P. J. Broe

Infiltrating immune cells, but not tumour cells, express FasL in non-small cell lung cancer: No association with prognosis identified in 3-year follow-up.

Non‐small cell lung cancer (NSCLC) remains a difficult disease to treat and independent prognostic markers other than tumour stage and histology have not emerged. The immune cell content of solid tumours has been associated with tumour regression and at times, tumour progression. The involvement of immune cells in prognosis of NSCLC is poorly described. Poor immune responses within solid tumours have been linked with tumour production of immunosuppressive cytokines. Tumour expression of FasL is thought to disarm responses through the transduction of a death signal in Fas‐expressing T cells. The existence of the ‘tumour counterattack’ in vivo has been questioned. We undertook to measure T cell and macrophage infiltration of the tumour bed in NSCLC and report the association between immune cell content and prognosis in a limited, 3‐year analysis of survival (n = 113). In addition we investigated FasL expression (n = 45). T cells and macrophages were found to frequently infiltrate lung tumours, albeit in small numbers. Generally there were more T cells infiltrating than macrophages. T cell and macrophage numbers were not associated with prognosis. Lung tumours were found not to express FasL, although occasional immune cells surrounding tumour cells were strongly positive. FasL expression was not associated with prognosis in this series. Thus, immune cells infiltrating NSCLC are not capable of suppressing tumour growth, nor are they associated with tumour progression. We report that lung tumours do not express the FasL, and that although some immune cells are FasL positive, this is not a reflection of general immune cell activation.

Acute upper gastrointestinal haemorrhage and colitis: an unusual presentation of Wegener's granulomatosis.

Wegeners granulomatosis is a rare necrotizing vasculitis usually affecting the respiratory tract and kidneys. The aetiology is unknown and it usually occurs in patients over the age of 40. Involvement of the gastrointestinal tract in Wegeners granulomatosis is relatively rare and usually occurs long after the onset of initial symptoms. Acute colitis as a presenting feature of Wegeners granulomatosis is very rare with only a few reports in the literature. We describe a young woman who presented initially to hospital with gastrointestinal features and then developed a severe colitis and severe gastrointestinal haemorrhage. This preceded the development of respiratory tract features with severe pulmonary haemorrhage, haemoptysis and the development of rapidly progressive renal failure and nasal septal perforation. Following treatment with intravenous steroids and cyclophosphamide, gastrointestinal symptoms and signs improved dramatically, as did her pulmonary disease. She still remains dialysis dependent, due to end-stage renal disease secondary to glomerulonephritis.

Management of patients undergoing splenectomy in an Irish Teaching Hospital: impact of guidelines

IntroductionOverwhelming post-splenectomy infection (OPSI) has a 50–70% mortality rate and carries a lifetime risk for the asplenic patient. Specific British guidelines have been developed to reduce its incidence.AimsTo determine whether British guidelines were being followed in our own institution and what impact they had on overwhelming post-splenectomy infection.MethodsRetrospective chart review of 100 splenectomies performed by Department of Surgery, Beaumont Hospital from January 1990 to January 2000.ResultsTwenty per cent of patients were discharged without any recommended vaccinations. Prophylactic antibiotics were not prescribed in 53% of patients. Just 12% of charts document a verbal explanation of the complications and management of asplenia to the patient. Overall septic mortality was 12%, of whom 8% died in hospital and 4% after discharge.ConclusionManagement of the asplenic patient has improved but is far from complete. A central register of asplenic patients and national asplenic guidelines should be established in Ireland to ensure optimum patient care.

An “all comers” policy for ruptured abdominal aortic aneurysms: how can results be improved?

OBJECTIVE To review our experience of a non-selective policy for the treatment of ruptured abdominal aortic aneurysm to see if the policy was justified, and to identify any preoperative risk factors that adversely influenced outcome. DESIGN Retrospective study. SETTING Teaching hospital, Republic of Ireland. SUBJECTS 258 patients admitted with abdominal aortic aneurysms between January 1982 and December 1993. INTERVENTIONS Definitive surgical treatment. MAIN OUTCOME MEASURES Morbidity, mortality, and risk factors. RESULTS In-hospital mortality for all patients was 43% (110/258). Overall, women did worse than men (28/44, 64%, died, compared with 96/214, 45%, p=0.03). The mortality among patients over the age of 80 (23/45, 51%) was not significantly different from that among younger patients (97/202, 48%). Blood pressure, platelet count, and haemoglobin concentration were all significantly lower preoperatively among those who died (p < 0.05). CONCLUSIONS Age alone cannot be used to justify witholding definitive surgical treatment. Treatment should be aimed towards reversing haematological and haemodynamic abnormalities preoperatively to try to improve outcome.

