capecitabine in patients with advanced unresectable pseudomyxoma peritonei

Pseudomyxoma peritonei (PMP) is a rare neoplastic process characterised by progressive intra-abdominal dissemination of mucinous tumour, and generally considered resistant to systemic chemotherapy. A phase II study in patients with advanced unresectable PMP was undertaken to evaluate the combination of systemic concurrent mitomycin C (7 mg m(-2) i.v. on day 1) and capecitabine (1250 mg m(-2) b.d. on days 1-14) in a 3-weekly cycle (MCap). Response was determined by semiquantitative assessment of disease volume on serial computed tomographic (CT) scans and serum tumour marker (CEA, CA125, CA19-9) changes at 12 weeks. Between 2003 and 2006, 40 patients were recruited through a national centre for the treatment of peritoneal surface tumours. At baseline, 23 patients had progressive disease and 17 had stable disease. Of 39 assessable patients, 15 (38%, 95% confidence intervals (CIs): 25, 54%) benefited from chemotherapy in the form of either reductions in mucinous deposition or stabilisation of progressive pretreatment disease determined on CT scan. Notably, two patients, originally considered unresectable, following MCap and re-staging underwent potentially curative cytoreductive surgery. Grade 3/4 toxicity rates were low (6%, 95% CIs: 4, 9%). Twenty out of 29 assessed patients (69%, 95% CIs: 51, 83%) felt that their Global Health Status improved during chemotherapy. This is the first trial to demonstrate an apparent benefit of systemic chemotherapy in patients with advanced unresectable PMP.

Practicalities and costs of adhesions

In spite of postoperative adhesions being common there appears to be a reluctance to use anti-adhesion products routinely. This article compares the incidence of adhesions with other conditions in order to identify the level of risk. The health economics surrounding adhesion-related disease are described. This combined information may be of help to convince health practitioners of the need to take a more active role in adhesion prevention. The SCAR project has identified the risk of adhesion-related disease. This is compared with published risks of other common clinical situations. An economic model first described by the author in 2002 has been revised with 2006 costs [1]. The SCAR data demonstrates a directly related risk of re-admission in certain groups of 9.4% over 5 years [2]. The frequency of including this fact in the consenting process is low (<15%) [3]. Legal precedent has identified a risk of >2% warrants inclusion in the consent process; failure to do so could be considered negligent [4]. Use of an anti-adhesion product with a cost of 130 euros with an efficacy of 25% in 1 year in the UK could save over 40 million euros over a 10-year period. Adhesion risk is frequent enough to include in consent. Failure to do this and avoidance of treatment, which may reduce adhesions will have major financial consequences on healthcare systems.

Adhesions and colorectal surgery - call for action

Mounting evidence highlights that adhesions are now the most frequent complication of abdominopelvic surgery, yet many surgeons are still not aware of the extent of the problem and its serious consequences. While many patients go through life without apparent problems, adhesions are the major cause of small bowel obstruction and a leading cause of infertility and chronic pelvic pain in women. Moreover, adhesions complicate future abdominal surgery with important associated morbidity and expense and a considerable risk of mortality. Studies have shown that despite advances in surgical techniques in recent years, the burden of adhesion-related complications has not changed. Adhesiolysis remains the main treatment even though adhesions reform in most patients. Recent developments in adhesion-reduction strategies and new anti-adhesion agents do, however, offer a realistic possibility of reducing the risk of adhesions forming and potentially improving the clinical outcomes for patients and reducing the associated onward burden to healthcare systems. This paper provides a synopsis of the impact and extent of the problem of adhesions with reference to the wider literature and also consideration of the key note papers presented in this special supplement to Colorectal Disease. It considers the evidence of the risk of adhesions in colorectal surgery and the opportunities and strategies for improvement. The paper acts as a 'call for action' to colorectal surgeons to make prevention of adhesions more of a priority and importantly to inform patients of the risks associated with adhesion-related complications during the consent process.

