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Background Ajmaline is a pharmaceutical agent now administered globally for a variety of indications, particularly investigation of suspected Brugada syndrome. There have been previous reports suggesting that repetitive use of this agent may cause severe liver injury, but little evidence exists demonstrating the same effect after only a single administration. Case presentation A 33-year-old man of Libyan origin with no significant past medical history underwent an ajmaline provocation test for investigation of suspected Brugada syndrome. Three weeks later, he presented with painless cholestatic jaundice which peaked in severity at eleven weeks after the test. Blood tests confirmed no evidence of autoimmune or viral liver disease, whilst imaging confirmed the absence of biliary tract obstruction. A liver biopsy demonstrated centrilobular cholestasis and focal rosetting of hepatocytes, consistent with a cholestatic drug reaction. Over the course of the next few months, he began to improve clinically and biochemically, with complete resolution by one year post-exposure. Conclusion Whilst ajmaline-related hepatotoxicity was well-recognised in the era in which the drug was administered as a regular medication, clinicians should be aware that ajmaline may induce severe cholestatic jaundice even after a single dose administration.

Squamous cell carcinoma (SCC) is highly malignant and refractory to therapy. The majority of existing mouse SCC models involve multiple gene mutations. Very few mouse models of spontaneous SCC have been generated by a single gene deletion. Here we report a haploinsufficient SCC mouse model in which exon 3 of the Tp53BP2 gene (a p53 binding protein) was deleted in one allele in a BALB/c genetic background. Tp53BP2 encodes ASPP2 (ankyrin repeats, SH3 domain and protein rich region containing protein 2). Keratinocyte differentiation induces ASPP2 and its expression is inversely correlated with p63 protein in vitro and in vivo. Up-regulation of p63 expression is required for ASPP2(Δexon3/+) BALB/c mice to develop SCC, as heterozygosity of p63 but not p53 prevents them from developing it. Mechanistically, ASPP2 inhibits ΔNp63 expression through its ability to bind IκB and enhance nuclear Rel/A p65, a component of the NF-κB transcription complex, which mediates the repression of p63. Reduced ASPP2 expression associates with tumor metastasis and increased p63 expression in human head and neck SCCs. This study identifies ASPP2 as a tumor suppressor that suppresses SCC via inflammatory signaling through NF-κB-mediated repression of p63.

Background & Aims Hirmi Valley liver disease was first reported in 2001 in Tigray, Ethiopia. 591 cases, including 228 deaths, were reported up to December 2009. The pyrrolizidine alkaloid acetyllycopsamine was detected in stored grain and residents reported adding the pesticide DDT (dichlorodiphenyldichloroethylene) directly to their food stores. We aimed to characterise the clinical features of the disease, and explore the role of these chemicals in its aetiology. Methods 32 cases were examined and full clinical histories taken. Nine cases underwent liver biopsy in hospitals. Serum and urine samples were collected from cases and controls. Urine was analysed for acetyllycopsamine by UPLC-MS. Total DDT in serum was measured by ELISA. Hepatotoxicity of DDT and acetyllycopsamine alone or in combination was explored in C57BL/6J mice. Results Clinical presentation included epigastric pain, abdominal swelling, bloody diarrhoea, hepatomegaly, splenomegaly, and ascites. Histology revealed acute injury characterised by centrilobular necrosis or chronic injury with bile ductular reaction, cytomegaly and fibrosis but no hepatic vein occlusion. Acetyllycopsamine was detected in urine samples taken in the affected area with significantly greater concentrations in 45 cases than in 43 controls ( p =0.02). High levels of DDT (>125ppb) were detected in 78% of serum samples. In mice, DDT (3×75mg/kg) significantly increased the hepatotoxicity (plasma ALT, p =0.0065) of acetyllycopsamine (750mg/kg), and in combination induced liver pathology similar to Hirmi Valley liver disease including centrilobular necrosis and cytomegaly. Conclusions This novel form of disease appears to be caused by co-exposure to acetyllycopsamine and DDT.

The optimum lymph node yield for tumour staging following surgery for rectal cancer remains controversial. This study aimed to determine the optimum number of lymph nodes needed to accurately determine stage III rectal cancer.Sixty-three thousand three hundred and eighty-one patients from the surveillance, epidemiology and end resulted database, who underwent surgery for rectal adenocarcinoma in 1995-2009, were included. The primary outcome was detection of stage III rectal cancer, assessed by multivariable logistic regression.Each additional node examined increased the chance of stage III diagnosis by 3.9% (adjusted odds ratio 1.039, p0.001). Optimum histopathological stage was reached following retrieval of 18 nodes in patients treated without neoadjuvant radiotherapy (n = 49,162) and 16 nodes in those treated with neoadjuvant radiotherapy (n = 14,219). For stage I and II cancer, retrieval of a minimum of 8 and 14 nodes, respectively, was associated with optimum five-year overall survival. For stage III cancer, increasing number of positive lymph nodes and increasing lymph node ratio (0.5) were independent negative predictors of survival; total lymph node yield did not correlate with survival.Eighteen lymph nodes for those treated without neoadjuvant radiotherapy and 16 nodes for those treated with it were needed to prevent stage migration in rectal cancer. These findings provide further evidence of the importance of the technique of proctectomy and of careful pathologic assessment.

