A bioinformatic analysis of the role of TP53 status on the infiltration of CD8+ T cells into the tumor microenvironment

CD8+ T cells play basic roles in the immune system in a tumor microenvironment (TME) to fight cancer. Several reports have suggested signs of the involvement of tumor protein p53 (TP53) in a complex immune system network. Moreover, our previous research indicated that TP53 orchestrates the polarization and infiltration of macrophages into the TME. In the present study, the clinical function of TP53 status (wild/mutant) in CD8+ T cell infiltration was assessed using more than 10,000 The Cancer Genome Atlas (TCGA) samples from 30 cancer types through Tumor Immune Estimation (TIMER). Our investigation revealed that CD8+ T cell infiltration was higher in head and neck squamous cell carcinoma (HNSC) and uterine corpus endometrial carcinoma (UCEC) patients with wild-type TP53 than in those with mutant TP53. Wild-type TP53 conferred a good prognosis for HNSC and UCEC (P<0.05). In contrast, CD8+ T cell infiltration in lung adenocarcinoma (LUAD) patients with wild-type TP53 was much lower than in those with mutant TP53. Notably, clinical outcomes for LUAD with wild-type TP53 were poor (P<0.05). This study was the first to provide insights into the novel association of TP53 with CD8+ T cells infiltration in the TME in patients with HNSC, LUAD, and UCEC. Therefore, TP53 status acts as a prognostic marker, and this can be used as a basis to further study the effect of targeting TP53 in these patients. Furthermore, our study found that TP53 status was a reliable predictive factor and therapeutic target in patients with HNSC and UCEC.

Reducing radiation exposure and cancer risk for children with scoliosis: EOS the new gold standard

PURPOSE

Children are exposed to significant radiation doses during the investigation and treatment phases of scoliosis. EOS is a new form of low-dose radiation scan which also yields great image quality. However, currently its use is discouraged in the UK due to higher costs. We aimed to quantify the additional radiation dose and cancer risk.

METHODS

We retrospectively reviewed all paediatric cases who received both standing whole spine roentgenograms and EOS scans as part of their investigations for scoliosis during a six-month period. We compared the radiation doses between the two modalities and estimated the additional mean lifetime cancer risk per study.

RESULTS

We identified 206 children (mean age 14.4) who met the criteria of having both scans. Dose area products (dGycm2) were converted to estimated effective doses (mSv). The total mean doses were 0.68 mSv (PA 0.49 + Lat 0.19) for plain films, and 0.13 mSv (PA 0.08 + Lat 0.04) for EOS scans (p < 0.001). Additional lifetime cancer risk of a plain film was 543% greater than EOS for both sexes (1/10727 versus 1/5827 in males, 1/34483 versus 1/6350 in females).

CONCLUSION

There is approximately 5.4-fold increase in risk of cancer for both boys and girls with roentgenograms over EOS, with girls being the most impacted. This carries a significant impact when considering the need for repeat imaging on additional lifetime malignancy risk in children. In our opinion, EOS dual planar scanning is the new gold standard when X-ray of the whole spine is required.

LEVEL OF EVIDENCE

III.

Thoracolumbar spine trauma: a guide for the FRCS examination

Thoracolumbar spine injuries are commonly seen in trauma settings and have a high risk of causing serious morbidity. There can be controversy when it comes to classifying thoracolumbar injuries within the spinal community, but there remains a need to classify, evaluate and manage thoracolumbar fractures. This article aims to provide a guide on classification of thoracolumbar spine injuries using the AO Spine Thoracolumbar Injury Classification System (AO TLICS).

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Staging Pouch Surgery in Ulcerative Colitis in the Biological Era

Restorative proctocolectomy, or ileal pouch anal anastomosis, is considered the standard treatment for intractable ulcerative colitis. When the pelvic pouch was first introduced in 1978, a two-stage procedure with proctocolectomy, construction of the pelvic pouch, and a diverting loop with subsequent closure were suggested. Over the decades that the pelvic pouch has been around, some principal technical issues have been addressed to improve the method. In more recent days the laparoscopic approach has been additionally introduced. During the same time-period the medical arsenal has developed far more with the increasing use of immune modulators and the introduction of biologicals. Staging of restorative proctocolectomy with a pelvic pouch refers to how many sessions, or stages, the procedure should be divided into. The main goal with restorative proctocolectomy is a safe operation with optimal short- and long-term function. In this paper we aim to review the present knowledge and views on staging of the pouch procedure in ulcerative colitis, especially with consideration to the treatment with biologicals.

