Better survival for patients with colon cancer operated on by specialized colorectal surgeons - a nationwide population-based study in Sweden 2007-2010.

AIM: Mortality and complication rates after surgery for colon cancer are high, especially after emergency procedures. The aim of the present study was to evaluate the importance of the formal competence of surgeons for survival and morbidity. METHOD: The Swedish Colorectal Cancer Registry prospectively records data on patients diagnosed with cancer within the colon and rectum. A cohort of patients operated on for colon cancer between 2007 and 2010 were followed 5 years after surgery. Data on postoperative morbidity, mortality and long-term survival were compared with regard to formal competency of the most senior surgeon attending the procedure. RESULTS: This analysis includes 13 365 patients operated on for colon cancer, including 10 434 elective procedures and 2931 emergency cases. The overall 5-year survival was higher for those operated on by subspecialist colorectal surgeons compared with general surgeons (60% vs 48%; P < 0.001). Five-year survival after elective surgery was 63% vs 55% (P < 0.001) and 35% vs 31% (P < 0.05) after emergency procedures when performed by colorectal surgeons compared with general surgeons. Postoperative 30-day mortality was 3% after surgery performed by colorectal surgeons compared with 7% when performed by general surgeons. Mortality at 90 days was 6% after surgery performed by colorectal surgeons compared with 11% for patients operated on by general surgeons (P < 0.001). CONCLUSION: Subspecialization in colorectal surgery is associated with better outcome for patients operated on for colon cancer, and effort should be made to increase the availability of colorectal surgeons for both acute and elective colon cancer surgery.

Temperature-controlled airflow ventilation in operating rooms compared with laminar airflow and turbulent mixed airflow.

AIM: To evaluate three types of ventilation systems for operating rooms with respect to air cleanliness [in colony-forming units (cfu/m3)], energy consumption and comfort of working environment (noise and draught) as reported by surgical team members. METHODS: Two commonly used ventilation systems, vertical laminar airflow (LAF) and turbulent mixed airflow (TMA), were compared with a newly developed ventilation technique, temperature-controlled airflow (TcAF). The cfu concentrations were measured at three locations in an operating room during 45 orthopaedic procedures: close to the wound (<40cm), at the instrument table and peripherally in the room. The operating team evaluated the comfort of the working environment by answering a questionnaire. FINDINGS: LAF and TcAF, but not TMA, resulted in less than 10cfu/m3 at all measurement locations in the room during surgery. Median values of cfu/m3 close to the wound (250 samples) were 0 for LAF, 1 for TcAF and 10 for TMA. Peripherally in the room, the cfu concentrations were lowest for TcAF. The cfu concentrations did not scale proportionally with airflow rates. Compared with LAF, the power consumption of TcAF was 28% lower and there was significantly less disturbance from noise and draught. CONCLUSION: TcAF and LAF remove bacteria more efficiently from the air than TMA, especially close to the wound and at the instrument table. Like LAF, the new TcAF ventilation system maintained very low levels of cfu in the air, but TcAF used substantially less energy and provided a more comfortable working environment than LAF. This enables energy savings with preserved air quality.

Effects of long-term administration of cancer-promoting substances on oral subepithelial mast cells in the rat.

The role of oral subepithelial mast cells in the defence against tumours is a matter of controversy. The effect of established and suggested carcinogens, such as the carcinogen 4-nitroquinoline-N-oxide (4-NQO) and Herpes simplex virus type 1 (HSV-1), in combination with oral snuff on lower lip subepithelial mast cells (MC) was studied in rats. The rats were exposed to prolonged use of oral snuff. The test substances were administered in a surgically created canal in the lower lip of the rats. There were 15 rats in each test group and 10 rats in the control group. The amount of countable subepithelial mast cells decreased significantly when the rat oral mucosa was exposed to the oral carcinogen 4-NQO but the effect of oral snuff and HSV-1 infection was weak. Our findings suggest that mast cells play a role in immunological cell defence against chemical carcinogens. Further studies are needed to clarify the mechanisms.

Presence of human papilloma viruses in intraosseous ameloblastoma.

