Defining core patient descriptors for perforated peptic ulcer research: international Delphi

BACKGROUND

Perforated peptic ulcer (PPU) remains a common condition globally with significant morbidity and mortality. Previous work has demonstrated variation in reporting of patient characteristics in PPU studies, making comparison of studies and outcomes difficult. The aim of this study was to standardize the reporting of patient characteristics, by creating a core descriptor set (CDS) of important descriptors that should be consistently reported in PPU research.

METHODS

Candidate descriptors were identified through systematic review and stakeholder proposals. An international Delphi exercise involving three survey rounds was undertaken to obtain consensus on key patient characteristics for future research. Participants rated items on a scale of 1-9 with respect to their importance. Items meeting a predetermined threshold (rated 7-9 by over 70 per cent of stakeholders) were included in the final set and ratified at a consensus meeting. Feedback was provided between rounds to allow refinement of ratings.

RESULTS

Some 116 clinicians were recruited from 29 countries. A total of 63 descriptors were longlisted from the literature, and 27 were proposed by stakeholders. After three survey rounds and a consensus meeting, 27 descriptors were included in the CDS. These covered demographic variables and co-morbidities, risk factors for PPU, presentation and pathway factors, need for organ support, biochemical parameters, prognostic tools, perforation details, and surgical history.

CONCLUSION

This study defines the core descriptive items for PPU research, which will allow more robust synthesis of studies.

Rectal cancer: prognostic indicators of long-term outcome in patients considered for surgery

PURPOSE

Patients and clinicians seek an accurate prognosis after resectional surgery for rectal cancer. The aim of this study was to determine long-term outcomes after potentially curative surgery for rectal cancer with particular focus on factors associated with longer-term survival that are available to surgeons in the early post-operative setting.

METHODS

We conducted a retrospective review of a prospectively gathered database of all primary rectal adenocarcinomas considered for surgery in the University Hospitals of Leicester National Health Service (NHS) Trust between 1998 and 2007. Survival was calculated using a Kaplan-Meier method. Factors thought to be associated with survival were subjected to univariate analysis followed by Cox proportion regression.

RESULTS

One thousand and twelve patients with primary rectal adenocarcinoma diagnosed between 1998 and 2007 were identified. Eight hundred and fifty three patients did not have metastases at the time of presentation and 726 patients underwent major resectional surgery. Five-year survival was 66 %. Patients' age, Dukes' stage, UICC stage, nodal involvement and circumferential resection margin status were independently associated with long-term survival on multivariate analysis.

CONCLUSION

This is one of the largest series of rectal cancers from a single NHS trust. We have demonstrated that age, Dukes' stage and CRM status are associated with long-term survival. These clinical factors are readily available to the surgeon at the time of first post-operative review and can provide a good clinical guide to prognosis.

A transperineal approach to perineal hernia repair using suture anchors and acellular porcine dermal mesh

Perineal hernia following major pelvic surgery is a rare but recognised complication. Various surgical approaches to the repair of a symptomatic perineal hernia have been described. We describe the first reported use of the Mitek suture anchors to secure an acellular porcine dermal graft to the ischia during the transperineal repair of a large perineal hernia.

Nonresectional palliative abdominal surgery for patients with advanced colorectal cancer

OBJECTIVE

Nonresectional palliative abdominal surgery (e.g. defunctioning stoma/bypass) may be appropriate for patients unsuitable for curative resection, to deal with complications of advanced colorectal malignancy such as obstruction. Our aim was to review the outcome of surgery in these patients within our institution.

METHOD

All patients undergoing palliative surgery without resection for colorectal carcinoma between July 1998 and January 2007 were identified from our prospectively compiled colorectal cancer database. Data were extracted related to patients' demographics, presentation, tumour site, operative intervention, complications, oncological therapies, length of hospital stay and postoperative survival.

RESULTS

One hundred and ninety-three patients were identified with a median age of 79 years (31-94 years). Fifty per cent were operated on an emergent basis for obstruction or perforation, and 50% on an elective basis. One hundred and sixty-nine patients had defunctioning stomas formed of which 156 were loop stomas. Twenty-four patients underwent bypass procedures. Thirty-day mortality rate was 13.5% and postoperative morbidity rate 47%. Median survival was 247 days, with 1-year survival of 38%. Patients undergoing operation on an emergent basis had poorer long-term survival (127 vs 320 days, P = 0.002).

CONCLUSION

Nonresectional palliative abdominal surgery is associated with relatively high morbidity and mortality, particularly when performed in the emergency setting. However, in this patient group with a very poor outlook, it may be offered with reasonable survival expectations.

Restorative proctocolectomy. Does ethnicity affect outcome?

OBJECTIVE

Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) is well-established in the management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). We review outcome of pouch surgery from a single centre, comparing non-South Asian and South Asian Caucasian populations.

METHOD

Patients undergoing RPC for UC and FAP during a 10-year period between January 1997 and January 2007 were identified from hospital records. Data were collected retrospectively from case notes on early and long-term results.

RESULTS

A total of 107 patients underwent pouch formation for UC (94%) or FAP (6%) and 22 (21%) were from the Asian subcontinent. Eighty-seven (81%) underwent a three-stage procedure and 20 (19%) a two-stage procedure. Postoperative complications occurred in 40 (37%) patients, being major in 11 (10%) patients with relaparotomy required in 9 (8%) with no difference between South Asian and non-South Asian Caucasian patients. Long-term pouch function, with a median of five times over 24 h (range 2-15), was similar between the two groups. The incidence of pouchitis was 57 (53%) and this was significantly greater in the South Asian population [17/21 (77%); 39/86 (46%); P = 0.006].

CONCLUSION

Surgical results were similar in South Asian and non-South Asian Caucasian patients, but the incidence of pouchitis was greater in the former group.

Colorectal cancer: presentation and outcome in British South Asians

AIM

Colorectal cancer (CRC) has a lower incidence in patients of South Asian origin compared with British Caucasians. There are however little data available regarding the demographics of these patients, their presentation and outcome. Leicester has a high South Asian immigrant population, and we aim to define any potential differences in presentation, pathogenesis and outcome between our Caucasian and South Asian ethnic groups.

