Rene Lafreniere

Influence of level and depth on recurrence rate in thin melanomas

A population-based study of the biology of the thin-level melanoma according to site, Breslows thickness, and Clarks level was undertaken. Two hundred fifteen patients were studied with a mean follow-up of 41 months. Overall, 23 patients (10.7%) had recurrences, 8 locally, 9 regionally, and 6 systemically, despite an adequate local excision. A multivariate analysis was done. In the patients with thin lesions (less than 1 mm), increasing level (p < 0.002) and head and neck site (p < 0.04) increased the risk of recurrence. Increasing thickness of melanoma up to 1 mm did not influence the risk. This study identifies a group of high-risk melanoma patients for whom adjuvant therapy to decrease recurrences should be studied.

Impact of Surgeon Training on Outcomes After Resective Hepatic Surgery

BackgroundHigher hospital and surgeon volumes have been associated with improved outcomes after hepatic resection. Subspecialty training has not previously been associated with improved outcomes after hepatic resection. The objective of this study was to determine what effects, if any, surgeon’s volume and training had on the outcomes after hepatic resection.MethodsAdministrative procedure codes were used to identify all adult patients from the fiscal year 1991–1992 to 2003–2004 who underwent a hepatic resection in two large urban health regions in Canada (Calgary and Capital health regions). The primary outcomes were operative mortality and postoperative complications.ResultsThere were 1107 hepatic resections in the stated time period performed by a total of 72 surgeons. There were 66 deaths, resulting in an in-hospital mortality rate of 6.0%, and an overall complication rate of 46%. Statistically significant predictors of operative mortality were: urgency of admission, diagnosis of primary hepatic malignancy, extent of resection, and increasing burden of comorbid medical illness. Surgeon training along with patient’s sex, the urgency of admission, diagnosis of primary hepatic malignancy, extent of resection, and increasing comorbidity were predictive of postoperative complications.ConclusionsThis study found surgeon training to be highly predictive of postoperative complications after hepatic resection.Higher hospital and surgeon volumes have been associated with improved outcomes after hepatic resection. Subspecialty training has not previously been associated with improved outcomes after hepatic resection. The objective of this study was to determine what effects, if any, surgeon’s volume and training had on the outcomes after hepatic resection. Administrative procedure codes were used to identify all adult patients from the fiscal year 1991–1992 to 2003–2004 who underwent a hepatic resection in two large urban health regions in Canada (Calgary and Capital health regions). The primary outcomes were operative mortality and postoperative complications. There were 1107 hepatic resections in the stated time period performed by a total of 72 surgeons. There were 66 deaths, resulting in an in-hospital mortality rate of 6.0%, and an overall complication rate of 46%. Statistically significant predictors of operative mortality were: urgency of admission, diagnosis of primary hepatic malignancy, extent of resection, and increasing burden of comorbid medical illness. Surgeon training along with patient’s sex, the urgency of admission, diagnosis of primary hepatic malignancy, extent of resection, and increasing comorbidity were predictive of postoperative complications. This study found surgeon training to be highly predictive of postoperative complications after hepatic resection.

Production of a new model of slowly progressive Heymann nephritis

Summary.  A slowly progressive autoimmune kidney disease was induced in Sprague Dawley rats by subcutaneous injection of a chemically modified kidney antigen (rKF3), incorporated into Alum and Distemper complex vaccine, followed by subcutaneous injections of an aqueous preparation of the same antigen. Pathogenic autoantibodies developed, which reacted with fixed glomerular nephritogenic antigen. Subsequently, immunopathological events lead to chronic progressive immune complex glomerulonephritis and proteinuria.

