Lessons learnt from the construction and implementation of a prospective ventral hernia database.

PURPOSE: The New England VA Hernia Registry was created in 2011 to prospectively collect relevant details of ventral hernia repairs, with the intention to assess and improve long term outcomes. The goal of this study is to assess registry compliance. METHODS: All ventral hernia operations performed in five VA hospitals between 2011-2022 were obtained. We assessed compliance at the hospital and surgeon level. RESULTS: 3,516 cases were performed. Overall compliance with registry entry was 37.5%, ranging from 10.8% to 67.2% across hospitals. At the hospital level, there was a negative correlation between average yearly hernia volume per surgeon and registry compliance (r2 = 0.53). Surgeon compliance varied within hospitals and over time. CONCLUSION: Registry compliance was low and highly variable. Lack of interest, incentives, oversight, and surgeon turnover are possible factors for noncompliance. Building a registry with these factors in mind, providing timely feedback, and conducting frequent audits may improve compliance.

Air-classified faba bean protein fraction as a substitute to soybean meal in pelleted and extruded broiler diets.

1. The hypothesis that air-classified faba bean protein fraction (FBP) can replace soybean meal (SBM) in pelleted or extruded broiler diets without adverse effect on performance or nutrient digestibility was tested.2. At 17 d of age, male broilers were randomly distriibuted among four dietary treatments consisting of either SBM or FBP (main dietary protein source) and pelleting or extrusion as processing methods. Treatments had 10 replicate pens containing five birds each.3. Compared to SBM, birds fed FBP had significantly lower feed intake, less weight gain and had poorer feed conversion.4. Pellet durability was high (above 92%) for all diets. In pelleted diets, FBP was harder than SBM whereas extruded diets had similar hardness. Pelleting increased water stability compared to extrusion. FBP diets were more water stable than the SBM diets.5. Gizzard content weight was 2.2-fold higher (P = 0.002) for birds given FBP compared to those fed SBM. The weight of the jejunum and ileum with contents was 1.4-fold lower for the FBP diets, and this effect was larger (P < 0.05) for the extruded FBP diet.6. Birds fed FBP diets had significantly higher nitrogen digestibility in the lower jejunum and ileum compared to those given SBM diets, while the starch digestibility coefficient was above 0.980 in all treatments.7. The high nutrient digestibility of FBP diets indicates that the poor performance of the FBP group was due to lower feed intake which was not explained by the differences in pellet durability or hardness. The reduced palatability of the FBP and the longer retention of the FBP diets in the upper gut are more likely to have depressed feed intake.

Interactions between starch source and gelatinisation degree on performance and small intestinal digestion in broiler chickens.

1. A 2 × 2 factorial arrangement was used to test the hypothesis that, in pelleted diets, legume starch is digested less rapidly and to a lesser extent than cereal starch, and that increased gelatinisation through extrusion would eliminate the differences between the starch sources. In addition, the trial examined whether a lower ratio of starch to nitrogen disappearance rate (SNDR) could improve feed conversion ratio (FCR).2. At 17 d of age, male broilers were randomly distributed among four dietary treatments, consisting of either wheat or faba bean starch-rich fraction (FBS) as the sole starch source and pelleting or extrusion as processing methods. Each treatment had 10 replicate pens containing five birds each.3. Extrusion resulted in a more extensive starch gelatinisation compared to pelleting, as expected.4. No difference in weight gain at 29 d of age was observed between birds fed starch sources. However, birds fed wheat tended (P = 0.080) to have better FCR than those fed FBS, while the effect of processing methods was insignificant. Thus, there was no interaction between starch source and processing method on FCR.5. In pelleted diets, FBS had lower and slower starch digestibility compared to wheat in all intestinal segments (P < 0.05). The interaction between starch source and processing method in all intestinal segments (P < 0.001) demonstrated that FBS responded more to gelatinisation through extrusion than did wheat. Thus, differences in starch digestibility between the wheat and FBS were eliminated with extrusion.6. Feeding extruded diets significantly increased the upper jejunal expression of GLUT1, GLUT2 and SGLT1 compared to pelleted diets, which suggested that glucose absorption was less likely to be a limiting factor for starch utilisation.7. Pelleting resulted in a lower ratio (P < 0.001) of SNDR compared to extrusion (on average 1.4-fold) but did not improve FCR.