PURPOSE: This study investigated the possibility that human papilloma virus (HPV) is a possible etiologic agent in the development of ameloblastoma. MATERIALS AND METHODS: DNA was extracted from 18 formalin-fixed, paraffin-embedded biopsy specimens and assayed for the presence of HPV DNA by PCR using the L1 consensus primer and specific primers for HPV types 6/11, 16 and 18. RESULTS: Eight samples (67%) were positive for HPV. Of the 8 HPV-positive samples, 7 were positive for HPV 18. Four of the HPV 18-positive samples were also positive for HPV 6/11. One HPV-positive sample was not positive for any of the type-specific primers. CONCLUSIONS: No conclusions can be drawn about the etiologic role of HPV from this study, but surgical manipulation is suggested to be one of the reasons for HPV presence attributable to contamination from the surface mucosal epithelium in these tumors.

Sense of coherence: quality of life before and after coronary artery bypass surgery--a longitudinal study.

The attention to patient outcome has nowadays extended from morbidity and mortality to an aspect of patients' benefits in terms of quality of life. One factor crucial for quality of life is coping capacity, in this study represented by the sense of coherence concept. Physical status and emotional state (often measured by comprehensive instruments not always suitable for clinical use) are also additionally used to reflect quality of life. The purpose was therefore to study sense of coherence and emotional state as indirect measures of quality of life in relation to coronary artery bypass grafting surgery. One hundred and eleven patients were studied by a developed questionnaire on five occasions in relation to the surgery: the week before the angiography, the day before surgery and then at 3, 6, and 12 months post-operatively. The main findings were: (1) The sense of coherence was changed (more than +/-10%) from before to 1 year after surgery in 41% of the patients, which is contrary to the theory of sense of coherence as a stable personality characteristic in adults. (2) Experience of depressed mood, stress, and anxiety decreased significantly from before to after surgery. (3) Beneficial outcome with regard to sense of coherence was significantly related to less experience of loneliness, depressed mood, stress and anxiety, and to less experience of chest pain 1 year after surgery. In conclusion, sense of coherence and emotional state variables, are suggested to be valuable as measurements of quality of life in relation to coronary artery bypass grafting surgery.

Human papilloma viruses in oral lesions.

Oral mucosa biopsies from 53 patients with different oral diseases, and from 12 healthy control patients, were examined by the PCR-technique using the L1 consensus primers and type-specific primers for HPV 6/11, 16 and 18. Three out of 24 (12.5%) oral cancer biopsies were HPV positive, 1 for HPV 18, 1 for HPV 16 and 6/11 and 1 for none of the specific primers. Six out of 22 (27.3%) lichen planus were HPV positive, 5 for HPV 18 and 1 for none of the specific primers. Seven leukoplakias were included in the study and 2 (29.6%) were positive for both HPV 16 and 6/11. None of the 12 control patients was HPV positive. No statistical difference between the use of tobacco and alcohol and HPV prevalence was found. An association between HPV infection and oral lesions was demonstrated in the studied population but the pathogenic influence of HPV infection remains unclear.

Epstein-Barr virus and human papillomavirus in snuff-induced lesions of the oral mucosa.

Epstein-Barr virus (EBV) and human papillomavirus (HPV) have been associated with benign as well as malignant oral lesions. We examined 43 patients with snuff-induced lesions and 22 control patients with clinically healthy oral mucosa for the presence of HPV and EBV. Polymerase chain reaction was performed on fresh frozen oral biopsies with degenerate consensus primers for HPV and nested primers for EBV. None of the 43 snuff-induced lesions or the 22 control biopsies were HPV-positive. Seven of the 43 (16.3%) snuff-induced lesions and one of the 22 (4.5%) controls were positive for EBV. The snuff-induced lesions were classified according to clinical severity, grade 1 lesions being the least severe and grade 4 the most severe. Eleven percent of grade 2 lesions, 15.8% of grade 3 lesions and 20% of grade 4 lesions were EBV-positive. Neither EBV nor HPV seem to be associated with snuff-induced lesions.

A pharmacokinetic study of 5-FU/leucovorin and alpha-interferon in advanced cancer.