METHOD

All patients of South Asian origin were identified from the Leicester CRC database between June 1998 and April 2007. Data were analysed regarding the patients' demographics, the presentation and treatment details, tumour characteristics and clinical outcome. Data were compared with Caucasian patients from the same database. Patients from an ethnic background other than South Asia or Caucasians were excluded from analysis.

RESULTS

3435 patients were included in the analysis, of which 134 (3.9%) were of South Asian ethnicity. 61.9% of South Asian patients were male compared with 56% of Caucasians. South Asians were significantly younger at presentation (61.4 vs 70.6 years, P < 0.001). South Asian patients had significantly more rectal tumours than their Caucasian counterparts (P = 0.002). South Asian patients were more likely to require initial oncological therapy, and were less likely to have resectional surgery than Caucasians (P = 0.006). Of the patients undergoing resectional surgery, the ASA grade, mode of surgery, tumour characteristics and Dukes' stage were similar. There was no difference in 5-year survival between the South Asian and Caucasian patients.

CONCLUSION

Patients of South Asian ethnicity are younger at their age of presentation and have a higher proportion of rectal tumours compared with British Caucasian patients. They are more likely to require initial oncological treatment and are less likely to undergo resectional surgery, therefore suggesting more advanced disease at presentation. Overall 5-year survival is the similar.

Enteral Clostridium difficile, an emerging cause for high-output ileostomy

The loss of fluid and electrolytes from a high-output ileostomy (>1200 ml/day) can quickly result in dehydration and if not properly managed may cause acute renal failure. The management of a high-output ileostomy is based upon three principles: correction of electrolyte disturbance and fluid balance, pharmacological reduction of ileostomy output, and treatment of any underlying identifiable cause. There is an increasing body of evidence to suggest that Clostridium difficile may behave pathologically in the small intestine producing a spectrum of enteritis that mirrors the well-recognised colonic disease manifestation. Clinically this can range from high-output ileostomy to fulminant enteritis. This report describes two cases of high-output ileostomy associated with enteric C difficile infection and proposes that the management algorithm of a high-output ileostomy should include exclusion of small bowel C difficile.

Terminal Ileum Perforation as a Consequence of a Migrated and Fractured Oesophageal Stent

Covered self-expanding metallic stents are commonly employed to relieve malignant oesophageal obstruction. We report a case of a patient with oesophageal cancer treated by stent insertion and curative chemoradiotherapy with subsequent stent migration to the stomach. The stent fractured with the distal fragment migrating as far as the terminal ileum where it caused perforation of the bowel.

Assessment of a patient consultation questionnaire-based scoring system for stratification of outpatient risk of colorectal cancer

BACKGROUND

The UK government's fast-track 2-week wait (2WW) rule and colorectal cancer guidelines aimed to detect patients at high risk of having colorectal cancer, but the yield has been poor. A patient consultation questionnaire (PCQ)-based scoring system may be an effective tool for prioritizing colorectal referrals. The aim of this study was to validate the system in a large and ethnically diverse population and to compare it with 2WW referrals.

METHODS

Over a 1-year period, all colorectal referrals (2WW and traditional letters) at nine hospitals in Leicestershire were sent a PCQ to complete and return. A weighted numerical score (WNS), which reflects the patient's risk of having colorectal cancer, was calculated and compared with the hospital diagnosis.

RESULTS

Of a total of 1422 PCQs returned, 83 patients were diagnosed with colorectal cancer. The 2WW referrals constituted 35.7 per cent of all referrals. The mean WNS of patients with colorectal cancer was significantly higher than that of the other patients (mean 76.3 versus 48.9 respectively; P < 0.001). For similar cancer detection rates (or sensitivity), the specificity of a WNS cut-off of 70 was significantly better than that of the 2WW system (82.7 versus 66.1 per cent; P < 0.001).

CONCLUSION

The PCQ-based WNS system improves specificity for detecting colorectal cancer, particularly when the WNS exceeds 70.

Factors that influence the adequacy of total mesorectal excision for rectal cancer

OBJECTIVE

In 1997 with the start of CRO7 trial it was agreed that adequacy of surgical resection of rectal cancer would be determined by a pathologically determined grading of the mesorectum the so called total mesorectal excision score (TME score). Scores ranged from 1-3 with 3 being a perfect specimen. The aim of this study was to investigate factors which may influence TME scores and establish if local recurrence is related to them.

METHOD

Data on all patients undergoing resectional surgery for rectal cancer in our unit are entered prospectively onto a database. Pathology reports of those patients who underwent total mesorectal excision were examined and the TME scores added to the database. Categorical variables were analysed using the chi2 test, continuous variables using ANOVA. Statistical significance was taken as P < 0.05.

RESULTS

Between January 2000 and June 2005, 518 patients underwent surgery for adenocarcinoma of the rectum, of these, 287 patients had a total mesorectal excision for mid or lower third tumours under the care of seven colorectal surgeons. All resected specimens were scored by a Consultant GI pathologist. Two hundred and fourteen patients underwent anterior resection and 73 underwent abdomino-perineal resection. The median age of the patients was 73 years (range 38-95 years). One hundred and ninety-four patients were male. Seventy-eight patients were treated with preoperative radiotherapy, 59 short course and 19 long course. TME scores were TME1 n = 30, TME2 n = 99, TME3 n = 158. Fifteen patients developed local pelvic recurrence at 2 years. Total mesorectal excision scores were not statistically influenced by Dukes' stage, width of tumour, preoperative radiotherapy or grade of surgeon. Male patients were statistically more likely to have a TME score of 2 or 3 compared with female P = 0.04. Patients undergoing an anterior resection were statistically more likely to have a TME score of 2 or 3 compared with abdomino-perineal resection P = 0.0001. Tumours with a circumferential resection margin (CRM) of more than 1 mm were more likely to have a TME score of 2 or 3 score (P = 0.0001). There was no relationship between TME and local recurrence (P = 0.966).

CONCLUSION

There is no relationship between the TME score in patients undergoing resectional surgery for adenocarcinoma of the rectum and the development of local recurrence at 2 years. Other factors such as CRM involvement are more likely to have an impact on local recurrence. The factors that influence the quality of TME are the operative procedure of anterior resection, male gender and CRM positivity. There appear to be no deleterious effects on the TME score by Specialist Registrars performing the operation under Consultant supervision. While TME scores may be an index of a technical performance, they appear to have little role in predicting future outcomes.