Effect of crop retention time and acidification of the feed on phytase efficacy in broiler chickens.

1. An in vitro test to study the effect of pH reduction on phytic acid degradation over time for four commercial phytases was conducted. Changing the pH level affected phytate degradation over time differently for the various phytases (P < 0.05).2. The phytase with the largest response of pH reduction in the in vitro test and a feed pH level of 4.5 was chosen for the broiler experiment. The effect of intermittent feeding, addition of 500 FYT C. braakii-derived phytase and 1% formic acid were tested in a 2 x 2 x 2 factorial arrangement. Ten pens containing 10 birds each were fed each of the treatment combinations from 15 to 36 d of age. Ad libitum fed birds had two 4-h dark periods with 2-h light in-between, while intermittently fed birds in addition had restricted access to the feed through except for four 1-h and one 2-h feeding bouts.3. In addition to assessing performance, excreta were collected on a pen basis. The tibia and contents from jejunum and ileum were collected from one bird per pen. In addition, crop contents were collected from the intermittently fed birds 80, 160 and 240 min after the start of feeding.4. Phytase improved performance, ileal and jejunal P digestibility, P retention and tibia ash and P concentration (P < 0.001). Intermittent feeding increased jejunal P digestibility and P retention (P < 0.001), but ileal P digestibility increased only in the intermittently fed birds compared to the ad libitum fed birds without phytase addition (P = 0.025). Acidification increased jejunal P digestibility only in the ad libitum fed birds (P = 0.019). There was a considerable inositol hexakisphosphate degradation into lower isomers in the crop after 80 min for diets with phytase (InsP3 and 4:P < 0.001), and acidification further increased this degradation (InsP4:P = 0.007). After 160 min retention time, the effect of phytase and acidification was even higher with more significant (P < 0.05) interactions.5. The current data showed that prolonged retention time in the crop combined with feed acidification increased phytase efficacy by improving the phytate degradation.

Varying starch to fat ratios in pelleted diets: II. Effects on intestinal histomorphometry, Clostridium perfringens and short-chain fatty acids in Eimeria-challenged broiler chickens.

1. The hypothesis behind the study was that a high dietary starch level (HS) would lead to impaired gut health compared to a low-starch diet (LS) in Eimeria-challenged broilers. The effects of two diets with different starch to fat ratios on intestinal histomorphometry, Clostridium perfringens counts and toxin profile, necrotic enteritis prevalence and abundance of short-chain fatty acids (SCFAs) were examined. 2. A total of 1,920 one-day-old Ross 308 broiler chickens were fed one of two isocaloric diets formulated either with high (32:1) or low (2:1) starch to fat ratios from d 10 to 29 of age. Each treatment group had 12 pen replicates containing 80 broilers each. On d 17, the chickens were challenged with Eimeria vaccine strains. Samples were collected on d 16, 21-23 and 29. 3. Whereas villus length increased gradually throughout the study in the HS group, a peak level was reached on d 21-23 in the LS group. On d 29, the HS group had significantly longer villi than the LS group. 4. Caecal SCFA concentrations were higher in the HS group compared to the LS group on d 16. In both groups, the SCFA level peaked on d 21-23, with the most pronounced increase seen in the LS group. 5. The C. perfringens netB:cpa ratio increased from d 16 to 29 in the HS group. C. perfringens counts and necrotic enteritis prevalence were similar between the two groups. 6. Diet affected the dynamics of small intestinal villus length and caecal SCFA abundance. These findings suggest that structural remodelling of the small intestine is an adaptation to different dietary starch levels, and that caecal SCFA abundance is associated with the availability of substrate for the microbiota in the posterior intestinal segments. Chickens adapted to higher levels of dietary starch might be more robust against Eimeria infections due to increased mucosal surface area. Studies with other dietary starch sources are required to clarify the impact of dietary starch levels on intestinal health in Eimeria-challenged broilers.

Varying starch to fat ratios in pelleted diets: I. Effects on nutrient digestibility and production performance in Eimeria-challenged broiler chickens.