946 Introduction: Closed Loop Audit Looking at How We Are Complying with Paediatric Supracondylar Fracture (BOAST 11) Management; Results Compared With 2018 To 2019 (Full Cycle)

Background

Supracondylar fractures. Most common childhood elbow fracture. Can be difficult to manage. Risk of significant complications

Method

Results

• NV documentation, 2018:2019, Improved (36%à45%), Inadequate (45%) in comparison to BOAST guideline.

Night ops

• Appropriate as per BOAST guideline

Surgical technique

Conclusions

Recommendations:

Addison's disease associated with hypokalemia: a case report

BACKGROUND

Primary adrenal insufficiency (Addison's disease) is a rare medical condition usually associated with hyperkalemia or normokalemia. We report a rare case of Addison's disease, coexisting with hypokalemia, requiring treatment.

CASE PRESENTATION

In this case, a 42-year-old man was admitted to the intensive care unit with a history of loss of consciousness and severe hypoglycemia. His blood tests showed metabolic acidosis, low concentrations of cortisol 6 nmol/L (normal 68-327 nmol/L), and high plasma adrenocorticotropic hormone 253 pmol/L (normal 1.6-13.9 pmol/L), and he was diagnosed with primary adrenal insufficiency. Surprisingly, his serum potassium was low, 2.3 mmol/L (normal 3.5-5.1 mmol/L), requiring replacement over the course of his admission. Computed tomography scan of the adrenal glands showed features suggestive of unilateral adrenal tuberculosis. Investigations confirmed renal tubulopathy. The patient responded favorably to cortisol replacement, but never required fludrocortisone.

CONCLUSIONS

Coexistence of hypokalemia with Addison's disease is unusual. We recommend investigation of the cause of hypokalemia in its own right, if it occurs with primary adrenal insufficiency.

Suboptimal sleep and incident cardiovascular disease among African Americans in the Jackson Heart Study (JHS)

BACKGROUND

Suboptimal sleep, including insufficient/long sleep duration and poor sleep quality, is a risk factor for cardiovascular disease (CVD) common but there is little information among African Americans, a group with a disproportionate CVD burden. The current study examined the association between suboptimal sleep and incident CVD among African Americans.

METHODS

This study included 4,522 African Americans without CVD at baseline (2000-2004) of the Jackson Heart Study (JHS). Self-reported sleep duration was defined as very short (<6 h/night), short (6 h/night), recommended (7-8 h/night), and long (≥9 h/night). Participants' self-reported sleep quality was defined as "high" and "low" quality. Suboptimal sleep was defined by low quality sleep and/or insufficient/long sleep duration. Incident CVD was a composite of incident coronary heart disease and stroke. Associations between suboptimal sleep and incident CVD were examined using Cox proportional hazards models over 15 follow-up years with adjustment for predictors of CVD risk and obstructive sleep apnea.

RESULTS

Sample mean age was 54 years (SD = 13), 64% female and 66% reported suboptimal sleep. Suboptimal sleep was not associated with incident CVD after covariate adjustment [HR(95% CI) = 1.18(0.97-1.46)]. Long [HR(95%CI) = 1.32(1.02-1.70)] and very short [HR(95% CI) = 1.56(1.06-2.30)] sleep duration were associated with incident CVD relative to recommended sleep duration. Low quality sleep was not associated with incident CVD (p = 0.413).

CONCLUSIONS

Long and very short self-reported sleep duration but not self-reported sleep quality were associated with increased hazard of incident CVD.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Calibration and validation of the DNDC model to estimate nitrous oxide emissions and crop productivity for a summer maize-winter wheat double cropping system in Hebei, China

The main aim of this paper was to calibrate and evaluate the DeNitrification-DeComposition (DNDC) model for estimating N₂O emissions and crop productivity for a summer maize-winter wheat double cropping system with different N fertilizer rates in Hebei, China. The model's performance was assessed before and after calibration and model sensitivity was investigated. The calibrated and validated DNDC performed effectively in estimating cumulative N₂O emissions (coefficient of determination (1:1 relationship; r²) = 0.91; relative deviation (RD) = -13 to 16%) and grain yields for both crops (r² = 0.91; RD = -21 to 7%) from all fertilized treatments, but poorly estimated daily N₂O patterns. Observed and simulated results showed that optimal N fertilizer treatment decreased cumulative N₂O flux, compared to conventional N fertilizer, without a significant impact on grain yields of the summer maize-winter wheat double cropping system. The high sensitivity of the DNDC model to rainfall, soil organic carbon and temperature resulted in significant overestimation of N₂O peaks during the warm wet season. The model also satisfactorily estimated daily patterns/average soil temperature (^o C; 0-5 cm depth) (r² = 0.88 to 0.89; root mean square error (RMSE) = 4 °C; normalized RMSE (nRMSE) = 25% and index of agreement (d) = 0.89-0.97) but under-predicted water filled pore space (WFPS; %; 0-20 cm depth) (r² = 0.3 to 0.4) and soil ammonium and nitrate (exchangeable NH₄⁺ & NO₃^-; kg N ha^-1; r² = 0.97). With reference to the control treatment (no N fertilizer), DNDC was weak in simulating both N₂O emissions and crop productivity. To be further improved for use under pedo-climatic conditions of the summer maize-winter wheat double cropping system we suggest future studies to identify and resolve the existing problems with the DNDC, especially with the control treatment.

