Predictors of 1-Year Survival After Endovascular Aneurysm Repair.

OBJECTIVE/BACKGROUND: The purpose of this study was to determine the preoperative variables that best predict 1-year survival following elective endovascular aneurysm repair (EVAR), a period of time that would suggest the patient had benefited from the procedure. Most EVAR survival studies focus on early and late survival; scant information is available for 1-year survival. METHODS: Data from two Australian audits of EVAR (1999-2001 and 2009-13) were combined (n = 1,647). Preoperative variables included routine demographic data, clinical health assessments, computed tomography-derived anatomical data, and all-cause mortality. Univariate and multivariate logistic regressions determined which variables best predicted 1-year survival. RESULTS: One-year survival after EVAR was 93.7% (1,544/1,647) and 30-day survival was 98.4% (1,620/1,647). Univariate analyses found that nine preoperative variables were significantly associated with 1-year survival. Five variables were included in the final multivariate model: American Society of Anesthesiologists physical status, aneurysm diameter, creatinine, respiratory assessment, and severity of iliac artery calcification (receiver-operator curve 0.717, R(2) = .117). Predicted 1-year survival ranged from 98.6% to 68.0%, based on differences in aneurysm size and patient comorbidities. CONCLUSION: Personalised 1-year survival risk enables surgeons and patients to consider seriously the risks and benefits of EVAR prior to surgery.

Development of an automated measure of iliac artery tortuosity that successfully predicts early graft-related complications associated with endovascular aneurysm repair.

OBJECTIVES: Iliac artery tortuosity has been linked to the likelihood of complications following endovascular aneurysm repair (EVAR). Measures of tortuosity can be established from CT images; however, the reproducibility of existing scoring techniques has not been clearly established. It remains unclear whether it is tortuosity at focal locations or for the vessel as a whole that is most relevant to adverse events. The two aims of this study were to develop an automated measure of iliac artery tortuosity to assist with surgical planning by providing an objective assessment of procedural difficulty, and to correlate this measure with early postoperative outcomes. DESIGN AND METHODS: Unlike existing approaches, the present measure of tortuosity considers spatial scale, which incorporates the effects of local anatomy. A computerized imaging algorithm was used to segment vasculature and establish a medial line and vascular boundary from contrast enhanced CT scans of 150 patients undergoing EVAR. Two tortuosity measures were examined: curvature and vessel to straight-line length (L1/L2-ratio). For a given spatial scale, the maximum tortuosity was computed on both iliac arteries and the artery with the lower maximum was selected for analysis. Correlation of tortuosity with early (<30 day) and longer-term graft-related complications was assessed. RESULTS: Maximal tortuosity at a 10 mm scale was a significant predictor of early (<30 day) complications (p = .016 for curvature and p = .006 for L1/L2-ratio), but not of long-term complications. Aneurysmal diameter was independent of tortuosity (Pearson's r value = -.006). CONCLUSION: The results demonstrate that, at a local scale, tortuosity measures are correlated with early outcomes. The spatial scale at which tortuosity is measured is important. The optimal scale of 10 mm implies that adverse events could be linked to a focal anatomical location.

Simvastatin plus nitric oxide synthase inhibition modulates remote organ damage following skeletal muscle ischemia-reperfusion injury.

UNLABELLED: Ischemia-reperfusion injury (IRI) to the lower extremities causes both local damage and serious dysfunction to remote organs, including lungs and kidneys. However, effective therapies are not available. This study aims to determine if simvastatin reduced the severity of remote damage following IRI. METHODS: Rats were given simvastatin before hind limb IRI. Lung and kidney tissues were assessed for neutrophil infiltration using myeloperoxidase assays and basement membrane damage by quantitative immunohistochemical measurement of collagen IV. The effect of nitric oxide synthase (NOS) inhibition on remote damage after IRI and simvastatin was assessed using the NOS inhibitor, L-NIO. RESULTS: Simvastatin (2 mg/kg) protected kidneys against IRI-induced neutrophil infiltration. Simvastatin also inhibited the IRI-induced activation of MMP-9 in the lungs. However, paradoxically, simvastatin exacerbated IRI-induced neutrophil infiltration into the lungs. IRI induced collagen IV degradation in the lungs but not in the kidneys. The degree of collagen breakdown in the lungs was significantly ameliorated by 2 mg/kg simvastatin. NOS inhibition markedly protected both the lungs and the kidneys against IRI-induced neutrophil infiltration but did not alter collagen IV degradation. Administration of simvastatin to L-Nio-treated animals enhanced the degree of protection against IRI-induced neutrophil infiltration in the kidneys but not in the lungs. CONCLUSIONS: Simvastatin protects against remote IRI-induced damage in the lungs and kidneys, suggesting statins may reduce the severity of IRI during major vascular surgery.