To develop novel metabolite-based models for diagnosis and staging in colorectal cancer (CRC) using high-resolution magic angle spinning nuclear magnetic resonance (HR-MAS NMR) spectroscopy.Previous studies have demonstrated that cancer cells harbor unique metabolic characteristics relative to healthy counterparts. This study sought to characterize metabolic properties in CRC using HR-MAS NMR spectroscopy.Between November 2010 and January 2012, 44 consecutive patients with confirmed CRC were recruited to a prospective observational study. Fresh tissue samples were obtained from center of tumor and 5 cm from tumor margin from surgical resection specimens. Samples were run in duplicate where tissue volume permitted to compensate for anticipated sample heterogeneity. Samples were subjected to HR-MAS NMR spectroscopic profiling and acquired spectral data were imported into SIMCA and MATLAB statistical software packages for unsupervised and supervised multivariate analysis.A total of 171 spectra were acquired (center of tumor, n = 88; 5 cm from tumor margin, n = 83). Cancer tissue contained significantly increased levels of lactate (P0.005), taurine (P0.005), and isoglutamine (P0.005) and decreased levels of lipids/triglycerides (P0.005) relative to healthy mucosa (R2Y = 0.94; Q2Y = 0.72; area under the curve, 0.98). Colon cancer samples (n = 49) contained higher levels of acetate (P0.005) and arginine (P0.005) and lower levels of lactate (P0.005) relative to rectal cancer samples (n = 39). In addition unique metabolic profiles were observed for tumors of differing T-stage.HR-MAS NMR profiling demonstrates cancer-specific metabolic signatures in CRC and reveals metabolic differences between colonic and rectal cancers. In addition, this approach reveals that tumor metabolism undergoes modification during local tumor advancement, offering potential in future staging and therapeutic approaches.

AimNonresponse to neoadjuvant therapy is a significant challenge for clinicians managing solid cancers. This study aimed to determine whether epithelial mesenchymal transition (EMT) was associated with nonresponse to neoadjuvant therapy in patients with locally advanced rectal cancer. MethodRepresentative tissue specimens from the tumour-invasive front of consecutive patients undergoing resection of rectal cancer from 2009 to 2011 were used. Patients with marked regression to neoadjuvant therapy were classified as responders and the remainder were classified as nonresponders. Markers of EMT included reduced immunohistochemical expression of membranous E-cadherin, increased nuclear beta-catenin expression and tumour budding. In-situ hybridization was used to assess the expression of microRNA-200c (mir200c), an upstream master-regulator of EMT. ResultsOf 103 patients undergoing resection of rectal cancer, 69 received neoadjuvant chemoradiotherapy; 65% of these were nonresponders. Reduced expression of mir200c was significantly associated with a higher T grade. Reduced membranous E-cadherin, increased nuclear beta-catenin and tumour budding individually predicted the presence of extramural vascular invasion. Reduced E-cadherin, nucleic beta-catenin, reduced expression of mir200c and tumour budding were all significantly associated with nonresponse to neoadjuvant therapy (all P

Deregulated Toll-like receptor (TLR)-triggered inflammatory responses that depend on NF-κB are detrimental to the host via excessive production of proinflammatory cytokines, including TNF-α. Stat2 is a critical component of type I IFN signaling, but it is not thought to participate in TLR signaling. Our study shows that LPS-induced lethality in Stat2 −/− mice is accelerated as a result of increased cellular transmigration. Blocking intercellular adhesion molecule-1 prevents cellular egress and confers survival of Stat2 −/− mice. The main determinant of cellular egress in Stat2 −/− mice is the genotype of the host and not the circulating leukocyte. Surprisingly, lethality and cellular egress observed on Stat2 −/− mice are not associated with excessive increases in classical sepsis cytokines or chemokines. Indeed, in the absence of Stat2, cytokine production in response to multiple TLR agonists is reduced. We find that Stat2 loss leads to reduced expression of NF-κB target genes by affecting nuclear translocation of NF-κB. Thus, our data reveal the existence of a different mechanism of LPS-induced lethality that is independent of NF-κB triggered cytokine storm but dependent on cellular egress.

Consensus abstract Background The management of primary rectal cancer beyond total mesorectal excision planes (PRC-bTME) and recurrent rectal cancer (RRC) is challenging. There is global variation in standards and no guidelines exist. To achieve cure most patients require extended, multivisceral, exenterative surgery, beyond conventional total mesorectal excision planes. The aim of the Beyond TME Group was to achieve consensus on the definitions and principles of management, and to identify areas of research priority. Methods Delphi methodology was used to achieve consensus. The Group consisted of invited experts from surgery, radiology, oncology and pathology. The process included two international dedicated discussion conferences, formal feedback, three rounds of editing and two rounds of anonymized web-based voting. Consensus was achieved with more than 80 per cent agreement; less than 80 per cent agreement indicated low consensus. During conferences held in September 2011 and March 2012, open discussion took place on areas in which there is a low level of consensus. Results The final consensus document included 51 voted statements, making recommendations on ten key areas of PRC-bTME and RRC. Consensus agreement was achieved on the recommendations of 49 statements, with 34 achieving consensus in over 95 per cent. The lowest level of consensus obtained was 76 per cent. There was clear identification of the need for referral to a specialist multidisciplinary team for diagnosis, assessment and further management. Conclusion The consensus process has provided guidance for the management of patients with PRC-bTME or RRC, taking into account global variations in surgical techniques and technology. It has further identified areas of research priority.

