bluuebunny/crossref_metadata_2025 huggingface dataset:
The naive T‐lymphocyte compartment is well preserved in patients with chronic myelogenous leukaemia in chronic phase
Authors: Isoda Atsushi , Yokohama Akihiko , Matsushima Takafumi , Tsukamoto Norifumi , Nojima Yoshihisa , Karasawa Masamitsu
Published: March 2003

Summary. In chronic myelogenous leukaemia (CML), clonal change occurs in all myeloid and B‐cell lineages, but very rarely T‐cell lineages. A detailed three‐colour cytometric analysis of peripheral lymphocytes was performed in 22 patients with chronic‐phase CML (CP‐CML). CD45 gating analysis was used to discriminate between lymphocytes and basophils. The peripheral lymphocyte pool was comprised of a significant proportion of naive CD4 cells, defined by a CD4+45RA+ phenotype [47·0 ± 19·6% (mean ± SD) of the total CD4+ cells], and naive CD8 cells, defined by a CD8+CD45RA+CD28+ phenotype (35·1 ± 19·7% of total CD8+ cells), even in patients with long disease duration. The percentage of CD8 naive T cells showed inverse correlation with age, whereas no correlation was observed with disease duration. Possible explanations for the preservation of naive lymphocytes include (1) that the naive T cells differentiated from co‐existing normal stem cells or (2) that long‐lived naive T cells persisted from the CML onset and expanded peripherally (thymus independent). Either mechanism or a combination of both mechanisms might contribute to maintaining the naive compartment size.
Increased resistance to activated protein C after short‐term oral hormone replacement therapy in healthy post‐menopausal women
Authors: Post Marinka S. , Rosing Jan , Van Der Mooren Marius J. , Zweegman Sonja , Van Baal W. Marchien , Kenemans Peter , Stehouwer Coen D. A.
Published: March 2003

Summary. As hormone replacement therapy is associated with an early excess risk of venous thrombosis, we investigated the effect of different oral hormone replacement therapies on resistance to activated protein C, and on levels of factor VIII antigen (FVIII:Ag) and factor XI antigen (FXI:Ag). In a prospective, randomized, placebo‐controlled 12‐week study, 60 healthy post‐menopausal women daily received either placebo (n = 16) or 2 mg of micronized 17β‐oestradiol, either alone (E2, n = 16) or sequentially combined with dydrogesterone 10 mg (E2 + D, n = 14) or trimegestone 0·5 mg (E2 + T, n = 14). Medication was given orally. Normalized activated protein C sensitivity ratios (nAPCsr) were determined by quantifying the effect of activated protein C on the endogenous thrombin potential. FVIII:Ag and FXI:Ag were determined by enzyme‐linked immunosorbent assay. Compared with baseline and placebo, the nAPCsr increased (92% to 142%; all P < 0·001) in all active treatment groups after both 4 and 12 weeks. Compared with placebo, hormone replacement therapy was not associated with significant changes in FVIII:Ag. After 4 and 12 weeks, FXI:Ag levels were significantly decreased in the E2 group (mean percentage changes from baseline versus placebo: −15·0%, P = 0·001 at 4 weeks and −16·6%, P = 0·003 at 12 weeks) and in the E2 + D group (−10·4%, P = 0·02 and −10·4%, P = 0·02). In conclusion, all hormone replacement regimens were associated with a large increase in resistance to activated protein C. In contrast, hormone replacement therapy had no effect on FVIII:Ag. Oral E2 and E2 + D had a small, favourable effect on FXI:Ag.
The effects of chemotherapeutic agents on the regulation of thrombin on cell surfaces
Authors: Paredes Nethnapha , Xu Ling , Berry Leslie R. , Chan Anthony K. C.
Published: March 2003

Summary. Thromboembolic disorders are common in cancer patients. Two major contributing factors are central venous catheters for drug delivery and the use of l‐aparaginase, which decreases the plasma antithrombin level, but the causes of the hypercoagulable state in these patients are not fully understood. In this study, the T24/83 cell line was used as a model to investigate the effects of chemotherapeutic agents on cell surface thrombin regulation. Plasma thrombin generation and prothrombin consumption was increased in most of the treated cells, particularly vincristine‐ and adriamycin‐treated cells (P < 0·05), compared with controls. However, no free thrombin generation or prothrombin consumption was observed in factor VII (FVII)‐depleted plasma. No significant differences in the levels of thrombin–α2‐macroglobulin (IIa–α2M) and thrombin–anti‐thrombin (TAT) were observed between controls and any of the treatments, except for vincristine‐ and adriamycin‐treated cells, which showed a significant difference in TAT production (P < 0·05). Also, there was an upregulation in tissue factor (TF) mRNA expression in etoposide‐, methotrexate‐ and vincristine‐treated monolayers compared with controls, as well as an upregulation in TF protein production in vincristine‐treated cells. The data suggests that thrombin generation occurs via the extrinsic (TF‐dependent) coagulation pathway on cell surfaces and that some chemotherapeutic agents are able to upregulate TF mRNA and protein expression in T24/83 cells.
Mu class glutathione S‐transferase mRNA isoform expression in acute lymphoblastic leukaemia
Authors: Kearns Pamela R. , Chrzanowska‐Lightowlers Zofia M. A. , Pieters Rob , Veerman Anjo , Hall Andrew G.
Published: March 2003