Computer Aided Design Using a Knowledge Base Approach and its Application to the Design of Jigs and Fixtures

The design of jigs and fixtures is generally on the critical path of a new product and thus speed is essential in both their design and subsequent manufacture. They must also be well and economically designed. This paper describes an interactive C ADC AM based jig and fixture design procedure which has been developed using a knowledge base which could subsequently become part of an expert system. The approach used both increases the speed of design and encourages designers to improve standardization to speed manufacture. The procedure starts with the component which is to be machined and ends by producing a general arrangement and detail drawings of a finished jig. The paper describes the elements of the software package, JIGS, which implements the procedure. JIGS is shown to offer designers considerable flexibility in its use.

Unreasonable expectations in emergency colorectal cancer surgery

OBJECTIVES

The recently published ACPGBI colorectal cancer (ACPGBI CRC) scoring system for predicting operative mortality has been suggested as an instrument to improve patient consent procedures and to compare results between centres. This study compares the results of a surgical unit against the standards set by the ACPGBI colorectal cancer model and for emergency surgery, against the p-POSSUM instrument.

METHODS

Data for the ACPGBI CRC model were collected prospectively through 2003 at the Leicester Royal Infirmary. Additional data needed for the p-POSSUM was retrospectively collected from case records. The actual mortality was compared with that predicted by the models.

RESULTS

Seventy-two colorectal cancer operations were performed during the study period. The observed operative mortality in elective cases was lower, and in emergency cases higher, than predicted by the ACPGBI CRC model. With emergency cases the predicted mortality using P-POSSUM was significantly higher than that using the ACPGBI CRC model, particularly in the presence of faecal contamination.

CONCLUSION

The ACPGBI CRC model may be accurate for elective cases, but appears to significantly underestimate predicted mortality in the emergency setting, both actual and predicted by p-POSSUM. This may be due to a failure to incorporate adequate weighting for faecal peritonitis and the associated systemic insult into the ACPGBI model.

Constitutive activation of extracellular signal-regulated kinase 2 by synergistic point mutations

Constitutively active mutant forms of signaling enzymes provide insight into mechanisms of activation as well as useful molecular tools for probing downstream targets. In this study, point mutations in ERK2 at conserved residues L73P and S151D were identified that individually led to 8-12-fold increased specific activity and in combination reached 50-fold, indicating synergistic interactions between these residues. Examination by mass spectrometry, phosphatase sensitivity, and Western blotting revealed that the mutations enhanced ERK2 activity by facilitating intramolecular autophosphorylation predominantly at Tyr-185 and to a lesser extent at Thr-183 and that phosphorylation at both sites is required for activation. A set of short molecular dynamics simulations were carried out using different random seeds to sample locally accessible configurations. Simulations of the active mutant showed potential hydrogen bonding interactions between the phosphoryl acceptor and catalytic nucleophile, which could account for enhanced intramolecular autophosphorylation. In intact cells, the ERK2 mutants were functionally active in phosphorylating Elk-1 and RSK1 and activating the c-fos promoter. This activity was only partially reduced upon treatment of cells with the MKK1/2 inhibitor, U0126, indicating that in vivo the mechanism of ERK2 activation occurs substantially through autophosphorylation and partially through phosphorylation by MKK1/2.

Pemphigus vulgaris: clinicopathologic review of 33 cases in the oral cavity

A retrospective study was conducted on all cases of pemphigus vulgaris occurring on oral mucosal surfaces in the files of the Oral Pathology Laboratory at Temple University from 1974 to 1996. A total of 35 biopsies from 33 patients were reviewed, 25 female and eight male. Patient ages ranged from 27 to 79 years; the mean age was 56.5. The most common clinical complaint was of painful ulcers that failed to resolve within several weeks. Thirty patients had no known history of pemphigus, while in three patients a history of pemphigus was known. The most common clinical impression was that of mucous membrane pemphigoid, but the differential diagnosis included other vesiculoerosive conditions.

The effect of pelvic ileal reservoir volume and antiperistaltic reflux on emptying efficiency

PURPOSE

The emptying efficiency of four different designs of pelvic ileal reservoir was compared using two different techniques of measurement.

METHOD

Thirty-four patients were studied one year after restorative proctocolectomy. In each the ileal reservoir was filled with methyl cellulose paste labeled with 51chromium-chromate and technetium Tc 99m-diethylenetriamine pentaacetic acid. Percentage evacuation was calculated from 1) the difference in 51chromium activity between the recovered effluent and the total paste administered and 2) gamma camera measurements of technetium Tc 99m-diethylenetriamine pentaacetic acid activity within the ileal reservoir before and after evacuation.

RESULTS

Median evacuation using the 51chromium method was 84, 90, 70, and 75 percent for the W40, W30, J40, and J30 reservoirs respectively. The results were not significantly different from those obtained using the gamma camera: 83, 87, 67, and 71 percent (P = not significant). Patients with either type of W reservoir evacuate isotope-labeled paste more efficiently than patients with J40 reservoirs (P < 0.05 and P < 0.001, respectively) but not J30 reservoirs (P = not significant). However, if the actual volume of paste evacuated during a visit to the lavatory is measured, it is greatest for J40 reservoirs (median, 300 ml compared with 258 ml for W40, 289 ml for W30, and 268 ml for J30; P = not significant).

CONCLUSIONS

Gamma camera measurement of ileal reservoir emptying is as accurate as our previous standard technique and provides a qualitative record of pouch evacuation, which may reveal reasons for inefficient emptying. The gamma camera images reveal that the difference in emptying percentage between W and J pouches is because of reflux of paste into the afferent ileum occurring more frequently in J pouches than in W pouches. The effect of this phenomenon on emptying is more than compensated for by the increase in reservoir capacity created by the reflux.

