Managing Contamination and Diverse Bacterial Loads in 16S rRNA Deep Sequencing of Clinical Samples: Implications of the Law of Small Numbers.

In this article, we investigate patterns of microbial DNA contamination in targeted 16S rRNA amplicon sequencing (16S deep sequencing) and demonstrate how this can be used to filter background bacterial DNA in diagnostic microbiology. We also investigate the importance of sequencing depth. We first determined the patterns of contamination by performing repeat 16S deep sequencing of negative and positive extraction controls. This process identified a few bacterial species dominating across all replicates but also a high intersample variability among low abundance contaminant species in replicates split before PCR amplification. Replicates split after PCR amplification yielded almost identical sequencing results. On the basis of these observations, we suggest using the abundance of the most dominant contaminant species to define a threshold in each clinical sample from where identifications with lower abundances possibly represent contamination. We evaluated this approach by sequencing of a diluted, staggered mock community and of bile samples from 41 patients with acute cholangitis and noninfectious bile duct stenosis. All clinical samples were sequenced twice using different sequencing depths. We were able to demonstrate the following: (i) The high intersample variability between sequencing replicates is caused by events occurring before or during the PCR amplification step. (ii) Knowledge about the most dominant contaminant species can be used to establish sample-specific cutoffs for reliable identifications. (iii) Below the level of the most abundant contaminant, it rapidly becomes very demanding to reliably discriminate between background and true findings. (iv) Adequate sequencing depth can be claimed only when the analysis also picks up background contamination. IMPORTANCE There has been a gradual increase in 16S deep sequencing studies on infectious disease materials. Management of bacterial DNA contamination is a major challenge in such diagnostics, particularly in low biomass samples. Reporting a contaminant species as a relevant pathogen may cause unnecessary antibiotic treatment or even falsely classify a noninfectious condition as a bacterial infection. Yet, there are few studies on how to filter contamination in clinical microbiology. Here, we demonstrate that sequencing of extraction controls will not reveal the full spectrum of contaminants that could occur in the associated clinical samples. Only the most abundant contaminant species were consistently detected, and we present how this can be used to set sample specific thresholds for reliable identifications. We believe this work can facilitate the implementation of 16S deep sequencing in diagnostic laboratories. The new data we provide on the patterns of microbial DNA contamination is also important for microbiome research.

Bacteria and fungi in acute cholecystitis. A prospective study comparing next generation sequencing to culture.

OBJECTIVES: Guidelines for antibiotic treatment of acute cholecystitis are based on studies using culture techniques for microbial identification. Microbial culture has well described limitations and more comprehensive data on the microbial spectrum may support adjustments of these recommendations. We used next generation sequencing to conduct a thorough microbiological characterization of bile-samples from patients with moderate and severe acute cholecystitis. METHODS: We prospectively included patients with moderate and severe acute cholecystitis, undergoing percutaneous or perioperative drainage of the gall bladder. Bile samples were analyzed using both culture and deep sequencing of bacterial 16S rRNA and rpoB genes and the fungal ITS2-segment. Clinical details were evaluated by medical record review. RESULTS: Thirty-six patients with moderate and severe acute cholecystitis were included. Bile from 31 (86%) of these contained bacteria (29) and/or fungi (5) as determined by sequencing. Culture identified only 40 (38%) of the 106 microbes identified by sequencing. In none of the 15 polymicrobial samples did culture detect all present microbes. Frequently identified bacteria often missed by culture included oral streptococci, anaerobic bacteria, enterococci and Enterobacteriaceae other than Klebsiella spp. and Escherichia coli. CONCLUSIONS: Culture techniques display decreased sensitivity for the microbial diagnostics of acute cholecystitis leaving possible pathogens undetected.

Tissue Inhibitor of Metalloproteinase-1 Is Confined to Tumor-Associated Myofibroblasts and Is Increased With Progression in Gastric Adenocarcinoma.