Summary. Glutathione S‐transferases (GSTs) are implicated in cytotoxic drug resistance in leukaemia. In a previous study, expression of mu class GST (GSTM) was associated with poor prognosis in childhood acute lymphoblastic leukaemia (ALL), however, that study did not differentiate between individual GSTM isoforms. This study, therefore, investigated individual GSTM isoform expression in ALL blasts at the mRNA level. Leukaemic blasts from 21 children with ALL were studied. Interindividual variation in the pattern of GSTM mRNA isoform expression was demonstrated. GSTM2 transcript was expressed in all patients in contradistinction to GSTM5, which was not detected in any sample. GSTM3 and GSTM4 expression varied between individuals, with GSTM3 expressed in 62% and GSTM4 in 24% of patients. Lymphoblast expression of GSTM3 was positively related to good prognosis whereas expression of GSTM4 was not related to clinical outcome in this small cohort. No relationship was demonstrated with established indicators of prognosis, including sex, age, immunophenotype and presenting white cell count. The results suggest that expression of GSTM3 may play a role in determining prognosis in childhood ALL and could provide more information for accurate stratification of treatment. Further studies are required to determine whether there is a causal relationship between GSTM3 expression and clinical outcome.
Defective expression of the T‐cell receptor‐CD3 ζ chain in T‐cell acute lymphoblastic leukaemia
Authors: Torelli Giovanni F. , Paolini Rossella , Tatarelli Caterina , Soriani Alessandra , Vitale Antonella , Guarini Anna , Santoni Angela , Foa Robin
Published: March 2003

Summary. This study analysed the T‐cell receptor (TCR)‐CD3 ζ complex and the signal transduction apparatus of T‐acute lymphoblastic leukaemia (T‐ALL) blasts, and investigated the function of the ubiquitin‐proteasome system. In all nine T‐ALL samples studied, the leukaemic cells showed a marked reduction in the expression of the ζ chain, while a variety of tyrosine kinases (p56lck, ZAP70 and SYK) were normally present. There was no expression of the FcεRIγ chain. To confirm that this aberration was specific to immature T‐ALL blasts, we investigated two patients with lymphoproliferative disorders of granular lymphocytes (LDGL), characterized by the expansion of mature T lymphocytes and found normal ζ chain expression. The reduction of the ζ chain protein was not reversible after 72 h stimulation with the anti‐CD3 monoclonal antibody and interleukin 2, either alone or in combination. Northern blot analysis indicated that the reduced protein expression did not correspond to a defect at the mRNA level, nor were mutations in the coding region of the ζ chain found. We, therefore, hypothesized that the observed reduction of protein expression in T‐ALL blasts could be secondary to an increased degradation at the proteasome level. Following selective inhibition of the proteasome, a marked increase of the ζ chain expression was observed. Moreover, an increase in the surface expression of CD3 was also documented. Taken together, these results indicate that the expression of the ζ subunit of the TCR‐CD3 complex is consistently reduced in T‐ALL blasts and that degradation of the protein is mediated by the proteasome system.
Peripheral blood stem cell contamination evaluated by a highly sensitive molecular method fails to predict outcome of autotransplanted multiple myeloma patients
Authors: Galimberti Sara , Morabito Fortunato , Guerrini Francesca , Palumbo Giuseppe Alberto , Azzará Antonio , Martino Massimo , Benedetti Edoardo , Di Raimondo Francesco , Petrini Mario
Published: March 2003

Summary. To evaluate the clinical impact of minimal residual disease in multiple myeloma, apheretic products from 51 autotransplanted patients were tested by fluorescent (GeneScan) polymerase chain reaction (PCR). Sixty‐nine per cent of harvests were contaminated when evaluated for IgH rearrangement. Forty‐six patients responded to transplant, with 52·9% achieving complete response (CR). The clinical response of patients was significantly influenced by the number of re‐infused CD34+ cells. Positive PCR results of re‐infused harvests were not significantly related to patient outcome. Median overall survival (OS) was 33 months, and a significant advantage for patients transplanted by 12 months from diagnosis was observed. Moreover, OS was longer for patients receiving PCR‐negative stem cells, with 72% of patients surviving to 70 months in the group receiving PCR‐negative harvests vs 48% in the group transplanted with contaminated precursors (not statistically significant). Ex vivo purging caused a reduction of contamination of up to 3 logs; nevertheless, 80% of purged harvests remained PCR‐positive and the purging procedure did not alter response or survival rates. Thus, the failure of a predictive role for this highly sensitive molecular method could be explained by the assumption that in vivo persisting malignant cells are the true source of relapse in MM.
Tumour necrosis factor‐α transcription in transferrin‐stimulated human blood mononuclear cells: is transferrin receptor involved in the signalling mechanism?
Authors: Lopez Marcelo , Rios Ernesto , Schlesinger Liana , Olivares Manuel , Nunez Marco T. , Munoz Carlos
Published: March 2003