Background/Aims: The way in which liver biopsies showing chronic hepatitis are reported is undergoing re-evaluation. A related question is how the inflammatory and fibrotic changes in these liver biopsies can be semi-quantitatively assessed so that comparisons can be made between groups of patients and the effect of treatment on disease progression studied. Methods: We have carried out a blinded trial in which 20 cases of chronic viral hepatitis were assessed by five histopathologists, using the Knodell and Scheuer scoring systems (two of the most commonly used systems), on two separate occasions. The results were analysed using Kappa statistics, and also by seeing for how many slides the pathologists showed no significant disagreement. Results: While both systems produced good inter- and intra-observer variation when fibrosis was assessed the Scheuer system produced slightly higher Kappa values. The Scheuer system produced considerably better agreement when the severity of inflammation was examined. A multirater kappa analysis confirmed that both systems showed better agreement for fibrosis scores than for inflammation scores. Conclusion: We conclude that, while both systems produced reasonable agreement, this was greater using the Scheuer system. When any new scoring system is being developed, the question of reproducibility needs active consideration.

Research into the pathogenesis of acetaminophen (paracetamol)-induced hepatotoxicity has concentrated on the generation of toxic metabolites by the hepatocytes. It has, however, recently been shown that human macrophages cultured with acetaminophen secrete increased quantities of tumour necrosis factor (TNF). This study examines whether macrophages have a direct role in acetaminophen toxicity, using a mouse model in which it is possible to eliminate more that 99 per cent of hepatic macrophages by previously injecting liposomes containing dichloromethylene disphosphonate (DMDP). Acetaminophen-induced liver damage was assessed biochemically and histologically. It was shown that the liver damage occurring 0.5, 1, and 2 h after an intraperitoneal injection of acetaminophen was significantly less in mice previously injected with liposomes containing DMDP than in previously untreated mice, or mice previously injected with empty liposomes. By 4 h there was no difference between the groups. We conclude that macrophages play an early and probably a direct role in mediating the liver damage due to acetaminophen. This is consistent with the role that macrophages have been shown to play in the pathogenesis of alcohol-induced liver damage.

Background Real time electrospray ionization mass spectrometry (REIMS) enables detailed analysis of tumour lipid chemistry, based on real time analysis of electrocautery smoke plumes. Methods: This was a prospective, observational study performed at St. Mary's Hospital, London, UK. Patients undergoing elective surgical resections for colorectal cancer were recruited and fresh samples were analyzed ex-vivo using a typical electrosurgery hand piece and monopolar diathermy. Sampling was performed using cutting mode with a standard generator and 30W of output power (ValleylabTM). The hand piece was modified to allow aspiration of the electrosurgical aerosol to a Xevo G2-S iKnife QTof mass spectrometer (Waters Corporation). Raw mass spectrometric data were converted to imzML format (MSConvert) and imported into MATLAB (R2014a) for pre-processing. A prospective database of healthy, dysplastic and malignant colorectal tissues was built and multivariate analysis was performed using principal component analysis and linear discriminant analysis. Classification of each individual tissue type was performed using leave-one-patient-out cross-validation. Results 40 consecutive patients were recruited (22 male, median age 68y, range 47-90). Of the 23 tumor samples 10 were rectal adenocarcinoma and 13 colonic adenocarcinoma. TNM staging of the tumour samples was as follows: T2 (8), T3 (11) T4 (4), N0 (12), N1 (6) N2 (5), M0 (22), M1 (1). Distinction of healthy and malignant colorectal tissue for the whole data set demonstrated an overall classification accuracy of 94.4% and a sensitivity of 92.4%, Specificity 96.8% (ROC AUC 0.98). The diagnostic accuracy for dysplasia was 93.7% (Specificity 95.1%, sensitivity 85.7%, AUC 0.97). Increases in glycerophospholipids (p Conclusion REIMS chemical histology provides near real time diagnostic and prognostic information for stratifying oncological and surgical therapy. Citation Format: James Macalister Kinross, Laura Muirhead, James Alexander, Julia Balog, Cristina Guallar-Hoya, Abigail Speller, Ottmar Golff, Rob Goldin, Ara Darzi, Jeremy Nicholson, Zoltan Takats. iKnife: Rapid evaporative ionization mass spectrometry (REIMS) enables real-time chemical analysis of the mucosal lipidome for diagnostic and prognostic use in colorectal cancer. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3977.