The tissue inhibitor of metalloproteinase-1 (TIMP-1) inhibits the extracellular matrix-degrading activity of several matrix metalloproteinases, thereby regulating cancer cell invasion and metastasis. Studies describing the expression pattern and cellular localization of TIMP-1 in gastric cancer are, however, highly discordant. We addressed these inconsistencies by performing immunohistochemistry and in situ hybridization analyses in a set of 49 gastric cancer lesions to reexamine the TIMP-1 localization. In addition, we correlated these findings to clinicopathological parameters. We show that strong expression of TIMP-1 protein and mRNA was observed in a subpopulation of stromal fibroblast-like cells at the periphery of the cancer lesions. In a few cases, a small fraction of cancer cells showed weak expression of TIMP-1 protein and mRNA. The stromal TIMP-1-expressing cells were mainly tumor-associated myofibroblasts. In the normal-appearing mucosa, scattered TIMP-1 protein was only found in chromogranin A positive cells. TIMP-1-positive myofibroblasts at the invasive front of the tumors were more frequently seen in intestinal than in diffuse histological subtype cases (p=0.009). A significant trend to a higher number of cases showing TIMP-1 staining in myofibroblasts with increasing tumor, node, metastasis (TNM) stage was also revealed (p=0.041). In conclusion, tumor-associated myofibroblasts are the main source of increased TIMP-1 expression in gastric cancer.

Challenges and outcome of surgery for bowel obstruction in women with gynaecologic cancer.

INTRODUCTION: Bowel obstruction is associated with a reduction in quality of life and survival among cancer patients, and the entity is traditionally treated by general surgeons without dedication to the different malignancies that cause bowel obstruction or to palliation. This study aims to identify and improve outcome of bowel obstruction in women with a history of a gynaecologic cancer. METHODS: Women operated for bowel obstruction were screened for a history of gynaecologic cancer and their records were reviewed. RESULTS: Bowel obstruction followed cancer treatment by a median of 18.4 months (range 2.3-277) in 59 women. A malignant cause was identified in 53% and recurrence of cancer in 61%. The cause of malignant bowel obstruction was peritoneal carcinomatosis (19%), obstructing tumour and carcinomatosis (31%) and solitary tumour (3%). Ovarian cancer (OR: 6.29, 95% CI 1.95-20.21), residual tumour during initial surgery (R2-stage) (OR: 18.7, 96% CI: 4.35-80.46) and chemotherapy (OR: 7.19, 95% CI: 2.28-22.67) were all associated with malignant bowel obstruction. Surgery solved 84% of malignant bowel obstructions, but median survival was brief (2.5 months, 95% CI: 1.4-3.6) when compared to benign bowel obstruction (95.3 months, 64.7-125.9) (p < 0.001). Readmission for bowel obstruction occurred after a median of 4.3 months (95% CI: 3.1-5.5) in surviving patients with malignant bowel obstruction and after a median of 84.5 months (95% CI: 73.6-95.3) with adhesive obstruction (p < 0.001). CONCLUSIONS: Increased awareness of the aetiology to bowel obstruction may improve treatment strategy in these women. Women with malignant bowel obstruction should be carefully identified and differentiated in order to improve quality of life rather than pursuing emergency surgical procedures.

Acute elevation of intra-abdominal pressure contributes to extravascular shift of fluid and proteins in an experimental porcine model.

