Pelvic insufficiency fractures frequently occur following preoperative chemo-radiotherapy for rectal cancer - a nationwide MRI study.

AIM: The aim of this prospective case-control study was to evaluate the rate of pelvic insufficiency fractures (PIFs) in Denmark using MRI at the 3-year follow-up. All patients had rectal cancer and had undergone surgery with or without preoperative chemo-radiotherapy (CRT). METHOD: Patients registered with primary rectal cancer in the Danish Colorectal Cancer Group database, who underwent rectal cancer resection from April 2011 through August 2012, were invited to participate in a national MRI study aiming to detect local recurrence and evaluate quality of the surgical treatment. Pelvic MRI including bone-specific sequences 3 years after treatment was obtained. The primary outcome was the rate of PIFs; secondary outcome was risk factors of PIFs evaluated in multivariate analysis. RESULTS: During the study period, 890 patients underwent rectal cancer surgery. Of these, 403 patients were included in the MRI study and had a 3-year follow-up MRI. PIFs were detected in 49 (12.2%; 95% CI 9.0-15.4) patients by MRI. PIFs were detected in 39 patients (33.6%; 95% CI 24.9-42.3) treated with preoperative CRT compared to 10 (3.5%; 95% CI 1.3-5.6) non-irradiated patients (P < 0.001). In a multivariate analysis female gender (OR = 3.52; 95% CI 1.7-7.5), age above 65 years (OR = 3.20; 95% CI 1.5-6.9) and preoperative CRT (OR = 14.20; 95% CI 6.1-33.1) were significant risk factors for PIFs. CONCLUSION: Preoperative CRT in the treatment of rectal cancer was associated with a 14-fold higher risk of PIFs after 3 years, whereas female gender and age above 65 years each tripled the risk of PIFs.

Persistent infections with infectious pancreatic necrosis virus (IPNV) of different virulence in Atlantic salmon, Salmo salar L.

Infectious pancreatic necrosis virus (IPNV) is a prevalent pathogen in fish worldwide. The virus causes substantial mortality in Atlantic salmon juveniles and smolts when transferred to sea water and persistent infection in surviving fish after disease outbreaks. Here, we have investigated the occurrence of the virus as well as the innate immune marker Mx in the head kidney (HK) of Atlantic salmon throughout an experimental challenge covering both a fresh and a seawater phase. The fish were challenged with a high (HV) and low virulence (LV) IPNV. Both isolates caused mortality due to reactivation of the virus after transfer to sea water. In the freshwater phase, higher levels of virus transcripts were detected in the HK of fish infected with LV IPNV compared to HV, suggesting that the HV isolate is able to limit its own replication to a level where the innate immune system is not alerted. Further, ex vivoHK leucocytes derived from fish infected with the two isolates were stimulated with CpG DNA. Significantly, higher IFN levels were found in the LV compared to the HV group in the freshwater phase. This suggests that the viruses attenuate the antiviral host immune response at different levels which may contribute to the observed differences in disease outcome.

Stoma reversal after intended restorative rectal cancer resection in Denmark: nationwide population-based study.

BACKGROUND: Data on stoma reversal following restorative rectal resection (RRR) with a diverting stoma are conflicting. This study investigated a Danish population-based cohort of patients undergoing RRR to evaluate factors predictive of stoma reversal during 3 years of follow-up. METHODS: Patients from national registries with rectal cancer undergoing RRR or Hartmann's procedure with curative intent between May 2001 and April 2012 were included. Patients with a diverting stoma were followed from the time of primary rectal cancer resection to date of stoma reversal, death, emigration, or end of 3-year follow-up. The cumulative incidence proportion (CIP) of stoma reversal at 1 and 3 years was calculated, treating death as a competing risk. Factors predictive of stoma reversal were explored using Cox regression analysis. RESULTS: Of 6859 patients included, 35·7, 41·9 and 22·4 per cent respectively had a RRR with a diverting stoma, RRR without a stoma, and Hartmann's procedure with an end-colostomy. In patients with a diverting stoma, the CIP of stoma reversal was 70·3 (95 per cent c.i. 68·4 to 72·1) per cent after 1 year, and 74·3 (72·5 to 76·0) per cent after 3 years. Neoadjuvant treatment (hazard ratio (HR) 0·75, 95 per cent c.i. 0·66 to 0·85), blood loss greater than 300 ml (HR 0·86, 0·76 to 0·97), anastomotic leak (HR 0·41, 0·33 to 0·50), T3 category (HR 0·63, 0·47 to 0·83), T4 category (HR 0·62, 0·42 to 0·90) and UICC stage IV (HR 0·57, 0·41 to 0·80) were possible predictors of delayed stoma reversal. CONCLUSION: In one-quarter of the patients the diverting stoma had not been reversed 3 years after the intended RRR procedure.