An open-label study of olanzapine in children and adolescents with schizophrenia

The purpose of this open-label study was to evaluate the use of olanzapine in the treatment of children and adolescents with schizophrenia. Sixteen children who were 8-17 years of age and met DSM-IV criteria for schizophrenia were admitted into a 10-week, open-label, optimizing dose study of olanzapine. The Brief Psychiatric Rating Scale (BPRS), the Positive and Negative Syndrome Scale (PANSS), and the Clinical Global Impression (CGI)-Severity/Improvement scales were used to assess improvement during the study. Of the 16 subjects who completed the study, 12 demonstrated significant improvement on end of treatment BPRS, CGI, and PANSS scores compared with baseline. Male subjects showed greater improvement and also gained more weight. Weight gain occurred in all but 2 subjects. Weight gain was significant, with patients averaging a gain of about 6.2 kg during the 6-week course of the study. Two of the subjects experienced extrapyramidal symptoms. The average dose of olanzapine for all subjects was 0.17 mg/kg.

Electrochemical immunosensors for the simultaneous detection of two tumor markers

The microfabrication of electrochemical immunosensors for the simultaneous detection of two protein analytes is described. The sensors consisted of two iridium oxide electrodes (1-mm diameter) patterned on a glass substrate. Capture antibodies were immobilized on the porous iridium oxide electrodes by covalent attachment using (3-aminopropyl)triethoxysilane and glutaraldehyde. The spatial separation of the electrodes (2.5 mm) enabled simultaneous electrochemical immunoassays to be conducted without cross-talk between the electrodes. Proteins were measured using electrochemical ELISA, and detection was achieved by electrochemically oxidizing alkaline phosphatase-generated hydroquinone. Sensors for the simultaneous detection of goat IgG and mouse IgG, and for the tumor markers CEA and AFP, were developed. The sensors had detection limits of 1, 2, 1.2, and 1 ng/mL for goat IgG, mouse IgG, CEA, and AFP, respectively.

Zonisamide for bipolar depression

In recent years, research into bipolar depression has increased. Each year, more studies are published using different agents to treat this condition. In addition to effectiveness and tolerability, bipolar depression research has sought agents that do not induce cycling or mania. This paper evaluates an open-label pilot study on zonisamide for bipolar depression that examined the effectiveness and tolerability of this agent while observing for any switch to mania. Zonisamide was found to have a very low switch rate and modest effectiveness. However, a high dropout rate was observed--mostly due to side effects. Until further research is available, zonisamide is not recommended as a first-line treatment for bipolar depression.

A specific cadherin phenotype may characterise the disseminating yet non-metastatic behaviour of pseudomyxoma peritonei

Pseudomyxoma peritonei (PMP) is a rare neoplasm of mainly appendiceal origin, characterised by excess intra-abdominal mucin production leading to high morbidity and mortality. While histological features are frequently indolent, this tumour disseminates aggressively throughout the abdominal cavity, yet seldom metastasises. This study determined the expression of several markers of colorectal differentiation (carcinoembryonic antigen (CEA), cytokeratins (CK20 and CK7), epithelial membrane antigen), mucin production (MUC-2, interleukin-9 (IL-9), IL-9 receptor (IL-9Rα)), and cell adhesion (N- and E-cadherin, vimentin) in PMP tissue (n=26) compared with expressions in normal colonic mucosa (n=19) and colorectal adenocarcinoma (n=26). Expressions of CEA and cytokeratins were similar for PMP as those in colorectal adenocarcinomas with the exception that the CK20−/CK7− pattern was rare in PMP (Fisher's exact test: P=0.001). Similarly, expressions of mucin-related proteins were comparable for adenocarcinoma and PMP, with the exception that IL-9 expression was uncommon in adenocarcinoma (P=0.009). Pseudomyxoma peritonei demonstrated a specific pattern of adhesion-related protein expressions of increased N-cadherin, reduced E-cadherin, and increased vimentin (P=0.004), a phenotype suggesting a possible epithelial–mesenchymal transition state. Primary PMP cell cultures were successfully maintained and demonstrated marker expressions similar to those seen in in vivo tissues. These early characterisation studies demonstrate similarities between PMP and colorectal adenocarcinoma, but also reveal a specific cadherin phenotype that may characterise the distinct non-metastasising behaviour of PMP, and form the basis for future mechanistic and therapy-targeting research.

