EP.FRI.978 Colonoscopy perforation: A single centre experience

Aims

Colonic perforation is an adverse event of colonoscopy. This is around 1/1500 in diagnostic colonoscopy, 1/500 in polypectomy procedures & 1/50 in EMR procedure. This study is to evaluate the management of colonic perforation at a single centre.

Methods

Colonoscopy carried out on patients with colorectal cancer symptoms, family history, colorectal cancer & polyp surveillance. Retrospective study carried out since 2012 on all colonoscopies with evaluation of colonoscopy perforation. 

Conclusion

7 colonoscopy perforations encountered over 8 years, with incidence of 0.03 - 0.06 % per year. Surgery undertaken in 5 cases  with concomitant disease bowel (2 IBD’s & 3 diverticulitis). 2 cases of conservative management. Surgical resection of diseased bowel occurred in 4 cases with 4 cases of diversion stoma. One case of diversion stoma was subsequently reversed, whilst other 2 case were deemed medically unfit. Colonoscopy is carried out by JAG accredited endoscopists. Colonic perforation during colonoscopy is increased in: polypectomy (right colonic), therapeutic EMR, diseased bowel (IBD, diverticular disease), challenging colons. Management of colonoscopy perforation should individualized with early clinical & radiological diagnosis.

EP.FRI.976 ERAS after malignant colorectal resections: A single centre experience

Aims

ERAS employs a multi-modal rehabilitation aids post-op recovery following colorectal resections. ERAS applied in both laparoscopic + open surgery. This study aims to assess effectiveness of ERAS at a single centre.

Methods

A retrospective study at East Cheshire NHS Trust, since 2008. Descriptive demography & post-operative features were collected for all elective colorectal resections.

Results

Conclusion

ERAS associated with longer operative time (p < 0.05) (laparoscopic surgery), a shorter hospital stay was achieved (p < 0.05). Delayed ERAS occurred in 26.2 % of cases & can result in delayed discharge. Early ERAS deviations occurred in the presence of major surgical complications (ileus, anastomotic leaks, collections). Despite post-operative cardiac & pulmonary events, ERAS was maintained. A targeted rehabilitation programme especially in the elderly patients can lead to earlier recovery. 

Development and internal validation of clinical prediction models for outcomes of complicated intra-abdominal infection

BACKGROUND

Complicated intra-abdominal infections (cIAIs) are associated with significant morbidity and mortality. The aim of this study was to describe the clinical characteristics of patients with cIAI in a multicentre study and to develop clinical prediction models (CPMs) to help identify patients at risk of mortality or relapse.

METHODS

A multicentre observational study was conducted from August 2016 to February 2017 in the UK. Adult patients diagnosed with cIAI were included. Multivariable logistic regression was performed to develop CPMs for mortality and cIAI relapse. The c-statistic was used to test model discrimination. Model calibration was tested using calibration slopes and calibration in the large (CITL). The CPMs were then presented as point scoring systems and validated further.

RESULTS

Overall, 417 patients from 31 surgical centres were included in the analysis. At 90 days after diagnosis, 17.3 per cent had a cIAI relapse and the mortality rate was 11.3 per cent. Predictors in the mortality model were age, cIAI aetiology, presence of a perforated viscus and source control procedure. Predictors of cIAI relapse included the presence of collections, outcome of initial management, and duration of antibiotic treatment. The c-statistic adjusted for model optimism was 0.79 (95 per cent c.i. 0.75 to 0.87) and 0.74 (0.73 to 0.85) for mortality and cIAI relapse CPMs. Adjusted calibration slopes were 0.88 (95 per cent c.i. 0.76 to 0.90) for the mortality model and 0.91 (0.88 to 0.94) for the relapse model; CITL was -0.19 (95 per cent c.i. -0.39 to -0.12) and - 0.01 (- 0.17 to -0.03) respectively.

CONCLUSION

Relapse of infection and death after complicated intra-abdominal infections are common. Clinical prediction models were developed to identify patients at increased risk of relapse or death after treatment, these now require external validation.

Association between preadmission frailty and care level at discharge in older adults undergoing emergency laparotomy

Background

Older adults undergoing emergency abdominal surgery have significantly poorer outcomes than younger adults. For those who survive, the level of care required on discharge from hospital is unknown and such information could guide decision-making. The ELF (Emergency Laparotomy and Frailty) study aimed to determine whether preoperative frailty in older adults was associated with increased dependence at the time of discharge.

Methods

The ELF study was a UK-wide multicentre prospective cohort study of older patients (65 years or more) undergoing emergency laparotomy during March and June 2017. The objective was to establish whether preoperative frailty was associated with increased care level at discharge compared with preoperative care level. The analysis used a multilevel logistic regression adjusted for preadmission frailty, patient age, sex and care level.