Anorectal Function After Ileo-Rectal Anastomosis Is Better than Pelvic Pouch in Selected Ulcerative Colitis Patients

BACKGROUND

With a lifelong perspective, 12% of ulcerative colitis patients will need a colectomy. Further reconstruction via ileo-rectal anastomosis or pouch can be affected by patients' perspective of their quality of life after surgery.

AIM

To assess the function and quality of life after restorative procedures with either ileo-rectal anastomosis or ileal pouch-anal anastomosis in relation to the inflammatory activity on endoscopy and in biopsies.

METHOD

A total of 143 UC patients operated with subtotal colectomy and ileo-rectal anastomosis or pouches between 1992 and 2006 at Linköping University Hospital were invited to participate. Those who completed the validated questionnaires (Öresland score, SF-36, Short Health Scale) were offered an endoscopic evaluation including multiple biopsies. Associations between anorectal function and quality of life with type of restorative procedure and severity of endoscopic and histopathologic grading of inflammation were evaluated.

RESULTS

Some 77 (53.9%) eligible patients completed questionnaires, of these 68 (88.3%) underwent endoscopic evaluation after a median follow-up of 12.5 (range 3.5-19.4) years after restorative procedure. Patients with ileo-rectal anastomosis reported better overall Öresland score: median = 3 (IQR 2-5) for ileo-rectal anastomosis (n = 38) and 10 (IQR 5-15) for pouch patients (n = 39) (p < 0.001). Anorectal function (Öresland score) and endoscopic findings (Baron-Ginsberg score) were positively correlated in pouch patients (tau: 0.28, p = 0.006).

CONCLUSION

Patients operated with ileo-rectal anastomosis reported better continence compared to pouches. Minor differences were noted regarding the quality of life. Ileo-rectal anastomosis is a valid option for properly selected ulcerative colitis patients if strict postoperative endoscopic surveillance is carried out.

The metabolism of 5-methylcytosine residues in DNA

The fundamental biochemical processes of 5-methylcytosine (5-mC) synthesis, maintenance, conversion and removal determine the time and spatial pattern of DNA methylation. This has a strong effect on a plethora of physiological aspects of cellular metabolism. While the presence of 5-mC within the promoter region can silence gene expression, its derivative - 5-hydroxymethylcytosine exerts an opposite effect. Dysregulations in the metabolism of 5-mC lead to an altered DNA methylation pattern which is linked with a disrupted epigenome, and are considered to play a significant part in the etiology of several human diseases. A summary of recent knowledge about the molecular processes participating in DNA methylation pattern shaping is provided here.

Critical review of the impacts of grazing intensity on soil organic carbon storage and other soil quality indicators in extensively managed grasslands

Livestock grazing intensity (GI) is thought to have a major impact on soil organic carbon (SOC) storage and soil quality indicators in grassland agroecosystems. To critically investigate this, we conducted a global review and meta-analysis of 83 studies of extensive grazing, covering 164 sites across different countries and climatic zones. Unlike previous published reviews we normalized the SOC and total nitrogen (TN) data to a 30 cm depth to be compatible with IPCC guidelines. We also calculated a normalized GI and divided the data into four main groups depending on the regional climate (dry warm, DW; dry cool, DC; moist warm, MW; moist cool, MC). Our results show that taken across all climatic zones and GIs, grazing (below the carrying capacity of the systems) results in a decrease in SOC storage, although its impact on SOC is climate-dependent. When assessed for different regional climates, all GI levels increased SOC stocks under the MW climate (+7.6%) whilst there were reductions under the MC climate (-19%). Under the DW and DC climates, only the low (+5.8%) and low to medium (+16.1%) grazing intensities, respectively, were associated with increased SOC stocks. High GI significantly increased SOC for C4-dominated grassland compared to C3-dominated grassland and C3-C4 mixed grasslands. It was also associated with significant increases in TN and bulk density but had no effect on soil pH. To protect grassland soils from degradation, we recommend that GI and management practices should be optimized according to climate region and grassland type (C3, C4 or C3-C4 mixed).