ANTECEDENTES: Los datos sobre el cierre del estoma (stoma reversal, SR) tras la exéresis el recto con intención reconstructiva (restorative rectal resection, RRR) y estoma derivativo (diverting stoma, DS) son contradictorios. Este estudio analizó los factores predictivos del SR en una cohorte danesa de base poblacional de pacientes sometidos a RRR con un seguimiento de 3 años. MÉTODOS: Los pacientes con cáncer de recto a los que se realizó una RRR o una operación de Hartmann (Hartmann's operation, HO) con intención curativa desde mayo de 2001 hasta abril de 2012, se seleccionaron a partir de registros nacionales. Los pacientes con SD fueron seguidos desde la resección primaria del cáncer rectal hasta la fecha del SR, del fallecimiento, de su cambio de residencia o hasta el final del seguimiento (3 años). Se calculó la tasa de incidencia acumulada (cumulative incidence proportion, CIP) de RS a 1 y 3 años utilizando la muerte como factor de riesgo competitivo. Se identificaron los factores predictivos de SR mediante regresión múltiple de Cox. RESULTADOS: De los 6.859 pacientes incluidos, el 35,7%, 41,9% y 22,4% tenían una RRR con DS, una RRR sin estoma y una HO con colostomía terminal, respectivamente. En pacientes con SD, el CIP de SR fue del 70,3% (i.c. del 95%: 68,4-72,1) al año y del 74,3% (i.c. del 95%: 72,5-76,0) a los 3 años. Se identificaron como posibles factores predictivos relacionados con el retraso del SR, el tratamiento neoadyuvante (cociente de riesgos instantáneos, hazard ratio, HR 0,75; i.c. del 95% 0,66-0,85), una pérdida de sangre > 300 mL (HR 0,86; i.c. del 95% 0,76-0,97), la fuga anastomótica (HR 0,41; i.c. del 95% 0,33-0,50), las categorías T3 (HR 0,63; i.c. del 95% 0,47-0,83) y T4 (HR 0,62; i.c. del 95% 0,42-0,90) y el estadio IV UICC (HR 0,57; i.c. del 95%: 0,41-0,80). CONCLUSIÓN: En una cuarta parte de los pacientes no se había cerrado el estoma derivativo tres años después de la resección de cáncer rectal con intención reconstructiva.

Yeast beta-glucan stimulates respiratory burst activity of Atlantic salmon (Salmo salar L.) macrophages.

Previous studies have shown that head kidney macrophages isolated from glucan injected rainbow trout (Oncorhychus mykiss) and Atlantic salmon (Salmo salar L.) have increased ability to kill Aeromonas salmonicida. The present work was aimed at investigating the in vitro effects of glucan on the respiratory burst and bactericidal potential of Atlantic salmon head kidney macrophages. Salmon macrophages were incubated for 1-7 days with various concentrations of yeast beta-glucan (MacroGard) and tested for respiratory burst activity by the reduction of nitroblue-tetrazolium (NBT) after exposure to phorbol myristate acetate (PMA) or opsonized zymosan. The macrophages showed a marked increase in respiratory burst activity 4 to 7 days after addition of glucan. Macrophages treated with 0.1-1 microgram mL-1 gave a maximum respiratory burst response, whereas 10 micrograms mL-1 had no effect and 50 micrograms mL-1 was inhibitory. The glucan also triggered respiratory burst activity directly, but this occurred only at relative high concentrations with a maximal effect at > or = 200 micrograms mL-1. The validity of using the NBT-assay as a measure of respiratory burst activity was confirmed by using inhibitors of O2- production (superoxide dismutase, trifluoperazine and diphenylene iodonium). Despite the stimulatory effect of glucan on the respiratory burst activity of salmon macrophages, these cells did not show increased bactericidal activity against the avirulent and virulent strain of A. salmonicida. Upregulation of burst activity alone is thus apparently not sufficient to enhance bactericidal activity against this pathogen by Atlantic salmon macrophages.