Results

A total of 934 patients were included from 49 hospitals. Mean(s.d.) age was 76·2(6·8) years, with 57·6 per cent women; 20·2 per cent were frail. Some 37·4 per cent of older adults had an increased care level at discharge. Increasing frailty was associated with increased discharge care level, with greater predictive power than age. The adjusted odds ratio for an increase in care level was 4·48 (95 per cent c.i. 2·03 to 9·91) for apparently vulnerable patients (Clinical Frailty Score (CFS) 4), 5·94 (2·54 to 13·90) for those mildly frail (CFS 5) and 7·88 (2·97 to 20·79) for those moderately or severely frail (CFS 6 or 7), compared with patients who were fit.

Conclusion

Over 37 per cent of older adults undergoing emergency laparotomy required increased care at discharge. Frailty scoring was a significant predictor, and should be integrated into all acute surgical units to aid shared decision-making and discharge planning.

Multicentre study of short-course radiotherapy and transanal endoscopic microsurgery for early rectal cancer

Background

Organ-preserving treatment for early-stage rectal cancer may avoid the substantial perioperative morbidity and functional sequelae associated with total mesorectal excision (TME). The initial results of an organ-preserving approach using preoperative short-course radiotherapy (SCRT) and transanal endoscopic microsurgery (TEMS) are presented.

Methods

Patients with cT1–2N0 rectal cancers staged using high-quality MRI and endorectal ultrasonography received SCRT, with TEMS 8–10 weeks later, at four regional referral centres between 2007 and 2013. Patients were generally considered high risk for TME surgery (a small number refused TME).

Results

Following SCRT and TEMS, 60 (97 per cent) of 62 patients had an R0 resection. Histopathological staging identified 20 ypT0 tumours, 23 ypT1, 18 ypT2 and one ypT3. Preoperative uT category was significantly associated with a complete pathological response, which was achieved in 13 of 27 patients with uT0/uT1 disease and in five of 29 with uT2 (P = 0·010). Acute complications affected 19 patients, the majority following TEMS. No fistulas occurred and no stomas were formed. Surveillance detected four intraluminal local recurrences at a median follow-up of 13 months, all in patients with tumours staged as ypT2. Salvage TME achieved R0 resection in three patients and a stent was placed in one patient owing to co-morbidities.

Conclusion

SCRT with TEMS was effective in the majority of patients considered high risk for (or who refused) TME surgery.

Transanal endoscopic microsurgery

Transanal endoscopic microsurgery (TEMS) is a well established method of accurate resection of specimens from the rectum under binocular vision. This review examines its role in the treatment of benign conditions of the rectum and the evidence to support its use and compliment existing endoscopic treatments. The evolution of TEMS in early rectal cancer and the concepts and outcomes of how it has been utilised to treat patients so far are presented. The bespoke nature of early rectal cancer treatment is changing the standard algorithms of rectal cancer care. The future of TEMS in the organ preserving treatment of early rectal cancer is discussed and how as clinicians we are able to select the correct patients for neoadjuvant or radical treatments accurately. The role of radiotherapy and outcomes from combination treatment using TEMS are presented with suggestions for areas of future research.

Transanal endoscopic microsurgery

Transanal endoscopic microsurgery (TEMS) is a well established method of accurate resection of specimens from the rectum under binocular vision. This review examines its role in the treatment of benign conditions of the rectum and the evidence to support its use and compliment existing endoscopic treatments. The evolution of TEMS in early rectal cancer and the concepts and outcomes of how it has been utilised to treat patients so far are presented. The bespoke nature of early rectal cancer treatment is changing the standard algorithms of rectal cancer care. The future of TEMS in the organ preserving treatment of early rectal cancer is discussed and how as clinicians we are able to select the correct patients for neoadjuvant or radical treatments accurately. The role of radiotherapy and outcomes from combination treatment using TEMS are presented with suggestions for areas of future research.

Component separation in abdominal trauma

Component separation is established for complex hernia repairs. This case presents early component separation and release of the anterior and posterior sheath to facilitate closure of the abdominal wall following emergency laparotomy, reinforcing the repair with a biological mesh. On Day 11 following an emergency laparotomy for penetrating trauma, this patient underwent component separation and release of the anterior and posterior sheath. An intra-abdominal biological mesh was secured, and the fascia and skin closed successfully. Primary abdominal closure can be achieved in patients with penetrating abdominal trauma with the use of component separation and insertion of intra-abdominal biological mesh, where standard closure is not possible.

Chemical Vapor Deposition of Copper Alloys

Chemical vapor deposition of metals is becoming a desirable alternative to physical deposition techniques (e.g. sputtering, evaporation) for applications in chip wiring. This is due to the possibility of achieving highly conformal coverage and low processing temperatures. Additionally, it is convenient to be able to enhance the physical properties (e.g. corrosion resistance, adhesion, electromigration resistance) of metal films used for chip interconnection by incorporation of an alloying agent. We have investigated the possibility of extending our current copper deposition process to allow for the deposition of copper alloys. By careful selection of the precursors and reactor conditions, simultaneous decomposition of the two compounds to give clean alloy films is effected. Using this co-deposition method, Cu-Co and Cu-Te alloy films were prepared. Precursor and reaction chemistry are discussed as well as some properties of the resulting films.