Summary. Transferrin (Tf) and tumour necrosis factor‐alpha (TNF‐α) participate in immune response regulation. We studied the capacity of Tf to modulate ‘in vitro’ TNF‐α secretion, membrane expression and transcription by human blood mononuclear cells (BMNC). Women 25–45 years of age with normal iron status (n = 20) or with iron deficiency (ID, n = 20) due to gynaecological bleeding were studied. BMNC were incubated with different proportions of Fe‐exempt and Fe‐saturated Tf (apo‐Tf:holo‐Tf). Apo‐Tf or holo‐Tf uniformly induced TNF‐α secretion in the cell supernatants from both groups. Nevertheless, cytokine levels were significantly lower in ID subjects. For all Tf‐Fe saturations assayed, mean TNF‐α levels varied between 1·4–1·6 ng/ml and 0·4–0·7 ng/ml for normal and ID women respectively (P < 0·001). The addition of apo‐Tf enhanced TNF‐α secretion in a dose‐dependent manner, but the cytokine levels were lower in ID group. Tf did not induce pro‐TNF‐α expression in monocytes and lymphocytes from either group. Tf‐treated cells from normal individuals expressed approximately two to three times more TNF‐α mRNA than cells from ID subjects. Mean values ranged 96–110 atmol/ml in normal women and 24–31 atmol/ml in ID women for all Tf‐Fe saturation levels tested (P < 0·001). These results show that Tf‐induced TNF‐α secretion is transcriptionally regulated. The impaired TNF‐α transcription in cells from ID subjects indicates that the quality of the immune response is linked to the Fe status of mononuclear cells.
Assessment of combined bile acid and pH profiles using an automated sampling device in gastro-oesophageal reflux disease
Authors: Nehra D , Howell P , Pye J K , Beynon J
Published: March 2003

Background

Bile acid reflux is an important component of duodenogastro-oesophageal reflux but there is no effective method of quantifying it. The contribution of bile acids to oesophageal pH is unknown.

Methods

Oesophageal aspirates were collected over 15 h using a new automated suction device and pH was monitored in ten asymptomatic volunteers (group 1) and 30 patients with reflux oesophagitis (group 2, minimal mucosal injury; group 3, erosive oesophagitis; group 4, stricture or Barrett's oesophagus). Bile acid assay was performed by high-performance liquid chromatography.

Results

The concentration of bile acids was significantly higher in group 3 (median (interquartile range) 124 (50–301) µmol/l) and group 4 (181 (85–591) µmol/l) compared with group 1 (0 µmol/l) and group 2 (14 (0–100) µmol/l). Patients in groups 3 and 4 also had significantly greater DeMeester acid scores. Combined bile acid and oesophageal acid reflux was observed in eight of ten patients with stricture or Barrett's oesophagus. There was no correlation between total bile acid concentration and oesophageal acid or alkaline exposure.

Conclusion

This study supports the theory of toxic synergism between acid and bile acids in reflux oesophagitis. Bile acids may contribute to the pathogenesis of Barrett's metaplasia.
Correlation of the anatomical distribution of venous reflux with clinical symptoms and venous haemodynamics in primary varicose veins
Authors: Sakurai T , Gupta P C , Matsushita M , Nishikimi N , Nimura Y
Published: March 2003

Aim

The aim of this study was to correlate the anatomical distribution of venous reflux with clinical symptoms and venous haemodynamics in patients with primary varicose veins.

Methods

Venous reflux was examined using duplex colour Doppler ultrasonography in 266 legs in 191 patients. The venous refilling and reflux times were also measured.

Results

Of the 266 legs, 82 per cent had reflux in the long saphenous vein (LSV), 26 per cent in the short saphenous vein (SSV), 62 per cent had incompetent perforators (IPs) in the calf and 48 per cent had reflux in the deep veins. LSV reflux combined with SSV reflux and/or IPs was associated significantly with severe venous disease and abnormal venous haemodynamics. Femoropopliteal reflux played a role in the development of venous eczema and ulcers when combined with superficial venous reflux.

Conclusion

Patients at high risk of developing complications of venous disease may be identified by an accurate non-invasive evaluation of reflux patterns.
Effect of colonic obstruction on the distribution of matrix metalloproteinases during anastomotic healing
Authors: Savage F J , Lacombe D L P , Hembry R M , Boulos P B
Published: March 2003

Background

Anastomotic dehiscence is common after surgery for colonic obstruction. The strength of an anastomosis is dependent on collagen, which is degraded by matrix metalloproteinases (MMPs). The aim of this study was to determine the distribution of the MMPs and their inhibitor, tissue inhibitor of metalloproteinases (TIMP) 1 in an experimental model of colonic obstruction, with and without resection and anastomosis.

Methods

The distal colon of rabbits was obstructed with a Silastic ring for 24 h and then either the ring was removed or the obstructed segment was resected and an anastomosis formed. Rabbits were killed immediately or at intervals for up to 7 days after operation. The distribution of the MMPs and TIMP-1 was examined by indirect immunofluorescence.

Results

MMPs and TIMP-1 were present throughout the descending colon for 24 h in both groups. They persisted to the third day in rabbits with an anastomosis but by day 7 were restricted to the suture line. Their presence correlated with microscopic damage.

Conclusion

The extensive distribution of the MMPs suggests that these enzymes contribute to anastomotic dehiscence, but only in the immediate postoperative period.
Avoidable deaths still occur after large bowel surgery
Authors: Macarthur D C , Nixon S J , Aitken R J
Published: March 2003

Background

Postoperative death following large bowel surgery is relatively infrequent and no large study has analysed the cause of all deaths comprehensively and critically.

Methods

In-hospital deaths following large bowel surgery in South-East Scotland were reviewed by independent assessors. The audit was confidential but not anonymous. Independent assessors' reports were returned to consultants.