BACKGROUND: Intra-abdominal hypertension and abdominal compartment syndrome contribute significantly to increased morbidity and mortality in critically ill patients. This study describes pathophysiologic effects of the acutely elevated intra-abdominal pressure on microvascular fluid exchange and microcirculation. The resulting changes could contribute to development of organ dysfunction or failure. METHODS: 16 pigs were randomly allocated to a control-group (C-group) or an interventional group (P-group). After 60 min of stabilization, intra-abdominal pressure of the P-group animals was elevated to 15 mmHg by Helium insufflation and after 120 min to a level of 30 mmHg for two more hours. The C-group animals were observed without insufflation of gas. Laboratory and hemodynamic parameters, plasma volume, plasma colloid osmotic pressure, total tissue water content, tissue perfusion, markers of inflammation and cerebral energy metabolism were measured and net fluid balance and fluid extravasation rates calculated. Analysis of variance for repeated measurements with post-tests were used to evaluate the results with respect to differences within or between the groups. RESULTS: In the C-group hematocrit, net fluid balance, plasma volume and the fluid extravasation rate remained essentially unchanged throughout the study as opposed to the increase in hematocrit (P < 0.001), fluid extravasation rate (P < 0.05) and decrease in plasma volume (P < 0.001) of the P-group. Hemodynamic parameters remained stable or were slightly elevated in the C-group while the P-group demonstrated an increase in femoral venous pressure (P < 0.001), right atrial pressure (P < 0.001), pulmonary capillary wedge pressure (P < 0.01) and mean pulmonary arterial pressure (P < 0.001). The protein mass decreased in both study groups but was significantly lower in the P-group as compared with the C-group, after 240 min of intervention. The increased intra-abdominal pressure was associated with elevated intracranial pressure and reduced tissue perfusion of the pancreas and the gastric- and intestinal mucosa. CONCLUSION: Elevation of intra-abdominal pressure has an immediate impact on microvascular fluid extravasation leading to plasma volume contraction, reduced cardiac output and deranged perfusion of abdominal organs.

Adjuvant radiotherapy in retroperitoneal sarcomas. A Scandinavian Sarcoma Group study of 97 patients.

BACKGROUND: Currently there is no consensus on the use of adjuvant radiotherapy (RT) in retroperitoneal sarcoma (RPS). We have analysed clinical outcomes in patients with localised RPS treated at two Scandinavian Sarcoma Group (SSG) centres: Haukeland University Hospital (HUH), Bergen, Norway and Skåne University Hospital (SUH), Lund, Sweden to clarify the effects of adjuvant RT on local control and overall survival (OS). MATERIAL AND METHODS: Local databases and registers at HUH and SUH as well as the SSG central register were used to identify RPS patients. Patients with localised RPS who underwent surgery in Bergen between 1988 and 2009 and in Lund from 1998 to 2009 were included. Medical records were examined for clinical data, tumour characteristics, treatment factors and follow-up status. Archived tumour sections and tumour tissue were reviewed, and when necessary, restained and reclassified. Cox regression was used to analyse the association of potential prognostic factors with local recurrence-free survival (LRFS), metastasis-free survival (MFS) and OS. RESULTS: The study included 97 patients: 52 from Norway and 45 from Sweden. The proportion of high-grade tumours was 73%. The five-year LRFS, MFS and OS were 55%, 59% and 60%, respectively. RT was significantly associated with improved local control resulting in a five-year LRFS of 77% compared with 39% without (p < 0.001). Furthermore, five-year OS was 71% in the RT group in contrast to 52% with surgery alone (p = 0.019). In the adjusted analysis RT proved to be a significant factor also for MFS (HR = 0.42, 95% CI 0.20-0.88, p = 0.021). In addition, high-grade malignancy, large tumour and positive surgical margin were risk factors for local recurrence. High malignancy grade was the only significant adverse prognostic factor for metastasis. High age and high-grade malignancy were negative prognostic factors for OS. CONCLUSION: Adjuvant RT was significantly associated with an improved five-year LRFS and OS.

Long-term survival from adenocarcinoma of the esophagus after transthoracic and transhiatal esophagectomy.

BACKGROUND: The effects of transthoracic or transhiatal esophagectomy on the long-term survival of patients who had adenocarcinoma of the esophagus were compared, as were factors applicable in preoperative stratification of patient treatment. METHODS: A cohort of 147 consecutive patients with adenocarcinoma of the esophagus was evaluated for esophagectomy between 1984 and 2000. The patients were followed prospectively and observed survival rates of patients with a transthoracic or transhiatal approach to esophagectomy were compared by standardized mortality ratio (SMR) and relative mortality ratio (RMR) using the expected survival of a matched Norwegian population. RESULTS: A R0 resection was performed by transthoracic (n = 33) or a transhiatal (n = 55) esophagectomy in 88 (60%) patients with a median age of 61 (range: 35-77) and 70 (42-88) years, respectively (P <0.001). Tumor stages and other possible risk factors were similar in the two groups. Transthoracic or transhiatal esophagectomy resulted in a median survival time of 20.5 (95% confidence interval (CI): 10.4-57.6) and 16.4 (10.6-28.7) months, respectively. The respective survival rates were 31.2% and 27.8% by 5 years, and 21.3% and 16.6% by 10 years with an overall RMR of 1.14 (P = 0.63). Median survival time in the absence or presence of lymph node metastases was 74.0 (95% CI: 17.5-166.4) and 10.7 (7.9-14.9) months. The corresponding survival rates by 10 years with non-involved or involved nodes were 48.9% and 3.8% respectively (RMR 2.22, P = 0.007). Patients with a pT1-tumor were few and the survival rate was not very different from that of the general population (SMR = 1.7, 95% CI: 0.7-4.1). The median survival time of patients with a pT2-tumor was 30.4 (95% CI: 9.0-142) months and with a pT3-tumor 14 (9.2-16.4) months. The survival rates by 10 years among patients with a pT1 tumor were 57.0% (95% CI: 14.9-78.9), pT2 33.3% (11.8-52.2), and pT3 7.1% (1.9-15.5). The relative mortality for T3 stages compared to T1 stages was statistically significant (RMR = 3.22, P = 0.024). CONCLUSION: Transthoracic and transhiatal esophagectomy are both effective approaches for treatment of adenocarcinoma of the esophagus and survival of more than 10 years can be expected without adjuvant chemotherapy. However, increasing depth of tumor invasion and lymph node metastases reduce life expectancy.

Esophageal perforation: clinical patterns and outcomes from a patient cohort of Western Norway.

BACKGROUND: Esophageal perforation is a rare, often life-threatening condition, and management remains challenging. METHODS: Retrospective review of consecutive patients with esophageal perforation treated at two university hospitals between 2000 and 2010. Pertinent data from hospital records were retrieved for statistical calculations and evaluation of perforation score. RESULTS: Forty-seven patients [47% female, median age 62 years (range 15-88)] were included. The annual incidence was 4.7/1,000,000. Perforations were spontaneous in 14 patients (30%), iatrogenic in 25 (53%), and caused by trauma and foreign body impaction in 8 patients (17%). ASA score (p = 0.004), perforation localization (p = 0.001), diagnostic delay (p = 0.002), and perforation score (p < 0.001) differed significantly between patient groups with different etiology, but not between groups with different outcomes. Early diagnosis (≤24 h) was significantly associated with a low perforation score (p = 0.033). A non-operative approach was employed in 26 patients (55%) - more commonly for proximally localized perforations (p = 0.045). The non-operative group showed lower severe complication rates (p = 0.033), shorter ICU stays (p < 0.001) and durations of mechanical ventilation (p = 0.022). The overall 30-day mortality was 23.4%. CONCLUSION: Careful clinical evaluation and appropriate, individualized treatment are important. The high mortality may be partly explained by the underlying disease and the complexity of the clinical condition in many patients.

Prognosis in adenocarcinomas of lower oesophagus, gastro-oesophageal junction and cardia evaluated by uPAR-immunohistochemistry.