Chemical Vapor Deposition of Ruthenium and Osmium Films from Mono- and bis-(Cyclopentadienyl) Complexes as Precursors

We have investigated cyclopentadienyl (Cp) complexes of Ru and Os as precursors for low temperature CVD of pure ruthenium and osmium films. Films were grown on a variety of substrates in a warm-walled CVD reactor, equipped with a resistively heated wafer chuck, massflow controllers for carrier gas regulation, and a mechanically-backed oil-vapor diffusion pump. Typical depositions were done under ca. 1 Torr total pressure. Use of air or oxygen as a carrier gas and Cp2M (M = Ru or Os) as precursors gave high purity, conformal films of ruthenium and osmium at temperatures as low as 275°C and 350°C, respectively. Under these conditions, the only observable by-products were CO2 and H2O, indicating that surface-catalyzed, complete oxidation of the ligands was involved in the decomposition process. Growth rates, film purities, resistivities and conformality were measured.

Desmoplastic small round cell tumour: a review of literature and treatment options

INTRODUCTION

Desmoplastic Small Round Cell Tumour (DSRCT) is a rare but aggressive malignancy with poor outcome.

AIMS

To review the clinico-pathological features and radiological, histological and tumour markers of the disease and to evaluate the evidence for treatment options available.

METHODS

We report a clinical case from our centre and have conducted a review of the literature from Medline (Pubmed) database from 1989 to 2007.

RESULTS

DSRCT typically presents with advanced disease and is prevalent in young males. Lack of staging criteria and small numbers of patients make comparison of evidence for its treatment difficult.

CONCLUSION

Surgical excision is only recommended for non-metastatic disease with combination chemo-radiotherapy as an adjunct. These modalities used in isolation may have less impact. Furthermore, the side effect profile from radiotherapy may outweigh any survival benefit. For advanced disease, symptom control is most important as these modalities impact survival minimally and palliation of secondary symptoms is paramount. Multi-disciplinary team and specialist centre review for histology and oncology are essential in managing this disease process and will enable greater numbers of patients to be enrolled into therapeutic trials and future evolving therapies.

Management of renal tumors by image-guided radiofrequency ablation: experience in 105 tumors

Aims

In this article we present our experience with radiofrequency ablation (RFA) in the treatment of 105 renal tumors.

Materials and Methods

RFA was performed on 105 renal tumors in 97 patients, with a mean tumor size of 32 mm (11–68 mm). The mean patient age was 71.7 years (range, 36–89 years). The ablations were carried out under ultrasound (n = 43) or CT (n = 62) guidance. Imaging follow-up was by contrast-enhanced CT within 10 days and then at 6-monthly intervals. Multivariate analysis was performed to determine variables associated with procedural outcome.

Results

Eighty-three tumors were completely treated at a single sitting (79%). Twelve of the remaining tumors were successfully re-treated and a clinical decision was made not to re-treat seven patients. A patient with a small residual crescent of tumor is under follow-up and may require further treatment. In another patient, re-treatment was abandoned due to complicating pneumothorax and difficult access. One patient is awaiting further re-treatment. The overall technical success rate was 90.5%. Multivariate analysis revealed tumor size to be the only significant variable affecting procedural outcome. (p = 0.007, Pearson χ²) Five patients had complications. There have been no local recurrences.

Conclusion

Our experience to date suggests that RFA is a safe and effective, minimally invasive treatment for small renal tumors.

Solitary, late metastatic recurrence of renal cell carcinoma: two extraordinary cases

Late recurrence of renal cell carcinoma (RCC) has been well documented in the literature. We present two extraordinary cases of solitary, late metastatic recurrence of RCC. The first is a case of a solitary, adrenal metastasis excised 38 years after nephrectomy and the second is a case in which two solitary metastatic deposits were resected 14 and 26 years after excision of the primary tumor. In each of these patients the solitary metastases were initially believed to be primary tumors at other sites; however, on histological examination they were found to be metastatic RCC recurrences. In patients with a previous history of RCC presenting with apparently new solitary lesions, metastatic RCC must first be excluded.

Confocal microscopy of idarubicin localisation in sensitive and multidrug-resistant bladder cancer cell lines

Idarubicin is a highly lipophilic anthracycline and appears effective against tumours resistant to conventional anthracyclines. Confocal microscopy demonstrates predominantly cytoplasmic idarubicin accumulation. This distribution is unaltered by resistance status or the resistance reversing agent verapamil. Our results contrast with studies on conventional anthracyclines and suggest that nuclear accumulation may not be a prerequisite for anthracycline cytotoxicity.