Results

The audit documented 187 deaths. The independent assessors noted an adverse event in 78 patients (42 per cent). Twenty-six deaths (14 per cent) occurred following an anastomotic leak. A further 43 deaths (23 per cent) occurred because surgery was delayed (17) or there was undue delay in making the initial diagnosis (12) or recognizing a developing complication (14). Consultants operated on only half the patients classed as American Society of Anesthesiologists grade IV or V, or undergoing a second or subsequent operation.

Conclusion

Half the patients dying in this study had identifiable deficiencies in their management. There is a clear need for greater consultant input with critically ill patients.
Bile duct injury during laparoscopic cholecystectomy without operative cholangiography
Authors: Wright K D , Wellwood J M
Published: March 2003

Background

The role of operative cholangiography in the prevention of bile duct injuries is controversial. A prospective audit of biliary injury is presented.

Methods

Laparoscopic cholecystectomy without operative cholangiography was undertaken in a consecutive series of 1200 patients. All biliary injuries were recorded.

Results

Meticulous dissection proved to be a reliable safeguard against injury to the right hepatic, common hepatic and common bile ducts. However, four accessory ducts were sacrificed and localized injury to the common hepatic or common bile duct occurred in three patients. These injuries would not have been prevented by operative cholangiography.

Conclusion

Operative cholangiography is not a prerequisite for the safe performance of laparoscopic cholecystectomy and cannot be relied upon to prevent all biliary injuries.
Hepatic resection with cryotherapy to involved or inadequate resection margin (edge freeze) for metastases from colorectal cancer
Authors: Dwerryhouse S J , Seifert J K , Mccall J L , Iqbal J , Ross W B , Morris D L
Published: March 2003

Background

In patients undergoing liver resection for colorectal liver metastases, a resection edge either involved by tumour or with the tumour extending to within 1 cm is associated with a high risk of liver recurrence and survival is reduced markedly.

Methods

Twenty-six patients underwent cryotherapy of the resection edge following liver resection for metastases from colorectal carcinoma with an involved or inadequate (less than 1 cm) resection margin.

Results

At a median follow-up of 23 (range 1–47) months four patients were alive and disease free, and 21 had developed recurrence, of whom 13 had died. One patient died following surgery. Sixteen patients developed recurrences involving the liver, only five of which were at the resection margin.

Conclusion

Cryotherapy to involved or inadequate resection margins improves local disease control considerably. The use of resection edge cryotherapy might allow a greater proportion of patients with liver metastases to be usefully treated and help to avoid high-risk resections.
Improved survival in patients with rectal cancer: a population-based register study
Authors: Dahlberg M , Påhlman L , Bergström R , Glimelius B
Published: March 2003

Background

Between 1985 and 1989, only one centre in Sweden combined preoperative radiotherapy with total mesorectal excision (TME) in the primary treatment of rectal cancer. The aim of this study was to investigate whether this change in primary treatment had an impact on the outcome.

Method

The survival rate of 94 262 patients with colorectal cancer from the total Swedish population between 1960 and 1989 was analysed.

Results

A continuous improvement in relative survival rate occurred during the first year of follow-up for both colonic and rectal cancer. Some improvement was also seen during follow-up years 2–5, but this was much more pronounced during the last period (1985–1989) for rectal cancer in the county of Uppsala. The improvement was particularly marked during follow-up years 3–5.

Conclusion

There are strong indications from this study that altered primary treatment for rectal cancer results in improved long-term survival.
Anovestibular fistula to Bartholin's gland
Authors: Cripps N P J , Northover J M A
Published: March 2003

Background

Acquired fistulation from the anal canal to Bartholin's gland has not been reported before. This fistula has been identified in 11 women treated between 1991 and 1995.

Methods

All discharge diagnoses during this period were searched. The clinical records of patients managed for this diagnosis were reviewed.

Results

Eleven women aged 24–49 years were identified. Seven of 11 fistulas arose in association with inflammatory bowel disease (five Crohn's disease, two ulcerative colitis). Patients typically presented with the vulval passage of flatus and faeces or acute sepsis of Bartholin's gland. Time to diagnosis of the fistula ranged from 1 to 15 (median 8) months after the onset of symptoms. Anatomically, all fistulas were high trans-sphincteric or suprasphincteric. All eight fistulas for which repair was attempted (five in the presence of inflammatory bowel disease) remain healed at short-term follow-up. Proctocolectomy was undertaken in two patients with severe Crohn's colitis.

Conclusion

Ano–Bartholin's fistulas, although rare in general surgical practice, present with troublesome symptoms and may be repaired successfully. Gynaecologists and surgeons should be aware of this clinical entity to avoid unnecessary delays in treatment.
Multimodality treatment in the control of deep musculoaponeurotic fibromatosis
Authors: Skene A I , Barr L , A'Hern R P , Fisher C , Meirion Thomas J
Published: March 2003

Background

Deep musculoaponeurotic fibromatoses are rare soft tissue neoplasms with a propensity for local recurrence.

Methods

A retrospective analysis was carried out of the factors contributing to local disease control in 75 patients treated between 1963 and 1993.

Results

Multivariate analysis identified the type of surgical excision (P<0·001) and involvement of pathological resection margins (P<0·02) as significant factors contributing to local recurrence. After a median follow up of 47 months (range 24 months to 29 years) 31 (49 per cent) of the 63 patients who had an ‘adequate’ surgical resection developed local recurrence. The median time before development of local recurrence was 83·4 (range 8–129) months in patients with clear pathological resection margins. This was significantly shortened to 13·1 (range 2–35) months in those with positive margins (P<0·001).

