Improving patient survival with the colorectal cancer multi-disciplinary team.

OBJECTIVE: There is little information on the impact of the colorectal multi-disciplinary team (MDT) in the United Kingdom. Our single operator presented his patients before and after the inception of an MDT meeting in June 2002. The aim of this study was to assess the effect of this on his patients' survival, and trends in the use of adjuvant chemotherapy. METHOD: Data were collected on all patients (n = 310) undergoing colectomy for colorectal cancer by one surgeon. Excluding patients with Dukes A stage, the pre-MDT cohort from January 1997 to May 2002 was 176 and the post-MDT cohort from June 2002 to December 2005 was 134. Three-year survival rates were calculated using Kaplan-Meier life table analysis. Prognostic factors were analysed using Cox-proportional hazard regression, and chemotherapy data analysed using the chi-squared test. Independent prognostic indicators of chemotherapy prescription were examined using binary logistic testing. RESULTS: MDT status was shown to be an independent predictor of survival on hazard regression analysis (P = 0.044). A significantly greater number of patients were prescribed adjuvant chemotherapy in the post-MDT cohort (P = 0.0002). MDT status was shown to be a significant prognostic indicator of chemotherapy prescription (P < 0.0001). Three-year survival for Dukes C patients was 58% in the pre-MDT group, and 66% in the post-MDT group (P = 0.023). CONCLUSION: There was a significant increase in patients undergoing adjuvant postoperative chemotherapy after the inception of the MDT. This was associated with a significant survival benefit in patients with Dukes C disease. The data suggest that the MDT process has resulted in an increase in the prescription of adjuvant chemotherapy, with 3-year survival being greater after its inception.

Patient maintained sedation for colonoscopy using a target controlled infusion of propofol.

In this study, we evaluated safety and recovery using a patient maintained, target controlled infusion of propofol for sedation in 20 patients undergoing colonoscopy. Using a handset with a two-minute lockout interval, patients could make 0.2 micro g.ml(-1) increments to an initial target plasma concentration of 1 micro g.ml(-1) up to a maximum 4.5 micro g.ml(-1). Four patients became oversedated but required no airway or circulatory interventions. Subjects had a significant reduction in mean (SD) heart rate: 78.7 (15) vs. 69.8 (13.5) (p < 0.001) and in systolic blood pressure 121.1 (13.2) mmHg vs. 96.5 (8.6) mmHg (p < 0.001). Choice reaction time testing 15 min after colonoscopy showed a significant median (IQR [range]) rise of 162 (- 16, 383.3 [-199-859]) ms (p < 0.05). Six patients had faster reaction times postcolonoscopy. All patients denied unpleasant recall and were satisfied with the system. Although oversedation was a problem in this model, we conclude that patient maintained propofol sedation could be possible for colonoscopy.

Using mitochondria-targeted molecules to study mitochondrial radical production and its consequences.

The production of ROS (reactive oxygen species) by the mitochondrial respiratory chain contributes to a range of pathologies, including neurodegenerative diseases, ischaemia/reperfusion injury and aging. There are also indications that mitochondrial ROS production plays a role in damage response and signal transduction pathways. To unravel the role of mitochondrial ROS production in these processes, we have developed a range of mitochondria-targeted probe molecules. Covalent attachment of a lipophilic cation leads to their accumulation into mitochondria, driven by the membrane potential. Molecules developed so far include antioxidants designed to intercept mitochondrial ROS and reagents that specifically label mitochondrial thiol proteins. Here we outline how mitochondrial ROS formation and its consequences can be investigated using these probes.

Selective targeting of a redox-active ubiquinone to mitochondria within cells: antioxidant and antiapoptotic properties.