Risk of Rectal Cancer After Colectomy for Patients With Ulcerative Colitis: A National Cohort Study

BACKGROUND & AIMS

Patients with ulcerative colitis (UC) have an increased risk of rectal cancer, therefore reconstruction with an ileal pouch-anal anastomosis (IPAA) generally is preferred to an ileorectal anastomosis (IRA) after subtotal colectomy. Similarly, completion proctectomy is recommended for patients with ileostomy and a diverted rectum, although this approach has been questioned because anti-inflammatory agents might reduce cancer risk. We performed a national cohort study in Sweden to assess the risk of rectal cancer in patients with UC who have an IRA, IPAA, or diverted rectum after subtotal colectomy.

METHODS

We collected data from the Swedish National Patient Register for a cohort of 5886 patients with UC who underwent subtotal colectomy with an IRA, IPAA, or diverted rectum from 1964 through 2010. Patients who developed rectal cancer were identified from the Swedish National Cancer Register. The risk of rectal cancer was compared between this cohort and the general population by standardized incidence ratio analysis.

RESULTS

Rectal cancer occurred in 20 of 1112 patients (1.8%) who received IRA, 1 of 1796 patients (0.06%) who received an IPAA, and 25 of 4358 patients (0.6%) with a diverted rectum. Standardized incidence ratios for rectal cancer were 8.7 in patients with an IRA, 0.4 in patients with an IPAA, and 3.8 in patients with a diverted rectum. Risk factors for rectal cancer were primary sclerosing cholangitis in patients with an IRA (hazard ratio, 6.12), and colonic severe dysplasia or cancer before subtotal colectomy in patients with a diverted rectum (hazard ratio, 3.67).

CONCLUSIONS

In an analysis of the Swedish National Patient Register, we found that the risk for rectal cancer after colectomy in patients with UC is low, in relative and absolute terms, after reconstruction with an IPAA. An IRA and diverted rectum are associated with an increased risk of rectal cancer, compared with the general population, but the absolute risk is low. Patients and their health care providers should consider these findings in making decisions to leave the rectum intact, perform completion proctectomy, or reconstruct the colon with an IRA or IPAA.

Survival of ileal pouch anal anastomosis constructed after colectomy or secondary to a previous ileorectal anastomosis in ulcerative colitis patients: a population-based cohort study

OBJECTIVES

Ileorectal anastomosis (IRA) affects bowel function, sexual function and reproduction less negatively than ileal pouch anal anastomosis (IPAA), the standard reconstruction after colectomy for ulcerative colitis (UC). In younger UC patients, IRA may have a role postponing pelvic surgery and IPAA. The aim of the present study was to investigate the survival of IPAA secondary to IRA compared to IPAA as primary reconstruction, as this has not previously been studied in UC.

PATIENTS AND METHODS

All patients with UC diagnosis between 1960 and 2010 in Sweden were identified from the National Patient Registry. From this cohort, colectomized patients reconstructed with primary IPAA and patients reconstructed with IPAA secondary to IRA were identified. The survival of the IPAA was followed up until pouch failure, defined as pouchectomy and ileostomy or a diverting ileostomy alone.

RESULTS

Out of 63,796 patients, 1796 were reconstructed with IPAA, either primarily (n = 1720) or secondary to a previous IRA (n = 76). There were no demographic differences between the groups, including length of follow-up (median 12.6 (IQR 6.7-16.6) years and 10.0 (IQR 3.5-15.9) years, respectively). Failure of the IPAA occurred in 103 (6.0%) patients with primary and in 6 (8%) patients after secondary IPAA (P = 0.38 log-rank). The 10-year pouch survival was 94% (95% CI 93-96) for primary IPAA and 92% (81-97) for secondary.

CONCLUSIONS

Patients choosing IRA as primary reconstruction do not have an increased risk of failure of a later secondary IPAA in comparison with patients with primary IPAA.

Processable PMR-Type Polyimides: Process-Property Relationships, Curing Kinetics, and Thermooxidative Stability

The rheological and structural characteristics of polyimides with enhanced melt flow have been investigated. The polyimides were based on 2,3,3′,4′-biphenyltertracarboxylic dianhydride (PBDA) and a mixture of a diamine, 4,4′ (1,4-phenylene-bismethylene) bisaniline (BAX) and a triamine, 1,3,5-Tris (4-aminophenoxybenzene), TAB, where the amount of TAB was 4 and 8%. Melt viscosities of these polymers suggest that they are processable by resin infusion methods. Although curing occurs through the phenylethynyl endcap, the steric and electronic differences of the three amines results in different cure kinetics and heterogeneous crosslinking. This is manifested in multiple Tg values in the differential scanning calorimetry (DSC) scan of the cured samples. Rheological and DSC kinetic studies of the cure behavior indicate that the sample with 4% TAB cures more quickly than the system with 8% TAB and it has a lower activation energy (147 versus 185 kJ mole-1). Thermal gravimetric analysis (TGA) scans indicate that both TAB based samples are more thermally stable than PMR-15. The lower activation energy for 8% TAB, relative to 4% TAB (147.0 versus 170.2 kJ mole-1) suggests the additional branching present decreases the thermal stability.

