Quantification of fibronectin as a method to assess ex vivo extracellular matrix remodeling.

Altered architecture, composition and quality of the extracellular matrix (ECM) are pathological hallmarks of several inflammatory and fibro-proliferative pathological processes such as osteoarthritis (OA), rheumatoid arthritis (RA), fibrosis and cancer. One of the most important components of the ECM is fibronectin. Fibronectin serves as an adhesion molecule anchoring cells to the underlying basement membrane through direct interaction with integrin receptors. Fibronectin hereby modulates the properties of the ECM and affects cellular processes. Quantification of fibronectin remodeling could therefore be used to assess the changes in the ECM that occur during progression of fibro-proliferative pathologies. Ex vivo models are becoming state-of-the-art tools to study ECM remodeling as the cellular composition and the organization of the ECM are preserved. Ex vivo models may therefore be a valuable tool to study the ECM remodeling that occurs during progression of fibro-proliferative pathologies. The aim of this study was to quantify fibronectin remodeling in ex vivo models of cartilage and cancer. A competitive The enzyme-linked immunosorbent assay (ELISA) against the C-terminus of fibronectin was developed (FBN-C). The assay was evaluated in relation to specificity, technical performance and as a marker for quantification of fibronectin in cartilage and cancer ex vivo models. The ELISA was specific and technically stable. Cleavage of tumor tissue with MMP-2 released significantly higher levels of FBN-C compared to tissue with buffer only and western blot analysis revealed that FBN-C recognizes both full length and degraded fibronectin. When ex vivo cartilage cultures were stimulated with the anabolic factor TGFß and catabolic factors TNF-α and OSM, significantly higher levels of FBN-C were found in the conditioned media. Lastly, FBN-C was released from a cancer ex vivo model. In conclusion, we were able to quantify fibronectin remodeling in ex vivo models of cartilage and cancer. Quantification of fibronectin remodeling could be a valuable tool to understand ECM remodeling in ex vivo models of fibro-proliferative pathologies.

Leukocyte filtration does not affect lymphocyte subpopulations and NK cell function in recipients of blood transfusions.

BACKGROUND AND OBJECTIVES: The possible immunosuppressive action of blood transfusion has aroused great interest recently, particularly with respect to its effects on tumor growth and recurrence rate of malignant disease. MATERIALS AND METHODS: The effect of blood transfusion on lymphocyte subpopulations and NK cell function preoperatively and 6 months postoperatively was studied in 129 patients treated with elective surgery for colorectal malignancy. Forty-two patients (33%) received blood transfusions, 21 of them randomly allocated to receive leukocyte-depleted blood products. Investigation was by means of conventional laboratory methods. RESULTS: In 21 patients receiving a median of 3 units of non-leukocyte-depleted blood products (NLD), a significant reduction in CD4+ lymphocytes (44% vs. 40%, p < 0.01) occurred. In contrast, no significant changes in CD4+ lymphocytes were observed in the 21 patients transfused with leukocyte-depleted blood products (LD). However, with respect to lymphocyte subpopulations and NK cell function, differences between the NLD and LD groups were not significant. There was a marginal decrease in HLA-DR+ lymphocytes in the NLD patients without a history of previous transfusion. CONCLUSIONS: There seems to be no major change in lymphocyte subpopulations and NK cell function 6 months after blood transfusion. Thus we cannot confirm our previous findings of a reduced number of CD20+ cells after blood transfusion.

Prognostic value of cytosolic thymidine kinase activity as a marker of proliferation in breast cancer.

Thymidine kinase (TK) is involved in DNA synthesis by the salvage pathway. In this study, thymidine kinase (TK) was determined in routinely prepared cytosols of primary tumors from 290 breast-cancer patients. Enzyme activity was measured using a radioenzymatic method optimized for detection of the fetal isoenzyme. High levels of TK (> or = 126 mU/mg protein) were positively associated with histological grade in both pre/peri-and post-menopausal patients. In pre/peri-menopausal patients, high concentrations of TK were also found more frequently in progesterone receptor (PgR)-negative tumors than in PgR-positive samples. In post-menopausal patients, high levels of TK were associated with large tumor size, estrogen receptor (ER) negativity and PgR negativity. In univariate analysis, high levels of TK were strongly associated with shorter overall survival in both pre/peri- (p = 0.001) and post-menopausal patients (p = 0.02). Pre/peri-menopausal patients whose tumors had high levels of TK also had an increased risk of relapse (p = 0.001). In multivariate analysis (including treatment protocol, patient age, lymph-node involvement, tumor size, histological grade, ER and PgR status), TK status was found to be an independent prognostic factor for recurrence-free survival in pre/peri-menopausal patients with a weight similar to that of PgR status. In post-menopausal patients, TK was the only factor selected for overall survival.