Determination and reversal of resistance to epirubicin intravesical chemotherapy. A flow cytometric model

OBJECTIVE

To develop a method of determining the characteristics of epirubicin resistance and to study the reversal of such resistance in the intravesical treatment of superficial bladder cancer, using sensitive and resistant derivatives of a bladder cancer cell line in vitro.

MATERIALS AND METHODS

Epirubicin fluorescence and flow cytometry were used to measure the intracellular levels of epirubicin in both sensitive and resistant live cultured bladder tumour cells, with and without different doses of the resistance-reversing agent verapamil.

RESULTS

There was a reliable, highly significant and consistent difference in intracellular epirubicin concentration between the resistant and sensitive bladder tumour cells. In addition, it was possible to substantially reverse the features of resistant cell subline with additional verapamil.

CONCLUSION

Application of this assay to clinical specimens should allow better targeting of epirubicin intravesical chemotherapy and avoid the premature termination of such treatment in patients whose tumours remain sensitive to this agent. Furthermore, the addition of verapamil to intravesical epirubicin may permit effective treatment of those patients whose tumours have inherent or acquired resistance to epirubicin.

Determination and reversal of resistance to epirubicin intravesical chemotherapy. A confocal imaging study

OBJECTIVE

To evaluate the use of confocal microscopy in the study of resistance to epirubicin and to determine the effect of temperature, viability and a resistance-reversing agent on the intracellular distribution of this drug in sensitive and resistant derivatives of a superficial bladder cancer cell line.

MATERIALS AND METHODS

Viable and non-viable adherent cells were incubated in epirubicin solutions under various conditions. After incubation, the distribution of intracellular epirubicin fluorescence was visualized using confocal microscopy and a x50 water-immersion lens.

RESULTS

There was a striking and consistent difference between resistant and sensitive cells in the intracellular distribution of the drug. In addition to having greater overall levels of epirubicin fluorescence, sensitive cells accumulated epirubicin predominantly in the nucleus. Epirubicin fluorescence in resistant cells was cytoplasmic and granular in appearance. When incubated at 0 degrees C, both cell lines showed no nuclear uptake and thus resembled resistant cells at 37 degrees C. However, dead cells rapidly acquired brightly fluorescent nuclei. The resistance-reversing agent verapamil appeared to cause reversion of the resistant to the sensitive phenotype.

CONCLUSION

Confocal microscopy allows epirubicin-sensitive and resistant cultured tumour cells to be differentiated reliably and provides information about the mechanisms of action of, and resistance to, epirubicin. Applying this technique to clinical specimens should enable patients who have the resistant phenotype to be detected and the efficacy of intravesical resistance-reversing agents to be evaluated in such cases.

Primary pure teratoma of the testis

PURPOSE

Despite its histologically benign appearance, primary pure teratoma of the testis is believed to have metastatic potential and behave similarly to other nonseminomatous germ cell tumors. We present our experience with the natural history and management of pure teratoma.

MATERIALS AND METHODS

We reviewed the histological findings and clinical history of 15 patients with primary pure teratoma who were treated during a 15-year period, accounting for 4.2% of all nonseminomatous germ cell tumors treated during the same period. Fourteen patients were available for followup and are included in this report.

RESULTS

In 8 patients the tumor was composed entirely of mature teratoma and in 6 immature elements were also present, although this finding was not associated with an increased frequency of metastatic disease. Carcinoma in situ was found adjacent to the tumor in 12 cases. Of 10 patients with stage I disease at presentation who were entered on a surveillance program only 2 have had relapse. The remaining 4 patients had metastatic disease at presentation and, thus, metastatic disease occurred in a total of 6 of the 14 patients (43%) with a median followup of 46 months (range 5 to 197). Metastatic disease was confined to the retroperitoneum in all 6 patients and only 2 patients had elevated serum marker levels. Five patients were treated with primary chemotherapy followed by resection of a residual mass and in all cases teratoma was identified in the resected mass. One patient underwent surgical excision of a retroperitoneal mass, which contained teratoma and yolk sac tumor, followed by chemotherapy. All patients are alive without evidence of progressive disease.

CONCLUSIONS

In patients with primary pure teratoma of the testis metastatic disease may develop and the metastases may contain other subtypes of nonseminomatous germ cell tumors in addition to teratoma. There is probably a reduced frequency of relapse, which should be considered when advising patients with stage I disease, but otherwise management should be the same as for other testicular nonseminomatous germ cell tumors and the prognosis should be excellent.