Conclusion

Adequate surgical extirpation is the most important determinant in local disease control. Treatment of local recurrence ranged from observation during periods of disease stabilization to multimodality treatment for aggressive disease.
Prospective randomized trial of woven versus collagen-impregnated knitted prosthetic Dacron grafts in aortoiliac surgery
Authors: Quarmby J W , Burnand K G , Lockhart S J M , Donald A E , Sommerville K M , Jamieson C W , Browse N L
Published: March 2003

Background

Despite the theoretical advantages of coating knitted grafts with a material designed to reduce blood loss, their performance has not been directly compared with woven grafts in a prospective randomized trial. The aim of this study was to compare the graft handling qualities and operative blood loss of the two types of arterial prosthesis, as well as complication rate and patient survival at 1 year.

Methods

A total of 267 consecutive patients having surgery for occlusive or aneurysmal disease of the aortoiliac arteries were randomized to receive woven (141 patients) or knitted collagen-impregnated Dacron (126 patients) grafts. Graft patency was assessed on discharge and at 1 year by duplex imaging.

Results

Mean(s.d.) intraoperative blood loss was statistically greater with woven grafts (1690(1424) ml) compared with knitted (1363(1172) ml) (P = 0·049). An insignificant 1-year increase in mean(s.d.) graft diameter of 1·2(0·2) mm was found at the distal anastomosis in the knitted group. There was no difference in graft patency between the groups and only one graft became infected.

Conclusion

This study suggests that knitted and woven grafts have similar clinical performance and therefore the less expensive material (woven) should usually be selected unless haemorrhagic complications are anticipated.
Mortality following elective infrarenal aortic reconstruction: a Joint Vascular Research Group study
Authors: Galland R B
Published: March 2003

Background

This study aimed to define the cause of death in patients undergoing elective infrarenal aortic reconstruction.

Methods

Members of the Joint Vascular Research Group who had collected details prospectively of patients undergoing elective aortic reconstruction provided information on those who died.

Results

Details of 3786 patients were obtained. Some 171 patients died (133 following abdominal aortic aneurysm (AAA) and 38 after aortofemoral bifurcation graft (AFBG) for occlusive disease). The mortality rate following AAA repair was 4·8 per cent, rising to 16 per cent if repair was combined with either renal or distal reconstruction (P < 0·001). Similar results were obtained with AFBG (3·4 and 11 per cent respectively, P < 0·001). The first major complication encountered was cardiac (39·8 per cent), followed by bleeding (20·5 per cent), respiratory (13·5), and gut (5·3 per cent), or limb ischaemia (6·4 per cent). Bleeding was commoner following reconstruction for aneurysm compared with that for occlusive disease (P < 0·05). Eighty-six patients (50·3 per cent) died from the first major complication. Of the remainder, 45 (53 per cent) developed multisystem organ failure (MSOF). The most commonly involved systems were cardiac, respiratory and renal.

Conclusion

Cardiac problems were the major cause of death following infrarenal aortic reconstruction. MSOF is the ‘final common pathway’ in about half of the patients who survive the initial complication.
Surgical treatment of severe duodenal polyposis in familial adenomatous polyposis
Authors: Penna C , Bataille N , Balladur P , Tiret E , Parc R
Published: March 2003

Background

Patients with familial adenomatous polyposis (FAP) are at risk for adenomas and cancers in the duodenum but the ideal management of duodenal polyposis remains uncertain.

Methods

The outcome of surgical resection was analysed in 18 patients with FAP who had severe duodenal polyposis.

Results

Duodenotomy and clearance of duodenal adenomas was performed seven times in six patients. There were two duodenal leaks and, after a mean follow-up of 53 (range 36–72) months, duodenal adenomas recurred in all patients and five had severe polyposis. Pancreatoduodenectomy was performed in seven patients with severe duodenal polyposis. Histology of the specimens revealed two unsuspected duodenal carcinomas at an early stage. After a mean follow-up of 42 months all patients were alive and well, and there was no case of jejunal polyposis. Pancreatoduodenectomy was attempted in five patients with duodenal cancer and only one survived more than 4 years.

Conclusion

Surgical excision of duodenal adenomas should be discussed before carcinoma occurs. Surgical polypectomy fails to guarantee a polyp-free duodenum and carries a risk of postoperative complications whereas pancreatoduodenectomy eliminates the risk of duodenal cancer with an acceptable morbidity rate. Pancreatoduodenectomy could be offered to some patients with large or multiple villous duodenal adenomas repeatedly showing severe dysplasia.
Percutaneous aspiration for bacteriological studies in patients with necrotizing pancreatitis
Authors: Paye F , Rotman N , Radier C , Nouira R , Fagniez P-L
Published: March 2003

Background

Percutaneous computed tomography (CT)-guided aspiration of abdominal collections is performed in necrotizing pancreatitis to detect infection of necrosis, which is an adverse prognostic factor and requires surgical drainage. However, in the case of sterile aspirates, the outcome and the optimum management are subject to debate. This study examined the clinical and bacteriological outcome of patients with severe acute pancreatitis with initially sterile necrosis and assessed the efficiency of percutaneous drainage in this setting.

Methods

Seventeen patients hospitalized for necrotizing pancreatitis with a septic course underwent a preliminary sterile CT-guided aspiration. Eight patients underwent simultaneous percutaneous drainage of the punctured collection. Supportive therapy was continued unless severe clinical deterioration or proven secondary infection of necrosis indicated the need for necrosectomy and drainage.