Down-regulation of pathogenic autoantibody response in a slowly progressive Heymann nephritis kidney disease model

In the present article, we describe an antigen‐specific down‐regulation of a pathogenic autoantibody (aab)‐mediated disease process in an experimental autoimmune kidney disease in rats called slowly progressive Heymann nephritis (SPHN). This autoimmune disease is initiated and maintained by pathogenic immunoglobulin G (IgG) autoantibodies (aabs), which cause an immune‐complex (IC) glomerulonephritis associated with proteinuria. We achieved down‐regulated pathogenic aab response in SPHN rats by injections of an IC containing the native nephritogenic antigen and specific high‐titred nonpathogenic IgM aabs, in antigen excess. The injected IC increased the level of circulating nonpathogenic IgM aabs; the increased levels of specific IgM aabs in turn facilitated the removal of the injected altered nephritogenic and liberated autoantigens from the renal tubules and greatly diminished the production of pathogenic aabs and the build up of immune deposits in the glomeruli. While animals treated early had advantages over rats whose kidney disease was well established before treatment; animals treated late into the disease still manifested noticeable improvements in similar areas, i.e. with lessened proteinuria, kidney lesion reduction and a decreased pathogenic aab response. At the end of the experiment at 29 weeks, 80% of all the treated rats had insignificantly low levels of circulating IgG aabs, indicating cessation of pathogenic aab production and corresponding termination of the disease process. In contrast, most untreated rats with the kidney disease still had high levels of circulating pathogenic aabs at the end of the experiment, which maintained disease progression.

Infection control in the operating room: current practices or sacred cows?

Rene Lafreniere, MD, FRCSC, FACS: The issue of infection control in the operating room is an everyday concern for all members of the operating room team. We as surgeons, anesthetists, nurses, and patients all have opinions and beliefs about causes and prevention of infection and have strong beliefs about what should be done to eliminate or at least reduce the causative agents of infection. Infection control at one point was focused solely on what to do to prevent the patient from acquiring an infection. Nowadays, of course, we also worry about the potential impact of the patient on the health care team within the operating room environment. Currently, in the United States alone, an estimated 27 million surgical procedures are performed each year. Surgical infections can be very costly. In 1980, Cruse and Foord estimated that a surgical site infection increases a patient’s stay by approximately 10 days and costs an additional

Presence of immunoglobulin M antibodies around the glomerular capillaries and in the mesangium of normal and passive Heymann nephritis rats.

2,000.00. Although these figures are no doubt different in 2001, infections and their control are still of concern to all of us. The value of our infection control methodologies has been questioned by many. On October 23, 2000 at the annual meeting of the American College of Surgeons, a 2-hour symposium focusing on assessing infection prevention methodologies was held. Accepted and controversial standards related to the patient, the surgeon, and allied health were reviewed. Recommendations were made for all three categories in terms of full acceptance, partial acceptance, and rejection, and a plea was made for further studies to be performed to continue with the elimination of questionable practices in the operating room that are costly but of little or no value in the protection of the patient and the health care team. The following short paper summarizes what was said at the symposium.

Production of Heymann nephritis by a chemically modified renal antigen

Diffuse distribution of small, faintly staining, beaded deposits of rat immunoglobulin M (IgM) around the glomerular capillary blood vessels, and a more intensely staining larger deposition in the mesangium, were observed on the kidney sections of normal rats. As glomerular‐fixed nephritogenic antigens are known to be present on the epithelial aspect of the glomerular basement membrane (GBM), especially at the soles of foot processes and at the slit pores, it was assumed that the IgM antibodies were directed against these antigens. Investigation by immunofluorescent antibody double‐staining techniques of rat kidney sections obtained from normal and rabbit anti‐FX1A‐injected rats stained for the nephritogenic antigen showed that a number of antigenic sites in the glomeruli and in the mesangium shared antibody hits by heterologous rabbit IgG and autologous rat IgM antibodies. Most sites in the glomeruli stained specifically for rat IgM or rabbit IgG, but preferentially for the latter. The intensely fluorescent mesangial deposits stained mainly for rat IgM, indicating that at these sites the antigenic material was virtually saturated, while areas at the entry to the mesangial space also stained for rabbit IgG, indicating that at these locations free nephritogenic epitopes were still available for reaction with the anti‐FX1A antibody. Western blot analysis have shown that the rabbit anti‐rat FX1A IgG and the rat anti‐rat KF3 IgM antibodies are directed against the same renal tubular‐derived antigen with a molecular weight of 70,000. These experimental findings collectively demonstrate that the heterologous IgG and autologous IgM antibodies are directed against the same nephritogenic antigen, which is found in the glomeruli, the mesangium and the proximal convoluted tubules. Thus, the IgM autoantibody has a possible physiological role but, in addition, there is evidence of active immunophagocytic events, manifested in a rapid and continuous entrapment and expulsion of macromolecules after their processing by the mesangial cells of normal and passive Heymann nephritis rats.