CpG oligodeoxynucleotides and plasmid DNA stimulate Atlantic salmon (Salmo salar L.) leucocytes to produce supernatants with antiviral activity.

Unmethylated CpG dinucleotides are more frequent in the genomes of bacteria and viruses than of vertebrates. We report herein that plasmid DNA and synthetic oliogodeoxynucleotides (ODNs) containing unmethylated CpG induce production of antiviral cytokine activity in Atlantic salmon leucocytes, whereas ODNs with an inverted motif (GpC) or with methylated cytosines have nearly no stimulatory effect. The adherent cell population, representing mainly macrophages, is directly activated by CpG-ODN, while the effect on the non-adherent population is weak. Since the peak antiviral activity in ODN-stimulated leucocytes is seen after 48h, this might indicate that the unmethylated DNA stimulates the adherent cells to produce co-stimulatory molecules, which in turn stimulates production of antiviral cytokines in the non-adherent cell population. The potent immune activation by CpG ODNs points to possible new applications as adjuvant in fish vaccines.

Serum amyloid A transcription in Atlantic salmon (Salmo salar L.) hepatocytes is enhanced by stimulation with macrophage factors, recombinant human IL-1 beta, IL-6 and TNF alpha or bacterial lipopolysaccharide.

Serum amyloid A (A-SAA) has previously been reported to be an acute-phase protein in salmonids. Hepatocytes represent a major source of A-SAA in salmonids, but nothing is known about hepatocyte SAA synthesis in fish. In the present work, the expression of A-SAA transcripts in primary cultures of Atlantic salmon hepatocytes in response to macrophage derived cytokines, human recombinant cytokines and bacterial lipopolysaccharide (LPS) was studied by Northern blot analysis. The macrophage supernatants were prepared by stimulating Atlantic salmon head kidney macrophages with LPS, yeast glucan or a leukocyte derived macrophage activating factor (MAF). The supernatants from glucan- or MAF-stimulated macrophages had no effect on A-SAA expression of the hepatocytes, while supernatants from LPS-stimulated macrophages gave about a 2-fold increase in expression. The combination of either glucan and MAF, or LPS and MAF were more effective and these supernatants gave a 3.4- and 5.2-fold increase in A-SAA expression, respectively. The hepatocytes were also treated with the human recombinant cytokines TNFalpha, IL-1beta and IL-6, alone or in combination. The A-SAA response to each of them alone was modest, but TNFalpha and IL-6 or IL-1beta and IL-6 in combination gave a higher response than each cytokine alone. These data suggest that the expression of A-SAA by hepatocytes from Atlantic salmon is induced by cytokine-like molecules. Interestingly, hepatocytes treated directly with LPS gave a more than 10-fold increase in SAA mRNA expression, but it is not known if this is a direct effect of LPS on the hepatocytes or if it is mediated by other contaminating cell types.

Crossed immunoelectrophoretic analysis of Mycobacterium paratuberculosis.

Antigenic analysis of M. paratuberculosis revealed extensive cross-reactivity with M. avium; however, the number of cross-reactive antigens found was dependent on the strain of M. avium tested. One antigen was shown to be the common antigen while another appeared to be iron-regulated in its production. A commercial polyclonal antibody to M. paratuberculosis produced a CIE precipitin pattern comparable to that of the antibody produced for the present study. An antigen designated no. 6 was consistently precipitated by sera from cattle infected with M. paratuberculosis. This antigen exhibited complete cross-reaction with M. avium and partial cross-reaction with M. phlei. Among three commercially available complement fixation (CF) antigen that could be precipitated by M. paratuberculosis antibodies. A commercial antigen for use in an agar gel immunodiffusion test for Johne's disease diagnosis produced 12 precipitins with the M. paratuberculosis antibody, one of which was identical with antigen 6.

Uroflowmetry.