Multidrug resistance evaluation by confocal microscopy in primary urothelial cancer explant colonies

Assessing functional multidrug resistance (MDR) status in clinical biopsy material using drug autofluorescence has potential applications to clinical management. The small size of many cystoscopy specimens has led us to develop, as an alternative to flow cytometry, a protocol for studying epirubicin accumulation in adherent colonies of primary bladder cancer cells viewed live and in situ by confocal microscopy. The limitations to quantitation inherent in this technique are compensated for by preservation of cellular organisation and the elimination of non-malignant cells. Biopsy material is disaggregated and explanted into culture-grade petri dishes. After incubation for three to seven days plaques of epithelial cells have developed. Classical patterns of sensitive and resistant drug distribution are observed. Cells of the rolled edges of the colony accumulate more drug than those of the inner epithelial monolayer. Some central areas of larger colonies give the appearance of drug arrested at the intercellular junctions to give a fenestrated pattern. These observations contribute to the understanding of mechanisms in MDR as well as forming the basis for a clinical urological MDR evaluation protocol.

Orchiectomy after chemotherapy in patients with metastatic testicular cancer. Is it indicated?

BACKGROUND

A small proportion of patients with testicular germ cell tumors present with widely metastatic disease and are treated initially with chemotherapy. Little is known about the efficacy of systemic chemotherapy in eradicating the primary testicular germ cell cancer; however, there is concern that the testis may act as a sanctuary site for germ cell cancer in these patients, and orchiectomy, is, therefore, recommended after chemotherapy.

METHODS

The results from a clinical and pathologic review of 24 patients who underwent delayed orchiectomy after chemotherapy are presented. The testicular pathologic findings are correlated with those in extragonadal masses and also with a blinded review of postchemotherapy testicular ultrasound scans.

RESULTS

The most common testicular pathological finding was a dense fibrous scar that was found in all patients. Three patients had persistent testicular germ cell cancer, six had mature teratoma, and one had carcinoma in situ. There was a strong concordance between the major testicular pathologic findings and those in the resected extragonadal masses. All three patients with persistent testicular germ cell cancer subsequently had disease progression in the extragonadal sites. Testicular ultrasound examination did not distinguish accurately between residual tumor or scar in the testis.

CONCLUSION

Persistence of the primary testicular germ cell cancer is most likely due to the same heterogeneous response to chemotherapy observed in different metastatic sites. Because current imaging techniques cannot identify accurately those patients with residual testicular germ cell cancer or related testicular abnormalities that may predispose to subsequent relapse, orchiectomy after chemotherapy remains appropriate.

Cell-specific regulation of gene expression in mitochondria during anther development in sunflower

Mitochondrial gene expression was characterized during meiosis in sunflower anthers. In situ hybridization experiments showed that there was a marked accumulation of four mitochondrial gene transcripts (atpA, atp9, cob, and rrn26) in young meiotic cells. This pattern of transcript accumulation was only detected for mitochondrial genes and not for transcripts of two nuclear genes (atpB and ANT) encoding mitochondrial proteins or another nuclear gene transcript (25S rRNA). Immunolocalization studies showed that the pattern of accumulation of the protein product of the atpA gene, the F1-ATP synthase alpha subunit, reflects that of the transcript. The expression of the novel mitochondrial orf522, which is associated with the cytoplasmic male-sterile (CMS) phenotype, was also studied by in situ hybridization. The orf522 transcripts were reduced in abundance in meiotic cells in the presence of fertility restorer genes. These results suggest that mitochondrial gene expression is regulated in a cell-specific fashion in developing anthers and that the restorer gene(s) may act cell specifically.

Flexible cystoscopy in men: is topical anaesthesia with lignocaine gel worthwhile?

OBJECTIVE

The value of 2% lignocaine gel as a topical anaesthetic for flexible cystoscopy in men was tested in a prospective, randomized, double-blind, placebo controlled trial.

PATIENTS AND METHODS

A total of 138 patients were entered into the study. Group A patients (n = 75) received 10 ml of 2% lignocaine gel intraurethrally whilst 10 ml of plain lubricating gel was instilled in the remaining 63 patients (Group B). Patient discomfort was recorded by means of a four-point descriptive pain scale (completed by both surgeon and patient) and a 100 mm non-graphic rating visual analogue scale (patient only).

RESULTS

The results showed no significant difference between the two treatments irrespective of the method of recording.

CONCLUSION

This study shows that 2% lignocaine gel offers no advantage over plain lubricating gel in providing analgesia for flexible cystoscopy. In this situation good lubrication may be a more important factor than topical anaesthesia.

Nuclear restoration of cytoplasmic male sterility in sunflower is associated with the tissue-specific regulation of a novel mitochondrial gene

We have previously shown that cytoplasmic male sterility in sunflower is associated with the insertion into the mitochondrial DNA of a novel open reading frame (ORF) located 3' to the atpA gene. Here, we show that in mitochondria from the sterile line, this novel ORF (ORF522) is cotranscribed with atpA. We have identified the product of the ORF522 as being a 15 kDa protein previously observed in sterile plant mitochondria by in organello translation. Both Western blot analysis and in organello translation assays show reduced levels of the 15 kDa polypeptide upon restoration of fertility. Interestingly, this reduction is tissue specific since it is only observed in the male florets from restored hybrid plants. These results suggest that the 15 kDa novel polypeptide is probably responsible for the CMS phenotype. Northern blot analysis using RNA from both seedlings and male florets shows a flower-specific reduction in the level of the ORF522 transcript in the restored hybrid line. The reduction is not due to a reduced transcription rate as demonstrated by 'run-on' experiments using mitochondria isolated from male florets. This suggests that the product of the nuclear restorer gene acts at the post-transcriptional level to destabilize the novel mitochondrial transcript in a tissue-specific manner and restore male fertility.