Multiplex Measurement of Seven Tumor Markers Using an Electrochemical Protein Chip

An electrochemical immunosensor for performing multianalyte measurements of tumor markers is described. The sensor consisted of an array of immunosensing electrodes fabricated on a glass substrate. Each electrode contained a different immobilized antigen and was capable of measuring a specific tumor marker using electrochemical enzyme-based competitive immunoassay. Using this arrangement, multiple analytes could be measured simultaneously by performing the technical operations for a single assay. The biosensor was used to measure the concentrations of seven important tumor markers: AFP, ferritin, CEA, hCG-beta, CA 15-3, CA 125, and CA 19-9. The sensor had excellent precision and accuracy and was comparable in performance to single-analyte ELISAs (1.9-8.1% interassay CV; <2 ng/mL (or units/mL) detection limit for most analytes). Multianalyte assays provide significant advantages over single-analyte tests in terms of cost per test, labor, test throughput, and convenience. We anticipate that chip-based sensors, as described herein, will be suitable for the mass production of economical, miniaturized lab-on-a-chip devices that will have applications in a wide range of clinical, environmental, and biodefense applications.

A Synthetic Approach toward Nitiol: Construction of Two 1,22-Dihydroxynitianes

Synthetic work toward the total synthesis of nitiol has culminated in the construction of two epimeric hydroxylated derivatives, the 1,22-dihydroxynitianes. Key stereodefining steps in the construction of the A-ring fragment (13) were the use of a siloxy-epoxide rearrangement reaction, a Pauson-Khand reaction, a Norrish 1 photochemical cleavage reaction, and a highly regio- and stereoselective hydrostannylation reaction of an ynoate. The stereochemistry of the synthetically challenging C-ring fragment (20) was established using an Ireland-Claisen reaction and a Grubbs ring-closing metathesis process as key steps. The 12-membered B-ring of the nitiane skeleton was constructed using a copper-promoted Stille cross-coupling and a Kishi-Hiyama-Nozaki carbonyl addition reaction. Unfortunately, the carbonyl addition reaction produced hydroxyl functionality that could not be selectively removed. Consequently, a synthesis of epimeric 1,22-dihydroxynitianes, which are compounds that are structural hybrids of two natural products, nitiol and variculanol, was completed.

Electrochemical Multianalyte Immunoassays Using an Array-Based Sensor

A novel amperometric biosensor for performing simultaneous electrochemical multianalyte immunoassays is described. The sensor consisted of eight iridium oxide sensing electrodes (0.78 mm(2) each), an iridium counter electrode, and a Ag/AgCl reference electrode patterned on a glass substrate. Four different capture antibodies were immobilized on the sensing electrodes via adsorption. Quantification of proteins was achieved using an ELISA in which the electrochemical oxidation of enzyme-generated hydroquinone was measured. The spatial separation of the electrodes enabled simultaneous electrochemical immunoassays for multiple proteins to be conducted in a single assay without amperometric cross-talk between the electrodes. The simultaneous detection of goat IgG, mouse IgG, human IgG, and chicken IgY was demonstrated. The detection limit was 3 ng/mL for all analytes. The sensor had excellent precision (1.9-8.2% interassay CV) and was comparable in performance to commercial single-analyte ELISAs. We anticipate that chip-based sensors, as described herein, will be suitable for the mass production of economical, miniaturized, multianalyte assay devices.

Pseudomyxoma peritonei: unusual origin from an ovarian mature cystic teratoma

Pseudomyxoma peritonei (PMP) is classified into pathologically and prognostically distinct categories, such as disseminated peritoneal adenomucinosis (DPAM) and peritoneal mucinous carcinomatosis. There is overwhelming evidence that DPAM arises from a mucinous adenoma of the appendix. The one exception to this is the presentation of a mature ovarian cystic teratoma as PMP where the appendix is normal. This report describes such a case and discusses the presentation, histopathology, and treatment options.