Uroflowmetry is a widely used noninvasive screening modality for patients who present with symptoms of lower urinary dysfunction. However, it should be recognized that uroflowmetry represents the compound effect of bladder and urethral function because it may easily be misinterpreted. In elderly men with "prostatism", uroflowmetry is often sufficient to indicate treatment, while the value in women is less prominent. In pediatrics, more sophisticated urodynamic testing is crucial.

Intestinal and pulmonary mycotic lymphadenitis in cattle.

Among 4877 slaughtered cattle with tuberculosis-like lesions in lymph nodes, 94 cases (1.9 per cent) revealed fungal hyphae on histopathological examination. The survey period was 12 years and most of the affected animals (greater than 77 per cent) were beef cattle. Affected nodes were mesenteric in 84 cases (89.4 per cent), mediastinal and/or bronchial in seven cases (7.4 per cent), and in three cases (3.2 per cent), both mesenteric and mediastinal nodes were affected. The incidence of mycotic lymphadenitis was unrelated to year of study or season. Eighty-two of the cases were re-examined histologically and immunohistochemically. All lesions were granulomatous in nature and, in 26 cases, eosinophilic asteroid bodies (rosette formation) around hyphae were found. In 75 cases, immunofluorescence staining identified the agent as a zygomycete, probably Absidia corymbifera and, in one case, there was a concurrent infection with a Candida species. In seven cases that did not react with the antibodies employed, a diagnosis of zygomycosis was suggested on the basis of hyphal morphology. Hyphae of Aspergillus spp. were not found in any of the lesions. A concurrent fungal and mycobacterial infection (M. avium) was diagnosed in one case. Thus, zygomycetes are the main cause of macroscopically apparent mycotic lymphadenitis, a sporadic disease most probably caused by feeding with mouldy food stuffs.

Use of a dot enzyme-linked immunosorbent assay on absorbed sera for the diagnosis of bovine paratuberculosis.

This study describes the response of cattle to a dot enzyme-linked immunosorbent assay (ELISA) using sera absorbed with Mycobacterium phlei. Results obtained by visual observation are compared with those obtained using a densitometer. Infection status of cattle was determined by faecal culture. Cattle of different levels of exposure and disease manifestation were examined. A significantly higher dot ELISA response was observed (using both absorbed and non-absorbed sera) in animals with heavy shedding of M. paratuberculosis than in animals which tested negative by faecal culture or shed M. paratuberculosis at lower levels (P < 0.05). Paratuberculosis was diagnosed by visual determination of dot ELISA results using non-absorbed sera in 29 of 44 (65.9%) clinically-suspect animals giving positive results by faecal culture, and 85 of 93 (91.4%) cattle testing negative by faecal culture. With absorbed sera, the sensitivity of visual determination decreased to 15 of 44 (34.1%), while specificity increased to 91 of 93 (97.8%). Approximately 75% of cattle yielding positive results by dot ELISA were heavy bacterial shedders (> 1,500 colonies/g of faeces) at the time of serological testing. Comparison of the dot ELISA results determined visually with results obtained by objective densitometric measurement showed compatible specificity. Sensitivity of the dot ELISA was 65.9% for non-absorbed sera using visual evaluation and 87.5% using densitometric evaluation at a cut-off optical density value of 0.2. For absorbed sera, the values were 34.1% and 82.5%, respectively.

Lack of intracellular degradation of Mycobacterium paratuberculosis by bovine macrophages infected in vitro and in vivo: light microscopic and electron microscopic observations.

Blood-derived macrophages from clinically healthy cows and cows infected with Mycobacterium paratuberculosis were cultured in vitro and inoculated with heat-killed M paratuberculosis. Five weeks after infection, acid-fast bacteria continued to be demonstrated in the macrophages. Macrophage cultures also were infected with living M paratuberculosis and were examined by electron microscopy. Four weeks after infection, intact bacteria were found in all cultures. Electron microscopic examinations of intestinal macrophages from infected cows also demonstrated intracellular intact bacteria.

Comparison of subjective and objective test evaluations for use of Mycobacterium phlei-adsorbed serum in a dot-enzyme-linked immunosorbent assay for diagnosis of paratuberculosis in cattle.

Use of a dot-ELISA with serum adsorbed with Mycobacterium phlei or with nonadsorbed serum was compared. In addition, results attained using visual observation were compared with those obtained using a densitometer. Infection status of cattle was determined by results of culture of feces from a number of cattle with various degrees of exposure (low prevalence and test-negative) and disease manifestation (clinical suspect vs subclinical infection). Two paratuberculosis-negative herds, fecal culture-confirmed clinically suspect cases of paratuberculosis, and cows from 2 paratuberculosis-infected herds with diagnosis confirmed on the farm (low infection rate) were tested. Significant (P less than 0.05) increase in the dot-ELISA response was found in cattle with heavy M paratuberculosis shedding when nonadsorbed and adsorbed sera were used, compared with the response in cattle that were fecal culture-negative or were shedding M paratuberculosis at lower amounts. Paratuberculosis was diagnosed by visual determination in 29 of 44 (65.9%) of fecal culture-positive, clinically suspect cattle when nonadsorbed serum was used. Results of the visual test were negative in 85 of 93 (91.4%) of the fecal culture-negative cattle when nonadsorbed serum was used. However, when using M phlei-adsorbed serum, the sensitivity of the visual determination decreased to 34.1% (15/44), and the specificity increased to 97.8% (91/93).(ABSTRACT TRUNCATED AT 250 WORDS)

Paratuberculosis in cattle and free-living exotic deer.

Paratuberculosis was studied among dairy cows and exotic deer that shared grazing areas at Point Reyes National Seashore, California. Of the 10 dairy herds tested, 5 (50%) were infected with Mycobacterium paratuberculosis (based on results of fecal culture). Mycobacterium paratuberculosis was cultured from 9 (8.7%) of the 103 bovine fecal samples and from 4 (3.9%) of the 103 bovine rectal mucosa scapings tested. Of 89 fecal samples from 52 axis deer (Axis axis) and 37 fallow deer (Dama dama), 5 (9.6%) and 3 (8.1%), respectively, contained M paratuberculosis. Culture of intestinal necropsy samples from the same deer indicated that 3 (5.8%) of the axis deer and 2 (5.4%) of the fallow deer were infected with M paratuberculosis. The cows were tested for serum antibodies by the complement-fixation test and by radioimmunoassay. Of 95 sera tested by complement fixation, 15 (15.8%) were positive, as were 15 (14.7%) of 102 sera tested by radioimmunoassay. Culture results and serologic test results were compared on a herd basis.

[Waiting lists for men with benign urinary disorders]. / Ventelisteprojekt for maend med benigne vandladningsforstyrrelser.

This paper reflects the problems in having a large non-specific waiting-list. One hundred and twenty-eight patients were on a waiting-list under the main diagnosis of prostatism. This diagnosis revealed seven patients with cancer in the urinary tract system. Only two-thirds of the patients on the waiting-list were interested in further examination and treatment. This paper emphasizes the need for a more specific referral, when dealing with symptoms from the lower urinary tract system.

Relationship between urinary flow curve patterns and symptomatology in elderly males.

In a random sample of elderly males prostatic type flow curves constituted slightly more than 50%, but no differences were proven comparing persons with and without prostatism. Also no clinically significant relationships between symptoms of lower urinary tract dysfunction and the various flow curve patterns were established. A hypothesis is advanced concerning the sequence of flow curve changes in elderly males, from normal bell-shaped curves to prostatic and finally irregular types, reflecting prostatic hyperplasia with gradual detrusor decompensation.

Urodynamics in prostatism. I. Prognostic value of uroflowmetry.

A prospective study was undertaken to examine the prognostic value for the symptomatic outcome of prostatic surgery of preoperative urodynamic testing in patients with prostatism. The study design included selection of patients for prostatic surgery by means of classic non-urodynamic urologic investigations such as history, residual urine, serum creatinine, cystoscopy and possibly intravenous urography. In addition an extensive urodynamic work-up (uroflowmetry, cystometry and pressure-flow study with stop-test) was included. The results of the urodynamic studies were unknown to the surgeon selecting the patients for operation. This evaluation was repeated 6 months postoperatively. Totally 139 patients entered the study. The patients were classified according to the preoperative maximum flow rate (Qmax) and in spite of preoperative differences in uroflow, pressure-flow variables and symptom scores, no differences of clinical significance were noted postoperatively among the groups. However, the high-flow group (preoperative Qmax greater than or equal to 15 ml/sec) had a statistically significant lower success rate as judged by the patients subjective evaluation of the outcome of surgery. An analysis of diagnostic sensitivity and specificity indicated Qmax = 15 ml/sec as a relevant cut-off value regarding preoperative identification of patients at risk of a less favourable outcome of surgery. This group of patients was characterised by a higher incidence of persistent uninhibited detrusor contractions at follow-up and a lower incidence of preoperative infravesical obstruction. In conclusion we recommend uroflowmetry in the preoperative evaluation of patients with prostatism.

Urodynamics in prostatism. II. Prognostic value of pressure-flow study combined with stop-flow test.

In a prospective study the prognostic value of preoperative pressure-flow studies in prostatism was examined. The indications for prostatectomy were based on non-urodynamic data only. An extensive urodynamic evaluation was performed pre- and postoperatively, including uroflowmetry, water cystometry and pressure-flow study combined with stop-flow test. In total the data from 130 patients were considered. The material was classified with respect to the "urethral resistance relation" (URR) and the "bladder output relation" (BOR). According to the first criterion 87 patients were obstructed, 36 unobstructed, while 7 were unclassifiable and finally excluded. In most urodynamic variables, the two groups differed preoperatively, but no differences were revealed postoperatively. However, the obstructed group did considerably better postoperatively as to the symptomatic outcome. The success rate was 93% as opposed to 78% in the unobstructed patients (p less than 0.02). For the BOR classification, the theoretical maximum flow rate (Qm,est) was employed forming two groups: 57 patients with decreased bladder speed (Qm,est less than 35 ml/sec) and 41 patients with normal speed (Qm,est greater than or equal to 35 ml/sec). Few differences in urodynamic variables were found both pre- and postoperatively, but no significant difference was shown in success rates. In conclusion the URR proved a significant prognostic value in prostatism and is recommended in the preoperative work-up, especially in patients with equivocal uroflow studies. No convincing prognostic role could be attributed to the BOR.

Urodynamics in prostatism. III. Prognostic value of medium-fill water cystometry.

The influence of preoperative cystometric findings on the post-surgical outcome in prostatism was examined in a prospective study comprising 139 consecutive patients. A blinded study design was used, including an entirely non-urodynamic selection procedure for prostatic surgery. In addition an extensive urodynamic investigation was carried out including: spontaneous uroflowmetry, medium-fill water cystometry and pressure-flow study combined with stop-flow test. All patients were re-evaluated 6 months postoperatively, both symptomatologically and urodynamically. The patients were classified in three groups according to the preoperative detrusor function: normal, overactive in the standing position and overactive in the supine position. No significant urodynamic nor symptomatologic differences were shown, neither pre- nor postoperatively. Nor did the subjective outcome differ between the groups. Demonstration of postoperative (persistent) detrusor instability was associated with an unfavourable subjective outcome. While residual urine had no predictive importance, a preoperative maximum cystometric capacity less than 300 ml appeared to indicate postoperative failure. Significant association was found between urge and detrusor instability. In conclusion, cystometry is not worthwhile in the preoperative work-up in prostatism.

Urodynamics in prostatism. IV. Search for prognostic patterns as evaluated by linear discriminant analysis.

In order to examine the prognostic role of routine urodynamic testing in prostatism, a prospective study was undertaken. The patients were selected for prostatic surgery exclusively by means of non-urodynamic criteria, but in addition an extensive, blinded urodynamic work-up was performed, including uroflowmetry, pressure-flow study combined with stop-flow test and water cystometry. The study comprised 139 patients consecutively referred for prostatism. Six months postoperatively all patients were reexamined. Previously the preoperative urodynamic data from each modality were analysed separately. In an attempt to increase the prognostic information, all data were computed simultaneously using linear discriminant analysis. Several preoperative variables appeared valuable to discriminate between patients with favourable and unfavourable postoperative outcome, respectively. However, the results of classification employing even the best combinations of variables did not result in more than 88% of the patients being correctly classified. Furthermore, especially the patients with unfavourable outcome generally were misclassified. Several reasons for this lack of efficacy are briefly mentioned, including the great overlap in preoperative urodynamic data between patients with favourable and unfavourable postoperative outcome and the relatively low postoperative failure rate.