Adenocarcinomas of lower oesophagus, gastro-oesophageal junction and cardia in humans are highly invasive tumours with poor prognosis. The localisation of urokinase-type plasminogen activator receptor (uPAR) was determined in 66 patients; 60 with adenocarcinomas and six cases with Barrett's oesophagus. uPAR was expressed in nearly all cases of invasive adenocarcinomas by populations of cancer cells, macrophages and myofibroblasts at both the invasion front and the tumour core. In areas with high-grade dysplasia or with Barrett's metaplasia adjacent to the tumour tissue, no uPAR-immunoreactivity was found. High local expression of uPAR, therefore, appears to be a characteristic marker for invasive behaviour in this tumour, suggesting that uPAR's contribution to matrix degradation during invasive growth is a late event in carcinogenesis. Using a scoring system for semiquantitative estimation of uPAR-positivity on immmunohistochemically stained specimens, a significant association was found between poor overall survival and high uPAR-score for cancer cells in the tumour core and for macrophages peripherally at the tumour invasion zone. In multivariate analysis, these two uPAR-scores were confirmed as highly significant prognostic parameters independent of Tumour, Node, Metastasis (TNM)-stage and World Health Organization (WHO) classification. The proteolytic action of these malignant and nonmalignant accessory cells thus seemed to follow two main patterns: one dominated by uPAR positive cancer cells and one by uPAR-positive macrophages. Scoring of uPAR-positivity might be a useful parameter for onset of invasion and prognosis in these adenocarcinomas.

Urokinase plasminogen activator receptor on invasive cancer cells: a prognostic factor in distal gastric adenocarcinoma.

Gastric cancer is the second cancer causing death worldwide. The five-year survival for this malignancy is below 25% and few parameters have shown an impact on the prognosis of the disease. The receptor for urokinase plasminogen activator (uPAR) is involved in extracellular matrix degradation by mediating cell surface associated plasminogen activation, and its presence on gastric cancer cells is linked to micrometastasis and poor prognosis. Using immunohistochemistry, the prognostic significance of uPAR was evaluated in tissue samples from a retrospective series of 95 gastric cancer patients. uPAR was expressed by neoplastic cells, macrophages, myofibroblasts and neutrophils in both intestinal and diffuse subtypes. No association was demonstrated between the expression of uPAR on cancer cells and histological subtype (p = 0.64) or TNM stage (p = 0.75). Univariate analysis revealed a significant association between the expression of uPAR on tumor cells in the peripheral invasion zone and overall survival of gastric cancer patients (HR = 2.16; 95% CI: 1.13-4.14; p = 0.02). Multivariate analysis showed that uPAR immunoreactivity in cancer cells at the invasive front is an independent prognostic factor for overall survival in gastric cancer (HR = 2.39; 95% CI: 1.22-4.69; p = 0.011). In consequence, scoring of uPAR-positive cancer cells may be a direct measure for the invasive potential of gastric adenocarcinomas.

Time trends in incidence, etiology, and case fatality rate of the first attack of acute pancreatitis.

PURPOSE: The purpose of this study was to establish estimates of incidence and fatality rates, and to identify likely etiologies of first attack acute pancreatitis (FAAP) in an urban Norwegian population. MATERIAL AND METHODS: A total of 874 patients were discharged with a diagnosis of acute pancreatitis from the two hospitals in this region between 1.1.1996 and 31.12.2006. Patient records were reviewed and patients with a verifiable FAAP were identified. Demographic variables, likely etiology, and outcome were registered. RESULTS: FAAP was verified in 567 (65%) of the patients (300 women and 267 men) with a median age of 58 years (range 7-98). The average yearly incidence rate of FAAP was 14.6/100 000 and the gender-specific incidence rates increased yearly by approx. 6% (p = 0.006). There was a decline in diagnoses by s-Amylase from approx. 90% to 62% in 2006 and an increase in diagnoses obtained by CT (p < 0.001). The case fatality rate was low (3.5%), but higher among men (5.8%) than women (2%, p = 0.037). The case fatality rate was lowest among patients with gallstones (0.7%) and higher among patients with alcohol (9%), miscellaneous (10.4%), and non-assessed etiology (6.6%) of FAAP (p < 0.05). Male gender, increasing age, and etiology (alcohol, miscellaneous causes, and non-assessed) were associated with increased case fatality rate in an adjusted regression model (p < 0.001). CONCLUSIONS: The incidence rate of FAAP is low and differs from that of official registries. The case fatality rate is low, but related to gender, age, and likely etiology of FAAP.