Background: Lipid metabolic alterations are recognised as potential oncogenic triggers that promote malignant transformation. Here we performed spatially-resolved profiling of lipid signatures in colorectal cancer (CRC) tissue and matched healthy mucosa using desorption electrospray ionisation imaging mass spectrometry (DESI-MSI). The objectives of this study were to comprehensively define the CRC ‘lipidome’ and to assess lipid signatures in discrete histological regions-of-interest, specifically morphologically bland peri-tumoural epithelium (PT-e) and tumour stroma (T-s). Methods: Fresh frozen tissue sections from 42 patients with confirmed CRC were subjected to negative-ion mode DESI-MSI analysis. Mass spectra in the 200-1000 m/zrange were collated from CRC epithelium (CRC-e), PT-e, T-s and healthy tumour-remote epithelium (TR-e). Spectral signatures were subjected to multivariate analysis using a recursive maximum margin criterion (RMMC) algorithm operating in MATLAB. Results: Increased levels of long/very-long chain fatty acids (LCFA/VLCFA) were seen in CRC-e compared with TR-e(AUC = 0.99). Correspondingly, increased expression of lipogenic and elongase enzymes was found on IHC. Transmission electron microscopy was performed to evaluate peroxisomal distribution and morphology in CRC-e, as these organelles metabolise LCFA/VLCFA through β-oxidation, to negligibly low levels, in healthy cells. No discernible difference in peroxisomal distribution, abundance or structure was found between CRC-e and TR-e. PT-e demonstrated a lipid expression pattern almost identical to that of CRC-e, and markedly different from TR-e (AUC = 0.89). Conclusions: A shift towards increased LCFA/VLCFA production may be an important metabolic trait in CRC facilitated through upregulation of de novo lipogenesis and fatty acid elongation and concurrent impairment of peroxisomal β-oxidation. This phenotype was also observed in morphologically bland PT-e, suggesting that enhanced de novo LCFA/VLCFA biosynthesis and impaired peroxisomal function may represent important steps in peri-tumoural field cancerisation.

The effects of hepatitis C virus genotype and viraemia on disease outcome in patients with chronic hepatitis C virus infection were studied. Patients infected with genotype 1 tended to develop more severe disease, and to respond less well to interferon (IFN) treatment, but no pretreatment variable successfully predicted either the severity of the disease or the response to IFN. Failure to eliminate the virus during the first three months of therapy, however, predicted a failure to derive long term benefit from the current IFN regime. Hence pretreatment variables cannot be used to determine whether individual patients will respond to IFN, but observations during the first three months of therapy can be used to decide which patients will not respond to prolonged therapy. In these patients consideration should be given to changing the IFN dosing regime or using alternative treatments.

Extended lymphadenectomy in gastroesphageal cancer leads to improved long-term survival without compromising postoperative outcomes in Western patients to attain the standard achieved in Japanese centers.Cohort study comparing postoperative outcomes and long-term survival with data from the National Cancer Center (NCC) of Tokyo, Japan. Outcomes were also compared with data from the UK National Oesophago-Gastric Cancer Audit (NOGCA) and a representative cohort from southeast England. Prospectively collected data were independently audited.University medical center.From 2003 to 2010, 100 patients underwent gastrectomy and 109 underwent esophagectomy.Postoperative mortality and morbidity and long-term overall survival. Lymph node count was used as a measure for the extent of lymphadenectomy.One death occurred after esophagectomy and none after gastrectomy. Anastomotic leak rate was approximately 2% in both cohorts. Kaplan-Meier estimates of 5-year overall survival after gastrectomy and esophagectomy were 58.4% and 47.8%, respectively. Postoperative mortality and technical complications for gastric and esophageal cancer resections were similar to NCC rates (P = .20). Stage for stage 5-year survival rates in patients with esophageal cancer and stages II and III gastric cancer were similar to outcomes in the NCC. The 5-year survival for patients with gastric cancer was worse for those with stage I (P.001) and better for those with stage IV (P.001) disease compared with NCC rates. Postoperative outcomes and long-term survival were significantly better than those reported by the NOGCA and the data from the southeast of England (P.05).This study demonstrates that postoperative outcomes and long-term survival after gastroesophageal cancer resection can be improved in Western patients to the highest standard achieved in Japan.

RAS is frequently mutated in human cancers and has opposing effects on autophagy and tumorigenesis. Identifying determinants of the cellular responses to RAS is therefore vital in cancer research. Here, we show that autophagic activity dictates the cellular response to oncogenic RAS. N-terminal Apoptosis-stimulating of p53 protein 2 (ASPP2) mediates RAS-induced senescence and inhibits autophagy. Oncogenic RAS-expressing ASPP2 (Δ3/Δ3) mouse embryonic fibroblasts that escape senescence express a high level of ATG5/ATG12. Consistent with the notion that autophagy levels control the cellular response to oncogenic RAS, overexpressing ATG5, but not autophagy-deficient ATG5 mutant K130R, bypasses RAS-induced senescence, whereas ATG5 or ATG3 deficiency predisposes to it. Mechanistically, ASPP2 inhibits RAS-induced autophagy by competing with ATG16 to bind ATG5/ATG12 and preventing ATG16/ATG5/ATG12 formation. Hence, ASPP2 modulates oncogenic RAS-induced autophagic activity to dictate the cellular response to RAS: to proliferate or senesce.