Effect of omeprazole and sucralfate on prepyloric gastric ulcer. A double blind comparative trial and one year follow up.

This study compared healing rates, relief of symptoms, frequency of adverse events, and proportion of patients in remission after one year follow up in 104 patients with active prepyloric ulcer during treatment with 40 mg omeprazole once daily or 2 g sucralfate twice daily, using a randomised double blind controlled trial. Healing rates after two, four, and six weeks were (omeprazole/sucralfate) 49%/23%; 83%/59%; 90%/70% respectively. After two weeks, omeprazole was more efficient than sucralfate in relief of daytime and nocturnal epigastric pain, nausea, and heartburn. The proportion of patients in remission after one year follow up was significantly higher in the omeprazole group (p < 0.01). Of the healed patients ulcers recurred in 36% in the omeprazole group and in 46% in the sucralfate group. It is concluded that the ulcer healing rate was higher and symptom relief was more pronounced in the omeprazole group compared with the sucralfate group, and that more patients were still in remission after a one year follow up period.

The diagnostic value of serum urea/creatinine ratio in distinguishing between upper and lower gastrointestinal bleeding. A prospective study.

The predictive value of a urea/creatinine ratio > or = 100 for indicating upper gastrointestinal bleeding was evaluated in 78 consecutive patients with a history of gastrointestinal bleeding 24 hours or less before admission. Serum beta-2-microglobulin was measured to elucidate whether renal hypoperfusion plays a part in elevation of the urea/creatinine ratio. The predictive value of a urea/creatinine ratio > or = 100 in terms of upper gastrointestinal bleeding, was 95% (95% confidence interval (CI): 83-99%), whereas the predictive value of a urea/creatinine ratio < 100, indicating lower gastrointestinal bleeding, was 41% (CI: 25-59%). No statistically significant differences were found between serum beta-2-microglobulin levels in upper and lower gastrointestinal bleeders. We conclude that a urea/creatinine ratio > or = 100 strongly indicates an upper gastrointestinal bleeding source and that the main cause of a high ratio is not renal hypoperfusion.

The effect of previous blood transfusion on lymphocyte subsets and natural killer cell function in patients with colorectal cancer.

To elucidate the possible influence of previous blood transfusion on immune functions, the transfusion history of 153 patients admitted to hospital for elective colorectal surgery was correlated with lymphocyte subsets and natural killer (NK) cell function. The subsets determined were CD2, CD3, CD4, CD8, CD16, CD20, CD56, CD57 and HLA-DR-positive. The NK cell function was determined by measuring the killing capacity against cFDA-labelled K562 target cells monitored via a flow-cytometer. We found that 42 patients (27%) had been transfused before surgery, of these 13 had been transfused less than 30 days before surgery and 29 (19%) transfused more than 30 days before (median 10 years, range 0.1-37 years). In transfused patients, we found a significantly reduced number of B lymphocytes (CD20; p = 0.01), a reduction in HLA-DR-positive cells (p = 0.02) and a just significant reduction of NK cell function in transfused compared to nontransfused patients. The reduction in NK cell function is marginal and the NK cell function is within normal range, and probably without clinical significance. Reduction in NK cell function has been described before, whereas the reduction in B cells has not been reported earlier. The results may suggest an impaired humoral immunity and a minor reduction in cellular immunity in patients following blood transfusion.

The Nottingham Prognostic Index applied to 9,149 patients from the studies of the Danish Breast Cancer Cooperative Group (DBCG).