The SCAR-3 study: 5-year adhesion-related readmission risk following lower abdominal surgical procedures

OBJECTIVE

The Surgical and Clinical Adhesions Research (SCAR) and SCAR-2 studies demonstrated that the burden of adhesions following lower abdominal surgery is considerable and appears to remain unchanged despite advances in strategies to prevent adhesions. In this study, we assessed the adhesion-related readmission risk directly associated with common lower abdominal surgical procedures, taking into account the effect of previous surgery, demography and concomitant disease.

METHODS

Data from the Scottish National Health Service medical record linkage database were used to assess the risk of an adhesion-related readmission following open lower abdominal surgery during April 1996-March 1997.

RESULTS

Patients undergoing lower abdominal surgery (excluding appendicectomy) had a 5% risk of readmission directly related to adhesions in the 5 years following surgery. Appendicectomy was associated with a lower rate of readmission (0.9%), but contributed over 7% of the total lower abdominal surgery patient readmission burden. Panproctocolectomy (15.4%), total colectomy (8.8%) and ileostomy surgery (10.6%) were associated with the highest risk of an adhesion-related readmission. Overall, the risk of readmission was doubled in patients who had undergone abdominal or pelvic surgery within 5 years of the incident operation. A higher risk of readmission was also recorded in patients aged < 60 years compared with those aged > or = 60 yrs. The effect of gender was assessed. However, as the surgical codes used were found to be skewed towards women, these data have not been reported. Readmission risk was slightly higher in patients with concomitant peritonitis compared with patients without peritonitis. In contrast, Crohn's disease had no effect on risk. Patients with colorectal cancer had a lower risk of adhesion formation. However, this may have been due to the type of surgery performed in this patient group.

CONCLUSION

The identification of high-risk patient subgroups may assist in effectively targeting adhesion-prevention strategies and the proffering of preoperative advice on adhesion risk.

Comorbid anxiety disorders and divalproex sodium use among partial hospital patients with psychotic disorders

We conducted this study to determine anxiety disorder comorbidity and divalproex sodium use among 26 patients with psychotic disorders after their referral to a partial hospital. Each subject was diagnosed by structured interview, and 4 Brief Psychiatric Rating Scale (BPRS) items associated with agitation were assessed: anxiety, hostility, excitement, and tension. Subjects' medical records were then examined to determine discharge diagnoses from referring inpatient facilities as well as current medication use. Although we diagnosed many anxiety disorders, none was identified during hospitalization. Divalproex use was not associated with anxiety disorder frequency. Divalproex patients had significantly lower BPRS anxiety, tension, and excitement scores, as well as total BPRS agitation scores (P < .05). Our findings suggest that anxiety disorders are unrecognized among psychotic patients and that treatment guidelines for concurrent anxiety are needed.

Progressive myelopathy and neuropathy in New Zealand Huntaway dogs

AIM

To investigate the nature and cause of a progressive ataxia in three 20-month-old Huntaway dogs that were litter mates.

METHODS

Affected dogs were examined before they were humanely killed and submitted to necropsy. Selected formalin-fixed tissues were examined by light and electron microscopy.

RESULTS

The lesions were those of axon and myelin degeneration within sensory, proprioceptive and motor tracts of the spinal cord and to a lesser degree some peripheral nerves.

CONCLUSION

A progressive myelopathy and neuropathy, tentatively described as a central-peripheral distal axonopathy, was present in all 3 dogs. The cause was not determined but was likely to be either genetic or nutritional.

CLINICAL RELEVANCE

In the early stages of this disease, careful examination may be necessary to distinguish the signs of ataxia from orthopaedic disease such as hip dysplasia. Affected animals are unlikely to be of use as working dogs.

Hydroquinone diphosphate: an alkaline phosphatase substrate that does not produce electrode fouling in electrochemical immunoassays

Hydroquinone diphosphate (HQDP) was synthesized and compared to phenyl phosphate (PP) and 1-naphthyl phosphate (NP) as a substrate for alkaline phosphatase (AP) under electrochemical immunoassay (EIA) conditions. Voltammetric and amperometric experiments showed that electrochemical oxidation of hydroquinone (HQ), which is the AP hydrolysis product of HQDP, did not produce electrode passivation, even with repeated biosensor use. In contrast, phenol and 1-naphthol, the hydrolysis products of PP and NP, respectively, were shown to be irreversibly oxidized on the electrode surfaces, and produced rapid electrode passivation, resulting in complete loss of electrode signal. When employed as AP substrate in an iridium oxide based EIA, HQDP produced significantly larger amperometric responses (117 microA/cm2) compared to PP (31 microA/cm2) and NP (27 microA/cm2). The results presented in this paper show that HQDP is an attractive alternative to commonly used AP substrates such as NP and PP. The substrate shows excellent hydrolytic stability, produces larger amperometric responses (than PP or NP), and does not produce sensor passivation.