1. The hypothesis was that a diet with a high starch to fat ratio (HS) impairs nutrient digestibility and growth performance, as compared to a diet with a low starch to fat ratio (LS) in Eimeria-challenged broilers. From days 10 to 29, 12 replicate pens of birds were given isocaloric and isonitrogenous steam-pelleted diets with either HS or LS, by replacing the wheat starch in one diet by a mixture of rapeseed oil and inert sand in the other. On d 17, a 10-fold dose of live vaccine strains of Eimeria spp. was administered via drinking water. Ileal samples were collected on days 16 and 29. 2. Starch content in the ileum tended to be higher on d 16 and was significantly higher on d 29 in the HS group. 3. The HS diet did not induce exceedingly high levels of starch in the ileum, suggesting there was no starch overload in the gut. Ileal starch digestibility was improved with increasing dietary starch level from 23% to 45%. This demonstrated the capacity of the broiler chicken to digest high levels of starch regardless of Eimeria spp. infection. Ileal energy digestibility was not affected by the treatments. 4. Weight gain did not differ between treatments; however, birds fed the LS diet were less efficient in feed conversion as compared to those fed the HS diet. 5. The use of isolated starch and the unintended higher extent of starch gelatinisation in the HS diet may have contributed to the higher starch digestibility in birds given the HS diet. Thus, the hypothesis that high ratios of starch to fat in pelleted diets may impair starch digestibility and production performance in Eimeria-challenged broiler chickens was not verified. Further work is required to clarify this research question, taking into consideration the physical form of starch source and the potentially confounding role of feed processing on starch availability.

International classification of abdominal wall planes (ICAP) to describe mesh insertion for ventral hernia repair.

BACKGROUND: Nomenclature for mesh insertion during ventral hernia repair is inconsistent and confusing. Several terms, including 'inlay', 'sublay' and 'underlay', can refer to the same anatomical planes in the indexed literature. This frustrates comparisons of surgical practice and may invalidate meta-analyses comparing surgical outcomes. The aim of this study was to establish an international classification of abdominal wall planes. METHODS: A Delphi study was conducted involving 20 internationally recognized abdominal wall surgeons. Different terms describing anterior abdominal wall planes were identified via literature review and expert consensus. The initial list comprised 59 possible terms. Panellists completed a questionnaire that suggested a list of options for individual abdominal wall planes. Consensus on a term was predefined as occurring if selected by at least 80 per cent of panellists. Terms scoring less than 20 per cent were removed. RESULTS: Voting started August 2018 and was completed by January 2019. In round 1, 43 terms (73 per cent) were selected by less than 20 per cent of panellists and 37 new terms were suggested, leaving 53 terms for round 2. Four planes reached consensus in round 2, with the terms 'onlay', 'inlay', 'preperitoneal' and 'intraperitoneal'. Thirty-five terms (66 per cent) were selected by less than 20 per cent of panellists and were removed. After round 3, consensus was achieved for 'anterectus', 'interoblique', 'retro-oblique' and 'retromuscular'. Default consensus was achieved for the 'retrorectus' and 'transversalis fascial' planes. CONCLUSION: Consensus concerning abdominal wall planes was agreed by 20 internationally recognized surgeons. Adoption should improve communication and comparison among surgeons and research studies.

ANTECEDENTES: La nomenclatura de la inserción de una malla para la reparación de una hernia incisional ventral (ventral hernia, VH) es inconsistente y confusa. En la literatura indexada se usan varios términos, tales como 'inlay', 'sublay', y 'underlay' que pueden referirse a los mismos planos anatómicos. Este hecho frustra las comparaciones de técnicas quirúrgicas e invalida los metaanálisis que comparan resultados quirúrgicos en función del plano de inserción de la malla. En consecuencia, el objetivo de este estudio fue establecer una clasificación internacional de los planos de la pared abdominal (International Classification of Abdominal Wall Planes, ICAP). MÉTODOS: Se realizó un estudio Delphi, en el que participaron 20 cirujanos de pared abdominal reconocidos internacionalmente. Se identificaron diferentes términos que describían los planos de la pared abdominal anterior mediante la revisión de la literatura y el consenso de expertos. La lista inicial incluía 59 términos posibles. Los panelistas completaron un cuestionario que sugería una lista de opciones para los planos individuales de la pared abdominal. El consenso sobre un término fue predefinido cuando dicho término había sido seleccionado por ≥ 80% de panelistas. Se eliminaron los términos con una puntuación < 20%. RESULTADOS: La votación comenzó en agosto de 2018 y se completó en enero de 2019. Durante la Ronda 1, 43 (73%) términos fueron seleccionados por < 20% de los panelistas y se sugirieron 37 términos nuevos, dejando 53 términos para la Ronda 2. Cuatro planos alcanzaron un consenso en la Ronda 2 con los términos 'onlay', 'inlay', 'pre-peritoneal' e 'intra-peritoneal'. Treinta y cinco (66%) términos fueron seleccionados por < 20% de los panelistas y fueron eliminados. Después de la Ronda 3, se logró un consenso para 'anterectus' (ante-recto), 'interoblique' (inter-oblicuo), 'retrooblique' (retro-oblicuo) y 'retromuscular'. Se alcanzó un consenso por defecto para los planos 'retrorectus' (retro-recto) y 'transversalis fascial' (fascial transverso). CONCLUSIÓN: La ICAP ha sido desarrollada por el consenso de 20 cirujanos reconocidos internacionalmente. Su implementación debería mejorar la comunicación y la comparación entre cirujanos y estudios de investigación.