In primary, operable breast cancer, the Nottingham Prognostic Index (NPI) based on tumour size, lymph node stage and histological grade can identify three prognostic groups (PGs) with 10-year survival rates of 83%, 52%, and 13%. With the aim of defining a subset of patients having so good prognosis that adjuvant therapy can be withhold, the NPI was applied to a Danish population-based study group comprising 9,149 patients. As opposed to the British study, we used conventional axillary lymph-node staging. Histological grading was in both studies done by means of a similar slight modification of the Bloom and Richardson procedure, but in the Danish study only ductal carcinomas were graded. The 10-year crude survival was 68.1% for 4,791 patients with tumour size < or = 2 cm and 70.0% for 2,900 patients with grade I tumours. For 4,761 node-negative patients, the 10-year survival was also 70.0%, the expected survival being 89.3%. The relative mortality (observed:expected) was even at 10 years 2.1 demonstrating that more than 10 years observation time is necessary to estimate cumulated mortality. By application of the NPI, the Danish good PG comprising 27.3% of the patients had a 10-year survival of 79.0%. Thus, the index defined a subset with better survival than could be defined individually by each of its three components, but it did not succeed in defining a subset with survival similar to the expected; additional prognostic factors are therefore needed. The somewhat poorer survival of the Danish good PG may be ascribed to the British inclusion of non-ductal carcinomas, to interobserver variation present only in the Danish study, and to poorer expected survival of the Danish patients. The 10-year survival of the Danish moderate PG and poor PG was 56% and 25%, respectively. These improved survival rates are attributed to the administration of adjuvant therapies. There were virtually no node-positive patients in the good PG and no node-negative patients in the poor PG. Patients should therefore still be stratified initially by lymph-node status, but tumour size and histological grade are significant prognostic factors primarily within the node-negative group, and they should be included in future prognostication procedures.

Flow cytometric DNA ploidy defines patients with poor prognosis in node-negative breast cancer.

Flow cytometric DNA analysis was performed on fine-needle aspirates from frozen tumour biopsies from 421 node-negative, non-adjuvantly-treated breast-cancer patients with a median observation time of 6.75 years. Among premenopausal patients (n = 175), those having at least one DNA "hypoploid" subpopulation defined as DNA index (DI) < 0.96 or 1.44 < or = 1.92 (n = 81) were characterized by early recurrences (log-rank p = 0.05), Wilcoxon p = 0.007), poor overall survival (OS) (p < 0.001) and poor survival after recurrence (p < 0.001). In the postmenopausal group (n = 246), there were no significant difference among 7 different DI classes regarding either recurrence-free survival (RFS) or OS. S-phase fraction (SPF), divided into quartiles, predicted OS in premenopausal patients only (p = 0.02). Conventional multivariate Cox analysis of OS in the premenopausal group revealed hypoploidy to be the only independent prognostic factor involving a relative risk (RR) of 22.8. Age < or = 40 years was of marginal significance, whereas SPF, histological grade (WHO), oestrogen and progesterone receptor (PgR) content, tumour size and number of lymph nodes removed were excluded from the model. Application of the conventional Cox model to the premenopausal group regarding RFS was found inappropriate due to lack of proportionality of the hazards of hypoploidy due to lack of proportionately of the hazards of hypoploidy, SPF and histological grade. However, introduction of time-dependent co-variates using 2 years as cut-off level showed hypoploidy with a RR of 3.52 and age < or = 40 years with a RR of 3.28 to be independent prognostic factors. In the postmenopausal group, the conventional Cox model identified the number of lymph nodes removed to be the only independent prognostic factor regarding RFS as well as OS, whereas SPF < 9% (lowest quartile) was of marginal significance in RFS analysis. Hypoploidy was correlated to high SPF, low PgR content and low differentiation, indicating that hypoploid tumours proliferate rapidly and hormone-independently. These patients may therefore benefit from adjuvant chemotherapy administered while tumour burden and risk of drug resistance are still low.

[Colonic ileus. Treatment of colonic ileus, a 10-year patient material]. / Colonileus. Behandling af colonileus, et tiårigt materiale.

Morbidity and mortality have been evaluated in 238 patients with acute large bowel obstruction admitted over a ten year period. In two thirds, the cause of obstruction was a primary colonic carcinoma. Most of these patients (61%) had advanced disease and were over 70 years of age. Volvulus and cancer recurrences each accounted for 10%, and diverticulitis for eight percent. An overall mortality of 24% was found. Of 115 patients who had the obstructing lesion--primary carcinoma or diverticulitis--resected, a mortality of 8.7 was seen, higher for primary (14.9%) than for staged (4.4%) resections, in contrast the latter had a significantly longer hospital stay, 30 days as against 17 days when a primary resection was performed. Six non-lethal anastomotic leaks occurred. It is concluded, that patients with large bowel obstruction, most often caused by a colorectal carcinoma, are a high-risk group. In this retrospective study staged procedure compared with primary resection had lowest morbidity and mortality.

A double-blinded multicenter trial of somatostatin in the treatment of acute pancreatitis.