Results

Secondary infection of necrosis was observed in two patients of nine who had only fine-needle aspiration cytology of the collection, and in seven of eight it was drained percutaneously (P=0·01). Only one patient drained percutaneously recovered without surgery. Surgical drainage was required in 12 patients. The hospital mortality rate was 29 per cent and was not significantly affected by the bacteriological status of necrosis.

Conclusion

Percutaneous drainage of sterile collections predisposed to secondary infection of the necrosis and did not cure the patients. A first sterile percutaneous aspiration did not predict a favourable course and surgery frequently remains necessary.
Management of faecal incontinence following obstetric injury
Authors: Cook T A , Mortensen N J McC
Published: March 2003

Background

Faecal incontinence is common in women and the major aetiological factor is childbirth. Increasing numbers of women with faecal incontinence are presenting to surgical clinics.

Methods

A literature review was performed on Medline database for English language publications on obstetric injury. The incidence, presentation, assessment and treatment of faecal incontinence following obstetric injury were evaluated.

Results and conclusions

Third-degree tear occurs in association with less than 1 per cent of vaginal deliveries, but occult sphincter injury occurs at one-third of deliveries and may be significant in later life. Incontinence may result from sphincter damage or nerve injury, or both. Risk factors for these injuries can be identified. Clinical evaluation, anorectal physiology and endoanal ultrasonography allow accurate planning of subsequent surgery. Overlapping anterior anal sphincter repair provides symptomatic control of continence in 80 per cent of patients. Repair of an acute anal sphincter injury after a third-degree tear is controversial and a defined policy should be agreed between obstetric and colorectal teams.
Cerebral haemodynamics and embolization during carotid angioplasty in high-risk patients
Authors: Mccleary A J , Nelson M , Dearden N M , Calvey T A J , Gough M J
Published: March 2003

Background

Patients with symptomatic internal carotid artery (ICA) stenosis greater than 70 per cent in association with a contralateral ICA occlusion may have an increased risk of stroke following carotid endarterectomy. Such patients might benefit from the theoretically shorter ischaemic time offered by carotid angioplasty and stenting.

Methods

Nine patients who underwent carotid angioplasty and stenting were monitored using near-infrared spectroscopy, continuous jugular venous oximetry and transcranial Doppler ultrasonography to detect both haemodynamic ischaemia and embolic events.

Results

Significant ischaemia occurred in four of the nine patients once the stenosis had been crossed by the guidewire (spectroscopy and oximetry). Inflation of the angioplasty balloon resulted in a brief period of ischaemia and showers of emboli in all patients (ultrasonography) and this persisted for more than 3 min after balloon deflation in three patients. One patient had a major disabling stroke due to ICA thrombosis.

Conclusion

Angioplasty and stenting in these high-risk patients may not confer any advantage over conventional surgery in terms of both haemodynamic ischaemia and embolization.
Functional results following the antegrade continence enema procedure
Authors: Shankar K R , Losty P D , Kenny S E , Booth J M , Turnock R R , Lamont G L , Rintala R J , Lloyd D A
Published: March 2003

Background

Forty children who underwent the antegrade continence enema (ACE) procedure for faecal soiling were studied to determine factors predictive of outcome.

Methods

There were four patient groups: (1) ambulant with spinal dysraphism (n = 13), (2) wheelchair bound with spinal dysraphism (n = 14), (3) ambulant with miscellaneous disorders (n = 11) and (4) wheelchair bound with miscellaneous disorders (n = 2). Effectiveness of the procedure was assessed using technical evaluation and quality-of-life improvement (QOLI) scores (0–5). Objective assessment included colonic transit time (CTT) and anorectal manometry. Median follow-up was 21 (range 5–37) months.

Results

Some 28 of 40 children achieved continence. The procedure was reversed in four of 40 children. Of the other 36 children with a functioning ACE stoma, all reported improvement in quality of life (mean QOLI score 3·5). There were no significant differences in technical evaluation score, QOLI score, CTT, manometry findings or continence between ambulant groups and the wheelchair-bound group with miscellaneous disorders. QOLI score, anorectal squeeze pressure and continence were significantly poorer in those who were wheelchair bound with spinal dysraphism. Absent squeeze pressure was associated with poor outcome.

Conclusion

Wheelchair-bound children with spinal neuropathy have a poorer outcome following the ACE procedure. Although ACE is an effective method of promoting faecal continence, it is essential to determine the aetiology of incontinence and sphincter function before operation.
Lymphocyte function in wound healing and following injury
Authors: Schäffer M , Barbul A
Published: March 2003

Background

Injury activates a cascade of local and systemic immune responses.

Methods

A literature review was undertaken of lymphocyte function in wound healing and following injury.

Results

Lymphocytes are not required for the initiation of wound healing, but an intact cellular immune response is essential for a normal outcome of tissue repair. Injury affects lymphocyte immune mechanisms leading to generalized immunosuppression which, in turn, increases host susceptibility to infection and sepsis. Although the exact origin of post-traumatic immunosuppression remains unknown, stress hormones and immunosuppressive factors, such as inflammatory cytokines, prostaglandin E2 and nitric oxide, affect lymphocyte function adversely. Post-traumatic impairment of T lymphocyte immune function is reflected in decreased lymphocyte numbers, as well as altered T cell phenotype and activity. Antibody-producing B lymphocytes are variably affected by injury, probably secondary to alterations of T lymphocyte function, as a result of their close interaction with helper T cells. Therapeutic modulation of the host immune response may include non-specific and specific interventions to improve overall defence mechanisms.