Preoperative nutritional status predicts the severity of the systemic inflammatory response syndrome (SIRS) following major vascular surgery.

OBJECTIVES: This study examined the relationship between pre-operative nutritional status and systemic inflammatory response syndrome (SIRS) or sepsis following major vascular surgery. DESIGN AND METHODS: Subjects undergoing open AAA repair, EVAR or lower limb revascularisation were studied prospectively. Pre-operative nutrition was assessed clinically using Mini-Nutritional Assessment (MNA) and body composition was measured by dual energy X-ray absorptiometry (DEXA) scanning. SIRS severity was assessed for 5 post-operative days and sepsis noted within 30 days of surgery. RESULTS: Using MNA, neither SIRS severity nor sepsis occurrence differed significantly between 'well-nourished' subjects and those 'at risk of malnutrition'. Using DEXA, negative associations existed between body mass index and both SIRS score and SIRS duration. Fat free mass (FFM) was negatively associated with SIRS score and duration. Negative associations also existed between skeletal muscle mass (SMM) and SIRS score and duration. SMM was also negatively correlated with post-operative length of stay in hospital. There were no significant correlations between sepsis and any nutritional indices. CONCLUSIONS: Lower pre-operative nutritional indices, indicating protein energy malnutrition, were associated with more severe systemic inflammatory responses following major vascular surgery.

The role of statins in vascular disease.

BACKGROUND: Recent publications have highlighted the benefits of statins in non-cardiac occlusive disease but also the failure of vascular surgeons to recognise and treat the risk factors for atherosclerosis, in particular hypercholesterolaemia. The aim of this review is to clarify the current experimental and clinical evidence for the use of statins in vascular disease. METHODS: Literature compiled from an extensive search of Medline and the Cochrane database has been used for the basis of this review. RESULTS: Experimental and clinical evidence consistently reports that statins improve endothelial dysfunction, are anti-inflammatory, anti-proliferative, anti-thrombogenic and anti-proteolytic. These effects are known to inhibit atherogenesis and improve plaque stability. Independent groups support the use of statins in the prevention of both primary and secondary cardiac events. The National Stroke association recommends their use to reduce strokes following myocardial infarction and the Heart Protection Study reports benefits in patients with non-cardiac occlusive disease. CONCLUSIONS: There is substantial evidence advocating the use of statins in patients with clinically significant vascular disease. In the future this may evolve to include those patients at risk from neointimal hyperplasia, aneurysmal disease and ischaemia reperfusion injury.

Up-regulation of MMP-2 and MMP-9 leads to degradation of type IV collagen during skeletal muscle reperfusion injury; protection by the MMP inhibitor, doxycycline.

OBJECTIVES: to determine the role of matrix metalloproteinases, MMP-2 and MMP-9, in reperfusion injury following skeletal muscle ischaemia and whether inhibition of MMPs by doxycycline protects against tissue damage. METHODS: rats were anaesthetised and a tourniquet applied to the proximal thigh to occlude blood flow. Four hours of ischaemia was followed by reperfusion for 0, 4, 24 or 72 h. Two further groups received doxycycline for 7 days prior to bilateral ischaemia and 24 h reperfusion. Skeletal muscle from both limbs, kidneys and lungs were harvested for zymography and immunohistochemical staining for type IV collagen. RESULTS: upregulation of MMP-2 and MMP-9 was detected by zymography in the ischaemic leg and lung but not in the kidney. Quantitative immunohistochemical analysis showed marked degradation of type IV collagen in reperfused muscle, lung and kidney. Doxycycline-treated rats showed significant preservation of type IV collagen in skeletal muscle and a trend towards preservation in kidney and lung. CONCLUSIONS: MMP-2 and MMP-9 are strongly upregulated in skeletal muscle ischaemia/reperfusion injury and are also upregulated in remote organs, leading to degradation of basement membranes. Inhibition of MMP activity may therefore be potentially therapeutically useful in reducing the severity of reperfusion injury.

Methylation of CpG sites in exon 2 of the bcl-2 gene occurs in colorectal carcinoma.