Feed processing and structural components affect starch digestion dynamics in broiler chickens.

1. A 2 × 2 factorial design was used to test the hypothesis that impaired intestinal starch digestibility is attributable to rapid passage of digesta from the gizzard to the intestine, and that, compared to steam pelleting, increasing the availability of starch through extrusion cooking may alleviate the potential negative effect of rapid digesta flow on starch utilisation. 2. Thus, 7-d-old-broiler chickens were distributed to 48 cages and given a wheat-based (WB) pelleted diet containing either coarse oat hulls (OH-Pel) or fine cellulose (Cel-Pel) until d 19 to stimulate divergent development of the gizzard. Thereafter, both groups were further subdivided and challenged with a WB diet containing cellulose in either pelleted (Cel-Pel) or extruded (Cel-Ext) form on d 20 and 22. Either excreta or intestinal contents were collected at time intervals after feeding and analysed for marker and starch. 3. OH-Pel increased gizzard size and holding capacity. No excessively high starch levels (maximum 25 g/kg) were detected in the excreta. However, 8 h feed-deprived birds given Cel-Pel and challenged with Cel-Pel exhibited higher starch excretion and showed large individual variation during the first 135 min of collection. 4. Contrary to the OH-Pel group, more digesta and starch passed to the jejunum at 1 and 2 h and ileum at 2 and 3 h after feeding for birds given Cel-Pel, resulting in lower jejunal and ileal starch digestibility. 5. Increased starch gelatinisation through extrusion processing significantly improved starch digestibility regardless of gizzard function. However, at 1, 2 and 3 h after feeding, more digesta was retained in the foregut of birds given Cel-Ext. 6. The current data showed that starch degradation rate is associated with the flow of digesta which is linked to gizzard development, and that enzymatic hydrolysis of intact starch granules may be limited with more rapid feed passage through the gut.

Validation of an electronic tool for flagging surgical site infections based on clinical practice patterns for triaging surveillance: Operational successes and barriers.

BACKGROUND: Surveillance is an effective strategy for reducing surgical site infections (SSIs); however, current identification methods are resource-intensive. Therefore, we sought to validate an electronic SSI triaging tool for detection of probable infections and identify operational barriers and challenges. METHODS: A retrospective cohort study was conducted among all Veterans Affairs Surgical Quality Improvement Program (VASQIP)-reviewed surgeries at 2 Veterans Affairs medical centers from October 1, 2011-September 30, 2014. During the postoperative period, clinical and administrative variables associated with SSI (relevant microbiology order, antibiotic order, radiology order, and administrative codes) were extracted from the electronic medical record and used to score the probability (high, intermediate, and low) that an SSI occurred. VASQIP manual chart review was used as the gold standard of comparison. RESULTS: VASQIP manual review identified 118 SSIs out of 3,700 surgeries (3.2%). There were 2,041, 1,428, and 231 surgeries that met criteria for low, intermediate, and high probability for SSI. The tool's area under the curve was 0.86 (95% confidence interval, 0.82-0.89). The sensitivity among low-probability surgeries was 92.4%, and the specificity among high-probability surgeries was 95.1%. CONCLUSIONS: The electronic SSI tool has the potential to be used for triaging VASQIP surveillance toward the high-probability surgeries and to avoid manual review of surgeries with low probability of SSI.

Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017

IMPORTANCE: The human and financial costs of treating surgical site infections (SSIs) are increasing. The number of surgical procedures performed in the United States continues to rise, and surgical patients are initially seen with increasingly complex comorbidities. It is estimated that approximately half of SSIs are deemed preventable using evidence-based strategies. OBJECTIVE: To provide new and updated evidence-based recommendations for the prevention of SSI. EVIDENCE REVIEW: A targeted systematic review of the literature was conducted in MEDLINE, EMBASE, CINAHL, and the Cochrane Library from 1998 through April 2014. A modified Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to assess the quality of evidence and the strength of the resulting recommendation and to provide explicit links between them. Of 5759 titles and abstracts screened, 896 underwent full-text review by 2 independent reviewers. After exclusions, 170 studies were extracted into evidence tables, appraised, and synthesized. FINDINGS: Before surgery, patients should shower or bathe (full body) with soap (antimicrobial or nonantimicrobial) or an antiseptic agent on at least the night before the operative day. Antimicrobial prophylaxis should be administered only when indicated based on published clinical practice guidelines and timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made. In cesarean section procedures, antimicrobial prophylaxis should be administered before skin incision. Skin preparation in the operating room should be performed using an alcohol-based agent unless contraindicated. For clean and clean-contaminated procedures, additional prophylactic antimicrobial agent doses should not be administered after the surgical incision is closed in the operating room, even in the presence of a drain. Topical antimicrobial agents should not be applied to the surgical incision. During surgery, glycemic control should be implemented using blood glucose target levels less than 200 mg/dL, and normothermia should be maintained in all patients. Increased fraction of inspired oxygen should be administered during surgery and after extubation in the immediate postoperative period for patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation. Transfusion of blood products should not be withheld from surgical patients as a means to prevent SSI. CONCLUSIONS AND RELEVANCE: This guideline is intended to provide new and updated evidence-based recommendations for the prevention of SSI and should be incorporated into comprehensive surgical quality improvement programs to improve patient safety.

Performance and digestive function of broiler chickens given grit in the diet.

1. A series of experiments were carried out to study the effect of grit on broiler performance, gizzard development and fate of grit in the digestive tract. 2. In Experiment 1, performance, gizzard weight and content of grit in the gizzard of broiler chickens given access to granite-type grit was investigated. In Experiment 2, the effect of grit stones on performance and gizzard development was assessed in diets with or without whole wheat. 3. In Experiment 3, the effect of grit in the form of zeolite, granite or marble on gizzard development and digestive tract grinding and passage was studied in diets with or without whole wheat. 4. Grit stones had no effect on performance of broiler chickens, which may be explained by the fact that grit stones did not stimulate gizzard development to the same extent as with other structural materials. 5. The lack of stimulation is at least partly due to the fact that a majority of the grit stones eaten pass through the small intestine without being retained in the gizzard. 6. Grit in the form of marble reduced feed intake and weight gain.

Evaluation of surgical outcomes of retro-rectus versus intraperitoneal reinforcement with bio-prosthetic mesh in the repair of contaminated ventral hernias.

INTRODUCTION: Hernia repairs in contaminated fields are often reinforced with a bioprosthetic mesh. When choosing which of the multiple musculofascial abdominal wall planes provides the most durable repair, there is little guidance. We hypothesized that the retro-rectus plane would reduce recurrence rates versus intraperitoneal placement due to greater surface area contact of mesh with well-vascularized tissue. METHODS: Forty-nine of the 80 patients in an ongoing, prospective, multicenter study of contaminated ventral hernia repairs (RICH study, NCT00617357) achieved fascial closure after musculofascial centralization and reinforcement with non-crosslinked porcine acellular dermal matrix (Strattice™, LifeCell, Branchburg, NJ) and were retrospectively analyzed. The Strattice was placed in the retro-rectus position in 23 patients and in the intraperitoneal position in 26. RESULTS: Subjects were comparable in age, obesity, prior wound infection, presence of a stoma, and infected mesh removal (p > 0.05). More smokers were present in the intraperitoneal group (p = 0.02). Retro-rectus defects were significantly wider and had larger area than the intraperitoneal repairs. At the 1-year follow-up, 44 (90%) of patients were available for review. There was no difference in wound infections, seromas, or hematomas. Recurrent hernias were identified in 10% of retro-rectus repairs and 30% of intraperitoneal repairs (p = 0.14). CONCLUSIONS: In this retrospective analysis of a prospective multicenter study of large, contaminated ventral hernias, despite a larger hernia defect in the retro-rectus group, placement of the mesh in the retro-rectus compartment resulted in a similar recurrence rate to intraperitoneal mesh placement. Ongoing evaluation is important to establish longer-term outcomes and the validity of these findings.