Colorectal surgery: the risk and burden of adhesion-related complications

OBJECTIVES

Adhesions are associated with serious medical complications. This study examines the real-time burden of adhesion-related readmissions following colorectal surgery and assesses the impact of previous surgery on adhesion-related outcomes.

PATIENTS AND METHODS

The study used data from the Scottish National Health Service Medical Record Linkage Database to identify three cohorts of patients who had undergone open colorectal surgery during the financial years 1996-97, 1997-98 and 1998-99. Each cohort was followed up for at least 2 years and the number and category of adhesion-related readmissions was recorded. The influence of any previous operations on adhesion-related readmissions was also determined by performing a subanalysis within the 1996-97 cohort of patients who had no record of abdominal surgery within either the previous 5 or 15 years. The relative risk of adhesion-related readmissions was also assessed.

RESULTS

In the 1996-97 cohort, 9.0% of patients were readmitted within a year after surgery; 2.1% had complications directly related to adhesions and 6.9% had complications that were possibly related. After 4 years, 19.0% of patients were readmitted for reasons directly or possibly related to adhesions. Many patients were readmitted on more than one occasion and the relative risk of adhesion-related complications was 29.7 per 100 initial procedures over 4 years. In the subgroups that had no record of abdominal surgery within the previous 5 or 15 years, the relative risks of adhesion-related complications were 24.8% and 23.5%, respectively. There was no change in the rate of adhesion-related readmissions following colorectal surgery between 1996 and 1999.

CONCLUSION

Colorectal surgery is associated with a considerable rate of adhesion-related readmissions. Preventative measures should be considered to reduce this risk.

Novel amperometric immunosensors based on iridium oxide matrices

Novel immunosensors based on antibodies immobilized in electrochemically grown iridium oxide (IrOx) thin film matrices have been developed. Antibody loading in the oxide was evaluated using a non-competitive electrochemical immunoassay for IgG. Anti-IgG loading in the oxide was found to be dependent on the concentration of anti-IgG present in the oxide growth step, with 400 microg/ml anti-IgG producing maximum amperometric responses. To study the potential analytical properties of the matrix, the dose-response behavior of the sensors was determined using optimized alkaline phosphatase-linked IgG immunoassay. Hydroquinone diphosphate (HQDP) was used as enzyme substrate and the oxidation of hydroquinone was detected amperometrically at +420 mV. The sensors displayed a linear dose-response behavior for IgG concentrations between 10 and 200 ng/ml, saturating above 600 ng/ml, and had a low detection limit of 8 ng/ml.Finally, the method was used to produce sensors containing immobilized anti-transferrin. Using a non-optimized electrochemical immunoassay for human transferrin (HT), dose-response behavior was observed for HT concentrations between 100 and 600 ng/ml.The results presented in this paper show that IrOx matrices represent a new method for immunosensor fabrication. The oxide acts as a hydrophilic, highly porous, three-dimensional matrix that can immobilize antibodies and retain their activity. The method is attractive because it offers the potential for high antibody loadings and is suitable for mass production of sensors in an easy and economical manner.

Surgical impact of adhesions following surgery in the upper abdomen

Background

The Surgical and Clinical Adhesions Research (SCAR) study set out to determine the long-term morbidity associated with postoperative adhesions following open abdominal and pelvic surgery, including the burden associated with adhesions after surgery in the upper abdomen.

