An audit of operative notes: facts and ways to improve.

BACKGROUND: Accurate operation record keeping is an important element of risk management. Handwritten surgical notes are often produced as evidence in medico-legal malpractice cases and incomplete and illegible notes may be a source of weakness in a surgeon's defence. Therefore, we audited the surgical notes in a teaching hospital surgical department. METHODS: During 1 week 190 operative notes were audited for patient identity details, preoperative diagnosis, operation title and details, CMB code, postoperative instruction and author of the note. The operative notes were assessed by a medico-legal lawyer and a medical expert to establish level of legibility and usefulness in a virtual court case. RESULTS: Several operative notes were found incomplete (51.57%) missing important information as CMB code (13.68%), patient details (6.8%) preoperative diagnosis (6.31%), operation title (6.31%) and postoperative instruction (14.73%). Overall, only 92 notes were complete. CONCLUSION: This audit suggests that handwritten surgical notes generate several errors that could lead to confusion when notes are reviewed for further follow up or are produced as evidence in medico-legal disputes.

The PMAIP1 gene on chromosome 18 is a candidate tumor suppressor gene in human pancreatic cancer.

Frequent loss of heterozygosity on the long arm of chromosome 18 is observed in pancreatic cancer. Previous studies suggested the existence of one or more tumor-suppressor genes other than SMAD4 on chromosome 18. To identify the candidate tumor-suppressor gene(s), we compared gene expression by cDNA microarray analyses using a pancreatic cancer cell line Panc-1 and its hybrid cell lines showing suppressed cell growth after introduction of one normal copy of chromosome 18. The microarray analyses identified 38 genes on chromosome 18 that showed differential expressional levels. Among these genes, phorbol-12-myristate-13-acetate-induced protein 1 (PMAIP1/APR/NOXA) was identified as one of the candidates for tumor suppressor. Expression vector-mediated introduction of PMAIP1 suppressed cell proliferation, and RNAi-mediated knockdown of PMAIP1 induced recovery of cell growth. These results suggest that PMAIP1 may play an important role in the progression of pancreatic cancer.

Diagnostic features of benign pancreatic insulinomas. An analysis of three cases.

Insulinoma is a neuroendocrine tumour deriving mainly from the pancreatic islet cells that produces excessive amounts of insulin. Accurate preoperative detection and localization of insulinoma is essential for the selection of appropriate candidates for surgery. We present the case reports of three patients with benign pancreatic insulinoma. Preoperative assessment was performed by using transabdominal ultrasonography, computed tomography and magnetic resonance imaging. Their performances for the effectiveness in detecting and localizing benign insulinoma were compared. We concluded that an appropriate preoperative imaging assessment was in our case impossible, intraoperative inspection and palpation of the pancreas still being superior.

Chromosome 12, frequently deleted in human pancreatic cancer, may encode a tumor-suppressor gene that suppresses angiogenesis.

Several lines of evidence have suggested that the long arm of chromosome 12 may carry a tumor-suppressor gene(s) that plays a role in pancreatic ductal carcinogenesis. We have previously found a significant association between loss of heterozygosity of the 12q arm and a poor prognosis in pancreatic cancer patients. In this study, we introduced a normal copy of chromosome 12 into some pancreatic ductal carcinoma cells. Both anchorage-dependent and -independent proliferations as well as invasiveness were similar throughout the hybrid clones when compared with their corresponding parental cells. In sharp contrast, significant suppression of tumorigenesis was observed after inoculation of the hybrid clones into nude mice. Measurements made up to 1 month later showed that there was a significant delay in the growth of tumors into which the introduced normal copy of chromosome 12 had been restored. More significantly, using our dorsal skin chamber and an intravital microscopy system experiment in SCID mice, we demonstrated and visualized directly that implantation of the hybrids failed to promote the angiogenic phenotype encountered in the parental cells. Gene expression profiling using the complementary DNA microarray system identified a set of 24 genes differentially expressed between the hybrids and parental cells. An additional set of 18 genes was also identified that were differentially expressed between the hybrid clone that lost its growth-suppression activity and one that retained such activity. Another set of 25 genes mapped on 12q was detected that showed high expression levels in the hybrid clones retaining growth-suppressive activity. In summary, this study provides the first functional evidence of the existence of an additional tumor-suppressor gene(s) on chromosome 12, whose absence is responsible for the pathogenesis in pancreatic ductal carcinogenesis.