Activation of hepatic stellate cells (HSCs) and subsequent uncontrolled accumulation of altered extracellular matrix (ECM) underpin liver fibrosis, a wound healing response to chronic injury, which can lead to organ failure and death. We sought to catalogue the components of fibrotic liver ECM to obtain insights into disease etiology and aid identification of new biomarkers. Cell-derived ECM was isolated from the HSC line LX-2, an in vitro model of liver fibrosis, and compared to ECM from human foreskin fibroblasts (HFFs) as a control. Mass spectrometry analyses of cell-derived ECMs identified, with ≥99% confidence, 61 structural ECM or secreted proteins (48 and 31 proteins for LX-2 and HFF, respectively). Gene ontology enrichment analysis confirmed the enrichment of ECM proteins, and hierarchical clustering coupled with protein-protein interaction network analysis revealed a subset of proteins enriched to fibrotic ECM, highlighting the existence of cell type-specific ECM niches. Thirty-six proteins were enriched to LX-2 ECM as compared to HFF ECM, of which Wnt-5a and CYR61 were validated by immunohistochemistry in human and murine fibrotic liver tissue. Future studies will determine if these and other components may play a role in the etiology of hepatic fibrosis, serve as novel disease biomarkers, or open up new avenues for drug discovery.

Hepatic lipid is important in the pathogenesis and progression of hepatitis C-related liver disease. Polyunsaturated fatty acids have been shown to reduce viral replication in cell culture. Proton magic angle spinning magnetic resonance spectroscopy ((1) H MAS MRS) enables metabolic analysis of intact tissue. The aim was to examine the relationship between hepatic lipid composition by metabolic profiling of liver tissue at baseline and treatment response to pegylated-Interferon alfa2 and Ribavirin. Baseline liver biopsy samples from 31 patients with chronic hepatitis C were analyzed histologically and by (1) H MAS MRS. Indices of lipid composition were derived and partial least squares discriminant analysis with cross-validation was used to predict treatment outcome. Of 31 patients, 14 achieved sustained virological response (SVR). Lipid polyunsaturation (median (IQR)) was higher in SVR (3.41% (2.31)) than in treatment failure (TF) (2.15% (1.51)), P = 0.02. Lipid saturation was lower in SVR (85.9% (3.39)) than TF (86.7% (2.17)), P = 0.04. The total lipid content was lower in SVR (1.54% (0.81)) than TF (2.72% (3.47)), P = 0.004. Total choline to lipid ratio was higher in SVR (11.51% (9.99)) than TF (7.5% (6.82)), P = 0.007. Cross-validation correctly predicted the SVR group in 13 of 14 samples with 1 sample misclassified, and the TF group in all 17 samples. Lipid polyunsaturation was greater and total lipid lower in those with SVR, compared with TF. Metabolic profiling of intact liver biopsy samples predicted SVR with high accuracy. Hepatic lipid composition may impact on treatment success.

Contrast-enhanced ultrasound can be used to assess liver disease severity non-invasively by observing intra- and extrahepatic hemodynamic changes. Transit times are calculated to include intra- and extrahepatic components (hepatic vein transit time, HVTT) or the intrahepatic component (hepatic transit time, HTT), but these have not been compared directly. We aimed to compare diagnostic accuracy of HVTT and HTT in gauging the severity of chronic hepatitis C (CHC) and to assess inter- and intra-observer reliability. Recorded ultrasound scans performed on 75 patients with biopsy-staged CHC, using the microbubble contrast agent Sonovue were analyzed. Diagnostic accuracy of HTT and HVTT for diagnosis of cirrhosis was 0.78 and 0.71 (P = 0.24). Diagnostic accuracy of HTT and HVTT for diagnosis of fibrosis stage2 was 0.76 and 0.72 (P = 0.23). Negative predictive value for cirrhosis using this cut-off was high for both techniques (HVTT, 88%; HTT, 92%), suggesting utility for exclusion of cirrhosis. Inter-observer reliability for HTT and HVTT were 0.92 and 0.94, respectively. Intra-observer reliability for HTT and HVTT were 0.98 and 0.99. In this cohort, reliability exceeded 90% while diagnostic accuracy was in keeping with previous studies of microbubble transit time analysis. Despite higher numerical diagnostic accuracy for HTT, no significant difference was demonstrated between the techniques, suggesting that both methods can be used reliably.

The non-alcoholic fatty liver disease (NAFLD) activity score (NAS) is the histological tool used to assess disease severity based on steatosis, inflammation and hepatocyte ballooning. As steatosis contributes up to three of a potential eight points to NAS, it is important to quantify steatosis accurately. We sought to determine the optimum histological technique for identifying fat in tissue.Using tissue from a mouse model of NAFLD, with validation in human liver biopsies, the percentage steatosis and fat droplet size were assessed in haematoxylin and eosin (HE)- and Oil Red-O (ORO)-stained sections by light microscopy and digital image analysis (DIA). Results were compared to biochemical tissue triglyceride content and MRI assessment of hepatic lipid content. HE steatosis assessment correlated poorly with tissue triglyceride concentration. However, ORO DIA exhibited much higher sensitivity and specificity for steatosis and correlated very well with triglyceride concentration in mouse and human liver (R = 0.706, P = 0.001 and R = 0.894, P =0.041, respectively). MRI-based assessment of steatosis was inaccurate.ORO DIA is the most accurate method for detecting and quantifying steatosis. Although HE-based NAS remains clinically valid in both clinical research and experimental situations, ORO DIA is a more robust technique to assess liver steatosis accurately for NAS scoring.