Classification and valuation of postoperative complications in a randomized trial of open versus laparoscopic ventral herniorrhaphy.

PURPOSE: Generic instruments used for the valuation of health states (e.g., EuroQol) often lack sensitivity to notable differences that are relevant to particular diseases or interventions. We developed a valuation methodology specifically for complications following ventral incisional herniorrhaphy (VIH). METHODS: Between 2004 and 2006, 146 patients were prospectively randomized to undergo laparoscopic (n = 73) or open (n = 73) VIH. The primary outcome of the trial was complications at 8 weeks. A three-step methodology was used to assign severity weights to complications. First, each complication was graded using the Clavien classification. Second, five reviewers were asked to independently and directly rate their perception of the severity of each class using a non-categorized visual analog scale. Zero represented an uncomplicated postoperative course, while 100 represented postoperative death. Third, the median, lowest, and highest values assigned to each class of complications were used to derive weighted complication scores for open and laparoscopic VIH. RESULTS: Open VIH had more complications than laparoscopic VIH (47.9 vs. 31.5%, respectively; P = 0.026). However, complications of laparoscopic VIH were more severe than those of open VIH. Non-parametric analysis revealed a statistically higher weighted complication score for open VIH (interquartile range: 0-20 for open vs. 0-10 for laparoscopic; P = 0.049). In the sensitivity analysis, similar results were obtained using the median, highest, and lowest weights. CONCLUSION: We describe a new methodology for the valuation of complications following VIH that allows a direct outcome comparison of procedures with different complication profiles. Further testing of the validity, reliability, and generalizability of this method is warranted.

Laparoscopic ventral hernia repair during the learning curve.

Large series of laparoscopic ventral hernia repair have shown excellent results. However, published comparative studies have had conflicting outcomes. We retrospectively reviewed the first 29 laparoscopic ventral hernia repairs performed at a VA Medical Center from January 2000 to June 2001. The outcome was compared to that of open repairs performed during the same time period. Outcomes between the groups were similar in all respects, except for the length of stay. The conversion rate for the laparoscopic approach was 13.8%. There was one death in the laparoscopic group due to an unrecognized enterotomy. There were three recurrences in the open group and one in the laparoscopic group with a mean follow up of 13 months. In our series, laparoscopic hernia repair resulted in a shorter hospital stay but no other significant benefits, along with a risk of missed enterotomy. The risk-benefit ratio for this procedure may be high during the learning curve.

Structural features and expression analysis of a linear mitochondrial plasmid in rapeseed (Brassica napus L.).

A linear plasmid molecule about 11 kb in length is present in the mitochondria of some varieties of rapeseed (Brassica napus L.). This plasmid can be inherited from the male parent, through the pollen, as well as by the usual maternal route, although the main mitochondrial genome is maternally inherited in rapeseed. We determined the complete nucleotide sequence of this plasmid DNA and clarified its genetic organization. The length of the linear plasmid is 11,640 bp. At the termini of the plasmid molecule are inverted repeats of 327 bp. The GC content of the plasmid DNA is 30.9%; thus, the plasmid is quite AT-rich compared to the main mitochondrial genome in higher plants. The plasmid has six ORFs, two of which encode a phage-type DNA polymerase and a phage-type RNA polymerase, respectively. RT-PCR analyses revealed that all six ORFs are transcribed, and all four ORFs on the minus strand are probably cotranscribed from a single promoter located in the terminal inverted repeat. We also show here that at least three of the six ORFs are translated into proteins in rapeseed mitochondria, and expressed at relatively high levels in flowers, as shown by Western analysis. These results suggest that this linear DNA molecule is able to replicate as an autonomous replicon and to express the genes it carries in rapeseed mitochondria.

Telomerase activity and expression of telomerase RNA component and catalytic subunits in precancerous and cancerous colorectal lesions.