To evaluate the effect of somatostatin in the treatment of acute pancreatitis, 63 patients were randomly allocated to continuous intravenous infusion for three days of 250 micrograms of somatostatin (Dura Scan, Odense, Denmark) per hour (n = 33), or placebo (n = 30). Patients with a first attack of pancreatitis, serum amylase level of more than 450 units per liter and symptoms for less than 24 hours were eligible for participation in the study. Apart from a slightly significant faster decrease in serum amylase concentrations, we were unable to demonstrate any significant benefit from somatostatin with regard to paraclinical values and clinical course.

Surgical treatment of acute malignant large bowel obstruction.

OBJECTIVE: To evaluate the morbidity and mortality in all patients operated on urgently for acute large bowel obstruction caused by carcinoma of the colon or rectum during a 10 year period. DESIGN: Retrospective study. SETTING: Aalborg Hospital, Denmark. SUBJECTS: 156 consecutive patients operated on for obstructing primary colorectal cancers. MAIN OUTCOME MEASURES: Operations done, morbidity and mortality. RESULTS: 95 patients (61%) had advanced disease (Dukes' stage C or "D") and their median age was 73 years (range 38-93). 97 had the obstructing lesion resected with a 30 day mortality of 5%. 43 patients underwent primary resection and 4 died (9%), and 54 underwent staged resection with one death (2%). Complications were common, particularly after staged resections, median hospital stay being 19 days after primary, compared with 30 days after staged resection. 59 patients (38%) had palliative operations with 29 deaths (49%); in 39 the tumor was completely unresectable. CONCLUSION: Patients with obstructing primary colorectal cancers are a high risk group who are characterised by advanced disease and old age. Only prospective trials comparing different operations can assess whether it is possible to achieve a reduction in mortality.

Time to loco-regional recurrence after resection of Dukes' B and C colorectal cancer with or without adjuvant postoperative radiotherapy. A multivariate regression analysis.

Factors influencing time to loco-regional recurrence were identified in a multivariate regression analysis of data from a series of 468 radically operated patients (260 Dukes' B and 208 Dukes' C) with carcinoma of the rectum and the rectosigmoid. A number of clinical and pathological characteristics were prospectively collected and recorded. In addition, carcinoembryonic antigen (CEA) was measured within 1 week before surgery. The endpoint used was recurrence below the level of the umbilicus. All patients were followed for at least 5 years or until time of death. The two Dukes' stages B and C were analysed in two separate analyses using the Cox proportional hazards model. In patients with Dukes' B tumours, an increased risk of loco-regional recurrence was associated with perineural invasion, tumour located less than 10 cm from the anal verge, patient aged above 70 years, and small tumour size. In patients with Dukes' C tumours, the necessity to resect neighbour organs, perineural and venous invasion, tumour located less than 10 cm from the anal verge, and large tumour size were all associated with a poor loco-regional outcome. Postoperative radiotherapy was not a significant prognosticator for loco-regional control. An update of the 5-year results of the randomised study of post-operative radiotherapy (50 Gy with 2 Gy per fraction in an overall treatment time of 7 weeks) showed no survival benefit from adjuvant radiotherapy in either Dukes' category and no statistically significant improvement in the 5-year loco-regional control rate. However, when the comparison was restricted to a group of high-risk patients there was a statistically significant benefit from radiotherapy with respect to loco-regional control (P = 0.03) but not with respect to survival (P = 0.23). The potential advantage, in terms of the required number of patients, of restricting clinical trials of intensified loco-regional therapies to the high-risk patients, is illustrated.

Primary aorto-enteric fistula: a practicable curable condition? Pathogenetic and clinical aspects.

Primary aorto-enteric fistulas is now being a rare occurrence because of an aggressive approach in terms of surgery of abdominal aortic aneurysms. Three cases is presented in an attempt to elucidate the ethiology, pathogenesis and diagnostic possibilities when dealing with primary aorto-enteric fistulas. The clinical presentation of the patients with primary aorto-enteric fistulas is inconstant, but a hightened index of suspicion should be present when a patient presents with gastrointestinal bleeding of obscure origin, abdominal or back pain and an abdominal mass. Endoscopy and diagnostic imaging may detect a fistula, but a high rate of false negative investigations are produced. The result of diagnostic workup is often laparotomy, which is the safest diagnostic method and may save the patients life.

The value of sigmoideoscopy in the diagnosis of ischemic colitis following aortic reconstruction.

During a 4 1/2-years period sigmoideoscopy was performed when patients developed diarrhea and/or unexpected low abdominal pain within the first days following aortic reconstruction. In our investigation rigid sigmoideoscopy, revealed all the cases of major ischemic colitis.