Computer-aided diagnosis of ophthalmic diseases using optical coherence tomography (OCT) relies on the extraction of thickness and size measures from the OCT images, but such defined layers are usually not observed in emerging OCT applications aimed at "optical biopsy" such as pulmonology or gastroenterology. Mathematical methods such as Principal Component Analysis (PCA) or textural analyses including both spatial textural analysis derived from the two-dimensional discrete Fourier transform (DFT) and statistical texture analysis obtained independently from center-symmetric auto-correlation (CSAC) and spatial grey-level dependency matrices (SGLDM), as well as, quantitative measurements of the attenuation coefficient have been previously proposed to overcome this problem. We recently proposed an alternative approach consisting of a region segmentation according to the intensity variation along the vertical axis and a pure statistical technology for feature quantification. OCT images were first segmented in the axial direction in an automated manner according to intensity. Afterwards, a morphological analysis of the segmented OCT images was employed for quantifying the features that served for tissue classification. In this study, a PCA processing of the extracted features is accomplished to combine their discriminative power in a lower number of dimensions. Ready discrimination of gastrointestinal surgical specimens is attained demonstrating that the approach further surpasses the algorithms previously reported and is feasible for tissue classification in the clinical setting.

C57BL mice were depleted of macrophages by an intravenous injection of liposome-encapsulated dichloromethylene diphosphonate (DCMDP), and control mice were uninjected or injected with empty liposomes. One day after injection, a proportion of the DCMDP-treated and control mice was continuously exposed to ethanol vapor for 4 days. Albumin fractions were separated from the sera of both ethanol-unexposed and ethanol-exposed animals and tested for cytotoxicity against a monolayer of A9 cells using two indicators of cytotoxicity: detachment of adherent cells and a decrease in the ability of cells to reduce tetrazolium. The results show that, in mice exposed to ethanol, macrophages are a major source of the acetaldehyde in circulating cytotoxic acetaldehyde-albumin complexes and presumably also of free acetaldehyde.

In situ hybridization with oligonucleotide probes has been used to localise hepatitis A virus RNA genomic sequences in formalin-fixed and routinely processed human liver biopsies from three patients. Using radiolabelled Sulphur-35 antisense probes, viral genomic sequences were found in all three cases, but signal intensity was greatest in cases 1 and 2 with fulminant hepatitis, and was minimal in the third case of resolving hepatitis biopsied 2 months after acute illness. Localisation showed the viral RNA to be present in hepatocytes, sinusoidal cells and inflammatory cells in and around the portal tracts. Both cases showed signal in similar cell types, but the distribution of staining was predominantly periportal in case 1, whereas lobular staining was more apparent in case 2. Hybridization with sense polarity probes failed to detect any evidence of replicative intermediates of antigenomic viral RNA. The presence of hepatitis A RNA in phagocytic cells was confirmed using immunohistochemistry for a macrophage marker, CD68, combined with in situ hybridization. In all cases the signal was predominantly cytoplasmic, and this was confirmed with the use of tritiated probes.

The present review describes commonly employed metabolic profiling platforms and discusses the current and likely future application of these technologies in surgery.The metabolic adaptations that occur in response to surgical illness and trauma are incompletely understood. Evaluating these will be critical to the development of personalized surgical health solutions. Metabonomics is an advancing field in systems biology, which provides a means of interrogating these metabolic shifts.Recent literature regarding metabolic profiling technologies and their applications in surgical practice are discussed. Future strategies are proposed for the incorporation of these and next-generation technologies in the evaluation of all steps in the patient surgical pathway.Metabolite-based profiling has provided valuable insights into the metabolic irregularities that occur in cancer development and progression across a variety of cancer subclasses including colorectal, breast, prostate, and lung cancers. In addition, metabolic modeling has shown considerable promise in other surgical conditions including trauma and sepsis and in the assessment of pharmacotherapeutic efficacy.Metabonomics offers a posttranscriptional view of system activity providing functional information downstream of the genome and proteome. Information at this level will provide the surgeon with a novel means of evaluating major socioeconomic problems such as cancer and sepsis. In addition, the rapid nature of emerging next generation profiling platforms provides a viable means of "real-time" perioperative metabolic assessment and optimization.

Purpose: To assess the diagnostic accuracy of magnetic resonance imaging (MRI) in detecting colorectal tumour invasion according to seven intrapelvic compartments for planning exenterative pelvic surgery. Method: Sixty-three consecutive patients underwent preoperative MRI planning for exenterative surgery, defined as operative excision beyond conventional mesenteric planes for locally advanced (n = 23) and recurrent (n = 41) pelvic colorectal cancer. The institutional research committee approved of the study and waived the need for a consent form as the images were retrospectively assessed. Two radiologists reported tumour invasion for each of seven anatomic surgical resection compartments, blinded to histopathology and the intraoperative findings. Sensitivity, specificity and predictive values were calculated for the seven intrapelvic compartments. Cox regression analysis was used to calculate the risk of death and recurrence. Overall interobserver agreement was assessed using Cohen's Kappa coefficient (k). Results: The sensitivity of MRI was >= 93.3% in all but the lateral compartment where it was 89.3%. Specificity for the posterior (82.2%) and anterior compartments below the peritoneal reflection (86.4%) was lower compared to the other compartments. Agreement between the two radiologists was found to be good or very good for all compartments (k > 0.72). An MRI diagnosis of tumour invasion in the anterior compartment above the peritoneal reflection was associated with a poorer survival (p = 0.012). Conclusion: MRI is accurate in predicting the extent of colorectal tumour within the pelvis and therefore can be used to determine the type of surgery required for curative resection. It should always be used to stage patients with advanced colorectal pelvic cancer. (C) 2012 Elsevier Ltd. All rights reserved.