BACKGROUND: Aberrant bcl-2 expression frequently occurs in colorectal carcinoma. The current study investigated if CpG sites in bcl-2 were methylated in colorectal carcinoma and if methylation correlated with loss of expression of bcl-2 mRNA. METHODS: Methylation was assessed in 23 matched normal mucosae and colonic carcinomas by Southern blotting with methylation-sensitive enzymes. Expression of bcl-2 mRNA was assessed by Northern blotting. RESULTS: A SacII site in exon 2 of the bcl-2 gene was methylated in 5 carcinomas, plus an adjacent HpaII sites in 1 tumour. SacII site in the bcl-2 promoter were not methylated. Elevated levels of bcl-2 mRNA were detected in 3 carcinomas, 5 showed decreased expression and 4 were unchanged. CONCLUSIONS: De novo methylation of CpG sites in exon 2 of the bcl-2 gene occurs during the development of colorectal carcinoma. However, there was no relationship between expression of bc1-2 mRNA and methylation of specific CpG sites.

Expression of alternatively-spliced MDM2 transcripts in giant cell tumours of bone.

Giant cell tumours of bone (GCT) are characterized histologically by multinucleated bone resorbing giant cells in a background of ovoid spindle-shaped mesenchymal cells. Current evidence suggests that the latter comprise the tumour element of these lesions, although there are basic questions as to the factors that contribute to the tumourigenesis and progression of GCT. The deregulation of the p53/MDM2 pathway is an important pathogenetic event in many tumour types, prompting us to assess the expression of MDM2 by the stromal cells and giant cells of GCT. Northern blot analysis demonstrated that most of the GCT samples examined expressed increased levels of MDM2 when compared to normal human bone cells. However, Southern analysis failed to show any evidence of MDM2 gene amplification in the same samples, suggesting that increased levels of MDM2 mRNA were not a direct result of gene amplification, but rather due to altered transcriptional regulation of MDM2 gene. By RT-PCR analysis we found that 7/8 giant cell tumours expressed strongly a short alternatively spliced variant of MDM2, whereas other tumours of bone and normal human bone cells expressed predominantly full length MDM2. Sequence analysis confirmed this variant to be MDM2-b, a variant previously reported to confer a transformed phenotype. Cell fractionation of the GCTs has shown that the MDM2-b splice variant was expressed exclusively in the stromal population, whereas the full length MDM2 was expressed in the multinucleated giant cells of these lesions. Overexpression of a green fluorescent protein-tagged MDM2-b in human embryonic kidney cells (HEK-293), demonstrated predominantly nuclear localisation. Immunoprecipitation studies showed that MDM2-b is unable to physically associate with the p53 tumour suppressor protein. These results are consistent with the hypothesis that the stromal cells comprise the tumour element in giant cell tumours of bone and we speculate that expression of the MDM2-b splice variant contributes to their transformed phenotype in a p53 independent manner.

Apoptotic cell death makes a minor contribution to reperfusion injury in skeletal muscle in the rat.

OBJECTIVE: to determine if apoptotic cell death contributes to skeletal muscle reperfusion injury. METHODS: leg ischaemia was induced in rats with a tourniquet and maintained for 4 h before reperfusion for 24 or 72 h. Apoptosis was assessed by morphology, in situ end labelling of DNA fragments, DNA laddering, expression of p53 mRNA and detection of caspase-3-like proteolytic activity. RESULTS: increased caspase-3-like activity was detected in muscle following ischaemia and zero, 24 h or 72 h of reperfusion. Levels remained relatively low but with a highly significant difference in enzyme activity between the ischaemic and non-ischaemic legs (p <0.0001, Repeated Measures Analysis of Variance). Morphological examination showed considerable oedema, disruption of muscle fibres and infiltration of white cells into tissues. Muscle nuclei did not show any morphological evidence of apoptosis and were negative for DNA fragmentation, while occasional neutrophils contained fragmented DNA. Expression of p53 was not induced by ischaemia and reperfusion and DNA ladders were not detected. CONCLUSIONS: the cells undergoing apoptosis were infiltrating neutrophils rather than muscle cells and reperfused muscle was damaged largely by an inflammatory process involving considerable oedema.

Promoter region methylation does not account for the frequent loss of expression of the Fas gene in colorectal carcinoma.

Expression of the apoptosis-promoting Fas gene is frequently reduced or lost during the development of colorectal carcinoma. However, loss of heterozygosity at the Fas locus or Fas gene rearrangements do not account for the loss of expression of Fas, raising the possibility that methylation of the Fas promoter may inhibit gene expression in colorectal carcinomas. We have examined the Fas promoter region CpG island for evidence of hypermethylation in colorectal tumours. Forty-seven specimens of colorectal adenoma and carcinoma, as well as six samples of normal colonic mucosa, were examined by Southern blotting for methylation at HpaII and Cfol sites in this region. No methylation was detected in any of the specimens, suggesting that hypermethylation is not primarily responsible for the loss of expression of the Fas gene during colorectal tumorigenesis.