Nuclear restoration of cytoplasmic male sterility in sunflower is associated with the tissue-specific regulation of a novel mitochondrial gene

We have previously shown that cytoplasmic male sterility in sunflower is associated with the insertion into the mitochondrial DNA of a novel open reading frame (ORF) located 3' to the atpA gene. Here, we show that in mitochondria from the sterile line, this novel ORF (ORF522) is cotranscribed with atpA. We have identified the product of the ORF522 as being a 15 kDa protein previously observed in sterile plant mitochondria by in organello translation. Both Western blot analysis and in organello translation assays show reduced levels of the 15 kDa polypeptide upon restoration of fertility. Interestingly, this reduction is tissue specific since it is only observed in the male florets from restored hybrid plants. These results suggest that the 15 kDa novel polypeptide is probably responsible for the CMS phenotype. Northern blot analysis using RNA from both seedlings and male florets shows a flower-specific reduction in the level of the ORF522 transcript in the restored hybrid line. The reduction is not due to a reduced transcription rate as demonstrated by 'run-on' experiments using mitochondria isolated from male florets. This suggests that the product of the nuclear restorer gene acts at the post-transcriptional level to destabilize the novel mitochondrial transcript in a tissue-specific manner and restore male fertility.

Specific circulating anti-gliadin IgG-class antibody does not mediate intestinal enteropathy in gliadin-fed mice

The effects of specific circulating IgG antibody on the uptake of dietary antigen and in the generation of intestinal enteropathy have been investigated in Balb/c mice bred on a gluten-free diet. A monoclonal IgG1 antibody (GD3) was prepared against gliadin. After adoptive transfer into mice, this antibody was capable of mediating a type III hypersensitivity response in vivo to footpad challenge with gliadin. The titres of circulating GD3, as estimated in vitro by ELISA, correlated well with the degree of inflammation at sites of type III responses in vivo. Following footpad challenge with gliadin, titres of circulating GD3 antibody were reduced. GD3 antibody was tested for its ability to mediate inflammatory responses in vivo in the intestinal mucosa of mice fed with gliadin. Circulating GD3 antibody was removed selectively and specifically by dietary gliadin, compared to feeding with bovine serum albumin or maintenance on a gliadin-free diet only. However, we were unable to demonstrate any pathological changes in the intestine as a result of possible local antigen-antibody complex formation or deposition. Using radio-iodinated gliadin as a trace marker, no significant retention of gliadin in the intestinal mucosa was found in mice pre-injected with GD3 antibody. These data suggest that circulating IgG antibody has little effect on dietary antigen uptake in the gut, and alone is insufficient to mediate an enteropathy.

Regulation of intestinal immunoglobulin production in response to dietary ovalbumin

The effects of oral administration of ovalbumin (OVA) on intestinal immunoglobulin production was examined. Balb/c mice, bred and reared on an OVA-free diet, received either one dose or 14 consecutive daily intragastric doses of 25 mg OVA/dose. Single dose administration of OVA resulted in significant suppression of total immunoglobulins in the intestinal mucosa, particularly of the IgA isotype, although a very low titre anti-OVA IgG class antibody response was induced. After multiple peroral immunisations, there was more intestinal anti-OVA antibody induction and less suppression of total immunoglobulins. However, all the anti-OVA antibody was of the IgG isotype. In vitro production of mucosal immunoglobulins was not significantly reduced over 5 days, compared with controls, in either single or multiple administration groups, suggestive of a loss of T suppressor cell function in culture. Prior adoptive transfer of splenic and lymph node cells from mice preimmunised with OVA was capable of abrogating the local suppression of immunoglobulin production in vivo. Although adoptive transfer of bovine serum albumin-sensitised cells could also overcome some of the local suppression, complete restoration of normal immunoglobulin levels was not achieved. These data suggest that single oral administration of a novel dietary antigen induces a transient, non-specific suppression of intestinal immunoglobulin production, which can be overcome by antigen-specific T cells.