Functional analysis of chromosome 18 in pancreatic cancer: strong evidence for new tumour suppressor genes.

BACKGROUND: In a previous work, we demonstrated that loss of heterozygosity of 18q is a frequent event significantly associated with poor prognosis in pancreatic cancer. We hypothesized that restoration of heterozygosity of chromosome 18 in pancreatic cancer cells would reduce their tumorigenicity. This study was intended to provide functional evidence for the existence of new tumour suppressor gene(s) located on chromosome 18. METHOD: Restoration of heterozygosity was achieved by introducing a normal copy of chromosome 18 into pancreatic ductal carcinoma using a microcell-mediated chromosome transfer technique. The tumorigenicity and metastatic ability of both the parental cells and resulting hybrids were assessed in vitro and in vivo. RESULTS: In vitro growth of hybrid clones was significantly delayed compared to parental cells. This was paralleled by a significantly lower rate of promoting invasive carcinoma in nude mice and a longer latency with hybrid cells compared with parental tumour cells. Hybrid clones showed significant suppression in the number of surface lung metastases when compared with parental cells. CONCLUSION: These data represent strong functional evidence that chromosome 18q encodes strong tumour and metastasis suppressor activity that is able to switch human pancreatic cancer cells to a dormant phenotype.

The role of chromosome 18 abnormalities in the progression of pancreatic adenocarcinoma.

To date, the events that mediate tumor progression in pancreatic cancer are still poorly understood. Cytogenetic, allelotype, and somatic cell hybrid studies in human pancreatic adenocarcinoma have suggested that chromosome 18 may carry tumor suppressor genes (TSGs), including SMAD4. We previously identified that LOH of 18q at the SMAD4 locus, along with LOHs on 17p and 12q, positively associated with poor prognoses of pancreatic cancer patients. However, restoration of the SMAD4 gene did not suppress in vitro proliferation of pancreatic cancer cells that harbored homozygous deletion of this gene. An intraductal papillary mucinous neoplasm (IPMN ) is thought to be one of the premalignant lesions of the pancreas that progresses to carcinoma. Although there were frequent LOH (7/14, 50%) at the SMAD4 locus in IPMN samples, SMAD4 protein was observed immunohistochemically in tumor cells, and no mutations of the SMAD4 gene were observed, suggesting that it is the existence of a TSG in 18q, other than SMAD4, that suppresses cell growth. To functionally assess the activity of chromosome 18 in pancreatic cancer, we transferred a normal copy of the chromosome into pancreatic ductal carcinoma cells with and without completely inactivated SMAD4. In this study, in vitro growth of the hybrid cells was significantly suppressed compared with the parental cells, regardless of the initial SMAD4 status. To estimate the metastatic ability of the hybrids, we used a lung colonization model. At the end of the experiment, there was significant suppression of the number of surface metastases developing in mice injected with hybrids in comparison with those injected with parental cells. To identify and characterize genes that are involved in the progression of pancreatic cancer, we used micro-array expression analysis employing a 20k oligo-array system. It was revealed that there was increased expression of 4 genes relating to apoptosis in the 18 chromosome hybrids cells compared with the parental cells. We are now analyzing the function of these genes.

Restoration of SMAD4 by gene therapy reverses the invasive phenotype in pancreatic adenocarcinoma cells.