Negative surveillance endoscopy occurs frequently in patients with short-segment non-dysplastic Barrett's esophagus

Surveillance endoscopy of non-dysplastic Barrett's esophagus (NDBE) that fails to detect intestinal metaplasia (IM), or negative surveillance, is known to occur in clinical practice, although the frequency and possible outcomes in a large cohort in clinical practice is not well described. The goals of this study were to define frequency in which negative surveillance occurs and endoscopic outcomes in a screening cohort of short segment NDBE. A retrospective cohort (n = 184) of patients newly diagnosed with short segment NDBE at an outpatient academic tertiary care center between 2003 and 2011 were reviewed. Only those with one or more surveillance endoscopies were included to define a frequency of negative surveillance. Included patients were further assessed if they had two or more surveillance endoscopies and were classified into groups as sampling error or negative IM on consecutive surveillances based on the results of their surveillance endoscopies. The frequency of a negative surveillance endoscopy in all short-segment NDBE patients was 19.66% (92 endoscopic exams were negative for IM of 468 total surveillance exams). A negative surveillance endoscopy occurred in 40.76% (n = 75) patients. Sampling error occurred in 44.12% and negative IM on consecutive surveillance endoscopies in 55.88% of those with ≥ 2 surveillance endoscopies and an initially negative surveillance exam. The frequency of negative IM on consecutive surveillances was 19.00% of all patients who had two surveillance endoscopies. When the index diagnostic Barrett's esophagus segment length was < 1 cm, 32.14% (18/56) of all patients (with ≥ 2 surveillance endoscopies) had negative IM on consecutive surveillance endoscopies. Negative surveillance occurs frequently in short-segment NDBE. When an initial negative surveillance endoscopy occurs, it may be due to either a sampling error or lack of detectable IM on surveillance exam. When a <1 cm segment of NDBE is diagnosed, a significant proportion of patients may go on to have continuously undetected IM on consecutive surveillance endoscopic exams without intervention.

Dysplasia detection rate of confirmatory EGD in nondysplastic Barrett's esophagus

Current guidelines for endoscopic surveillance of Barrett's esophagus (BE) recommend that patients with newly diagnosed BE undergo confirmatory esophagogastroduodenoscopy (EGD) to exclude the presence of dysplasia. The extent to which confirmatory endoscopy alters management and detects missed dysplasia in newly diagnosed BE has not been reported. The frequency with which confirmatory endoscopy changed surveillance management in patients with newly diagnosed BE was assessed. A two center cohort analysis was conducted on patients newly diagnosed with BE. The rate of dysplasia on confirmatory endoscopy for patients who had nondysplastic BE was obtained. Demographic and endoscopic variables were assessed for association with dysplasia detection using Firth logistic regression model. Out of the 146 patients newly diagnosed with BE and initially determined to be without dysplasia, 12 had dysplasia on the confirmatory second EGD (8.2%). Eleven of 12 cases with dysplasia on confirmatory endoscopy had long-segment BE (LSBE). Among all the LSBE cases in our cohort, 11 had newly diagnosed dysplasia on confirmatory EGD, 29.7% (11/37). The average number of biopsies obtained from the 11 LSBE cases with dysplasia was comparable with the rest of the LSBE cases without dysplasia (6.73 and 5.42, respectively, P-value 0.205). The rate of dysplasia detection in short-segment BE (SSBE) was much lower, 0.95% (1 out of 105). There were no cases of high-grade dysplasia (HGD) or cancer detected in any SSBE case. HGD was detected on confirmatory EGD in two cases, both were LSBE. Segment length was the only statistically significant factor to predict the presence of dysplasia on confirmatory endoscopy (odds ratio 9.158, P. 0.008). Confirmatory EGD in newly diagnosed LSBE had significant rate of dysplasia detection (29.7%) in this cohort. Among patients with SSBE, there was a low rate of dysplasia detection with confirmatory EGD, less than 1% of cases. No additional cases of HGD or esophageal carcinoma in SSBE cases were detected. This suggests that the yield of confirmatory EGD is greater in patients with LSBE.