Background & Aims. Assess the clinical utility of the Prati criteria and normal ALT (Methods. Serology, radiology, and histology were obtained in 140 patients with CHB. Results. HBeAg+ group: 7 patients (7/56−12% HBeAg+ group) misclassified as “immunotolerant”, with HBV DNA > 6 log copies/ml and normal ALT, who in fact had moderate/severe fibrosis on liver biopsy. HBeAg− group: 10 patients with normal ALT and moderate/severe fibrosis on liver biopsy; 4 of these patients had >3 log copies/ml HBV DNA levels and 6 patients misclassified as “inactive carriers” with negative HBV DNA levels normal ALT and moderate/severe fibrosis (6/84−7% HBeAg− group). Two male HBeAg+ and three male HBeAg- patients with ALT between 20 and 30 IU/L and moderate/severe fibrosis on liver biopsy would have been further mischaracterised using the Prati criteria for normal ALT. Age and ethnic group were more important predictors of moderate/severe fibrosis in multivariate analysis. Conclusion. HBeAg status, age, ethnic origin with longitudinal assessment of LFTs and viral load should be studied in patients with “normal ALT” at the upper end of normal range (ALT 20–40 IU/L) to appropriately classify patients and identify patients for liver fibrosis assessment to inform treatment decisions.

A 24 year old male student from Poland attended the emergency department with a one week history of jaundice. He also had orange urine and non-specific abdominal pain, which he attempted to relieve by drinking alcohol. He had experienced no vomiting or change in bowel habit or stool consistency. There was no history of jaundice, illness, surgery, or blood transfusion. He was not taking any regular drugs and gave no history of drug allergies. He denied intravenous drug abuse but admitted taking ecstasy at a party a fortnight ago. He had recently spent two weeks in Poland over Christmas. During the previous week he had drunk about 21 units of alcohol. He was homosexual but had not been sexually active for two weeks before presentation. On examination he was afebrile and overtly jaundiced. His abdomen was soft, non-tender, he had no palpable masses, and bowel sounds were present. It was noticed that he had an abdominal piercing. There were no signs of hepatic encephalopathy. On admission his liver function tests were deranged: alanine aminotransferase (ALT) was 2891 IU/L (reference value

We present the results from a feasibility study which measures properties in the terahertz frequency range of excised cancerous, dysplastic and healthy colonic tissues from 30 patients. We compare their absorption and refractive index spectra to identify trends which may enable different tissue types to be distinguished. In addition, we present statistical models based on variations between up to 17 parameters calculated from the reflected time and frequency domain signals of all the measured tissues. These models produce a sensitivity of 82% and a specificity of 77% in distinguishing between healthy and all diseased tissues and a sensitivity of 89% and a specificity of 71% in distinguishing between dysplastic and healthy tissues. The contrast between the tissue types was supported by histological staining studies which showed an increased vascularity in regions of increased terahertz absorption.

The increasing incidence of non-alcoholic fatty liver diseases (NAFLD) and the consequent progression to cirrhosis is expected to become a major cause of liver transplantation. This will exacerbate the organ donor shortage and mean that 'marginal' fatty liver grafts are more frequently used. Autofluorescence spectroscopy is a fast, objective, and non-destructive method to detect change in the endogenous fluorophores distribution and could prove to be a valuable tool for NAFLD diagnosis and transplant graft assessment.A system was constructed consisting of a fibre probe with two laser diodes that provided excitation light at 375 and 405 nm, and an imaging spectrograph system. This was used to distinguish fluorescence spectra acquired from the harvested livers from mice with NAFLD of differing severity (healthy, mild steatotic and steatohepatitic). The fluorescence data were entered into a sparse multiclass probabilistic algorithm for disease classification. Histopathology, thiobarbituric acid reactive substances (TBARS) and alanine transaminase (ALT) assays were conducted in addition to the fluorescence measurementsTBARS and ALT assays enabled differentiation of the steatohepatitic group from the mild steatosis and control groups (P ≤ 0.028) but failed to separate the mild steatotic group from the control group. The three groups were all clearly differentiated from each other using fluorescence spectroscopy, and classification accuracy was found to be 95%.Fluorescence spectroscopy appears to be a promising approach for the analysis of diseased liver tissue.

Oncogene-induced senescence represents a key tumor suppressive mechanism. Here, we show that Ras oncogene-induced senescence can be mediated by the recently identified haploinsufficient tumor suppressor apoptosis-stimulating protein of p53 (ASPP) 2 through a novel and p53/p19 Arf /p21 waf1/cip1-independent pathway. ASPP2 suppresses Ras-induced small ubiquitin-like modifier (SUMO)-modified nuclear cyclin D1 and inhibits retinoblastoma protein (Rb) phosphorylation. The lysine residue, K33, of cyclin D1 is a key site for this newly identified regulation. In agreement with the fact that its nuclear localization is required for its oncogenic activity, we show that nuclear cyclin D1 is far more potent than wild-type (WT) cyclin D1 in bypassing Ras-induced senescence. Thus, this study identifies SUMO modification as a positive regulator of nuclear cyclin D1, and reveals a new way by which cell cycle entry and senescence are regulated. © 2011 Macmillan Publishers Limited All rights reserved.

