A systematic review of oncosurgical and quality of life outcomes following pelvic exenteration for locally advanced and recurrent rectal cancer.

INTRODUCTION: Pelvic exenteration (PE) is now the standard of care for locally advanced (LARC) and locally recurrent (LRRC) rectal cancer. Reports of the significant short-term morbidity and survival advantage conferred by R0 resection are well established. However, longer-term outcomes are rarely addressed. This systematic review focuses on long-term oncosurgical and quality of life (QoL) outcomes following PE for rectal cancer. METHODS: A systematic review of the PubMed®, Cochrane Library, MEDLINE® and Embase® databases was conducted, in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Studies were included if they reported long-term outcomes following PE for LARC or LRRC. Studies with fewer than 20 patients were excluded. FINDINGS: A total of 25 papers reported outcomes for 5,489 patients. Of these, 4,744 underwent PE for LARC (57.5%) or LRRC (42.5%). R0 resection rates ranged from 23.2% to 98.4% and from 14.9% to 77.8% respectively. The overall morbidity rates were 17.8-87.0%. The median survival ranged from 12.5 to 140.0 months. None of these studies reported functional outcomes and only four studies reported QoL outcomes. Numerous different metrics and timepoints were utilised, with QoL scores frequently returning to baseline by 12 months. CONCLUSIONS: This review demonstrates that PE is safe, with a good prospect of R0 resection and acceptable mortality rates in selected patients. Morbidity rates remain high, highlighting the importance of shared decision making with patients. Longer-term oncological outcomes as well as QoL and functional outcomes need to be addressed in future studies. Development of a core outcomes set would facilitate better reporting in this complex and challenging patient group.

The community prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in older people living in their own homes: implications for treatment, screening and surveillance in the UK.

Methicillin-resistant Staphylococcus aureus (MRSA) predominantly affects those over 65 years old. There may be a substantial pool of older people with MRSA in the community. We studied the prevalence in one London general practice, screening 258 older people living in their own home. MRSA (E-MRSA 15) was found in two participants (0.78%). Past history of MRSA was the only significant risk factor. The results of this and other studies suggest that national guidelines recommending early discharge for MRSA carriers have not resulted in widespread community acquisition amongst elderly people living in their own home. Community antibiotic policies for skin and soft-tissue infection do not require amendment. Patients with previous MRSA should be isolated and screened on admission especially to high-risk units.

Tissue photosensitizer detection by low-power remittance fluorimetry.

A simple adaptation of a commercial spectrofluorimeter which allows the semiquantitative determination of photodynamic therapy photosensitizer fluorescence in accessible tissues is described. Light from a xenon lamp is directed via a monochromator onto the tissue surface by a bifurcated random fibre bundle. Tissue fluorescence is directed to the emission monochromator and photomultiplier of the fluorimeter by the second limb of the fibre bundle. Although relatively simple, this device can be used to carry out a wide range of useful measurements in clinical and experimental photodynamic therapy. The sensitivity and reproducibility of the measurements were determined using mouse tumour and muscle tissue fluorescence measured in vivo compared with photosensitizer content measured by high performance liquid chromatography. As an illustration of the potential applications of such systems, the time courses of fluorescence in the skin of patients treated with the photosensitizers Photofrin(R) and metatetra(hydroxyphenyl)chlorin (mTHPC) (temoporfin) and the photobleaching of 5-aminolaevulinic acid-derived protoporphyrin IX during treatment, are described.

New technique to measure mucosal metabolism and its use to map substrate utilization in the healthy human large bowel.

A new method of assessing substrate utilization in gastrointestinal mucosal specimens is described. Small human endoscopic biopsy specimens with wet weights ranging between 1.4 and 12.2 mg were used to quantify the oxidation of three metabolic substrates, glucose, glutamine and butyrate, through to carbon dioxide over a 2-h period. The technique proved to be reproducible and capable of distinguishing variations in mucosal metabolism between individuals (P < 0.0001 for each substrate). Results were similar to those obtained previously using human and rat colonocytes. To characterize the metabolism of the healthy large bowel, specimens were obtained from five regions in 15 patients who had a normal colonoscopic examination. The results show that butyrate is the preferred fuel source of large bowel mucosa, followed by glutamine, then glucose (P < 0.01). There was no significant regional variation in utilization of the three substrates between the five regions; with respect to glutamine, this is contrary to previous findings.