CD22 forms a quaternary complex with SHIP, Grb2, and Shc. A pathway for regulation of B lymphocyte antigen receptor-induced calcium flux

CD22 is a cell surface molecule that regulates signal transduction in B lymphocytes. Tyrosine-phosphorylated CD22 recruits numerous cytoplasmic effector molecules including SHP-1, a potent phosphotyrosine phosphatase that down-regulates B cell antigen receptor (BCR)- and CD19-generated signals. Paradoxically, B cells from CD22-deficient mice generate augmented intracellular calcium responses following BCR ligation, yet proliferation is decreased. To understand further the mechanisms through which CD22 regulates BCR-dependent calcium flux and proliferation, interactions between CD22 and effector molecules involved in these processes were assessed. The adapter proteins Grb2 and Shc were found to interact with distinct and specific regions of the CD22 cytoplasmic domain. Src homology-2 domain-containing inositol polyphosphate-5'-phosphatase (SHIP) also bound phosphorylated CD22, but binding required an intact CD22 cytoplasmic domain. All three molecules were bound to CD22 when isolated from BCR-stimulated splenic B cells, indicating the formation of a CD22.Grb2.Shc.SHIP quaternary complex. Therefore, SHIP associating with CD22 may be important for SHIP recruitment to the cell surface where it negatively regulates calcium influx. Although augmented calcium responses in CD22-deficient mice should facilitate enhanced c-Jun N-terminal kinase (JNK) activation, BCR ligation did not induce JNK activation in CD22-deficient B cells. These data demonstrate that CD22 functions as a molecular "scaffold" that specifically coordinates the docking of multiple effector molecules, in addition to SHP-1, in a context necessary for BCR-dependent SHIP activity and JNK stimulation.

Work stressors and alcohol consumption among white-collar workers: a signal detection approach

OBJECTIVE

Previous findings regarding the relationship between work stress and alcohol consumption are inconsistent and inconclusive. One of the primary reasons for the inconsistency of the findings is that simple models, such as multiple regression analysis or analysis of variance (ANOVA), have been conventionally adopted in studies examining the relationship between work stressors and alcohol consumption. Since higher order interactions of multiple work stressors, which lead to heavy alcohol consumption, might not be fully uncovered within the framework of a multiple regression analysis or ANOVA, another approach to exploring the interactions of work stressors is presented in this study.

METHOD

A signal detection analysis method was used to evaluate higher order interactions of work stress variables and to obtain basic information on 465 Japanese male white-collar workers.

RESULTS

Of 11 work stressor or work position variables, four significant predictors of heavy alcohol consumption were identified.

CONCLUSIONS

Two procedures were successfully performed in this study: (1) evaluating several higher order interactions of work stressors associated with heavy alcohol consumption, and (2) obtaining basic information to permit dividing the subjects into subgroups for further analysis using models and independent variables unique to each subgroup.

Cell-cell and cell-substrate adhesion in cultured Drosophila imaginal disc cells

Drosophila imaginal disc cell lines were used to investigate various aspects of cellular adhesion in vitro. The distribution of PS integrins and their involvement in cell-cell and cell-substrate adhesion were assessed with the monoclonal antibody aBG-1 against the betaPS subunit, and both forms of adhesion were found to be impeded by the presence of the antibody. Adhesion to a number of extracellular matrix components was investigated, and the cells were found to adhere to human fibronectin. This adhesion was inhibited by aBG-1. The adhesion molecule fasciclin III was also found in these cells. Given that the cells are competent to perform cell-cell and cell-substrate adhesion, it was thought that apical basal polarity might be restored when other suitable conditions were provided, i.e., an artificial basement layer with feeder cells to provide nutrients basally to the cells, and some features of apical-basal morphology were seen in cells cultured under these conditions.

Adhesion of Drosophila imaginal disc cells in vitro

We have used our imaginal disc cell lines to carry out in vitro studies on the cell-cell and cell-substrate adhesion of Drosophila leg and wing disc cells. Single cells were allowed to reaggregate in roller culture, and this process was found to be partially dependent on the presence of magnesium and calcium ions in the suspension medium. Varying rates of reaggregation were observed in cells from different stages of a passage, correlating with the pattern of morphogenesis which occurs during the passage. We have demonstrated that cloned cell lines can be produced showing certain selected characteristics, such as reduced cell adhesiveness.

Screening and surveillance. OSHA's medical surveillance provisions

The OSH Act requires OSHA to include provisions for medical examinations of employees in its standards. However, the specific test and examinations criteria are not outlined in the OSH Act. Instead, each standard has specific medical surveillance requirements. These are specific to the adverse health effects triggered by exposure to the hazardous substance. The OSHA uses the term medical surveillance to refer to its employee examination and testing provisions. Most occupational health professionals call this activity employee screening and reserve the term surveillance for aggregate analysis of population data. It is important to remember this distinction when referring to OSHA standards. Many standards are challenged in court resulting in changes to medical surveillance provisions of the standards. Some court decisions support OSHA's language. In either case, the court often sets precedents for future standards.

CO2 laser sterilization in the surgical treatment of infected median sternotomy wounds

BACKGROUND

We examined the use of CO2 laser sterilization in the surgical treatment of infected median sternotomy wounds. Deep wound infection after median sternotomy is infrequent (1% to 5% of all cases) but is associated with significant morbidity, mortality, and cost.

METHOD

Twenty-four consecutive patients with median sternotomy wound infection were treated by one plastic surgeon using a CO2 laser to sterilize wounds after debridement and before flap closure. The rectus abdominis muscle flap was primarily used, but the choice of muscle flap was case dependent.

RESULTS

To date, no patient in this series has had postoperative wound infection, breakdown, or flap loss. One patient did have superficial skin loss.

CONCLUSION

Although the morbidity rate was 17%, all patients had intact wounds. None of the 5 deaths was related to wound infection. We found that CO2 laser sterilization in the surgical treatment of sternal wound infections decreased morbidity, mortality, and cost.

Absence of longitudinal changes in rheumatologic parameters after silicone breast implantation: a prospective 13-year study

There have been numerous questions regarding the association of polysiloxane with connective tissue disease and alteration of host immune response. C-reactive protein, rheumatoid factor, and anti-streptolysin-O titers were measured in 218 patients. These studies are routinely used in the diagnosis of autoimmune disease and mixed connective tissue disease. This prospective study has been in progress since 1985. The first patients were seen in July of 1985, and those individuals willing to participate were followed from 1985 to 1998. The implants included saline-filled elastomer shells and polysiloxane gel-filled elastomer shells. These groups were examined separately and in combination for changes between preoperative and postoperative states. In each instance, there was no statistical increase or decrease. Each patient underwent a physical examination and completed a questionnaire focusing on signs and symptoms of autoimmune and connective tissue diseases. The laboratory data and subjective clinical results demonstrated no significant differences between a nonimplanted group versus the saline group alone, the gel group alone, or the combined groups. The data failed to suggest any causal relationship between implants and autoimmune or connective tissue diseases over the study period of 13 years (since 1985).