Conclusion

Early resuscitation to restore lymphocyte function after injury is important for tissue repair and the prevention of immunosuppression.
Laparoscopic subtotal cholecystectomy in patients with complicated acute cholecystitis or fibrosis
Authors: Michalowski K , Bornman P C , Krige J E J , Gallagher P J , Terblanche J
Published: March 2003

Background

The open subtotal cholecystectomy technique has simplified removal of the difficult gallbladder. Increasing laparoscopic experience has made laparoscopic subtotal cholecystectomy (LSC) a feasible option in patients with complicated acute or chronic cholecystitis.

Methods

LSC was performed in 29 patients with severe inflammation or fibrosis of the gallbladder associated with gallstone disease over a 23-month period. These 29 patients (mean age 53 years; 22 women) constituted 8·5 per cent of the total number of laparoscopic cholecystectomies performed (n = 340) and 15·6 per cent of 186 patients with acute cholecystitis. Eighteen patients in the latter group underwent conversion to open cholecystectomy. The indications for LSC were acute cholecystitis/empyema (n = 23) and severe fibrosis (n = 6).

Results

The cystic duct was either clipped before division (n = 15), sutured (n = 2) or ligated using an Endoloop (n = 10). In two patients the gallbladder bed was drained without isolating the cystic duct. The posterior wall of the gallbladder was left intact to avoid excessive bleeding or damage to bile ducts in the gallbladder bed. A suction drain was inserted in 14 cases. Median operating time was 73 (range 45–130) min. One patient died after operation from a myocardial infarction. Six patients had local complications (two haematomas, three bile leaks, one minor wound sepsis) and nine developed respiratory infections. Median hospital stay was 5 (range 2–28) days.

Conclusion

LSC is a safe, relatively simple and definitive procedure allowing removal of a difficult gallbladder and reducing the need for open conversion or cholecystostomy in the majority of patients.
Glutaraldehyde cross-linked collagen in the treatment of faecal incontinence
Authors: Kumar D , Benson M J , Bland J E
Published: March 2003

Background

The treatment of faecal incontinence secondary to internal anal sphincter dysfunction is unsatisfactory. The aim of the study was to evaluate the efficacy of anal glutaraldehyde cross-linked (GAX) collagen injections in patients with a surgically incorrectable disorder.

Methods

Seventeen patients were studied: nine had idiopathic faecal incontinence, three had incontinence following haemorrhoidectomy, two following internal sphincterotomy, two following an internal sphincter defect from obstetric injury and one following treatment for fistula in ano. All patients were refractory to conservative treatment and were unsuitable for surgical repair. All had anorectal physiology and endoanal ultrasonography before and after GAX collagen injections.

Results

All patients tolerated the injection without side-effects. All patients had an intact external anal sphincter. Following injection, 11 patients showed marked symptomatic improvement. One patient reported symptomatic improvement but remained in clinical grade 3, and two reported minimal improvement. There was no improvement in three patients, but one of these had a repeat injection and showed significant improvement subsequently.

Conclusion

Injection of GAX collagen in the anal canal is a simple and well tolerated method of treating faecal incontinence due to internal sphincter dysfunction. Early results suggest it provides an easy and reliable alternative to the currently available methods that are often unsuccessful and at best unpredictable.
Diagnosis and treatment of sphincter of Oddi dysfunction
Authors: Tzovaras G , Rowlands B J
Published: March 2003

Background

Sphincter of Oddi dysfunction is a challenge from both the diagnostic and therapeutic point of view. There is much ongoing debate about the accuracy and usefulness of various diagnostic tests, as there is about the effectiveness of proposed therapeutic alternatives.

Methods

A comprehensive review of the past 15 years' literature was undertaken, using the Medline database and cross-referencing of major articles on the subject.

Results and conclusion

Endoscopic and surgical treatments result in similar outcomes, with considerable failure rates. The latter reflect the difficulties in accurate diagnosis and a lack of sound objective criteria for selecting patients for intervention. In addition, in some patients sphincter of Oddi dysfunction may be only part of a generalized motility disorder of the gastrointestinal tract.
Stimulation of inflammatory markers after blunt trauma
Authors: Giannoudis P V , Smith R M , Banks R E , Windsor A C J , Dickson R A , Guillou P J
Published: March 2003

Background

Inflammatory mediators are released after trauma and may be related to the pathogenesis of sepsis. A prospective combined study of the pattern of release of an inflammatory mediator, interleukin (IL) 6, leucocyte activation (polymorphonuclear leucocyte (PMN) CD11b receptor expression and plasma elastase-α1 proteinase inhibitor complex (E–α1PI)) and soluble endothelial adhesion molecule expression (soluble E-selectin (sE-selectin) and soluble intracellular adhesion molecule 1 (sICAM-1)) was performed in patients suffering blunt trauma without adult respiratory distress syndrome (ARDS) or multiple organ failure syndrome (MOFS).

Methods

Thirty-one patients with a mean Injury Severity Score (ISS) of 14 (range 9–57) were studied. Venous blood samples were collected within 6 h of injury and then at 1, 3, 5 and 7 days. Leucocyte CD11b expression was quantified by flow cytometry. Serum IL-6, plasma E–α1PI, sE-selectin and sICAM-1 were measured by enzyme-linked immunosorbent assay.