With the recognition of the central role of mitochondria in apoptosis, there is a need to develop specific tools to manipulate mitochondrial function within cells. Here we report on the development of a novel antioxidant that selectively blocks mitochondrial oxidative damage, enabling the roles of mitochondrial oxidative stress in different types of cell death to be inferred. This antioxidant, named mitoQ, is a ubiquinone derivative targeted to mitochondria by covalent attachment to a lipophilic triphenylphosphonium cation through an aliphatic carbon chain. Due to the large mitochondrial membrane potential, the cation was accumulated within mitochondria inside cells, where the ubiquinone moiety inserted into the lipid bilayer and was reduced by the respiratory chain. The ubiquinol derivative thus formed was an effective antioxidant that prevented lipid peroxidation and protected mitochondria from oxidative damage. After detoxifying a reactive oxygen species, the ubiquinol moiety was regenerated by the respiratory chain enabling its antioxidant activity to be recycled. In cell culture studies, the mitochondrially localized antioxidant protected mammalian cells from hydrogen peroxide-induced apoptosis but not from apoptosis induced by staurosporine or tumor necrosis factor-alpha. This was compared with untargeted ubiquinone analogs, which were ineffective in preventing apoptosis. These results suggest that mitochondrial oxidative stress may be a critical step in apoptosis induced by hydrogen peroxide but not for apoptosis induced by staurosporine or tumor necrosis factor-alpha. We have shown that selectively manipulating mitochondrial antioxidant status with targeted and recyclable antioxidants is a feasible approach to investigate the role of mitochondrial oxidative damage in apoptotic cell death. This approach will have further applications in investigating mitochondrial dysfunction in a range of experimental models.

Selective targeting of an antioxidant to mitochondria.

Mitochondrial oxidative damage contributes significantly to a range of human disorders, including neurodegenerative diseases, ischaemia-reperfusion injury and ageing-associated dysfunction. To prevent this damage we have delivered a molecule containing the active antioxidant moiety of vitamin E to mitochondria. This was carried out by covalently coupling the antioxidant moiety to a lipophilic triphenylphosphonium cation. This mitochondrially targeted antioxidant, 2-[2-(triphenylphosphonio)ethyl]-3,4-dihydro-2, 5,7,8-tetramethyl-2H-1-benzopyran-6-ol bromide (TPPB), accumulated several-hundred fold within the mitochondrial matrix, driven by the organelle's large membrane potential. When cells were incubated with micromolar concentrations of TPPB, they accumulated millimolar concentrations within their mitochondria. The amount of TPPB taken up by mitochondria was approximately 80-fold greater than endogenous levels of vitamin E. Consequently the targeted derivative of vitamin E protected mitochondrial function from oxidative damage far more effectively than vitamin E itself. The mitochondrially targeted antioxidant TPPB has potential as an antioxidant therapy for disorders involving mitochondrial oxidative damage. It also suggests a new family of mitochondrially targeted antioxidants, redox-active and pharmacologically active molecules designed to prevent damage or manipulate mitochondrial function.

Bioenergetic consequences of accumulating the common 4977-bp mitochondrial DNA deletion.

Mutations and deletions in mitochondrial DNA (mtDNA) lead to a number of human diseases characterized by neuromuscular degeneration. Accumulation of truncated mtDNA molecules (delta-mtDNA) lacking a specific 4977-bp fragment, the common deletion, leads to three related mtDNA diseases: Pearson's syndrome; Kearns-Sayre syndrome; and chronic progressive external ophthalmoplegia (CPEO). In addition, the proportion of delta-mtDNA present increases with age in a range of tissues. Consequently, there is considerable interest in the effects of the accumulation of delta-mtDNA on cell function. The 4977-bp deletion affects genes encoding 7 polypeptide components of the mitochondrial respiratory chain, and 5 of the 22 tRNAs necessary for mitochondrial protein synthesis. To determine how the accumulation of delta-mtDNA affects oxidative phosphorylation we constructed a series of cybrids by fusing a human osteosarcoma cell line depleted of mtDNA (rho0) with enucleated skin fibroblasts from a CPEO patient. The ensuing cybrids contained 0-86% delta-mtDNA and all had volumes, protein contents, plasma-membrane potentials and mitochondrial contents similar to those of the parental cell line. The bioenergetic consequences of accumulating delta-mtDNA were assessed by measuring the mitochondrial membrane potential, rate of ATP synthesis and ATP/ADP ratio. In cybrids containing less than 50-55% delta-mtDNA, these bioenergetic functions were equivalent to those of cybrids with intact mtDNA. However, once the proportion of delta-mtDNA exceeded this threshold, the mitochondrial membrane potential, rate of ATP synthesis, and cellular ATP/ADP ratio decreased. These bioenergetic deficits will contribute to the cellular pathology associated with the accumulation of delta-mtDNA in the target tissues of patients with mtDNA diseases.