Immune function, telomerase, and angiogenesis in patients with primary, operable nonsmall cell lung carcinoma

Lung carcinoma usually is advanced at the time of presentation and frequently shows metastatic spread. In recent times, prognostic factors such as c‐erbB‐2 in patients with breast carcinoma have provided useful information and beneficial therapeutic targets. The objective of this study was to evaluate angiogenesis, immune function, and telomerase expression in patients with nonsmall cell lung carcinoma (NSCLC) to determine their prognostic significance.

Severe abdominal injuries sustained in an adult wearing a pelvic seatbelt: a case report and review of the literature

In automobile accidents, the “seatbelt syndrome” (SBS) consists of a constellation of injuries, predominantly involving thoraco-lumbar vertebral fractures and intraabdominal organ injury. A recent amendment to Irish legislation has made the wearing of seatbelts mandatory for all rear seated passengers in an effort to protect children. Whilst rear seatbelts result in a significant reduction in morbidity and mortality following road traffic accidents (RTA), we present a case in which the rear lap seatbelt caused severe abdominal injuries. It is evident that the current rear seat lapbelt system is an inferior design associated with a significant morbidity and mortality when compared to three-point harness system and consideration should be given to replacing them in all motor vehicles.

ERCP in the management of patients having laparoscopic cholecystectomy: Re-Appraising current indications

SummaryThis study assessed the ability of biochemical tests and ultrasound to predict the presence of ductal calculi, and thereby refine the indications for ERCP, in patients before or after laparoscopic cholecystectomy. Thirteen of fifty-three patients investigated before laparoscopic cholecystectomy, and four of seventeen investigated after had stones confirmed at ERCP. The most sensitive indices for stones were raised serum alkaline phosphatase (0.76), aspartate transferase (0.75) and alanine transferase (0.76). The most specific indices were an abnormal ultrasound (0.92), raised serum amylase (0.78) and raised bilirubin (0.75). Serum bilirubin, amylase and ultrasound were all normal in twenty-seven patients and all of these had normal ERCPs. If patients with normal bilirubin, amylase and ultrasound were not referred for ERCP, no stones would have been overlooked and the number of ERCPs could have been reduced by 39%.

Transforming management of patients undergoing splenectomy in an Irish teaching hospital

BackgroundPost-splenectomy infection has a mortality rate of up to 70%. Previously we have published data confirming the poor adherence to best practice guidelines with relation to management of the asplenic patient. A defined protocol of care was established, staff education commenced and a ‘patient information leaflet’ made available.AimTo ascertain whether management of the asplenic patient has improved since the implementation of a structured programme of care.MethodRetrospective chart review of all splenectomies performed in Beaumont Hospital between 2002 and 2008.ResultsOverall, 75.9% of patients were documented as having received the recommended vaccinations. Of these, 48.7% were not timed according to recommended guidelines. Prophylactic antibiotics were documented as prescribed in all but five patients discharged.ConclusionsThese results demonstrate an improvement in post-splenectomy care between 2002 and 2008. However, further improvements are necessary.

Oxygen free radicals and acute pancreatitis: Fact or fiction?

The effect of oxygen free radical suppression was studied in the taurocholate model of acute pancreatitis in the rat using systemic allopurinol, superoxide dismutase (S.O.D.) and catalase. None of the treatments were beneficial which suggests that oxygen free radical suppression is unlikely to be clinically beneficial in acute pancreatitis.

Verapamil is beneficial in a model of post-ERCP pancreatitis

Objective To assess the effect of the calcium blocking drug, verapamil, in an experimental model of acute pancreatitis. Methods Acute pancreatitis was induced by retrograde taurocholate injection into the pancreato-biliary duct of Sprague-Dawley rats. The rats were then randomized into four groups and 1 ml saline or verapamil (1 g/kg) was administered before induction of pancreatitis or 2 h after taurocholate injection. Results Pancreatitis was confirmed by elevation of serum amylase levels and by histological alterations in pancreatic specimens from all animals. Survival was significantly increased in rats given verapamil prior to the induction of pancreatitis; however, delayed treatment was not effective. Conclusion This study suggests that verapamil may have a beneficial role in the prophylaxis of pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP).