Validation of the size morphology site access score in endoscopic mucosal resection of large polyps in a district general hospital.

BACKGROUND: Polyp assessment is multimodal and is vital prior to endoscopic mucosal resection. The size, morphology, site and access (SMSA) score has been validated in specialist endoscopic institutions. this study investigated the ability of this score to predict incomplete endoscopic resection of large colorectal polyps in a district general hospital. METHODS: Consecutive patients undergoing endoscopic mucosal resection of large (≥ 20 mm) colorectal polyps at Worthing Hospital. Clinical, endoscopic and histological data were taken from prospective databases. The primary outcome of the study was to investigate the correlation of the SMSA score with incomplete endoscopic resection. RESULTS: Between February 2015 and August 2018, 114 patients underwent colorectal endoscopic mucosal resection. Of these, 67 (59%) were male. The median (interquartile range) age of the study population was 72 years (65-78 years). Some 17 lesions (15%) were pedunculated, 76 (67%) were sessile and 21 were (18%) flat; 84 polyps (77%) were located in the left colon/rectum, with the remainder in the right colon; 51 lesions (45%) were 20-30 mm, 27 (24%) were 30-40 mm and 36 (31%) were greater than 40 mm in diameter. When reclassified into the SMSA score, 9 of the polyps (8%) were level 2, 64 (56%) were level 3 and 41 (36%) were level 4. Incomplete resection was clinically diagnosed in 9/114 (8%). The SMSA score was positively correlated with incomplete endoscopic resection, but not with additional procedure usage, complications or advanced histology. CONCLUSIONS: Many patients with large polyps can be managed outside of specialist units. This study has validated that the SMSA score was associated with incomplete endoscopic mucosal resection for large polyps in a district general hospital setting.

Autocrine regulators of MC3T3-E1 cell proliferation.

MC3T3-E1 cells, a clonal osteoblast-like mouse calvarial cell line, secrete several growth regulating factors. These regulators include insulin-like growth factor (IGF) type I, transforming growth factor beta (TGF-beta), and IGF-II in descending order of abundance. MC3T3-E1 cells in culture also produce two IGF binding proteins (IGFBP), M(r) 25 and 32 kD, having sequence identity with IGFBP-4 and IGFBP-6, respectively. In addition, this is the first observation that osteoblast-like bone cells in culture produce IGFBP-6. To determine if growth factors produced by MC3T3-E1 cells have autocrine actions on these cells, the effects of IGF-I, IGF II, TGF-beta 1, and IGFBP-4 on MC3T3-E1 cell proliferation were determined. Exogenous addition of IGF-I and IGF-II stimulated MC3T3-E1 cell proliferation, but TGF-beta 1 and IGFBP-4 inhibited MC3T3-E1 cell proliferation. Based on these findings, we conclude that MC3T3-E1 cells in culture produce autocrine regulators of MC3T3-E1 cell proliferation and that the actions of IGFs may also be regulated by IGFBPs produced by these same cells.

Parathyroid-responsive modifications in the nuclear matrix of ROS 17/2.8 rat osteosarcoma cells.

PTH is a mediator of skeletal development and remodeling that influences gene expression in osteoblastic cells. It is well established that PTH modulates the activity of membrane-associated second messenger signal transduction pathways. In these studies we have addressed the potential contribution of components of cell structure to the integration of PTH-related regulatory signals that influence the expression of bone cell genes. Chronic treatment of ROS 17/2.8 rat osteosarcoma cells with PTH is accompanied by changes in gene expression that are at least in part transcriptionally controlled. To explore the involvement of nuclear architecture in PTH-responsive modifications in gene expression, we investigated changes in the nuclear matrix after PTH treatment. Consistent with a role for the nuclear matrix in determining spatial organization and topology of chromatin as well as in the localization and targeting of transcription factors, we observed PTH-associated changes in a 200-kilodalton nuclear matrix protein in response to PTH. A significant down-regulation of synthesis was observed when nuclear matrix proteins were resolved electrophoretically in two-dimensional gels. This protein was restricted to the nuclear matrix and was not detected in the chromatin or cytoskeletal cellular fractions. These alterations in nuclear matrix proteins that occur after PTH treatment in osteosarcoma cells were phenotype related. They did not occur in UMR-106 POL or H4 hepatoma cells. Our findings support a role for the nuclear matrix in transducing PTH-mediated regulatory signals to facilitate the extent to which genes in osteoblasts are transcribed.

The techniques used to sedate ventilated patients. A survey of methods used in 34 ICUs in Great Britain.

A survey of sedation techniques for ventilated patients was performed by visiting 34 Intensive Care Units in Great Britain and Northern Ireland. The opiates in frequent used were phenoperidine (21 units - 62% of units), papaveretum (11 - 32%) and morphine (9-26%). Many units used more than one opiate. Levorphanol, buprenorphine, pethidine, fentanyl and codeine were little used. Frequent use of diazepam was found in 22 units (64%), of lorazepam in 11 (32%) and of Althesin in four (12%). Other sedative drugs, droperidol, chlormethiazole, chlorpromazine and ketamine were sued on an occasional basis. Continuous sedation using nitrous oxide was employed in nine (26%) of units-for more than 24 h in six (18%). All units used pancuronium - 31 (91%) used in frequently. Curare was in frequent use in five units (15%). There was wide variation in the way in which the drugs were used. A compromise between the ideal and the practicable method was common, depending more upon shortage of trained nursing staff than upon lack of funds for equipment or expensive drugs. The depth of sedation thought to be ideal depended on the state of the patient as well as the usual practice in the ICU - however a majority (23 = 67%) of units aimed to keep most patients well sedated and detached from the ICU environment. The use of very large doses of opiate to obtain the stress response was thought helpful in only six units (18%) and then in a minority of patients.

Large loop excision of the transformation zone (LLETZ) as an alternative to both local ablative and cone biopsy treatment: a series of 1000 patients.

One thousand patients, referred to the Oxford Colposcopy Clinic, were treated with either large loop excision of the transformation zone (LLETZ, 891 cases) or LLETZ cone (109 cases). Forty-five LLETZ cones were performed empirically, 64 under microcolposcopic guidance. Over 98% of patients were managed as outpatients under local anaesthesia, and 87% of new patients treated with LLETZ had treatment at their first visit. Ninety percent of patients had at least cervical intraepithelial neoplasia grade one (CIN I) and 73% had CIN II or worse. Seventeen cases of invasive or possibly invasive disease were detected, 6 of them unsuspected. The overall rate of complete excision of CIN or worse was 72%. Follow-up was cytologic with or without colposcopy depending on lesion severity. Ninety-one percent of 967 treated patients were free of dyskaryosis at a mean follow-up of 23 months, with complete excision of CIN or worse at LLETZ a significant predictive factor. No cases of invasive carcinoma have developed following treatment. Major morbidity was uncommon, with 3.8% severe hemorrhage. Stenosis was noted in 3.8% cases, mostly after LLETZ cone. One patient (0.1%) has reduced fertility possibly attributable to LLETZ. Questionnaire assessment revealed a very high degree of acceptability of the treatment to patients. LLETZ and LLETZ cone have proved highly acceptable and effective outpatient diagnostic and treatment alternatives to both local ablation and cone biopsy in the Oxford Colposcopy Clinic.

Attitudes to contraception in women seeking termination of pregnancy.

PIP: This study of attitudes toward contraception among women seeking abortion involved consecutive patients seen at intervals over a 10-month period. 253 women with an age range of 14-47 years were interviewed. Medical contraindications to use of the combined oral contraceptive (OC) pill were reported by 32 women (12.6%). In 17 cases the woman, not her doctor, had decided to stop OC use. The IUD was contraindicated in 8 women (3.2%). The women who used no contraception included a few who relied on the safe period or withdrawal. In those aged 19 or younger, 56 (57%) used no method at the time of conception and 39 of these had never used any contraceptive method. Sheath failure was said to have occurred in 80 conceptions (31.6%), and 15 women (5.9%) fitted with an IUD conceived. 32 women (12.6%) conceived while taking the combined OC. 27 of these women were aware that they had forgotten to take 1 or more of their pills. 2 women were prescribed antibiotics and were not advised to use other precautions. 2 women were taking a 20 mg estrogen pill, and it was only in these 2 that any method failure could be identified. All but 5 of the 133 women who selected the combined pill were under age 30. Tubal ligation was chosen by 14 of the 31 women aged 35 or older. Sources of information on contraception and associated fears were recorded, and women in whom either the pill or the IUD was contraindicated are excluded. In younger women the doctor was used less as a source of information than friends or books but more than school, boyfriend, or husband. The doctor was used more by women aged 30 or older. The number of women with "fears" was sizeable. 55.7% of those aged 19 or under lacked useful maternal advice. 28 said they had problems in obtaining contraceptive supplies and advice. There were 12 young women aged 14 or 15, 8 of whom had not sought contraceptive advice since they did not have boyfriends and their sexual encounters were isolated and unpremeditated. The advice reported to have been given by some doctors seems to have been inappropriate. All the women aged 30 years or older not needing contraception had undergone tubal ligation. The interviews were found to be helpful to many patients. Some found it useful to have an impartial listener at a time of emotional stress. Others found more positive help in clarifying their ideas and correcting misbeliefs. Planning for the future was considered particularly helpful.^ieng

Emergencies: communication is key.

PIP: An estimated 70% of induced abortions could be prevented through the use of postcoital/emergency contraception. A study has also shown that 90% of women who have had an induced abortion would have preferred to have used emergency contraception. Emergency contraception is safe, effective, and dependent upon good doctor-patient communication. Doctors need to explain to clients through leaflets and publicity in their clinics that they can provide confidential services, including emergency contraception. Practice nurses and receptionists must cooperate in the delivery of such services and the maintenance of client confidentiality. The methods available for emergency contraception are described, as well as when and when not to use them, what the patient needs to know, and how the service can be delivered in primary care. Hormonal emergency contraception, progestogen-only emergency contraception, and the IUD are discussed.^ieng

Secretory IgA antibody in cervicovaginal secretions from women with genital infection due to herpes simplex virus.

Sequential samples of cervicovaginal secretions from women with untreated first and recurrent episodes of genital infection due to herpes simplex virus type 2 (HSV-2) were assayed for IgA antibodies to HSV-2 by using fluorescent antibodies to human secretory piece (sIgA) and human IgA. Among women with first-episode genital herpes, sIgA antibody to HSV-2 was detected in 20 of 31 women from whom HSV was isolated from the cervix, compared with four of 13 women from whom it was not (P less than .05). Among women with first-episode genital herpes, the mean titer of sIgA antibody to HSV-2 peaked between days 9 and 16 of disease, whereas among women with recurrent genital HSV, the peak occurred at days 3-8 of disease. HSV-2 was not isolated from the cervix from any of 130 samples taken when titers of sIgA antibody to HSV-2 were greater than or equal to 1:2, compared with 98 of 259 samples taken when titers were less than or equal to 1:2 (P less than or equal to .01).

Microinvasive cervical carcinoma: a retrospective study of cases presenting to the Oxford Colposcopy Unit between 1989 and 1996.

This a retrospective analysis of 65 cases of microinvasive disease and 5-8 years of follow-up (mean 6.2 years), evaluating the effectiveness of cytology and colposcopy in the diagnosis of microinvasive disease and the role of conservative surgery in its management. Cervical cytology reports indicated disease more severe than CIN III in 23% of cases. A further 7% at colposcopy were thought to have possible invasive disease despite no indication from the smear report, this impression correlated with increasing depth of invasion (>1.40 mm).

The effects of the insulin-like growth factors and transforming growth factor beta on the Jun proto-oncogene family in MC3T3-E1 cells.

Previous studies have demonstrated that when cells of the mouse osteoblastic cell line MC3T3-E1 are exposed to IGF-I and IGF-II they exhibit rapid and transient induction of the transcript from the proto-oncogene c-fos [8]. To clarify the relationship between induction of cell proliferation and proto-oncogene expression in MC3T3-E1 cells, the acute affects of IGF-I and IGF-II, growth factors that stimulate cell proliferation, and of TGF-beta 1, which inhibits cell proliferation, northern analyses with cDNA-derived probes for the proto-oncogenes c-jun, jun-B, and jun-D were undertaken. Concurrent northern analyses with a probe for c-fos extended our previous results to include the effect of TGF-beta 1 on c-fos. IGF-I does not induce the c-jun, jun-B, or jun-D transcripts, the former and latter being produced at detectable levels constitutively. After 1 hour of exposure to IGF-II the c-jun transcript response ranges from onefold to 13-fold and the jun-D transcript response ranges around two-fold. After 1 hour of exposure to TGF-beta 1, the jun-B transcript response ranges from eightfold to 24-fold, the c-fos transcript response ranges between sixfold and sevenfold. The differences observed in the magnitude and kinetics of the induction provoked by these growth factors is consistent with the presence of a regulatory circuit acting through the Jun family members which may act to stimulate transcription differentially when bound to DNA either as homodimers or, with Fos family proteins, as heterodimers.

Insulin-like growth factor-I and insulin-like growth factor-II induce c-fos in mouse osteoblastic cells.

We investigated the expression of c-fos in mouse osteoblast-like cultures treated with insulin-like growth factor (IGF)-I and IGF-II. The IGFs are present in bone, are produced by osteoblast-like cells in culture, and stimulate osteoblast cell proliferation. Quiescent, subconfluent cultures of the clonal osteoblast-like mouse calvarial cell line, MC3T3-E1, were treated with 10 ng/ml of IGF-I or IGF-II. RNA was extracted at 0, 15, 30, 60, 120 and 240 minutes, and c-fos messenger RNA (mRNA) was analyzed on Northern blots. Both IGFs transiently increased c-fos mRNA levels 25-28 fold at 15-30 min. To determine if c-fos induction was unique to the MC3T3-E1 cell line, effects of IGF-1 and IGF-II (3 ng/ml) were also tested in quiescent, serum-free primary mouse calvarial cells. Levels of c-fos mRNA were increased at 15 and 30 minutes (40-fold with IGF-I and 5-fold with IGF-II). These results indicate that IGF-I and IGF-II caused a rapid and transient induction of c-fos mRNA in murine osteoblasts.

Sequence-specific DNA binding activities of nuclear matrix proteins of mammalian lens epithelial cells.

This study examines matrix and nonmatrix nuclear proteins of the rabbit lens epithelial cells. The nuclear matrix proteins were isolated by modified Penman technique, which requires presence of detergents and nucleases, whereas nonmatrix nuclear proteins were obtained by high salt extraction. The data from these experiments revealed presence of DNA binding activities for SP-1 and OCT-1 proteins in both matrix and non-matrix compartments of rabbit lens epithelial cells. Comparison of the relative abundance of SP-1 and OCT-1 binding activities in nuclear matrix and nonmatrix fractions suggest the distribution between these two compartments is cell type specific and possibly related to the control of cell growth.

Subnuclear distribution of the vitamin D receptor.

The subnuclear distribution of the vitamin D receptor was investigated to begin addressing the contribution of nuclear architecture to vitamin D-responsive control of gene expression in ROS 17/2.8 rat osteosarcoma cells. The nuclear matrix is an anastomosing network of filaments that is functionally associated with DNA replication, transcription, and RNA processing. The representation of vitamin D receptor in the nuclear matrix and nonmatrix nuclear fractions was determined by the combined application of 1) sequence-specific interactions with the vitamin D receptor binding element of the rat bone-specific osteocalcin gene promoter and 2) Western blot analysis. Both methods confirmed the presence of vitamin D receptor in the nonmatrix nuclear fraction and the absence of detectable vitamin D receptors associated with the nuclear matrix. In contrast, these same nuclear matrix proteins preparations exhibited association with the general transcription factor AP-1 and a bone tissue-specific promoter binding factor NMP2. NMP-2 exhibits recognition for a promoter domain contiguous to the vitamin D-responsive element of the osteocalcin gene, although the vitamin D receptor does not appear to be a component of the nuclear matrix proteins. Interrelationships between nuclear matrix proteins and nonmatrix nuclear proteins, in mediating steroid hormone responsiveness of a vitamin D-regulated promoter, are therefore suggested.

The tissue-specific nuclear matrix protein, NMP-2, is a member of the AML/CBF/PEBP2/runt domain transcription factor family: interactions with the osteocalcin gene promoter.

The nuclear matrix protein, NMP-2, was originally identified as an osteoblast-specific DNA-binding complex localized exclusively to the nuclear matrix. NMP-2 was shown to recognize two binding sites, site A (nt-605 to -599) and site B (nt -441 to -435), in the rat bone-specific osteocalcin gene promoter. This study shows that the NMP-2 binding sites A and B as well as a third NMP-2 binding site (nt -135 to -130) constitute a consensus sequence, ATGCTGGT, and represent an AML-1 recognition motif. AML-1 is a member of the AML transcription factor family which is associated with acute myelogenous leukemia and binds to the sequence TGCTGGT via its DNA-binding runt domain. Electrophoretic mobility shift assays reveal that a component of NMP-2 is a member of the AML/PEBP2/runt domain transcription factor family based on cross-competition with AML-1 consensus oligonucleotide. Limited immunoreactivity of NMP-2 with a polyclonal N-terminal AML-1 antibody and inability of the AML-1 partner protein CBF-beta to form complexes with NMP-2 indicate that NMP-2 is not identical to AML-1 but represents a variant AML/PEBP2/runt domain protein. Western and Northern blots reveal the presence of multiple AML-related proteins and AML-1 transcripts in several osseous cell lines. Furthermore, our results indicate that AML family members may selectively partition between nuclear matrix and nonmatrix compartments. Because proteins that contain a runt domain are implicated in tissue-specific transcriptional regulation, our results support the concept that the nuclear matrix mediates osteoblast-specific expression of the osteocalcin gene.