Growth and hemolysin production by Haemophilus pleuropneumoniae cultivated in a chemically defined medium.

A chemically defined medium (CDM) has been developed which supports both growth and hemolysin production by Haemophilus pleuropneumoniae. Although the growth rate in stationary cultures was substantially slower in CDM than in trypticase soy broth plus 0.6% yeast extract (TSBYE) and slightly slower than in heart infusion broth (HIB), extracellular hemolysin activity in CDM was slightly higher than in HIB and 16-fold greater than in TSBYE. Maximum hemolytic activity was produced in CDM in early to mid log phase of growth. Hemolytic activity in sterile, cell-free culture supernatant fluids persisted for over 10 days at 4 degrees C and 3-5 days at 37 degrees C, but was completely destroyed at 56 degrees C after 30 min. Total hemolysin inactivation was also achieved in the presence of trypsin or pronase (10 units/mL), but no decrease in hemolytic activity was noted in the presence of DNase or RNase. Iron had little effect on the hemolytic activity in the early stages of growth. However, in the later stages of growth, iron had a pronounced effect with hemolytic activity decreasing as the iron concentration increased from 1 to 500 microM. None of these iron concentrations had any effect on the hemolytic activity when added directly to prepared cell-free culture supernatant fluids. The extracellular hemolysin produced by H. pleuropneumoniae in CDM appears to be a heat-labile protein the activity of which is influenced by iron at certain phases of growth.

Isolation, purification, and partial characterization of a lipopolysaccharide from Haemophilus pleuropneumoniae.

Lipopolysaccharide (LPS) from Haemophilus pleuropneumoniae 1536, serotype 2, was isolated and purified by a procedure designed to be equally satisfactory for both smooth- and rough-type LPS. The LPS yield was 53%. Analysis of the preparations revealed that protein, nucleic acid, and cellular phospholipid contamination was negligible (less than 0.1%). Analysis of the sugar content of the LPS by gas-liquid chromatography and colorimetric analysis revealed the presence of rhamnose, mannose, galactose, glucose, heptose, glucosamine, galactosamine, and 3-deoxy-D-manno-2-octulosonic acid. The heptose and glucose contents appeared to be unusually high. The fatty acids of the LPS consisted of a mixture of C14:0 and C16:0 in a ratio of about 4.5:1 (50% of the total) and 3-hydroxy C14:0. When used as a preparatory dose for the dermal Shwartzman reaction, as little as 10 micrograms of the LPS injected intradermally in rabbits produced reddening and swelling. After intravenous injection of a 100-micrograms LPS provoking dose, necrosis was observed at all intradermal injection sites. Limulus amebocyte lysate gelation was observed with an LPS concentration as low as 0.5 ng/ml. A typical biphasic fever response was noted in rabbits injected with as little as 0.25 ng of LPS per kg of body weight.

Siderophore production by Proteus mirabilis.

Studies on the isolation and characterization of Proteus mirabilis siderophores provided no evidence that these bacteria synthesize catechol- or hydroxamate-type siderophores. However, gas chromatograph analysis in conjunction with mass spectroscopy revealed the presence of alpha-hydroxyisovaleric acid, a previously unknown metabolite. Additional substantiating evidence for the presence of alpha-hydroxyisovaleric acid in these bacteria was obtained from experiments involving the use of thin-layer chromatography and an ultraviolet absorption spectrum. This compound was found to be capable of removing iron from the synthetic chelator, ethylene-diamine-di-orthohydroxyphenyl acetic acid, and supplying that iron to the bacteria both in a solid agar medium and in a liquid medium. Proteus mirabilis was found to possess an enzyme capable of catalyzing the reaction by which alpha-hydroxyisovaleric acid is converted to alpha-ketoisovaleric acid, an intermediate in the valine biosynthetic pathway.