High-dose preoperative chemoradiotherapy in esophageal cancer patients does not increase postoperative pulmonary complications: correlation with dose-volume histogram parameters.

PURPOSE: To investigate the association of high-dose preoperative chemoradiotherapy (CRT) and dose-volume histogram (DVH) parameters of lungs with incidence of postoperative pulmonary complications and to identify predictive clinical factors of pulmonary complications. METHODS: Data of 65 patients were collected retrospectively. Thirty-five patients underwent transthoracic esophagectomy (TTE) alone and 30 received cisplatin and 5-fluorouracil, concomitant with radiotherapy, median dose 66Gy, and followed by TTE. From the DVH for each lung alone and for both lungs together as one organ we generated total lung volume, mean radiotherapy dose, relative and absolute volumes receiving more than a threshold dose, and relative and absolute volumes receiving less than a threshold dose. Postoperative pulmonary complications were defined as pneumonia or respiratory failure. RESULTS: Sixty percent of the patients in the TTE alone group had postoperative pulmonary complications versus 63% in the CRT+TTE group. Postoperative mortality was 8.6% and 16.7% in the respective patient groups (p=NS). None of the DVH parameters was associated with postoperative pulmonary complications. Squamous cell carcinoma was an adverse factor related to increased postoperative pulmonary complications. CONCLUSION: High-dose preoperative CRT was not associated with increased postoperative pulmonary complications in this cohort of esophageal cancer patients.

High-dose chemoradiotherapy followed by surgery versus surgery alone in esophageal cancer: a retrospective cohort study.

BACKGROUND: We aimed to assess whether high-dose preoperative chemoradiotherapy (CRT) improves outcome in esophageal cancer patients compared to surgery alone and to define possible prognostic factors for overall survival. METHODS: Hundred-and-seven patients with disease stage IIA - III were treated with either surgery alone (n = 45) or high-dose preoperative CRT (n = 62). The data were collected retrospectively. Sixty-seven patients had adenocarcinomas, 39 squamous cell carcinomas and one undifferentiated carcinoma. CRT was given as three intensive chemotherapy courses by cisplatin 100 mg/m2 on day 1 and 5-fluorouracil 1000 mg/m2/day, from day 1 through day 5 as continuous infusion. One course was given every 21 days. The last two courses were given concurrent with high-dose radiotherapy, 2 Gy/fraction and a median dose of 66 Gy. Kaplan-Meier survival analysis with log rank test was used to obtain survival data and Cox Regression multivariate analysis was used to define prognostic factors for overall survival. RESULTS: Toxicity grade 3 of CRT occurred in 30 (48.4%) patients and grade 4 in 24 (38.7%) patients of 62 patients. One patient died of neutropenic infection (grade 5). Fifty percent (31 patients) in the CRT group did undergo the planned surgery. Postoperative mortality rate was 9% and 10% in the surgery alone and CRT+ surgery groups, respectively (p = 1.0). Median overall survival was 11.1 and 31.4 months in the surgery alone and CRT+ surgery groups, respectively (log rank test, p = 0.042). In the surgery alone group one, 3 and 5 year survival rates were 44%, 24% and 16%, respectively and in the CRT+ surgery group they were 68%, 44% and 29%, respectively. By multivariate analysis we found that age of patient, performance status, alcoholism and >or= 4 pathological positive lymph nodes in resected specimen were significantly associated with overall survival, whereas high-dose preoperative CRT was not. CONCLUSION: We found no significant survival advantage in esophageal cancer stage IIA-III following preoperative high-dose CRT compared to surgery alone. Patient's age, performance status, alcohol abuse and number of positive lymph nodes were prognostic factors for overall survival.