The present study was designed to study 5-FU pharmacokinetics after interferon. Weekly bolus 5-FU (500 mg/m2), immediately followed by leucovorin (60 mg/m2) was given in 14 weekly cycles to 55 gastrointestinal and breast cancer patients. Interferon-alpha was given on days 2, 4 and 6, starting from cycle 2 at a dose of 0.5 million units (MU) and stepwise increased to 12 MU in cycles 12 and 13. Five patients could not tolerate the treatment even at the lowest dose of interferon and 22 patients were unavailable for the pharmacokinetic analysis because of dose reductions of 5-FU. Five patients were able to follow the protocol to 12 MU, whereas most patients were unable to continue owing to toxicity. 5-FU pharmacokinetics was analysed every second cycle. Peak concentration and AUC were increased after 12 MU of interferon, but no other significant influence of interferon on pharmacokinetic parameters of 5-FU was observed.

Predictors of chest pain after coronary artery bypass grafting.

To identify preoperative biopsychosocial factors characterizing patients who will experience chest pain (self-reported) one year after coronary artery bypass grafting (CABG), 111 patients under 61 years of age were evaluated by questionnaire before CABG and 12 months postoperatively. A "Coronary Health Profile" was evolved to study quality-of-life indicators, e.g. "Sense of Coherence" (SOC), emotional state (loneliness, depressed mood, stress, anxiety) and social support as well as experience of chest pain, and the results were correlated to biomedical data. Chest pain was experienced in the first postoperative year by 34% of the patients. These patients, who were younger than those without chest pain, generally had a body mass index >25, as well as lower preoperative values for SOC, poorer emotional state and social support. Independent predictors in a multivariate stepwise logistic regression analysis were moderate/weak SOC, ejection fraction <50%, and moderate/severe mood depression. We conclude that biomedical as well as psychosocial factors have a significant impact as predictors of chest pain (of any origin) after CABG, and must be considered in preoperative evaluation. The findings indicate the need for biopsychosocial support/intervention before as well as after CABG.

Rapid method for relative gene expression determination in human tissues using automated capillary gel electrophoresis and multicolor detection.

The aim of this study was to evaluate a direct and automated post-polymerase chain reaction (PCR) detection system to simultaneously determine the relative gene expression levels of nine cancer-related human genes. Total RNA was prepared from flash-frozen biopsies derived from human colorectal tumors or normal mucosa and reverse-transcribed to cDNA which was PCR-amplified using primer pairs corresponding to the studied genes. In each reaction, the forward primer was labeled with a fluorescent dye. The PCR products were pooled and an internal size standard with a uniquely colored fluorescent dye was added. The samples were then subjected to automated capillary gel electrophoresis. Fragment analysis software was used to calculate the relative gene expression using beta-actin as the reference gene. We found that automated capillary gel electrophoresis with multicolor detection is a rapid, accurate and highly reproducible method for separation and quantification of PCR-amplified cDNA.

High-throughput DNA extraction from old paraffin-embedded biopsies.

We have developed a rapid and reliable microporous spin-column-based method for high-throughput extraction of DNA from old paraffin-embedded biopsies. The method was developed specifically for PCRs and molecular genetic studies. De-waxing and DNA extraction from tissues is performed in only one vessel, minimizing pipetting steps and eliminating supernatant/pellet procedures. All steps are performed at 60 degrees, 55 degrees and 95 degrees C minimize deleterious DNase activity. The amount of the extracted DNA was measured spectrophotometrically, and the quality of the extracted DNA and the PCR products was controlled on ethidium bromide-stained 3% agarose gel. The presented method for DNA extraction is less laborious and more convenient than previously published methods. It provides means by which extensive, paraffin-embedded material can be subjected to molecular genetic studies.

Chemical stability and human plasma pharmacokinetics of reduced folates.

The in vitro stability and plasma pharmacokinetics of 5,10-methylenetetrahydrofolic acid (CH2FH4), tetrahydrofolic acid (FH4), 5-methyltetrahydrofolic acid (CH3FH4), and 5-formyltetrahydrofolic acid (5-CHOFH4) were studied in view of their potential usefulness in cancer chemotherapy. Analysis of reduced folates was done on a high-performance liquid chromatography (HPLC) system. The high sensitivity of FH4 and CH2FH4 to oxidation can be circumvented by use of high concentrations of the folates, addition of ascorbate, and by thorough exclusion of atmospheric O2. Intravenous injection of 200 mg FH4 or CH2FH4 resulted in average peak concentrations of 69.2 +/- 3.2 nmol/ml and 46.3 +/- 2.6 nmol/ml, respectively. The plasma concentration curves support the concept that these highly oxygen-sensitive reduced folates can be reliably administered as pharmaceuticals to cancer patients through the use of a suitable air-occlusive system for their preparation and administration.

Rapid quantitative PCR determination of relative gene expression in tumor specimens using high-pressure liquid chromatography.

A reverse transcriptase polymerase chain reaction (rt-PCR) for quantification of gene expression has been optimized for analysis of folylpolyglutamate synthase (FPGS) and thymidylate synthase (TS), using beta-actin as an internal standard (house-keeping gene). Total RNA was isolated from tumor tissue, reversely transcribed to cDNA and PCR amplified with primers specific for TS, FPGS and beta-actin in separate vials. PCR products were separated and quantified by high-pressure liquid chromatography (HPLC) without addition of radioactive or fluorescent markers, which minimizes labor and occupational hazards. The day-to-day variation in the HPLC analysis was 2.7% and the within sample variations for rt-PCR/HPLC analysis of TS and FPGS were 18.5% for both assays. This method provides a tool for convenient gene expression analysis in clinical biopsies.

[Diverticulitis is increasing among the elderly. Significant cause of morbidity and mortality]. / Divertikulit ökande problem bland äldre. Orsakar betydande morbiditet och mortalitet.

The prevalence of diverticulosis in western countries has increased and two-thirds of the population over the age of 85 are now affected. Diverticulitis results from inflammation and subsequent perforation of a colonic diverticulum. Mild forms of diverticulitis usually present with gradually increasing symptoms from the lower left quadrant of the abdomen, whereas acute complicated disease is characterised by dramatic onset of abdominal pain, followed by fever within a few hours. The standard treatment for uncomplicated diverticulitis is bowel rest, with liquid diet or intravenous fluids in combination with antibiotics. Patients not responding to conservative treatment within the first 24 hours require further evaluation by computed tomography or ultrasonography. If an abscess is present, it can often be drained percutaneously. In cases of perforation and peritonitis, surgical intervention is mandatory, though no consensus exists as to the choice of procedure. Fistula formation and intestinal obstruction are also indications for surgical intervention, although the frequent recurrent attacks which commonly afflict these patients are seldom associated with severe complications. Prophylactic resection is not to be recommended for patients with diverticular disease, but a high-fibre diet may afford protection by preventing further complications.

5-fluorouracil (5-FU) and 5,10-methylene tetrahydrofolate (5,10-CH2FH4) as adjuvant therapy in an experimental rodent colon carcinoma model.

Eradication of micrometastases is the goal for adjuvant therapy following a radical surgical procedure for cancer. We report an experimental study with 5,10-methylenetetrahydrofolate (5,10-CH2FH4) modulation of 5-fluorouracil (5-FU) cytotoxicity in adjuvant treatment. A colon adenocarcinoma cell suspension was inoculated intrahepatically in a rodent experimental model. Intravenous 5-FU (30 mg/kg) in combination with 5,10-CH2FH4 (15 mg/kg or 30 mg/kg) was administered after 1, 2, 3, 4 and 7 days. 5-FU alone reduced the tumor take to fifty percent compared to one hundred percent tumor take in control animals (p < 0.05), while 5-FU in combination with 5,10-CH2FH4 (regardless of folate-dose) eliminated tumor take (p < 0.0001). This makes 5,10-CH2FH4 a promising agent for modulation of 5-FU cytotoxicity in adjuvant cancer treatment.

Detection of thymidylate synthase gene expression levels in formalin-fixed paraffin embedded tissue by semiquantitative, nonradioactive reverse transcriptase polymerase chain reaction.