Downregulation of a pathogenic autoantibody response by IgM autoantibodies directed against the nephritogenic antigen in slowly progressive Heymann nephritis

An autoimmune kidney disease morphologically and functionally similar to Heymann nephritis (HN) was induced in mature male Sprague Dawley rats by repeated weekly IP injections of a chemically modified azo sonicated ultracentrifuged (u/c) rat kidney fraction 3 (rKF3) antigen in an aqueous medium. The experiment was terminated 15 weeks after the first injection of the chemically altered antigen. Serum samples collected and analysed by an indirect fluorescent antibody test on normal rat kidney sections during the course of the experiment showed a gradual rise in circulating pathogenic autoantibodies directed against the proximal tubular brush border regions. Proteinuria was present and significantly increased in the urine of two of eight rats. The arising immune‐complex glomerulonephritis (ICGN) revealed typical HN kidney disease lesions in 70% of the rats in histological, direct fluorescent antibody and electron‐microscopical examinations. Control rats injected similarly with the an unmodified version of the same antigen did not develop the HN‐characteristic morphological and functional changes. To our knowledge, this is the first time that the autoimmune kidney disease designated as an active HN has been produced by the administration of a chemically altered renal antigen in an aqueous solution and not by the usual presentation of the nephritogenic renal antigen in an adjuvant.

Reduced Incidence of Slowly Progressive Heymann Nephritis in Rats Immunized With a Modified Vaccination Technique

The purpose of the study was to find out if a new modified vaccination technique would be effective in downregulating immunopathological events during the course of an experimental autoimmune kidney disease (which is morphologically and functionally similar to Heymann nephritis) called ‘slowly progressive Heymann nephritis’ (SPHN). We have shown that the pathogenic IgG autoantibody (aab)‐induced experimental autoimmune kidney disease process can be downregulated early on as well as during the chronic progressive phase, when rats were restimulated. The IgM aab, resulting from stimulation by immune complexes made up of rat kidney fraction 3 (rKF3) antigen and rat anti‐rKF3 IgM antibody in antigen excess (MIC), can greatly diminish pathogenic aab production by removing or blocking nephritogenic antigens. Reduced IgG aab production limits the formation of damaging immune complexes (IC) in the glomeruli and development of proteinuria. At the end of the experiment 60% and 80% of the MIC‐treated groups had no pathogenic IgG aab in their circulation, while all the untreated SPHN rats had high levels of IgG aab associated with disease progression manifesting in increased proteinuria and severe immune complex glomerulonephritis.

The role of autoimmunologists in investigating and treating autoimmune disorders

A slowly progressive Heymann nephritis (SPHN) was induced in three groups of rats by weekly injections of a chemically modified renal tubular antigen in an aqueous medium. A control group of rats received the chemically unmodified version of the antigen in an aqueous solution. One group of SPHN rats were pre- and post-treated with weekly injections of IC made up of rKF3 and rarKF3 IgM antibody at antigen excess (MIC) (immune complexes [ICs] containing sonicated ultracentrifuged [u/c] rat kidney fraction 3 [rKF3] antigen and IgM antibodies specific against the antigen, at slight antigen excess). One group of SPHN rats were post-treated with MIC 3 weeks after the induction of the disease and one group of SPHN animals received no treatment. The control group of rats received pre- and post-treatment with sonicated u/c rKF3. The incidence of immune-complex glomerulonephritis (ICGN) in the untreated SPHN rats was 87%, in the pre- and post-treated animals 13%, and in the post-treated-only rats 20%. Rats receiving sonicated ultracentrifuged rKF3 antigen did not develop ICGN. The present experiment demonstrates that the development of SPHN can be not only prevented but also effectively terminated by our newly developed modified vaccination technique.