T-cell function, T-cell phenotype and its role in responsiveness to recombinant human erythropoietin in hemodialysis patients

Resistance to recombinant human erythropoietin (Epo) occurs in a small proportion of hemodialysis (HD) patients. In this study we investigated the relationship between T-cell phenotype (using flow cytometry), T-cell function (by measuring in vitro cytokine production) and responsiveness to Epo in HD patients and to compare the results with those from healthy controls. T-cell phenotypes were assessed and T-cell function was studied. The study included 24 chronic renal failure (CRF) patients on HD treated with rHuEPO as well as 14 normal control subjects. Dual-colour immunofluorescence and flow cytometry were used to compare the surface antigen expression on freshly isolated CD4+ and CD8+ T-cells from PBMC of the studied groups. Levels of a panel of selected cytokines (IL-4, IFN-gamma, slL-2R and IL-10) were determined in PBMC culture supernatants and in plasma samples (TNF-alpha, IFN-gamma, IL-6, slL-2R) using (ELISA) kits. Patients were followed-up for 24 months and a survival study was carried out. T-cells from poor responders showed increased proportions of CD4+/CD28- cells and CD8+/CD28- cells compared with both good responders and controls. Compared with their CD28+ counterparts, CD4+/CD28- T-cells produced significantly more IFN-gamma, enabling them to function as pro-inflammatory cells. There was no difference in secretion of IFN-gamma, slL-2R or IL-4 in PBMC cultures obtained from HD patients and controls. However, Unstimulated PBMC from poor responders generated increased levels of IL-10 poor compared with both good responders and controls. Plasma slL-2R and IL-6 were significantly elevated in both good and poor responders compared with controls. Plasma levels of IFN-gamma and TNF-alpha were undetectable in both HD patients and controls. In the follow up period, more deaths were occurring among the poor responders than the good responders. Based on the finding of the this study we may suggest that, in the absence of any obvious cause, poor response to Epo may be mediated by generation of cytokines from a subpopulation of activated T-cells, which might promote apoptosis in erythroid progenitor cells in the bone marrow.

Superior orbital fissure syndrome in herpes zoster ophthalmicus

AIM

To report a case of superior orbital fissure syndrome (SOFS) in a patient with herpes zoster ophthalmicus (HZO).

MATERIALS AND METHODS

A case report.

RESULTS

A 71-year-old male with HZO presented acutely to accident and emergency complaining of right vision loss, double vision and drowsiness. The right visual acuity was counting fingers. There was no relative afferent pupillary defect. He had interstitial keratitis, ptosis, proptosis and total ophthalmoplaegia. The signs indicated HZO complicated by SOFS. Brain imaging and lumbar puncture confirmed the diagnosis of varicella zoster encephalitis. Systemic acyclovir and prednisolone led to recovery of visual acuity and ocular motility in addition to resolution of his proptosis and ptosis.

CONCLUSION

SOFS is a rare complication of herpes zoster infection. With the appropriate treatment and follow-up, patients may be reassured that recovery of their visual acuity and ocular motility will occur.

Prognostic value of P53 and thymidylate synthase (TS) overexpression in patients with squamous cell carcinoma of the head and neck treated with neoadjuvant chemotherapy

6081

Background: Neoadjuvant cisplatin-based chemotherapy has been widely used in the last decade for organ preservation or unresectable disease in advanced stage head and neck cancer. Thymidylate synthase (TS) and p53 are central molecules in the regulation of cell growth. Differences in the intracellular expression of these proteins by tumor cells may have predictive value for response to chemotherapy and early failure in patients with squamous cell cancer of the head and neck (SCCHN). We examined the expression of P53 and TS that have been associated with chemotherapy resistance. Methods: Immunohistochemistry was used to assess the tumor cell expression of TS and p53 in pre-therapy biopsies from 65 patients with SCCHN treated with induction chemotherapy. Results: The overall response rate for cisplatin-based neoadjuvant treatment was 80%. The expression of P53 and TS was associated with resistance to neoadjuvant treatment, but none reached statistical significance. Overall survival (OS) was strongly correlated with the absence of p53 expression. The OS at 3 years was 80% in the p53-negative group, whereas it was 29% in the p53-positive group for patients treated with neoadjuvant chemotherapy (P < 0.0001). Expression of TS was also significantly correlated with decreased OS after neoadjuvant treatment. In the TS-negative group, the 3-year OS rate was 69% compared with 38% in the TS-positive group (P = 0.0063). Conclusions: Our data showed that p53 and TS may be clinically important predictors of survival in patients receiving neoadjuvant chemotherapy for head and neck cancer.

No significant financial relationships to disclose.