We describe a new, simple and reliable semiautomated strategy for quantifying mRNA from archival specimens by using oligo(dT)25 paramagnetic beads and the reverse-transcriptase polymerase chain reaction (PCR) coupled with quantitative digital image analysis (Q-DIA). To evaluate the experimental conditions, we examined thymidylate synthase (TS) gene expression in mRNA isolated from both flash-frozen and formalin-fixed paraffin-embedded human biopsy samples using biopsy material obtained from 2 patients prior to chemotherapy with 5-fluorouracil. Following the electrophoretic separation of the PCR products through a 20% polyacrylamide gel, quantitation of the perimeters of the silver-nitrate-stained PCR products will be done by Q-DIA using a video frame-grabber board attached to a CCD camera using Image-Pro+ software. Validation of this approach will involve a comparison of the observed gene expression levels to TS protein levels obtained by tissue homogenization assays of TS, tetrahydrofolate, 5,10-methylenetetrahydrofolate, 2'-deoxyuridine-5'-monophosphate and 5-fluoro-2'-deoxyuridylate (FdUMP), by established [3H]FdUMP ligand-binding assays. The novelty of this method is that it offers a low-cost means whereby Q-DIA is performed directly from the gel to rapidly and accurately determine the level of TS gene expression, which is standardized against the beta-actin housekeeping gene. In the protocol described herein, gene expression studies can be done quickly and without the use of radioactive substances in both normal clinical samples shock frozen at the time of surgical excision and in formalin-fixed paraffin-embedded archival samples, which are commonly available in all hospital pathology departments. To demonstrate the utility of this method, mRNA was extracted from both nonpathological and tumor biopsies originating from both types of material from the same patients. TS gene expression in the flash-frozen and archival materials was compared to the level of TS intracellular enzyme activity in the same samples and a correlation of 89 and 80% between the shock-frozen and archival material relative to TS intracellular enzyme activity levels was observed. These findings suggest that routine semiautomated quantitative analysis of rare mRNA transcripts, e.g. TS, from archival material can be applied for retrospective studies.

Novel mutations in the APC gene and clinical features in Swedish patients with polyposis coli.

The adenomatous polyposis coli (APC) gene was investigated in Swedish patients with familial adenomatous polyposis (FAP). A combination of analyses including single stranded conformation polymorphism (SSCP), heteroduplex (HD), protein truncation test (PTT) and direct sequencing was used to enable optimal mutation detection. Three novel mutations in the gene were identified, i.e. nt2644C- > T (giving an Arg876Stop mutation), nt4025del173 (leading to premature truncation of the protein at codon 1337) and nt3526insG (giving truncation at codon 1178). In addition, one previously described mutation, i.e. the 5-bp-deletion nt3942del5(AAAGA) in codon 1309 (giving a premature termination of the protein at codon 1314) was detected. All four mutations were located in the 5'-half of exon 15. The two latter mutations were associated with the CHRPE (congenital hypertrophy of retina pigment epithelium) phenotype (CHRPE was not examined in the other two cases). The patients with mutations in codon 1309 and 1336 had a more severe FAP phenotype.

The role of reactive oxygen metabolites in the transcriptional regulation of IFN-gamma gene expression by histamine in NK cells following IL-2 stimulation.

The secretion of interferon-gamma (IFN-gamma) by natural killer (NK) cells following in vitro stimulation with interleukin-2 (IL-2) is inhibited by co-incubation with autologous monocytes at a transcriptional level by more than sixty-fold. In this study, we investigate the nature of the inhibitory signal and particularly the role of reactive oxygen metabolites (ROMs). It was found that the inhibition of IFN-gamma was operating at a pre-translational level, this was indicated by the inability of CD 56(+)-enriched natural killer cells to accumulate IFN-gamma mRNA in the presence of elutriated monocytes. Both catalase, a scavenger of hydrogen peroxide and histamine, a biogenic amine which inhibits the generation of ROMs by monocytes, strongly abrogated the inhibition of IFN-gamma production. We thereby conclude that histamine behaves synergistically with IL-2 at a transcriptional level to induce IFN-gamma even in an admixture of NK cells and monocytes.

Rapid detection of thymidylate synthase gene expression levels by semi-quantitative competitive reverse transcriptase polymerase chain reaction followed by quantitative digital image analysis.

We describe a simplified and reliable polymerase chain reaction (PCR) method to quantify thymidylate synthase (TS) gene expression levels from clinical human tumor biopsy samples as small as 100 mg using the beta-actin housekeeping gene as a reference standard. The semiquantitative RT-PCR is carried out by the coamplification of the target template and an external competitor using primer pairs common to both templates in the same reaction vessel. Quantitative digital image analysis is performed directly after electrophoresis, thus mRNA quantification is done quickly and without the use of radioactive substances. The observed relative TS gene expression levels varied between 3- and 40-fold, but most of the values were grouped within a 10-fold range. There is an observed 89% correlation between TS mRNA expression and protein levels. These findings suggest that preliminary experiments used to determine the linear range of RT-PCR amplification in non-competitive semiquantitative PCR experiments, and the use of radioactive substances to quantify PCR products may be unnecessary.