Tenckhoff catheter salvage by closed stiff-wire manipulation without fluoroscopic control.

OBJECTIVE: To describe the results of Tenckhoff catheter salvage by a modified, closed, stiff-wire manipulation technique without the use of general anesthesia or fluoroscopy, and compare this with previously described techniques. DESIGN: Retrospective study in patients treated with continuous ambulatory peritoneal dialysis (CAPD) over a 41-month period. SETTING: Renal unit in an inner city hospital. PATIENTS: Eighteen patients using CAPD who had 22 episodes of outflow failure due to radiologically confirmed malposition of straight two-cuff Tenckhoff catheters. INTERVENTIONS: Closed stiff-wire manipulation of malpositioned Tenckhoff catheter without the use of general anesthesia or fluoroscopy. MAIN OUTCOME MEASURES: Initial success rate of manipulation, catheter and technique (CAPD) survival, and procedure-related complications. RESULTS: Catheter manipulation was technically successful in 21 of 22 cases. An additional six episodes of malposition occurred ranging from 2 to 630 days after the primary manipulation (median 7 days). A second manipulation was carried out in four cases that resulted in long-term success in two. Three patients were forced to discontinue CAPD for reasons other than catheter malposition, and the overall success rate at 1 month (patient successfully performing CAPD) was 59.1% (+/-0.1%). No major complications were experienced during the procedure and no episodes of peritonitis occurred. CONCLUSION: The technique described is relatively straightforward, does not require fluoroscopy or general anesthetic, and its success is comparable to previously reported methods of Tenckhoff catheter salvage. We would recommend this technique of catheter salvage in patients with Tenckhoff catheter malposition in whom conservative treatment has failed.

Alterations to glutathione and nicotinamide nucleotides during the mitochondrial permeability transition induced by peroxynitrite.

Peroxynitrite is a biologically important oxidant that damages mitochondria in a number of ways. We investigated the interaction of peroxynitrite with the mitochondrial glutathione pool by measuring the formation of oxidised glutathione and glutathione-protein mixed disulfides in mitochondria exposed to either peroxynitrite or tert-butylhydroperoxide. In contrast to tert-butylhydroperoxide, peroxynitrite converts 40-50% of mitochondrial glutathione to products other than disulfides, primarily higher oxidation states of sulfur. These data show that peroxynitrite interacts with mitochondria quite differently from oxidants commonly used in studying mitochondrial oxidative stress. Peroxynitrite also induces a permeability transition in the mitochondrial inner membrane, and here we show that this permeability transition is prevented by the NAD(P)H-linked substrates glutamate and malate and by the thiol reagent dithiothreitol. Glutamate and malate prevented complete oxidation of the NAD(P)H pool by peroxynitrite or tert-butylhydroperoxide but did not prevent oxidation of the mitochondrial glutathione pool or the formation of glutathione-protein mixed disulfides. This study is consistent with regulation of the permeability transition by critical protein thiol groups, whose redox state responds to that of the mitochondrial NAD(P)H pool, but which do not equilibrate directly with the mitochondrial glutathione pool.

Laparoscopic-assisted reversal of Hartmann's procedure: a simplified technique and audit of twelve cases.

Laparoscopic-assisted reversal of Hartmann's procedure was performed in 12 patients over a 2-year period. The group comprised three patients with colonic carcinoma and nine with diverticular disease, their mean age being 62 years (range 40-73). In all twelve cases, intestinal continuity was successfully restored, without conversion to open surgery, in a median anesthetic time of 165 min (range 110-240). One patient required a temporary defunctioning colostomy and two other patients had three complications. The median postoperative hospital stay was 8 days (range 5-12). We report a retrospective audit of this consecutive series of 12 patients, showing that laparoscopic-assisted reversal of Hartmann's is technically feasible. We also give details of the morbidity associated with the technique.

Superoxide production by mitochondria in the presence of nitric oxide forms peroxynitrite.

The mitochondrial respiratory chain continually produces superoxide leading to high levels of mitochondrial oxidative stress. This oxidative damage has been attributed to the formation of hydroxyl radicals and hydrogen peroxide from superoxide. Alternatively, mitochondrial superoxide may react with nitric oxide forming the potent oxidant peroxynitrite, thus damaging mitochondrial protein, lipid and DNA. To test this hypothesis we induced mitochondrial superoxide formation in the presence of nitric oxide. Here we demonstrate that mitochondrial superoxide reacts with nitric oxide to form peroxynitrite, suggesting that mitochondria may be a significant intracellular source of peroxynitrite.

Laparoscopic conversion of polya gastrectomy to Roux-en-Y.

We describe a patient who underwent laparoscopic conversion of a Polya gastrectomy to a Roux-en-Y. We used the "Endo Stitch" (Autosuture Co., Ascot, UK) to simplify the creation of a laparoscopic anastomosis. The patient required minimal analgesia and made a rapid and uncomplicated recovery.

Cyclosporin A blocks 6-hydroxydopamine-induced efflux of Ca2+ from mitochondria without inactivating the mitochondrial inner-membrane pore.

Oxidative stress causes Ca(2+)-loaded mitochondria to release Ca2+. The mechanism of this efflux is unclear, but it appears to be associated with the opening of a pore in the mitochondrial inner membrane. Pore opening depolarizes the mitochondria, letting solutes enter the mitochondrial matrix, causing swelling. Cyclosporin A (CsA) prevents opening of this pore. The neurotoxin 6-hydroxydopamine (6HD) autoxidizes, producing free radicals, which cause oxidative stress. In this paper it is shown that 6HD-induced efflux from Ca(2+)-loaded mitochondria was prevented by CsA. The 6HD-induced Ca2+ efflux was not accompanied by mitochondrial swelling, depolarization of the mitochondrial inner membrane or movement of radiolabelled sucrose into the mitochondrial matrix. In agreement with others [Schlegel, Schweizer and Richter (1992) Biochem. J. 285, 65-69], these findings suggest that the mitochondrial pore remained closed during pro-oxidant-induced Ca2+ efflux. However, the implication that CsA blocks pro-oxidant-induced Ca2+ efflux by some mechanism other than inactivating the mitochondrial pore, suggests that the interaction of CsA with mitochondria may be more complex than is currently supposed.

Bioassay of transforming growth factor-beta activity in acidic protein extracts from primary breast cancer specimens.

Acidic protein extracts have been made from breast tumour specimens, collected at the time of primary surgery. The extracts were partially purified by gel filtration and then tested for transforming growth factor-beta activity in a reproducible cell 3H-thymidine incorporation assay. Purified TGF-beta causes a reproducible increase in NRK colony formation and inhibits incorporation of 3H-thymidine by mink lung cells. However, some of the breast cancer extracts were stimulatory in the mink lung lung assay implying that a mitogenic factor like epidermal growth factor (EGF) was co-purified. Fourteen out of thirty extracts were scored positive for TGF-beta in the NRK colony forming assay and these tumours presented at an earlier clinical stage and were predominantly well differentiated.

Allograft rejection in CD4+ T cell-reconstituted athymic nude rats--the nonessential role of host-derived CD8+ cells.