A comparative study of two devices used for cervical cell sampling raises some doubts about liquid-based cytology

The objective of this study was to compare the quality of smears obtained by a newly designed cervical cell sampler (the implement) to those obtained with the cervex brush, using liquid-based cytology (LBC). A prospective randomized controlled trial with the approval of the local ethics committees after informing the Medical Devices Agency in the UK was used in this study. The study was carried out in colposcopy clinics in two district general NHS Trust Hospitals in London. A total of 200 women were recruited (100 from each hospital). The women were randomized into two groups, each of them having two smears at the same time. One hundred (50%) of the women had their first smear with the new implement, and the other 100 (50%) had their first smear with the cervex brush. The main outcome of this study is good-quality smears, assessed by evidence of effective sampling of the transformation zone, including immature metaplastic cells and also endocervical cells. Eighty-five percent of the smears taken by the new implement showed good-quality smears compared to 91% of those taken by the cervex brush, a statistically marginally nonsignificant result, with P value = 0.052 (McNemar exact test). A larger number of good-quality smears, judged by evidence of sampling of transformation zone, were obtained with the cervex brush, though the difference was statistically marginally nonsignificant, using the British society for clinical cytology criteria. Surprisingly, despite the use of LBC, there was a higher rate of inadequate smears obtained with both the devices (8% with each) compared to our previous study using the conventional slide test (1.3% with the new implement and 1.8% with the Jordan's spatula).

Diagnostic difficulties of pelvic splenosis: case report

We report the case of a 38-year-old woman who presented with chronic lower abdominal pain. Her past medical history included a splenectomy due to abdominal trauma. Ultrasound examination revealed four pelvic tumors which, upon laparotomy, were found to be the result of splenosis. Approximately 100 cases of splenosis have been reported but only a minority of them have been published in the gynecological literature. Our case indicates that those involved in pelvic scanning (even of asymptomatic women) and/or treating those complaining of lower abdominal pain or presenting with pelvic tumors should be aware of splenosis as a possible diagnosis.

In vitro assessment of anti - cutaneous leishmaniasis activity of some Sudanese plants

Examination of crude methanol extracts of four Sudanese plants (Azadirachta indica, Acacia nilotica, Balanites aegyptiaca and Allium sativa) revealed that only three species had a considerable in-vitro anti-leishmanial activity on Leishmania major promastigotes. The plants Azadrachta indica, Allium sativa, and Acacia nilotica gave a LC50 of 10.2, 4.94, and 89.38 microg/ml, respectively. Extracts of Balanites aegyptiaca had a moderate biological activity on L major promastigotes.

Serious perinatal complications of non-proteinuric hypertension: an international, multicentre, retrospective cohort study

OBJECTIVE

To determine the proportion of births complicated by either a pre-existing or a gestational non-proteinuric hypertension, presenting at <34 weeks' gestation, and the associated incidence with 1 or more serious perinatal complications or birth weight <3rd centile for gestational age.

METHODS

A retrospective chart review was conducted in 5 international centres, from 1998 to 2002, where "tight" control (normalization) of blood pressure (BP) is the norm. International Classification of Diseases (ICD) codes were used to identify women who delivered at > or =20 weeks' gestation, with any hypertensive disorder of pregnancy. Women were included if they had a diastolic blood pressure (dBP) of 90 to 109 mm Hg, due to either a pre-existing or a gestational non-proteinuric hypertension, presenting at <34 weeks' gestation. Women were excluded if they had ongoing severe hypertension, or if at presentation with dBP of 90 to 109 mm Hg, they had 1 or more of the following: proteinuria, an indication for "tight" control of BP or imminent delivery, or a known intrauterine fetal death or lethal fetal anomaly. Data were collected on paper forms, scanned into an electronic database, and summarized descriptively by type of hypertension.

RESULTS

There were 305 eligible women (0.7% deliveries, 12.8% hypertensive deliveries) identified with non-proteinuric hypertension that was either pre-existing (133 [43.6%]) or gestational (172 [56.4%]). Regardless of hypertension type, 16.4% (n = 50) of pregnancies were complicated by birth weight <3rd centile or 1 or more serious perinatal complications, 34.3% (n = 100) by preterm birth, 30.8% (n = 94) by preeclampsia, and 2.0% (n = 6) by serious maternal complications.

CONCLUSION

Non-proteinuric pre-existing or gestational hypertension, presenting before 34 weeks' gestation, identifies a subpopulation of hypertensive pregnant women at both substantial perinatal risk and maternal risk. The CHIPS (Control of Hypertension In Pregnancy Study) trial is designed to determine how best to manage the hypertension of such women in order to optimize perinatal outcome.

Use of the Tesio catheter for hemodialysis in patients with end-stage renal failure: a 2-year prospective study

BACKGROUND

The Tesio catheter system has been proposed to be a reliable source of vascular access for the dialysis patient with low rates of infection and other complications. Whether such catheters provide reliable short- and long-term access remains undetermined.

METHODS

This study prospectively examined all Tesio lines inserted over a 2-year period in patients with end-stage failure with careful recording of all catheter complications and reasons for catheter loss.