Extended lymph node dissection in colorectal cancer surgery. Reliability and reproducibility in assessments of operative reports.

BACKGROUND: Stratification of surgical strategies or techniques by operative reports is rarely validated. This study evaluates the assessment of lymph node dissection from operative reports and the possible survival benefit of extended lymph node dissection. METHODS: The operative reports of 342 colorectal resections (R0) were assessed twice by two surgeons. The lymph node dissection was classified as limited or extended according to a novel scheme. Intraobserver reproducibility and interobserver reliability were evaluated by kappa (kappa) statistics and a Cox model. RESULTS: For colonic resections, the reproducibility of assessments was moderate or substantial (kappa: 0.42-0.75), and the reliability was moderate (kappa: 0.54-0.58). For rectal resections, reproducibility was moderate (kappa: 0.45-0.58), and reliability was fair (kappa: 0.29-0.36; all kappa values: p < 0.001). The 5-year survival rates of colonic cancer patients subject to a limited or extended procedure were 52% (45-60%, 95% confidence interval) and 69% (53-84%; p = 0.034), respectively. The hazard ratios of extended lymph node dissection (limited as reference) were 0.34 (0.14-0.86; p = 0.023) for stage I and II and 1.11 (0.50-2.44) for stage III. In rectal cancer patients, the 5-year survival rates of a limited or extended procedure were 63% (54-72%) and 55% (37-73), respectively. CONCLUSIONS: Valid assessment of lymph node dissection can be obtained from operative reports. Extended lymph node dissection improves long-term survival rates of colonic cancer patients.

Urokinase plasminogen activator receptor is expressed in invasive cells in gastric carcinomas from high- and low-risk countries.

Gastric cancer is the second cancer causing death worldwide. Both incidence and mortality rates vary according to geographical regions. The receptor for urokinase plasminogen activator (uPAR) is involved in extracellular matrix degradation by mediating cell surface associated plasminogen activation, and its presence on gastric cancer cells is linked to micro-metastasis and poor prognosis. Immunohistochemical analyses of a set of 44 gastric cancer lesions from Costa Rica showed expression of uPAR in cancer cells in both intestinal subtype (14 of 27) and diffuse subtype (10 of 17). We compared the expression pattern of uPAR in gastric cancers from a high-risk country (Costa Rica) with a low-risk country (Norway). We found uPAR on gastric cancer cells in 24 of 44 cases (54%) from Costa Rica and in 13 of 23 cases (56%) from Norway. uPAR was seen in macrophages and neutrophils in all cases. We also examined the nonneoplastic mucosa and found that uPAR was more frequently seen in epithelial cells located at the luminal edge of the crypts in cases with Helicobacter pylori infection than in similar epithelial cells in noninfected mucosa (p = 0.033; chi(2) = 4.54). In conclusion, the expression of uPAR in cancer cells in more than half of the gastric cancer cases suggests that their uPAR-positivity do not contribute to explain the different mortality rates between the 2 countries, however, the actual prevalence of uPAR-positive cancer cells in the gastric cancers may still provide prognostic information.

Prolapse of the rectum, long-term results of surgical treatment.