Results

Serum IL-6, CD11b expression and E–α1PI levels were significantly raised above control values (P < 0·0001) on admission, slowly returning towards control values over the study period (median IL-6, 140 pg/ml versus undetectable; CD11b, 14·8 versus 6·4 mean channel fluorescence units; E–α1 PI, 208 versus 52 µg/l). The sICAM-1 level rose to a median of 539 ng/ml at 5 days (control 243 ng/ml). The median sE-selectin level also progressively increased to a maximum level of 80 ng/ml at 5 days (control 49 ng/ml). Eleven patients developed postoperative sepsis. Significant differences in CD11b expression were seen at days 3, 5 and 7 and in E–α1 PI at 6 h, 24 h and 3 days in patients who subsequently developed sepsis (P < 0·05). Severe injury (ISS 16 or greater) was associated with significantly greater responses in these measurements.

Conclusion

These data show that markers of inflammation are specifically stimulated by trauma even when ARDS and MOFS do not occur. The CD11b receptor on PMNs may be useful in screening patients destined to develop post-traumatic sepsis.
Clinical significance of clonality in thyroid nodules
Authors: Kim H , Piao Z , Park C , Chung W Y , Park C S
Published: March 2003

Background

Many different neoplastic and hyperplastic thyroid diseases present with clinically apparent thyroid nodules. Clonality analysis indicates whether a nodule arises from the polyclonal proliferation of a group of cells or forms a clone from a genetically altered cell and thus provides objective information on the origin of the thyroid nodules. Clonality was studied in thyroid nodules using the polymerase chain reaction (PCR) assay in the X-linked human androgen receptor (HUMARA) gene by random X chromosome inactivation in women.

Methods

DNA samples were obtained from 28 nodules in 21 women. All nodules and non-tumour thyroid tissues were fractioned selectively under a cryostat. Genomic DNA was isolated and digested with HhaI. PCR amplification of the HUMARA locus was performed using PCR mixtures containing [α-32P]2′-deoxycytidine 5′-triphosphate. The PCR products were analysed by denaturing gel electrophoresis.

Results

The HUMARA alleles were heterogenous in 18 of 21 patients. Among the 23 nodules from 18 patients, all of the eight papillary thyroid carcinomas were monoclonal. Two solitary nodules from follicular adenomas were monoclonal. Of the 13 follicular nodules from nodular goitres, ten were polyclonal and three were monoclonal. The monoclonal follicular nodules were larger in size (3·5 versus 2·0 cm, P < 0·05) and had a tendency towards more cystic changes than polyclonal nodules.

Conclusion

PCR-based clonality study of thyroid nodules may help to distinguish hyperplastic from neoplastic nodules.
Comparison of duplex imaging and arteriography in the evaluation of lower limb arteries
Authors: Aly S , Sommerville K , Adiseshiah M , Raphael M , Coleridge Smith P D , Bishop C C R
Published: March 2003

Background

The aim of this study was to assess the accuracy of duplex imaging, compared with arteriography, in detecting arterial disease distal to the renal arteries.

Methods

Some 177 legs were studied in 90 patients (59 men, 31 women; median age 68 years) with peripheral arterial disease. Each patient had conventional intra-arterial angiography and duplex ultrasonography. Each leg was divided into 17 arterial segments, and the disease in each segment was quantified by measuring the peak systolic velocity ratio across any arterial lesion that was identified.

Results

Compared with angiography, duplex imaging was able to detect arterial disease with an overall sensitivity of 92 per cent, specificity of 99 per cent, positive predictive value 91 per cent and negative predictive value 100 per cent, and with a κ value of 0·87 (95 per cent confidence interval (c.i.) 0·81–0·93). Duplex was able to determine the length of the arterial lesion with a sensitivity of 89 per cent and a specificity of 98 per cent with a κ value of 0·88 (95 per cent c.i. 0·86–0·90). When the surgeon's final management decision concerning each vascular lesion was used as the reference, duplex and arteriography were equivalent, with an accuracy of 84 per cent and 85 per cent respectively in identifying the management used.

Conclusion

Duplex ultrasonography is reliable in detecting arterial lesions in peripheral arteries and could be used routinely in the initial evaluation of patients with lower limb arterial disease.
Histological study of colonic ischaemia after aortic surgery
Authors: Welch M , Baguneid M S , Mcmahon R F , Dodd P D F , Fulford P E , Griffiths G D , Walker M G
Published: March 2003

Background

Colonic ischaemia is a well documented complication of abdominal aortic reconstruction. In this prospective study patients had routine preoperative and postoperative colonoscopy and biopsy, in order to determine the true incidence and implications.

Methods

Fifty-six patients undergoing elective infrarenal aortic surgery, 28 for aneurysm and 28 for occlusive disease, had colonoscopy and biopsy before and 1 week after operation.

Results

Colonic ischaemia was identified histologically in biopsies from 16 (30 per cent) of 53 patients. Almost half the patients had normal macroscopic appearances. Two factors exhibited a statistically significant association with the development of ischaemia: prolonged cross-clamp time (P < 0·05) and postoperative diarrhoea (P < 0·001). Co-morbidity was much higher in patients with colonic ischaemia (P < 0·005). Overall morbidity was significantly greater in the aneurysm group (P < 0·05).

Conclusion

Colonic ischaemia is common after aortic reconstruction. When suspected, colonoscopy with biopsy is diagnostic.