Expression of the LFA-1 beta 2 integrin (CD11a/CD18) and ICAM-1 (CD54) in normal and coeliac small bowel mucosa

The leucocyte adhesion molecules (beta 2 integrins) comprise CD11 alpha-chains and a common beta-chain (CD18). CD11a (leucocyte function-associated antigen 1, LFA-1) is expressed by most T cells, and is involved in antigen presentation by macrophages via its counter-receptor, intercellular adhesion molecule (ICAM-1, CD54). By criteria of double-label immunofluorescence of cryostat tissue sections, virtually all lamina propria T cells of the normal small bowel were found to express LFA-1 strongly. By contrast, only 30-60% of intra-epithelial lymphocytes (IEL) expressed detectable LFA-1, most of which were LFA-1 weak and CD18-. ICAM-1 was expressed strongly only by vascular endothelium. In coeliac disease, there was a modest increase of diffuse ICAM-1 expression in the lamina propria, mainly in the subepithelial zone, where ICAM-1+ macrophages were occasionally seen. There was also a slight overall increase in CD11a expression by IEL, seen predominantly in surface epithelium and mainly by the CD4+ minority subset, but not by CD4-CD8- (TcR gamma delta +) cells. These data suggest that the LFA-1/ICAM-1-dependent antigen presentation pathway is of minor importance to IEL in the normal small bowel, and does not assume a major role in coeliac disease.

Gamma delta T cell receptor-positive cells of the human gastrointestinal mucosa: occurrence and V region gene expression in Heliobacter pylori-associated gastritis, coeliac disease and inflammatory bowel disease

T cells expressing the gamma delta heterodimer of the T cell receptor (TCR) were studied with respect to their occurrence and expression of gamma delta TCR variable region (V) genes in the normal gastrointestinal mucosa and in a variety of inflammatory conditions. In controls, gamma delta TCR+ cells were a minority population confined to the epithelial compartment of stomach, small bowel and colonic mucosae. Unlike in the periphery, gastro-intestinal gamma delta TCR+ intraepithelial lymphocytes (IEL) were mainly V delta 1+ (89.98 +/- 17.70%); few were V delta 2+ (6.04 +/- 13.8%) or V gamma 9+ (11.38 +/- 10.73%). All gamma delta TCR+ IEL were CD5low; nearly half were CD8+ and the remainder were CD4-CD8- 'double negatives'. There was no significant change from normal in percentages of gamma delta TCR+ IEL in H. pylori-associated gastritis, Crohn's disease and ulcerative colitis. However, in coeliac disease, gamma delta TCR+ IEL were elevated from 2.54% (+/- 1.71) in controls to 29.6% (+/- 16.1) in untreated patients (P less than 0.001) and 18.5% (+/- 7.2) in treated patients (P less than 0.001) and more were CD4-CD8-. Otherwise, gamma delta TCR+ IEL phenotypes were little changed: the majority remained V delta 1+V delta 2-V gamma 9- and all were CD5low. These data suggest that increased gamma delta TCR+ IEL are not a generalized response to intestinal inflammation or to stress proteins, although the typical V delta 1+V delta 2-V gamma 9- CD5low phenotype is retained.

The growing teratoma syndrome

Thirteen patients with metastatic non-seminomatous germ cell tumours and enlarging metastases consisting of teratoma differentiated only were identified. Patients were managed with surgical resection soon after the growing lesions were documented. Surgical morbidity was minimal and 12 patients are alive (10 are disease-free) at a median follow-up of 28 months.

Expression of leukocyte adhesion molecules by mucosal mononuclear phagocytes in inflammatory bowel disease

Leukocyte adhesion molecules are important in cell-cell interactions of the immune system. Lymphocyte function-associated antigen 1 (cluster designation 11a) mediates interactions between T cells and mononuclear phagocytes through its ligand, the intercellular adhesion molecule 1 (CD54), whereas complement receptors 3 (CD 11b) and 4 (CD11c) are involved in complement-mediated phagocytosis. Expression of CD11 molecules and intercellular adhesion molecule 1 was studied in colonic biopsy specimens from 20 patients with inflammatory bowel disease and 10 normal controls. In normal colon, few mononuclear phagocytes expressed lymphocyte function-associated antigen 1 and intercellular adhesion molecule 1 at high densities. The major adhesion molecule was CD11c. Thus, the largest population of normal colonic mononuclear phagocytes was represented by quiescent, resident macrophages with likely phagocytic function. In inflammatory bowel disease, mononuclear phagocytes showed only a slight increase in CD11a expression and no significant change in expression of CD11b and CD11c. By contrast, the percentage of mononuclear phagocytes expressing intercellular adhesion molecule 1 was increased from 6.9% +/- 3.9% in controls to 69.2% +/- 12.8% in ulcerative colitis (P less than 0.001) and to 45.7% +/- 22.8% in Crohn's disease (P less than 0.01), showing a close relationship with histological activity. The increased expression of intercellular adhesion molecule 1 in inflammatory bowel disease indicates a state of immunological activation induced by local release of inflammatory cytokines. Such induction of intercellular adhesion molecule 1 on mononuclear phagocytes may be important in the maintenance of chronic inflammation by facilitating interactions with T cells and T-cell antigen recognition.