To investigate the role of telomerase activity in colorectal adenoma-carcinomas, telomerase activity, human telomerase RNA component (hTERC) and human telomerase reverse transcriptase (hTERT) mRNA were quantitatively analyzed in human cancerous and precancerous colorectal tissues. Sixty-six colorectal tumor specimens, including 10 invasive carcinomas, 6 mucosal carcinomas and 50 adenomas were evaluated. Ten specimens of normal tissue were also included in the study. Telomerase activity was assayed by semiquantitative fluorescence using the TRAP-eze(TM) telomerase detection kit. Analysis of the expression of each telomerase subunit gene was performed by real-time PCR amplification. There was a positive correlation between histological atypia and telomerase activity (rho = 0.700, p < 0.0001), hTERT mRNA expression (rho = 0.603, p < 0.0001), and hTERC expression (rho = 0.290, p < 0.05). There was also a positive correlation between the levels of hTERT mRNA and telomerase activity (r = 0.455, p < 0.01). Significant differences in the levels of hTERT mRNA were shown between normal tissues and the adenomas (p < 0.05) and between the mucosal carcinomas and invasive carcinomas (p < 0.05). The values of hTERC expression in neoplastic tissues were significantly higher than in the normal tissues; however, there were no significant differences between the adenomas and the carcinomas. In summary, although upregulation of hTERC expression is an early event in adenoma development, hTERT mRNA expression is gradually upregulated during the adenoma-carcinoma sequence and may be a rate-limiting determinant of telomerase activity.

MDM2/p53 protein expression in the development of colorectal adenocarcinoma.

The murine double minutes 2 (MDM2) oncoprotein inhibits p53-mediated tumor suppression. MDM2 has been shown to be overexpressed in sarcomas and more recently was implicated in the pathogenesis of carcinomas. The purpose of this study was to determine the expression pattern of MDM2 in adenomas and colorectal adenocarcinomas and decide whether there is a correlation between MDM2 and p53 protein status. Paraffin-embedded tissues from 52 colorectal cancer (CRC) specimens and their adjacent normal tissue (N-CRC) were studied. In addition, 56 sporadic adenomas were investigated for the immunohistochemical expression of MDM2 and p53 proteins. Immunoreactivity of p53 indicating p53 gene mutation (p53+) was significantly higher in CRC (44%) compared to adenomas (23.2%) (P <0.01). None of the N-CRC specimens expressed the immunoreactive p53 protein. MDM2 overexpression (MDM2+) was similar in adenomas (30.3%) and CRC (25%), but only 2 (3.8%) of 52 N-CRC specimens showed overexpression of MDM2. In most cases MDM2 expression was associated with negative p53 expression (wild-type p53) in both adenomas (r = 0.59, P <0.001) and CRC (r = 0.69, P <0. 0001). No correlation was found between MDM2, p53 expression, and either the histologic grade, nodal stage or morphology of the tumors. There is greater p53 mutation in CRC compared to adenomas and N-CRC. The data indicate that MDM2 is overexpressed in CRC and is significantly associated with wild-type p53 compared to N-CRC specimens from the same patient. The MDM2 expression pattern is similar in adenomas and CRC, which may suggest that MDM2 overexpression is an early event in the progression of CRC.

Squamous cell carcinoma of the pancreas.

Squamous cell carcinoma of the pancreas is a controversial entity. Although some reports show that it is metastatic from another source, others demonstrate that it is a primary tumor. Between 1988 and 1997, fourteen cases of pancreatic squamous cell carcinoma were identified in the records of our pathology department. In seven instances the features were consistent with squamous cell carcinoma with no adenomatous component. The records of six of these patients were available for review and constitute the basis for this report. Five patients were diagnosed by means of percutaneous CT-guided fine-needle aspiration, whereas the sixth patient was diagnosed using a transduodenal core needle biopsy. At the time of diagnosis four patients had lung lesions, three patients had liver lesions, and two patients had lytic bone lesions. One patient had a 6 cm esophageal lesion. Surgical intervention had no impact on treatment or palliation in one of the patients. Chemotherapy and radiation therapy, alone or in combination, were ineffective in all patients. Median survival from the time of diagnosis was 2 months. We conclude that in cases of squamous cell carcinoma of the pancreas, every effort should be made to exclude adenomatous components histologically within the tumor and to exclude another primary source of squamous cell carcinoma. This will allow a better understanding of this entity and a refinement of therapy.