Effects of intrastriatal cannabinoids on rotational behavior in rats: interactions with the dopaminergic system

The effect of unilateral intrastriatal cannabinoid receptor stimulation on rotational behavior in rats was explored. The potent cannabinoid agonist CP 55,940 (5 microg/0.5 microl) induced contralateral turning when microinjected unilaterally into the striatum. The D2 dopamine agonist quinpirole reversed this contralateral rotation but failed to affect motor behavior on its own. Finally, the D1 dopamine agonist SKF 82958 inhibited movement when administered into the striatum and this inhibition was reversed by co-administration of the cannabinoid agonist. Surprisingly, microinjections of the cannabinoid agonist into the striatum induced movement through activation of the striatonigral pathway and/or inhibition of the striatopallidal pathway, while the D1 dopamine agonist produced the opposite effect.

Local effects of cannabinoids on spontaneous activity and evoked inhibition in the globus pallidus

The globus pallidus has been identified as a site of action for the motor effects of cannabinoids. A previous report from this laboratory demonstrated that systemic administration of the potent and selective cannabinoid receptor agonist (R)-(+)-[2,3-dihydro-5-methyl-3-[(4-morpholinyl) methyl]pyrrolo[1,2,3-de]-1,4-benzoxazin-6-yl] (1-napthalenyl) methanone (WIN 55,212-2) inhibits rat pallidal neurons and reverses the inhibition of pallidal activity produced by electrical stimulation of the striatum. The current study used in vivo single unit electrophysiology/micropressure ejection to investigate whether the effects of cannabinoids on spontaneous activity and evoked inhibition in the globus pallidus are locally mediated. Micropressure ejection of either WIN 55,212-2 or CP 55,940 into the globus pallidus inhibited spontaneous activity in the globus pallidus. Local administration of the cannabinoid receptor antagonist, N-piperidino-5-(4-chlorophenyl)-1-(2,4-dichlorophenyl)-4-methyl-3-pyrazo le-carboxamide (SR141716A), did not produce an effect on its own but blocked the effect of WIN 55,212-2 on spontaneous activity of pallidal neurons. The decrease in pallidal activity produced by WIN 55,212-2 was not blocked by coadministration of bicuculline, suggesting this effect is independent of GABA(A) receptors. Micropressure ejection of cannabinoids into the globus pallidus did not reverse the inhibitory effect of striatal stimulation in the globus pallidus. Taken together, these findings suggest that pallidal cannabinoid receptors mediate an inhibition of spontaneous activity in the globus pallidus.

Squamous cell carcinoma of gingiva and edentulous alveolar ridge: a clinicopathologic study

All oral squamous cell carcinomas were retrieved from the files of Temple University's Oral Pathology Laboratory from 1967 through 1994 for a clinicopathologic study of those occurring on the gingiva. A total of 1,193 cases had sufficient data for tabulation and statistical analysis, of which 300 (25%) arose on the gingiva or alveolar ridge. The largest number of these cases (211/300) occurred on the mandibular gingiva or alveolar ridge. The mean age of the patients was 66.66 years, with males accounting for 57% of cases. Many case comparison analyses of oral squamous cell carcinomas do not separate oral subsites or specifically address carcinoma of the gingiva. The results were compared with other published series and suggest that further studies are needed because of the wide range of reported figures on the incidence of gingival squamous cell carcinomas.

Ipsilateral turning behavior induced by unilateral microinjections of a cannabinoid into the rat subthalamic nucleus

The subthalamic nucleus contains cannabinoid receptors and cannabinoid receptor mRNA. However, the role of cannabinoid receptors in this nucleus has not been examined. In order to investigate the functional role of cannabinoid receptors in the rat subthalamic nucleus, turning activity was observed following unilateral microinjection of the synthetic cannabinoid CP 55,940. CP 55,940 (10 microg) induced ipsilateral turning. This effect was blocked by coadministration of the cannabinoid receptor antagonist SR141716A (5 microg). These results suggest that cannabinoid receptors in the subthalamic nucleus mediate an inhibition of motor activity.

Paradoxical high anal resting pressures in men with idiopathic fecal seepage

PURPOSE

Fecal incontinence has been a matter of concern for many years, but seepage is poorly understood, especially in men.

METHODS

We compared the results of anorectal physiologic tests in a group of 16 male patients who complained of fecal soiling but had no previous history of anorectal surgery or disease and had normal clinical examinations with findings of 16 normal male controls. Physical examination and proctosigmoidoscopy were normal in each patient.

RESULTS

Maximum anal resting pressure (median interquartile range) was 136 (120-145) cm H2O in the "seepage" group and 104 (83-112) cm H2O in controls (P < 0.01). Inflation volumes at which patients and controls experienced rectal sensation were 45 (35-80) and 90 (75-100) ml of air, respectively (P < 0.01). Maximum tolerated volumes in the rectum were 130 (85-180) ml of air in the seepage group and 190 (140-240) ml of air in controls (P < 0.01). Median length of the anal sphincter was 3.75 (3.5-4) cm in patients and 3 (3-3.5) cm in controls (P < 0.01). Maximum squeeze pressures, sensation in the anal canal, and sphincter relaxation in response to rectal distention were similar in the two groups.

CONCLUSION

Male patients with "idiopathic" fecal seepage have a long anal sphincter with abnormally high resting tone.

Organ transplanting in Japan: the debate begins

OBJECTIVES

Japan is currently considering changing its long-standing policy of banning most organ transplants. This paper reviews the current state of organ transplantation in Japan and presents results from a recently conducted survey regarding attitudes toward the removal of organs from brain-dead donors, and potential methods of allocating those organs in a fair manner.

METHODS

Survey data were collected by the Research Project Team on Network Systems for Organ Transplants funded by the Japanese Ministry of Health and Welfare. The sample consisted of 1093 randomly selected citizens. Predictors of attitudes supporting organ transplantation were analyzed using logistic regression.

RESULTS

Although many Japanese people support organ transplantation, few are willing to donate their organs. General knowledge of transplantation was the best predictor of support for such a program and willingness to donate organs. In addition, younger respondents and male respondents were more likely to support programs and donate organs. Implications of these results are discussed.

Association between attitudes toward health promotion and opinions regarding organ transplants in Japan

Health promotion activities to educate the public about health lifestyles have been performed widely in industrialized countries where chronic adult diseases have become prevalent. According to a basic principle of health promotion activities, the symptoms of many diseases are regarded as the result of inadequate health behavior, curable by modifying health behavior. It is thus possible that an exposure to health promotion activities might instill negative attitudes towards organ transplants, because program participants may conclude that persons who need an organ transplant have become unhealthy as the result of their own poor health habits. In this study, two types of surveys were undertaken to test this hypothesis. The subjects of the first cross-sectional study were 712 male and female Japanese citizens, and those of the second case-control study were 240 female company employees in Japan. In the first study, a logistic regression analysis was used and the following findings were obtained. (1) Compared with the persons who felt that they did not have enough practical knowledge about individual health practices, those who felt that they had adequate knowledge were 0.66 times less likely to support organ transplants. (2) Compared with those who were not willing to spend money on healthful things, the persons who were willing to do so were 0.51 times less likely to support organ transplants. In the second case-control study, it was revealed that the subjects who had negative attitudes towards organ transplants had consistently healthier lifestyles than did those who had positive attitudes towards organ transplants. Based upon the present findings and the nature of the basic principles of health promotion activities, we infer that community health promotion activities have a negative influence upon citizens' opinions of organ transplants. Since these findings have health policy implications, more studies are necessary to conclusively evaluate the effects of health promotion activities upon attitudes toward organ transplants.

Regulation of B lymphocyte development and activation by the CD19/CD21/CD81/Leu 13 complex requires the cytoplasmic domain of CD19

B lymphocyte development and function are regulated in part by the CD19 cell surface receptor complex, which is composed of at least four proteins; CD19, CD21 (CR2, complement receptor 2), CD81, and Leu 13. Because this complex has eight membrane-spanning domains and six cytoplasmic regions, determining the molecular basis for its function and signal transduction activities has not been straightforward. In this study, the contribution of the CD19 cytoplasmic domain to the in vivo function of the CD19/CD21/CD81/Leu 13 complex was assessed by generating CD19-deficient mice that expressed a transgene that encoded only the extracellular and transmembrane domains of CD19. Mice expressing this transgene were similar, if not identical, to CD19-deficient mice with abnormal B cell development, a lack of B-1 cells, increased surface IgM levels on B cells, modest mitogen responses, minimal serum Ig levels, and low humoral immune responses. The results of this study indicate that specific signals generated through the cytoplasmic domain of CD19 are essential for B lymphocyte development and function, and that CD19 is the dominant signaling component of the CD19 complex. Moreover, expression of the CD19 cytoplasmic domain is required for optimal signaling through the B cell Ag receptor complex.

Regulation of B lymphocyte development and activation by the CD19/CD21/CD81/Leu 13 complex requires the cytoplasmic domain of CD19

B lymphocyte development and function are regulated in part by the CD19 cell surface receptor complex, which is composed of at least four proteins; CD19, CD21 (CR2, complement receptor 2), CD81, and Leu 13. Because this complex has eight membrane-spanning domains and six cytoplasmic regions, determining the molecular basis for its function and signal transduction activities has not been straightforward. In this study, the contribution of the CD19 cytoplasmic domain to the in vivo function of the CD19/CD21/CD81/Leu 13 complex was assessed by generating CD19-deficient mice that expressed a transgene that encoded only the extracellular and transmembrane domains of CD19. Mice expressing this transgene were similar, if not identical, to CD19-deficient mice with abnormal B cell development, a lack of B-1 cells, increased surface IgM levels on B cells, modest mitogen responses, minimal serum Ig levels, and low humoral immune responses. The results of this study indicate that specific signals generated through the cytoplasmic domain of CD19 are essential for B lymphocyte development and function, and that CD19 is the dominant signaling component of the CD19 complex. Moreover, expression of the CD19 cytoplasmic domain is required for optimal signaling through the B cell Ag receptor complex.

Lymphangiomas of the oral cavity: a clinicopathologic, immunohistochemical, and electron-microscopic study

PURPOSE

This study evaluated the demographics, treatment outcomes, histology, and basement lamina characteristics of a large series of lymphangiomas.

MATERIAL AND METHODS

Forty-seven lymphangiomas of the oral cavity were evaluated microscopically and representative specimens were also evaluated immunohistochemically (IMH) and by electron microscopy (EM).

RESULTS

Patient's ages ranged from 2 to 84 years. The dorsal surface of the tongue was the most common site. Discontinuities in the basement membrane were detected with IMH and EM.

CONCLUSION

The discontinuous basement membrane may explain why sclerosing agents have not been effective as a form of treatment for lymphangioma.

Ligation of L-selectin through conserved regions within the lectin domain activates signal transduction pathways and integrin function in human, mouse, and rat leukocytes

L-selectin is a cell surface adhesion receptor that mediates leukocyte rolling along vascular endothelium at sites of inflammation and lymphocyte attachment to endothelial cells within peripheral lymphoid tissues. Since ligation of L-selectin through its ligand recognition region may mimic physiologic ligand binding, a new panel of mAbs that engaged a conserved ligand-binding region within the lectin domains of human, mouse, and rat L-selectin were generated using L-selectin-deficient mice. Indeed, appropriate ligation of L-selectin generated transmembrane signals that resulted in immediate intercellular adhesion following cell-cell contact of lymphocytes, neutrophils, and L-selectin cDNA-transfected cells. Ab binding to only some epitopes within the lectin domain of L-selectin induced adhesion, while mAb binding to numerous other epitopes or other domains of L-selectin had no effect. PPME (yeast polyphosphomonoester core polysaccharide), a complex carbohydrate that mimics the natural L-selectin ligand, also induced potent intercellular adhesion. The induction of intercellular adhesion required cellular energy, an intact cytoskeleton, and cytoplasmic kinase activity as well as the membrane proximal and cytoplasmic domains of L-selectin. Therefore, ligation of L-selectin through specific ligand-binding epitopes identified by the mAbs generated in this study can generate transmembrane signals. Signaling through L-selectin may enhance leukocyte-endothelial cell interactions by serving as an activation/priming step during rolling, thereby promoting subsequent firm cell-cell adhesion in the presence of inflammatory mediators.