Expression of T-cell receptors TcR1 (gamma/delta) and TcR2 (alpha/beta) in the human intestinal mucosa

Cryostat sections of normal human adult gastrointestinal mucosae were studied by double-label immunofluorescence with antibodies to CD3, CD4, CD8, CD5 and CD6, in parallel with antibodies beta F1 and TCR delta 1 against beta-chains and delta-chains of the T-cell receptor (TcR) types TcR2 (alpha/beta) and TcR1 (gamma/delta), respectively. Virtually no TcR1+ were found within the lamina propria. In the epithelial compartment, TcR1+ cells were infrequent: in the small bowel, congruent to 2% of T cells were TcR1+. In the colonic epithelium, the percentage of T cells expressing gamma/delta-chains was higher, with a mean value approximating 15-20%, although this apparently large percentage increase compared with small bowel reflects in part a much lower density of colonic IEL, as absolute numbers of TCR delta 1+ cells were comparable. Of the TcR1+ population, about half were CD4- CD8-, 'double negatives' and the remainder were CD8+. TcR1+ cells were also CD5- CD6-, irrespective of expression of CD8. No CD4+ cells expressing TcR1 were observed: essentially all CD4+ cells were beta F1+, with some variability of labelling intensity. Approximately 30-50% of the CD8+ subset expressed the beta F1 antigen strongly. However, in the remaining TcR1- CD8+ cells, which were all of the CD5- CD6- phenotype, expression of the beta F1 antigen was only detectable when streptavidin and biotin conjugates were used for amplification of labelling. Thus, the CD8+ CD5- subset, a prominent population of the epithelial compartment of the small bowel, was either TcR2dull in the majority or TcR1+ in a minority. Our data imply that gamma/delta TcR1 cells may be actively excluded from intestinal lamina propria, and that any preferential localization that does occur is limited and is rather a feature of the colonic mucosa, rather than the small bowel.

Colonic mucosal T lymphocytes in ulcerative colitis: expression of CD7 antigen in relation to MHC class II (HLA-D) antigens

T-cell subsets and their activation state were examined by double-label immunofluorescence of cryostat tissue sections of the colon from 21 patients with ulcerative colitis (UC) and 30 histologically normal controls. Expression of MHC class I (HLA-A, B, C) and class II (HLA-D) antigens was studied in parallel. In the normal colonic mucosa, the CD4:CD8 ratio in the epithelial compartment approximated 1:1, and in the lamina propria, 2.55:1. Of the CD8+ (cytotoxic/suppressor) subset, approximately half did not express the CD5 "pan-T" marker in either compartment. Virtually no Leu8+ cells were observed, implying that the CD4+ subset consisted of helper, rather than suppressor-inducer cells. Classical markers of T-cell activation (CD25, HLA-D) and proliferation were absent, and strong expression of the CD7 "immunostimulation" marker was approximately equal in both CD4 and CD8 subsets. The epithelium was uniformly negative for class II antigens, but positive for class I. In UC, there were no significant alterations in CD4:CD8 ratios in either compartment, and there were no changes with respect to phenotype of the subsets. In 11 of 19 patients (mainly with total colitis), enterocytes were HLA-D+. In this HLA-D+ group, there was an increase in the percentage of CD4+ cells coexpressing CD7; this difference was significant (P less than 0.02) in the lamina propria. Increased expression of CD7 was also found by the CD6+ T cell subset (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Lack of a serologic response to an E1B protein of adenovirus 12 in coeliac disease

The description of an amino acid sequence homology between the E1B-58-kDa protein of adenovirus 12 and gliadin has led to the suggestion that previous infection by this virus and subsequent exposure to gliadin could trigger the development of coeliac disease in susceptible individuals as a result of immunologic cross-reactivity. We have sought to measure specific antibodies to the E1B-58-kDa protein in 23 coeliac patients and 10 normal subjects. The sera were analysed by radioimmunoprecipitation with metabolically labelled adenovirus-12-transformed rat cells (which express the E1B-58-kDa protein), followed by separation on polyacrylamide gels. None of the coeliac sera had evidence of antibodies to the E1B-58-kDa protein. These data suggest that coeliac patients show little evidence of humoral immunity to the specific adenovirus 12 E1B-58-kDa protein implicated in the aetiology of coeliac disease.

Responses of antigen-specific long-term murine T cell lines to wheat gliadin fractions

Recent evidence suggests that the four electrophoretically defined gliadin subfractions (alpha, beta, gamma and omega) of wheat can induce the typical pathological finding of coeliac disease. We have prepared long-term murine T cell lines to gliadin and its four major subfractions. The cell lines were tested in proliferative assays with each homologous gliadin subfraction, and to the other gliadin subfractions. There was some cross-reactivity, with unfractionated gliadin and its alpha-subfraction being the most antigenic, while omega-gliadin was the least. These data demonstrate that gliadin components are effective stimuli for specific T cell responses, and further suggest that the alpha-gliadin subfraction generates the highest specific responses. This accords with observations in man that all four gliadin subfractions exacerbate coeliac mucosa, but that the alpha-subfraction is the most active.