AIMS: This study evaluates patency and functional results of abdominal and perineal treatment approaches to prolapse of the rectum. METHODS: A database search identified patients operated upon for prolapse of the rectum. The operations were abdominal or perineal approaches. The patient's records were reviewed, patients alive were contacted, and a self-report form evaluated functional results. Patients were followed until the prolapse recurred. RESULTS: A primary operation for prolapse of the rectum was performed in 56 patients. Median age was 59 years (range 20-87) and 78 (40-91) for abdominal and perineal approaches, respectively (p < 0.001). The average length of the prolapses was 8.7 cm (2-25) and 8.6 cm (2-15) for abdominal or perineal approaches. All prolapses treated with a Thiersch's operation recurred within a few months and all prolapses treated with the Delorme's operation recurred within 5 years, whereas the 5-year patency of the abdominal approach was 93% (p < 0.001). No prolapses recurred after mesh rectopexy and the 5-year patency of resection rectopexy was 86%. The abdominal approaches improved stool evacuation and constipation significantly, and anal leakage improved somewhat (p = 0.065). The median hospital stay was 11 (4-20) and 7 (2-155) days after abdominal and perineal approaches (p = 0.003). Complications occurred in 20% of patients. CONCLUSIONS: The patency of abdominal approach to prolapse of the rectum is better than that of perineal repairs. The abdominal approaches also have a favorable effect on constipation and anal insufficiency. Perineal approaches should be reserved for patients with a very short life expectancy.

Crohn's disease but not chronic ulcerative colitis induces the expression of PAI-1 in enteric neurons.

OBJECTIVES: Chronic inflammation of the intestinal wall is the common characteristic of Crohn's disease and ulcerative colitis; disorders, which in some cases can be difficult to distinguish. The inflammation also affects the local neuronal plexuses of the enteric nervous system. It is known that plasminogen activator inhibitor-1 (PAI-1) and urokinase receptor (uPAR) are upregulated in neurons after experimental peripheral nerve injury and have been linked to nerve regeneration. METHODS: The expression of PAI-1 and uPAR in neuronal cells in lesions of the gastrointestinal tract was analyzed by immunohistochemical techniques. RESULTS: PAI-1 was found in a subset of neurons primarily located in the submucosal plexus of the small and large intestine in 24 of 28 cases (86%) with Crohn's disease, but in none of 17 cases with chronic ulcerative colitis and other severe inflammatory conditions in the intestinal wall. The PAI-1 was seen in the perikarya of the neurons and a few proximal axons, whereas nerves were negative. uPAR was seen in nerves in all types of lesion varying from 21% to 88% of the cases, most frequent in colon adenocarcinomas. No uPAR-positive nerves were detected in normal colon. CONCLUSIONS: PAI-1-positive neurons in inflammatory bowel disease are linked to chronic inflammation in Crohn's disease, implying PAI-1 as a potential parameter for the differential diagnosis between Crohn's disease and ulcerative colitis. The findings also suggest that PAI-1 in neurons is related to pain and that both PAI-1 and uPAR are involved in neuronal repair in the inflamed tissue.

Survival and an overview of decision-making in patients with cholangiocarcinoma.

BACKGROUND: Cholangiocarcinoma is rare, accounting for approximately 3% of all gastrointestinal cancers. This study aimed to identify the survival rate among surgically treated and palliated patients, and secondly to identify parameters that could predict a curative resection. METHODS: A total of 121 patients, 55 men and 66 women, median age 70 years (range 31-91), who had been treated for cholangiocarcinoma in the period of 1990-2005 were evaluated retrospectively. RESULTS: Curative resection was performed in 40 patients (33%), whereas 81 received palliative treatment (67%). 16% (19 of 121) of the patients had an explorative laparotomy without tumour resection. Age above 65 years (OR 3.4; 95% CI 1.4-8.4; P=0.008), weight loss (OR 8.5; 95% CI 1.5-46; P=0.01) or tumour location (The resection rate of hilar cholangiocarcinoma was lower than that of intrapancreatic cancer.) (OR 2.7; 95% CI 1.7-4.5; P=0.001) predicted palliative treatment. The adjusted 5-year survival rate of patients who received tumour resection and palliative treatment was 30% and 1.2 %, respectively (P<0.001). The survival rate of patients who were subjected to hepatectomy (70%) was better than that of patients who had a local or distal resection (20%) (P=0.02). CONCLUSIONS: In few patients with a resectable cholangiocarcinoma, an explorative laparotomy is often necessary to evaluate resectability. However, long-term survival is significantly better in patients who received radical surgical resection.