RESULTS

100 catheters were inserted in 82 patients giving a total experience of 13,749 catheter days; 74 catheters were inserted into the jugular veins, the remainder into the femoral veins; 82 insertions were covered with antibiotics. At the end of the study, 29 catheters remained in situ. Of the remaining 71 catheters, 27 catheters were removed because of fashioning of definitive access. Nine catheters were lost due to infection and 10 were lost due to non-function; 19 patients died with a functioning catheter. Episodes ofnon-function were the major complications, although catheter patency was restored in 90% of cases utilizing urokinase and warfarin. Overall 80% of femoral and 16% of jugular catheters required anticoagulation.

CONCLUSIONS

Tesio catheters inserted into the jugular or femoral veins can provide excellent access whilst awaiting definitive dialysis access. They are well-tolerated with a low complication rate compared to standard temporary central venous catheters. Non-function remains a significant problem, especially in femoral catheters, which should be anticoagulated following insertion. Because of our results we suggest that these catheters be used as part of the co-ordinated approach to the management of vascular access in end-stage renal failure patients without definitive access.

Efficacy and safety of intravenous levosimendan compared with dobutamine in severe low-output heart failure (the LIDO study): a randomised double-blind trial

BACKGROUND

Levosimendan, a novel calcium sensitiser, improves myocardial contractility without causing an increase in myocardial oxygen demand. We compared the effects of levosimendan and dobutamine on haemodynamic performance and clinical outcome in patients with low-output heart failure.

METHODS

Patients were recruited into a multicentre, randomised, double-blind, double-dummy, parallel-group trial. Under continuous haemodynamic monitoring, an initial loading dose of levosimendan of 24 microg/kg was infused over 10 min, followed by a continuous infusion of 0.1 microg kg(-1) min(-1) for 24 h. Dobutamine was infused for 24 h at an initial dose of 5 microg kg(-1) min(-1) without a loading dose. The infusion rate was doubled if the response was inadequate at 2h. The primary endpoint was the proportion of patients with haemodynamic improvement (defined as an increase of 30% or more in cardiac output and a decrease of 25% or more in pulmonary-capillary wedge pressure) at 24 h. Analyses were by intention to treat.

FINDINGS

103 patients were assigned levosimendan and 100 dobutamine. The primary haemodynamic endpoint was achieved in 29 (28%) levosimendan-group patients and 15 (15%) in the dobutamine group (hazard ratio 1.9 [95% CI 1.1-3.3]; p=0.022). At 180 days, 27 (26%) levosimendan-group patients had died, compared with 38 (38%) in the dobutamine group (0.57 [0.34-0.95]; p=0.029).

INTERPRETATION

In patients with severe, low-output heart failure, levosimendan improved haemodynamic performance more effectively than dobutamine. This benefit was accompanied by lower mortality in the levosimendan group than in the dobutamine group for up to 180 days.

Ketorolac, diclofenac, and ketoprofen are equally safe for pain relief after major surgery

BACKGROUND

Ketorolac is approved for the relief of postoperative pain but concerns have been raised over a possible risk of serious adverse effects and death. Two regulatory reviews in Europe on the safety of ketorolac found the data were inconclusive and lacked comparison with other non-steroidal anti-inflammatory drugs. The aim of this study was to compare the risk of serious adverse effects with ketorolac vs diclofenac or ketoprofen in adult patients after elective major surgery.

METHODS

This prospective, randomized multicentre trial evaluated the risks of death, increased surgical site bleeding, gastrointestinal bleeding, acute renal failure, and allergic reactions, with ketorolac vs diclofenac or ketoprofen administered according to their approved parenteral and oral dose and duration of treatment. Patients were followed for 30 days after surgery.

RESULTS

A total of 11,245 patients completed the trial at 49 European hospitals. Of these, 5634 patients received ketorolac and 5611 patients received one of the comparators. 155 patients (1.38%) had a serious adverse outcome, with 19 deaths (0. 17%), 117 patients with surgical site bleeding (1.04%), 12 patients with allergic reactions (0.12%), 10 patients with acute renal failure (0.09%), and four patients with gastrointestinal bleeding (0.04%). There were no differences between ketorolac and ketoprofen or diclofenac. Postoperative anticoagulants increased the risk of surgical site bleeding equally with ketorolac (odds ratio=2.65, 95% CI=1.51-4.67) and the comparators (odds ratio=3.58, 95% CI=1.93-6.70). Other risk factors for serious adverse outcomes were age, ASA score, and some types of surgery (plastic/ear, nose and throat, gynaecology, and urology).

CONCLUSION

We conclude that ketorolac is as safe as ketoprofen and diclofenac for the treatment of pain after major surgery.