The activity of caspase-3-like proteases is elevated during the development of colorectal carcinoma.

Activated caspase-3-like proteases promote apoptotic cell death by cleaving cellular substrates. Caspase-3-like activity was measured in colonic carcinomas and in matched normal colonic mucosa from 31 patients and was significantly elevated in 25/ 31 colonic carcinomas and adenomas when compared to normal mucosa (P < 0.0001). Caspase-3-like activity was much higher in normal mucosa and tumours of female subjects than of males (P < 0.0001). No correlation was obtained between caspase-3-like activity and location of the tumour, tumour grade, stage, or patient age. The marked increase in caspase-3-like activity in colorectal carcinomas may reflect an increase in the proportion of cells undergoing spontaneous apoptosis.

Cloning of the human uroplakin 1B cDNA and analysis of its expression in urothelial-tumor cell lines and bladder-carcinoma tissue.

The human uroplakin 1B (UPK1B) gene codes for a structural protein which is a terminal differentiation component of the asymmetric unit membrane on the apical surface of the mammalian bladder. UPK1B is a member of the tetraspan family of proteins, many of which have de-regulated patterns of expression in cancer. Using polymerase-chain-reaction techniques, we have cloned a partial human UPK1B cDNA which codes for the putative full open reading frame for the UPK1B protein. The deduced human UPK1B protein sequence has 92% and 93% amino-acid homology with bovine UPK1b and mink TI1 proteins respectively. Using Northern analysis, we show that the human UPK1B gene is highly expressed in normal human urothelium. However, expression of UPK1B mRNA was undetectable or markedly reduced in 11 out of 16 samples of transitional-cell-bladder-carcinoma tissue and in all 5 bladder-carcinoma cell lines when compared with normal urothelial tissue. The molecular mechanism of down-regulation of RNA expression does not appear to involve gross gene rearrangements or allelic loss.

Hereditary non-polyposis colorectal cancer syndrome.

Hereditary non-polyposis colorectal cancer (HNPCC) syndrome may account for up to 4% of the total colorectal cancer burden in our community. It is assuming an increasingly important role, both as a clinical management issue and as a model for the application of laboratory and clinical genetic services in cancer detection and prevention. Recent developments in the understanding of the molecular biology of the condition have underpinned recommendations for consideration of genetic testing for DNA mismatch repair gene mutation, recommendations that may have far-reaching implications in terms of the numbers of patients offered genetic testing and for associated costs (both financial and psychological). The aim of this review is to highlight the clinical, pathologic and molecular biologic features of HNPCC that underlie the clinical management of affected index patients and their at-risk family members.

Deregulation of apoptosis in colorectal carcinoma: theoretical and therapeutic implications.

Apoptosis, or programmed cell death, maintains the structure of the colonic crypts by providing a balance to the rate of cell proliferation. Colorectal carcinoma arises partly from a disruption in this balance in the favour of uncontrolled growth. Until recently, most research into colon cancer has focused on the molecular regulators of cell-cycle progression and proliferation, but it is now evident that apoptosis is also defective. A failure of cells to die in response to premalignant damage may allow the progression of the disease and maintain the resistance of cancer cells to cytotoxic therapy. This review outlines the importance of apoptosis in the normal colon and presents recent studies that demonstrate that induction of apoptosis is defective in colonic tumours. When the molecular regulation of apoptosis is better understood, this knowledge may lead to the earlier detection of patients at greater risk of developing colorectal carcinoma, and also to the development of more effective therapies.

Down-regulation of Fas gene expression in colon cancer is not a result of allelic loss or gene rearrangement.