Ligation of L-selectin through conserved regions within the lectin domain activates signal transduction pathways and integrin function in human, mouse, and rat leukocytes

L-selectin is a cell surface adhesion receptor that mediates leukocyte rolling along vascular endothelium at sites of inflammation and lymphocyte attachment to endothelial cells within peripheral lymphoid tissues. Since ligation of L-selectin through its ligand recognition region may mimic physiologic ligand binding, a new panel of mAbs that engaged a conserved ligand-binding region within the lectin domains of human, mouse, and rat L-selectin were generated using L-selectin-deficient mice. Indeed, appropriate ligation of L-selectin generated transmembrane signals that resulted in immediate intercellular adhesion following cell-cell contact of lymphocytes, neutrophils, and L-selectin cDNA-transfected cells. Ab binding to only some epitopes within the lectin domain of L-selectin induced adhesion, while mAb binding to numerous other epitopes or other domains of L-selectin had no effect. PPME (yeast polyphosphomonoester core polysaccharide), a complex carbohydrate that mimics the natural L-selectin ligand, also induced potent intercellular adhesion. The induction of intercellular adhesion required cellular energy, an intact cytoskeleton, and cytoplasmic kinase activity as well as the membrane proximal and cytoplasmic domains of L-selectin. Therefore, ligation of L-selectin through specific ligand-binding epitopes identified by the mAbs generated in this study can generate transmembrane signals. Signaling through L-selectin may enhance leukocyte-endothelial cell interactions by serving as an activation/priming step during rolling, thereby promoting subsequent firm cell-cell adhesion in the presence of inflammatory mediators.

Type A and Type B behaviors, work stressors, and social support at work

BACKGROUND

How Type A personality is related to the stress process has been investigated. However, in the occupational health field, stressful aspects of the work environment for Type A or B workers have not been fully revealed.

METHODS

In the present study, using signal detection analysis, we analyzed data concerning work stressors and social support (SS) at work among Japanese white-collar workers (n = 560) and identified the respective aspects of work that are stressful for Type A and B workers. We also evaluated the interactions of SS at work and stressor variables among Type A and B workers, individually.

RESULTS

Except for one significant predictor, i.e., being unable to learn new things at work, the significant predictors of mental stress were generally quite different for Type A and B workers. Specifically, SS from management was a cause of mental stress for certain groups of Type A workers.

CONCLUSIONS

It was revealed that the stressful aspects of work environment varied markedly in accord with the Type A vs Type B personality status of the subjects. The results also implied that even support from management can be stressful for Type A workers who had heavy workloads. The present study used specific measures sensitive to individual stressors and identified specific subgroups with the same work stressors. The findings provide information that is useful for stress reduction intervention.

Plasmacytoma of the oral cavity and jaws: a clinicopathologic study of 13 cases

Plasmacytoma of the jaw bones and oral cavity, as in other anatomic sites, comprises three distinct entities: multiple myeloma, solitary plasmacytoma of bone, and extramedullary plasmacytoma. This article is a retrospective study of 13 cases; 9 occurred in the mandible and 4 in the maxilla. The most common radiographic finding was a radiolucency that many times was superimposed on the roots or apices of nearby teeth. The most common symptom was localized pain, and the most frequent clinical sign was a raised red lesion on the alveolar ridge. The disease affects older persons, and the posterior mandible is the most frequently reported location. The degree of dysplasia of tumor cells was evaluated as there is a reported correlation with survival rates.

CD22 is both a positive and negative regulator of B lymphocyte antigen receptor signal transduction: altered signaling in CD22-deficient mice

B cell activation following antigen receptor cross-linking can be augmented in vitro by ligation of cell surface CD22, which associates with the SHP1 protein tyrosine phosphatase. The targeted deletion of CD22 in mice demonstrated that CD22 differentially regulates antigen receptor signaling in resting and antigen-stimulated B lymphocytes. B cells from CD22-deficient mice exhibited the cell surface phenotype and augmented intracellular calcium responses characteristic of chronically stimulated B cells, as occurs in SHP1-defective mice. Thus, CD22 negatively regulates antigen receptor signaling in the absence of antigen. However, activation of CD22-deficient B lymphocytes by prolonged IgM cross-linking resulted in modest B cell proliferation, demonstrating that CD22 positively regulates antigen receptor signaling in the presence of antigen.

Langerhans' cell histiocytosis: report of three cases with unusual oral soft tissue involvement

Three cases of Langerhans' cell histiocytosis (histiocytosis X) are reported in which the clinical presentations were (1) soft-tissue enlargements, (2) oral ulcerations, and (3) leukoplakia. Each case was without bone involvement at the time of diagnosis, and two patients were older than 60 years of age. Definitive diagnoses were aided with the use of immunohistochemistry.

[Problems related to organ transplantation as an allocation of scarce medical resources: a review]

The criteria for allocation of medical resources at three different stages which lead to organ transplantation are discussed, along with advantages and disadvantages. When each criterion was examined individually, it was difficult to determine the best criterion for selection of recipients of donated organs in the most ethically desirable fashion. However, when we examined the suggested criteria on the basis of an actual case, the efficacy of transplantation or expected length of the survival years was most often used as a criterion to select the recipients of donated organs. To increase more support for organ transplantation in our society, it is necessary to more fully discuss how scarce donated organs should be allocated to recipients in a fair and equitable manner.

Prospective controlled trial of duplicated (J) versus quadruplicated (W) pelvic ileal reservoirs in restorative proctocolectomy for ulcerative colitis

AIMS

A prospective randomised controlled trial was conducted to find out what influence the design of the pelvic reservoir had on the functional outcome.

PATIENTS AND METHODS

Sixty patients received either a duplicated (J) or a quadruplicated (W) reservoir, constructed with either 30 or 40 cm of ileum. Each patient underwent laboratory tests of anorectal function before and one year after operation.