Methods

Scotland's National Health Service hospital admissions are recorded by the Scottish Medical Record Linkage system. This system allows detailed analysis of hospital activity throughout Scotland including follow-through of individual patients, with sophisticated accuracy checks to ensure the quality and totality of the data set. Within the SCAR study, the total number of individuals who underwent an open abdominal or pelvic procedure in 1986 was defined, a subset of whom underwent surgery in the anatomical area of the upper abdomen (fore gut and related organs). Disease (International Classification of Diseases version 9) and procedure (Office of Population Censuses and Surveys 3/4) codes for adhesion-related problems or reoperations that might be complicated by the presence of adhesions were identified. For the purposes of the study only readmissions for directly related adhesion complications during the following 10 years were considered (e.g. small bowel obstruction and adhesiolysis). The study was steered by a multidisciplinary panel of surgeons, gynaecologists and health economists.

Results

In 1986 in Scotland, a total cohort of 8714 patients had open surgery in the upper abdomen which was considered likely to cause adhesions. This compared to 12 585 undergoing open surgery in the lower abdomen (mid hindgut) and 8489 in the female reproductive tract. The majority of patients in this cohort underwent open surgery on the gallbladder (44·4 per cent) or stomach (20·6 per cent). During the 10-year study 3293 individuals (37·8 per cent) required one or more readmissions for surgical or medical treatment for conditions either related to adhesions or involving a reoperation which could be complicated by adhesions. In total, 7048 surgical or medical readmissions were identified, with a mean of 2·1 readmissions per patient. At least 321 (4·6 per cent) of these readmissions were a direct result of abdominal or pelvic adhesions, constituting a large clinical burden. Analysis of readmissions over time showed that this burden continued steadily over the 10-year study period. As well as this workload burden, there was a risk for the patient associated with open surgery on the foregut with a mean of 3·7 readmissions for direct adhesion complications for every 100 initial procedures. This rate varied according to the site of initial surgery: 3·0 per 100 procedures for open surgery of the gallbladder, 3·5 per 100 for the stomach and 7·3 per 100 for open surgery on the pancreas.

Conclusion

The SCAR study provides the first epidemiological assessment of postoperative adhesions. Using an extremely conservative view, the medical and surgical impact following open surgery in the upper abdomen is considerable with 4·6 per cent of readmissions over a 10-year period directly attributable to adhesions. The full impact of adhesions, including their effect on subsequent surgery, is likely to be considerably greater and extensive research is being progressed with the SCAR data set to investigate further the burden and associated costs, and optimum strategies to reduce the problem.

Objective comparison of stapled anopexy and open hemorrhoidectomy: a randomized, controlled trial

PURPOSE

This trial compares stapled anopexy with open hemorrhoidectomy in patients with prolapsing (Grade 3) hemorrhoids. Particular attention was paid to changes in anorectal physiology, nature of tissue resected, quality-of-life assessments, and cost implications of the treatments studied.

METHODS

An initial pilot study was followed by a randomized, controlled trial in a District General Hospital in the United Kingdom. All patients had Grade 3 hemorrhoids. Nineteen patients were studied in the pilot study, with 99 patients in the randomized, controlled trial. All patients in the pilot study and 59 in the randomized, controlled trial underwent stapled anopexy. Thirty patients in the randomized, controlled trial underwent open hemorrhoidectomy. Of the 59 patients in the stapled group, 32 were treated with the Ethicon PPH stapling device, and 27 received stapling with a reusable Autosuture stapling device. The following variables were measured: demographic details, quality of life (Medical Outcomes Study Short Form 36 and directed questions), anorectal manometry, and histology.

RESULTS

There was no difference in the case mix within or between the groups. The stapled anopexy groups showed a significant reduction in operative time (P < 0.001) and blood loss (P < 0.001) compared with open hemorrhoidectomy. Open hemorrhoidectomy resulted in significantly greater usage of protective pads postoperatively (P < 0.001) and longer rehabilitation (P < 0.006).

CONCLUSIONS

Stapled anopexy is an effective alternative treatment for prolapsing hemorrhoids that allows reduced operative time and shorter rehabilitation. It does not appear to affect continence or overall quality of life.