Expression of Fas, an apoptosis-inducing receptor, in colonic epithelium is progressively reduced during malignant transformation. We have examined the human Fas gene for loss of heterozygosity (LOH) and gross rearrangements in colon tumours and matched normal mucosa. Polymerase chain reaction (PCR) primers were designed to span a DraI restriction fragment length polymorphic site in the gene. Heterozygosity was detected in normal DNA samples by PCR amplification of the polymorphic site and restriction enzyme digestion. Thirty-eight of 88 patients (43%) with colon carcinomas were informative for the assay, and LOH was detected in 6 of the 38 (16%) corresponding tumours. Tumours from three patients with LOH did not express detectable Fas mRNA, and Fas expression was reduced or absent in 7 of 11 tumours from informative patients without LOH. Southern blotting of tumour DNA samples was used to detect rearrangement of the Fas gene, but no altered hybridization patterns were observed in 64 tumours analysed. These findings indicate that disruption of the Fas gene is not primarily responsible for the loss of Fas protein expression reported in colon cancer. We have also shown that loss of Fas gene transcription is common in these tumours, which may be due to epigenetic gene silencing.

Growth-regulatory activity of the growth arrest-specific gene, GAS1, in NIH3T3 fibroblasts.

The growth arrest-specific gene, Gas-1, is preferentially expressed in quiescent NIH3T3 cells and inhibits DNA synthesis, suggesting that Gas-1 may be a tumor suppressor gene. When GAS1 cDNA, under the control of the strong constitutive CMV promoter, was transfected into NIH3T3 cells, no stable transfectant cell lines were produced, confirming that high levels of expression of GAS1 mRNA inhibit proliferation. GAS1, under the control of a dexamethasone-inducible promoter, was also transfected into NIH3T3 cells, resulting in normal numbers of transfectant clones. When expression of GAS1 mRNA was induced with dexamethasone, the growth rate was greatly inhibited. Morphological changes characteristic of growth arrest were also observed. To determine if antisense inhibition of expression of Gas-1 will transform normal fibroblasts, GAS1 cDNA, cloned in the antisense orientation, was transfected into NIH3T3 cells and expression of endogenous Gas-1 mRNA was inhibited. The GAS1-antisense cells had altered morphology and grew to a much higher saturation density than control cell lines with a loss of contact inhibition. However, there was no change in requirements for serum or any development of anchorage-independence. Antisense inhibition of expression of GAS1 is therefore insufficient to transform the cells, suggesting that additional genetic events are required for a fully malignant phenotype.

Tumor-suppressive activity of the growth arrest-specific gene GAS1 in human tumor cell lines.

The GAS1 gene product induces growth arrest through a p53-dependent mechanism. To investigate whether GAS1 is a tumor suppressor gene, we transfected GAS1-negative human tumor cells with GAS1 plasmids and analyzed growth characteristics of stable transfectants. When a constitutively expressing GAS1 plasmid was transfected into A549 cells, no stable colonies expressing GAS1 were isolated. When A549 cells were transfected with a dexamethasone-inducible GAS1 plasmid, expression of GAS1 inhibited growth in vitro, and fewer slow-growing tumors arose in nude mice. GAS1 also inhibited proliferation of an HT1080 subline with wild-type (wt) p53 and normal MDM2. However, when the HT1080 subline HTD114 was transfected with the constitutive GAS1 plasmid, there was no reduction in colony number. GAS1-transfectant clones had unaltered growth in vitro, were morphologically unchanged and showed no difference in their ability to form tumors in nude mice. Although HTD114 cells contain wt p53, levels of MDM2 were elevated by 10-15 fold. The HT1080-6TGc5 subline with mutant p53 and normal MDM2 was also refractory to GAS1. Our results show that GAS1 suppresses the growth and tumorigenicity of human tumor cells and overexpression of MDM2 or p53 mutation inhibits the GAS1-mediated growth-suppressing pathway.

Chromosomal localization of the human urothelial "tetraspan" gene, UPK1B, to 3q13.3-q21 and detection of a TaqI polymorphism.

The TI1/UPK1b gene codes for a protein of the "tetraspan" family and is expressed as a differentiation product of the mammalian urothelium. A partial genomic clone of the human homologue of the TI1/UPK1b gene was isolated and used as probe to localize the human gene to chromosome 3q13.3-q21 by in situ hybridization. Using the same probe, a TaqI restriction fragment length polymorphism, with 29% heterozygosity, was identified by Southern analysis.

The human growth-arrest-specific gene GAS1 maps outside the candidate region of the gene for nevoid basal cell carcinoma syndrome.

The human growth-arrest specific gene GAS1 maps to chromosome bands 9q21.3-->q22, the region known to contain the tumour suppressor gene responsible for nevoid basal cell carcinoma syndrome (NBCCS). Because of its putative action as a tumour suppressor gene, the GAS1 gene was analysed as a candidate for the NBCCS gene. Using two-colour fluorescence in situ hybridization, the GAS1 gene maps outside the interval which, by genetic analysis, has been shown to contain the NBCCS gene.