RESULTS

One year after operation, 57 patients were available for assessment: each had good anal continence, though eight experienced minor leakage of mucus, and all were able to defer defecation for more than 15 minutes. Median bowel frequency in 24 hours (IQR) in patients with J reservoirs (5 (4-7)) did not differ significantly from that of patients with W reservoirs (5 (4-6)). Likewise, bowel frequency in patients with the smaller (30 cm) reservoirs did not differ significantly from bowel frequency in patients with the larger (40 cm) reservoirs. However, patients with large W40 reservoirs had the lowest bowel frequency of the four groups (median 4 per 24 hours, p = NS). The capacity and compliance of the W40 reservoirs were greater than those of the other types of reservoir, but the differences were not statistically significant.

CONCLUSIONS

These findings provide support for the use of a relatively small (30 cm), duplicated (J) ileal reservoir, which is simple to construct with linear stapling instruments.

Electrophysiological effects of a cannabinoid on neural activity in the globus pallidus

The globus pallidus contains a dense distribution of cannabinoid receptors and appears to be a site of action of cannabinoids in the production of catalepsy. Single unit electrophysiology was used to explore the role of cannabinoid receptors in the globus pallidus of the rat. Intravenous injections of the potent and selective synthetic cannabinoid (R)-(+)-[2,3-dihydro-5-methyl-3-[(4-morpholinyl)methyl]-pyrrolo [1,2,3-de]-1,4-benzoxazin-6-yl](1-napthalenyl) methanone (WIN 55,212-2; up to 0.5 mg/kg, i.v.) inhibited the spontaneous firing of neurons in the globus pallidus. In a second set of experiments, WIN 55,212-2 antagonized the inhibition of pallidal firing produced by electrical stimulation of the striatum. The pharmacological specificity of the effects of WIN 55,212-2 on basal and evoked activity in the globus pallidus was demonstrated by the lack of effect of the inactive enantiomer WIN 55,212-3. These results indicate that cannabinoids may produce functionally opposite effects on spontaneous and evoked activity in the globus pallidus: a decrease in spontaneous firing and a decrease in the inhibition of firing produced by the striatopallidal projection.

Does eversion of the anorectum during restorative proctocolectomy influence functional outcome?

PURPOSE

The aim of this study was to determine the effect of eversion of the anorectum during restorative proctocolectomy (RP) for ulcerative colitis on functional outcome.

METHODS

One hundred seventeen patients underwent RP with stapled end-to-end ileal pouch-anal anastomosis (EEA), without resection of the anal mucosa. Sixty-four underwent EEA with eversion of the anorectum, and 53 underwent EEA without eversion. Each patient underwent paired studies of anorectal function before and a median of 12 months after RP.

RESULTS

One year after RP, median (interquartile range) maximum resting pressure was 69 (range, 51-88) cmH2O in those patients who underwent eversion vs. 80 (range, 64-90) cmH2O in patients without eversion (P < 0.04). Threshold sensation in the upper, middle, and lower thirds of the anal canal were 9.1, 7.4, and 6.8 mA after eversion vs. 6.9, 4.9, and 3.8 mA without eversion (P = 0.003, P < 0.001, P < 0.001, respectively). Before operation, all patients had a rectoanal inhibitory reflex; however, after RP, 54 of 64 patients in the eversion group and 50 of 53 patients with a stapled EEA without eversion had an inhibitory reflex (P = not significant). Leakage of mucus was experienced by 11 patients who underwent eversion, compared with 9 patients without eversion. Fifty-six of 64 patients with eversion could defer defecation for more than 30 min compared with 43 of 53 patients without eversion. Twenty-two of 64 patients in the eversion group retained perfect discrimination between flatus and feces compared with 38 of 54 without eversion (P < 0.001). Level of the anastomosis was 1 (range, 0.5-3) cm above dentate line after eversion compared with 1.5 (range, 0-6) cm without eversion.

CONCLUSION

Clinical outcome after RP with eversion was not as good as outcome after stapled EEA without eversion. Such a conclusion requires confirmation in a prospective control trial.

Factors that influence functional outcome after coloanal anastomosis for carcinoma of the rectum

Thirty consecutive patients had laboratory assessment of anorectal function after rectal excision and stapled coloanal anastomosis for rectal carcinoma. Eleven patients experienced perfect continence but 19 had faecal leakage with or without urgency of defaecation. Median (interquartile range) function was related to the pressures generated in the anal sphincter at rest (good versus poor function: 80 (63-91) versus 51 (23-60) cmH2O, P < 0.01), during maximum squeeze (160 (126-203) versus 102 (58-112) cmH2O, P < 0.01) and during reflex inhibition (58 (23-63) versus 36 (18-54) cmH2O, P < 0.05). Poor function was significantly commoner in women than in men (P < 0.01). These findings suggest that occult damage may have occurred to the anal sphincter before low anterior resection. Careful preoperative evaluation with manometry and endoanal ultrasonography may detect such damage and allow selection of patients for colopouch reconstruction.

The perfect pelvic pouch--what makes the difference?

The aim of this study was to determine what factors are important for the achievement of perfect anal continence after restorative proctocolectomy. One hundred patients underwent paired studies of anorectal physiology before and one year after restorative proctocolectomy with pelvic ileal reservoir (11 S, 25 J, 64 W) with stapled ileoanal anastomosis, without mucosectomy. Fifty seven patients attained perfect anal continence and were able to discriminate flatus from faeces with such confidence that they were able to release flatus safely without fear of faecal soiling. The remaining 43 patients experienced minor problems in this regard. Four factors were found to correlate significantly with a perfect functional result (median, perfect v imperfect): maximum resting anal pressure (72 v 57 cm H2O, p < 0.02), the sensory threshold in the upper and mid-anal canal (7.3 v 8.6 and 5.3 v 7.0 mA, p < 0.05 and p < 0.02), compliance of the ileal reservoir (12.4 v 7.6 ml/cm H2O, p < 0.01), and the presence of a pouch-anal inhibitory reflex (56 of 57 patients v 29 of 43 patients, p < 0.01). The quality of anal continence depends on several factors: a complaint ileal reservoir, a strong sensitive anal sphincter, and normal reflex coordination of the activities of the reservoir and the sphincter. Excellent pouch-anal coordination is obtainable irrespective of the design of the reservoir, provided that these criteria are satisfied.