PVG-rnu/rnu nude rats reject fully allogenic renal (DA) and skin (BN, AO) allografts after the adoptive transfer of naive CD4+ T cells alone, but rejection is accompanied by the accumulation of many nude-derived CD8+ leukocytes within the graft. In addition, mononuclear cells infiltrating the rejecting renal grafts in these animals display cytotoxic activity in vitro against specific and third-party alloantigens. In this investigation we have treated CD4+ T cell-restored nude rats bearing renal or skin allografts with the mAb MRC OX8 to deplete the host of CD8+ cells. In vivo treatment with OX8 completely eliminated CD8+ cells from rejecting grafts of both kidney and skin, but it did not prevent graft rejection, nor did OX8 treatment abolish the cytotoxic effector cells found in nude rat spleen or in graft-infiltrating cells (GIC) of rejecting renal allografts. The nature of the cytotoxic activity was examined with anti-CD3 mAb 1F4, which was shown to block conventional CD8+ Tc killing in vitro but did not inhibit allogeneic target cell lysis by spleen cells from nude rats. The cytotoxic activity found in GIC of rejecting allografts was not inhibited by anti-CD3 mAb, suggesting that these cytotoxic effector cells were CD3-CD8- and were of extrathymic origin. We conclude that non-thymus-derived CD8+ GIC are not essential for allograft rejection in CD4+ T cell-restored nude rats.

Comparison of colour Doppler ultrasound with venography in the diagnosis of axillary and subclavian vein thrombosis.

The primary imaging technique in suspected venous occlusive disease has for many years been contrast venography. Recent studies have shown ultrasound with the addition of colour Doppler imaging to be a suitable alternative method in the diagnosis of lower limb venous thrombosis. We have applied these techniques to the upper limb venous system, and have performed a prospective study of 19 patients (30 limbs) comparing colour Doppler ultrasound with venography in the diagnosis of axillary and subclavian vein thrombosis, for which colour Doppler ultrasound has a sensitivity and specificity of 100%. If vein stenosis is included, the sensitivity falls to 89%. We propose that colour Doppler ultrasound is a suitable first-line alternative to venography in the diagnosis of axillary and subclavian vein thrombosis. In addition to showing the major venous drainage of the upper limb, ultrasound routinely assesses patency of the internal jugular vein, which is, on occasion, of clinical relevance when determining possible future sites of venous access. If, however, colour Doppler ultrasound is normal then bilateral upper limb venography is indicated to exclude a more central venous problem or localized stenotic lesion.

T cell requirements for the rejection of renal allografts bearing an isolated class I MHC disparity.

This study has examined the cellular and humoral responses underlying the rejection of rat renal allografts bearing an isolated RT1Aa class I MHC disparity. RT1Aa disparate kidneys were rejected promptly by high responder RT1u but not by low responder RT1c recipients (median survival time 10 d and greater than 100 d, respectively). The magnitude and phenotype of the cellular infiltrate were similar in rejecting and nonrejecting RT1Aa disparate kidneys. Paradoxically, graft infiltrating cells and spleen cells from RT1u recipients showed minimal ability to lyse donor strain lymphoblasts in vitro, whereas effector cells from RT1c recipients showed modest levels of cytotoxicity. Injection of RT1u rats with MRC OX8 mAb was highly effective at selectively depleting CD8+ cells from graft recipients but had no effect in prolonging the survival of RT1Aa disparate grafts despite the complete absence of CD8+ cells from the graft infiltrate, which included numerous CD4+ T cells and macrophages. RT1u, but not RT1c, recipients mounted a strong alloantibody response against RT1Aa disparate kidneys. Immune serum obtained from RT1u recipients that had rejected a RT1Aa disparate graft was able, when injected into cyclosporin-treated RT1u recipients, to restore their ability to reject a RT1Aa, but not a third-party RT1c, kidney. These results suggest that CD8+ cells in general and CD8+ cytotoxic effector cells in particular are unnecessary for the rapid rejection of RT1Aa class I disparate kidney grafts by high responder RT1u recipients. By implication, CD4+ T cells alone are sufficient to cause prompt rejection of such grafts and they may do so by providing T cell help for the generation of alloantibody.

A comparison of two types of catheters for continuous ambulatory peritoneal dialysis (CAPD).

This study was undertaken to critically examine the value of the curled Tenckhoff catheter for continuous ambulatory peritoneal dialysis (CAPD) access with respect to the incidence of catheter-related complications. In the setting of a prospective, randomised, double-blind comparison, we were unable to demonstrate any advantage of the curled Tenckhoff catheter over the conventional straight type.