SMAD4 is a critical cofactor in signal transduction pathways activated in response to transforming growth factor-beta (TGF-beta)-related ligands, regulating cell growth and differentiation. The roles played by SMAD4 inactivation in tumours highlighted it as a tumour-suppressor gene. However, restoration of the TGF-beta antiproliferative pathway following SMAD4 gene transfer in null-tumour cell lines is controversial. Herein, we report the inhibitory effects of SMAD4 on pancreatic tumour invasion and angiogenesis. Adenoviral transfer of this gene in a panel of SMAD4 homozygous-deleted human pancreatic tumour cell lines restored SMAD4 protein expression and function. Although it did not affect proliferation significantly in vitro, SMAD4 inhibited in vivo tumour growth in immunodeficient mice. In this xenograft setting, differential suppression of tumour growth in vivo was mediated, at least in part, through downregulation of vascular endothelial growth factor and expression of gelatinases. We documented the reduced invasion and angiogenesis histologically and by intravital microscopy, and gained mechanistic insight at the messenger and protein level. Finally, we found a negative reciprocal regulation between SMAD4 and ETS-1. ETS-1 is considered a marker for tumour invasion. Upon SMAD4 deletion, we detected high expression levels of ETS-1 in pancreatic tumour cells, suggesting the shift of the pancreatic tumour toward an invasive phenotype.

Inserting chromosome 18 into pancreatic cancer cells switches them to a dormant metastatic phenotype.

We demonstrated previously that restoration of chromosome 18 suppressed growth of pancreatic cancer cells in vitro, as well as that of tumors inoculated into nude mice. We also demonstrated that loss of 18q was associated with poor prognosis. Hence there is the possibility that the 18q arm harbors a gene(s) implicated in tumor progression and/or metastasis. In this study, we evaluated the effect of restoring chromosome 18 on metastasis in a few human pancreatic cancer cell lines with and without inactivation of SMAD4. After microcell-mediated chromosome 18 transfer, hybrid cells showed more than a 10-fold weaker metastatic ability than corresponding parental cells; mice injected with 1.25 x 10(6)/250 micro l hybrid clones via tail vein had less than one-tenth of the number of macroscopic metastases in the lung when compared with the control cells. Microscopic examination confirmed the decrease in the number of metastatic lesions. After inoculation of hybrid cells, more than 80% of the high-power fields showed no micrometastases, contrasting with their abundance after using the parental cells. Hybrid cells restored maspin expression irrespective of SMAD4 status in corresponding parental cells. On the other hand, significantly lower vascular endothelial growth factor and matrix metalloproteinase 2 secretion was observed by measuring levels in the conditioned media (CM); the averages were 22% and 20%, respectively. Angiogenesis assays using in vivo Matrigel plugs demonstrated that less neovascularization was observed in nude mice with hybrid cells than with corresponding parental cells. When cells were treated with CM from hybrids, the migration of human umbilical vascular endothelial cells was decreased, but it was partially restored with anti-vascular endothelial growth factor neutralizing antibody, as compared with CM from parental cells. These data represent the first functional evidence suggesting that chromosome 18q encodes a gene that strongly suppresses metastatic activity, possibly through dormancy.

Suppression of the tumorigenic phenotype by chromosome 18 transfer into pancreatic cancer cell lines.

A number of lines of evidence have suggested that the long arm of chromosome 18 apart from SMAD4 may carry a tumor-suppressor gene(s) that plays a role in the early stage of pancreatic ductal carcinogenesis. Thus, adenovirus-mediated introduction of SMAD4 does not suppress in vitro growth in cells with completely inactivated SMAD4, and frequent loss of 18q at the SMAD4 locus is observed in pancreatic cancers but no abnormalities of the normal SMAD4 homolog have been detected. In this study, we introduced a normal copy of chromosome 18 into some pancreatic ductal carcinoma cells with and without a complete inactivation of SMAD4. Both anchorage-dependent and -independent proliferation as well as invasiveness were significantly suppressed in the hybrid clones compared with that of their parental cells. Moreover, significant suppression of tumorigenesis was observed after inoculation in nude mice, irrespective of the SMAD4 status. Our present study provides the first functional evidence of the existence of an additional tumor-suppressor gene(s), other than SMAD4 and DCC, that is responsible for the pathogenesis in the early stage of pancreatic ductal carcinogenesis.