Abdominal situs inversus in a Holstein calf

Situs inversus is a rare congenital anomaly wherein the normal, left-right organ location is inverted. The anatomical inversion (heterotaxy) is usually detected in routine radiography or other medical interventions. A 5-month-old Holstein heifer calf was identified as a suspected situs inversus totalis during abdominal surgery. Following surgery the calf did not gain weight. On admission to the Ontario Veterinary Hospital, it was given a routine clinical examination and a detailed cardiovascular, Doppler ultrasound examination, which appeared normal. Because of declining health and chronic bloating in the heifer, euthanasia was performed. A detailed post-mortem dissection was carried out. No heart or lung anomalies were detected. Other thoracic organs were normal, except for a helical coil of the esophagus as it traversed the diaphragm. The rumen was located entirely on the right side of the abdomen and had a large area of adhesion to the parietal peritoneal wall. The left kidney was abnormally placed: retroperitoneal and cranial to the right. There were two spleens. The caudal vena cava was distended and twisted to the left. Thus the calf was situs inversus abdominalis. This suggests that the development of laterality in the early embryo may include both timing and positional regulation.

A noncontact wound measurement system

The instrument described in this manuscript was developed to perform objective, quantitative measurements of wound healing, which will enable service providers to assess, improve, and individualize the treatment given to each wound patient. It was designed to produce measures that will enable the care provider to assess the current state of the wound as well as gain insight into the time course of the wound healing by comparing the series of wound data collected over time. The record provided by the instrument could also assist in legal defense; a need that, unfortunately, cannot be ignored. The system uses a structured lighting pattern captured on a digital photograph of a wound to calculate the area and volume of debrided wounds. We used plaster molds with spherical indentations to represent various wounds to evaluate the precision of the system. Results indicate that when at least 144 of the data points in the picture lie within the wound borders, the surface area and wound volume are repeatable and the precision is within +/-3% of the calculated values based on the geometry of the spherical indentation.

Nefiracetam improves Morris water maze performance following traumatic brain injury in rats

Nefiracetam, a pyrrolidone derivative, is a nootropic agent that has facilitated cognitive function in a wide variety of animal models of cognitive dysfunction. The purpose of this study was to investigate the efficacy of the chronic postinjury administration of nefiracetam (DM-9384) in improving cognitive performance following central fluid percussion brain injury in rats. Twenty-four hours following surgical preparation, a sham injury or a moderate fluid percussive injury (2.1 atm) was delivered. Nefiracetam was administered chronically (0 or 9 mg/kg, po, for sham animals and 0, 3, or 9 mg/kg for injured animals) on postinjury days 1-15. Cognitive performance was assessed using the Morris water maze (MWM) on postinjury days 11-15. Chronic administration of 3 and 9 mg/kg nefiracetam attenuated MWM deficits produced by central fluid percussive brain injury. Importantly, the MWM performance of the injured animals treated with 9 mg/kg did not significantly differ from uninjured, sham animals. The 9-mg/kg dose of nefiracetam did not have a positive or negative effect on MWM performance of uninjured animals. The results of the present experiment suggest that a nootropic such as nefiracetam may be an appropriate treatment for trauma-induced cognitive dysfunction.

Stereocontrolled construction of the A-ring of nitiol using a Pauson-Khand cycloaddition-ring fragmentation strategy

[reaction: see text] A stereocontrolled construction of the A-ring of nitiol (1) is presented. Key features in this approach are a diastereoselective Pauson-Khand cycloaddition and a Norrish type 1 fragmentation reaction.

Postoperative adhesions: ten-year follow-up of 12,584 patients undergoing lower abdominal surgery

PURPOSE

Postoperative adhesions are a significant problem after colorectal surgery. However, the basic epidemiology and clinical burden are unknown. The Surgical and Clinical Adhesions Research Study has investigated the scale of the problem in a population of 5 million.

METHODS

Validated data from the Scottish National Health Service Medical Record Linkage Database were used to define a cohort of 12,584 patients undergoing open lower abdominal surgery in 1986. Readmissions for potential adhesion-related disease in the subsequent ten years were analyzed. The methodology was conservative in interpreting adhesion-related disease.

RESULTS

In the study cohort 32.6 percent of patients were readmitted a mean of 2.2 times in the subsequent ten years for a potential adhesion-related problem. Although 25.4 percent of readmissions were in the first postoperative year, they continued steadily throughout the study period. After open lower abdominal surgery 7.3 percent (643) of readmissions (8,861) were directly related to adhesions. This varied according to operation site: colon (7.1 percent), rectum (8.8 percent), and small intestine (7.6 percent). The readmission rate was assessed to provide an indicator of relative risk of adhesion-related problems after initial surgery. The overall average rate of readmissions was 70.4 per 100 initial operations, with 5.1 directly related to adhesions. This rose to 116.4 and 116.5, respectively, after colonic or rectal surgery-with 8.2 and 10.3 directly related to adhesions.

CONCLUSIONS

There is a high relative risk of adhesion-related problems after open lower abdominal surgery and a correspondingly high workload associated with these readmissions. This is influenced by the initial site of surgery, colon and rectum having both the greatest impact on workload and highest relative risk of directly adhesion-related problems. The study provides sound justification for improved adhesion prevention strategies.

Transcervical insemination techniques in the bitch

The benefits of using endoscopic TCI for frozen semen come from being able to achieve the same or better results without the need and risks of general anesthesia and surgery. The ability to do all fresh and chilled inseminations this way will certainly improve conception rates without the owner having to make a decision about exposing their bitch to the risks of anesthesia and surgery. The other potential uses open up a whole new field for canine theriogenology. Above all, the client response to the technique is overwhelmingly positive. At times the learning process will be discouraging, but the end result is worth the effort. The endoscope should not be treated as something special for frozen semen insemination but should be used at every opportunity in order to develop experience and expertise in all situations.

Equipment specifications for supported treadmill ambulation training

Supported Treadmill Ambulation Training (STAT) is a mode of therapy for gait retraining for patients with spinal cord injuries or other upper motor neuron dysfunction. The STAT program involves simultaneously supporting a portion of the patient's weight while gait training on a treadmill. STAT has been successful in improving the gait of many research subjects, but has not been widely applied in clinical practice. The goal of this study was to acquire practical, clinically useful information regarding this therapeutic intervention in order to remove barriers to its use. This manuscript enumerates equipment specifications for the treadmill, body weight support (BWS) system, and harness. The ergonomics of the work space are also considered, since the therapist(s) will need access to the patient's legs during therapy. The specific recommendations were determined through prior clinical experience, consultation of anthropometric tables, and application of engineering principles. The guidelines listed are intended to facilitate safe and effective application of the therapy at minimum hardware cost.

Positive and negative modulation of the GABA(A) receptor and outcome after traumatic brain injury in rats

Glutamate-mediated excitotoxicity has been shown to contribute to cellular dysfunction following traumatic brain injury (TBI). Increasing inhibitory function through stimulation of gamma-aminobutyric acid (GABA(A)) receptors may attenuate excitotoxic effects and improve outcome. The present experiment examined the effects of diazepam, a positive modulator at the GABA(A) receptor, on survival and cognitive performance in traumatically brain-injured animals. In experiment 1, 15 min prior to central fluid percussion brain injury, rats (n=8 per group) were injected (i.p.) with saline or diazepam (5 mg/kg or 10 mg/kg). Additional rats (n=8) were surgically prepared but not injured (sham-injury). Rats pre-treated with the 5 mg/kg dose of diazepam had significantly lower mortality (0%) than injured, saline-treated rats (53%). Also, diazepam-treated (5 mg/kg) rats had significantly shorter latencies to reach the goal platform in the Morris water maze test performed 11-15 days post-injury. In experiment 2, at 15 min post-injury, rats were given either saline (n=5) or 5 mg/kg diazepam (n=6). Rats treated with diazepam did not differ in mortality from injured rats treated with vehicle. However, rats treated with diazepam at 15 min post-injury had significantly shorter latencies to reach the goal platform in the Morris water maze than injured, vehicle-treated rats. In experiment 3, the post-injury administration of bicuculline (1.5 mg/kg, n=8), a GABA(A) antagonist, increased Morris water maze goal latencies compared to injured animals treated with saline (n=8). These results suggest that enhancing inhibitory function during the acute post-injury period produces beneficial effects on both survival and outcome following experimental TBI.