The terminal protein domain of the hepatitis B viral polymerase can inhibit the cellular response to interferon. To clarify the clinical relevance of this inhibitory effect, we examined the expression of terminal protein in liver biopsy specimens from patients with chronic hepatitis B infection. We found that expression of terminal protein is associated with a failure of hepatocytes to respond to interferon, as assessed by expression of the interferon-inducible protein β2-microglobulin. Patients whose liver specimens contained large numbers of cells expressing terminal protein tended not to respond to treatment. During interferon therapy the percentage of cells expressing terminal protein remained constant, but treatment significantly reduced the number of cells that expressed the hepatitis B nucleocapsid protein. Hence expression of terminal protein in a cell may prevent elimination of the virus by interferon therapy. (Hepatology 1993;17:757–762.)

Background and methods In advanced liver damage, hepatic regeneration can occur through proliferation of a resident hepatic progenitor cell (HPC) population. HPCs are located within a designated niche in close association with myofibroblasts and bone marrow (BM) derived macrophages. Extra-cellular matrix (ECM) laminin invariably surrounds HPCs, but the functional requirement of this matrix-cell association is untested in vivo. Using the collagen Iα1 (r/r) mouse (r/r), which produces mutated collagen I resistant to matrix metalloproteinase degradation and has an exaggerated fibrotic response to liver injury, we test the relationship between collagen degradation, laminin deposition, and the HPC response. Results Chronic fibrotic carbon tetrachloride (CCl 4 ) injury can induce a florid HPC response associated with dense laminin deposition. In the recovery phase after chronic CCl 4 injury, r/r mice have a markedly attenuated HPC response compared to wild-types, together with persistence of collagen I and failure to deposit ECM laminin. Similar results were found in r/r mice given the choline-deficient ethionine supplemented diet, another model of the HPC response. In cross-over sex-mismatched BM transplantation (BMT) experiments between r/r mice and wild-types, the blunted HPC response of r/r mice was not rescued by wild-type BMT and likewise not conferred on to wild-type recipients by r/r BMT, demonstrating that the attenuated HPC response in r/r mice is a property intrinsic to the liver. Conclusion Failure of ECM remodelling after chronic fibrotic liver injury hinders the ability of the liver to activate HPCs. Laminin-progenitor cell interactions within the HPC niche are a critical for HPC mediated regeneration.

Background: Recent decades have seen combination chemoradiotherapy become the standard treatment for anal squamous cell carcinoma (SCC). However, the burden of this disease continues to rise, with only 10% of patients with metastatic disease surviving >2 years. Further insight into tumour characteristics and molecular biology may identify novel therapeutic targets. This systematic review examines current prognostic markers in SCC of the anus. Methods: An extensive literature search was performed to identify studies reporting on biomarkers in anal cancer in the context of clinical outcome following treatment primarily with chemoradiotherapy. Results: In all, 21 studies were included. A total of 29 biomarkers were studied belonging to 9 different functional classes. Of these biomarkers, 13 were found to have an association with outcome in at least one study. The tumour-suppressor genes p53 and p21 were the only markers shown to be of prognostic value in more than one study. Conclusions: An array of biomarkers have been identified that correlate with survival following chemoradiotherapy in anal cancer. However, investigators are yet to identify a biomarker that has the ability to consistently predict outcome in this disease. Further studies are needed to elucidate whether these candidate biomarkers demonstrate their optimum value when they serve as targets for new therapeutic strategies.

Levene A P & Goldin R D (2010) Histopathology56, 426–429 Physiological hepatic nuclear vacuolation—how long does it persist? Aims: Nuclear vacuolation\glycogenation is a characteristic histological feature of non-alcoholic fatty liver disease (NAFLD) that can help distinguish it from alcohol-induced liver disease. There are, however, other associations of nuclear vacuolation of which the commonest is as a normal feature of childhood. The aim of this study was to identify how long this physiological nuclear vacuolation persists. Methods and results: Liver biopsy specimens from 872 patients with chronic hepatitis B virus infection (a condition known not to be associated with nuclear vacuolation) were studied to assess the frequency of nuclear vacuolation at different ages. All the patients studied had a body mass index of

Introduction Merkel cell carcinoma is an uncommon skin malignancy that has a high propensity for metastatic spread. A systematic literature search identified 17 cases describing metastasis to the gastrointestinal tract, with 7 cases involving the small or large bowel. To the best of our knowledge, this is the only case described of Merkel cell carcinoma metastasising to the ileocaecal valve. Case presentation We present a 74-year-old Filipino woman diagnosed with Merkel cell carcinoma of the skin with regional node involvement. Following excision and radiotherapy, the tumour recurred with metastasis to the ileocaecal valve. The patient died 28 months after the initial diagnosis. Conclusion The prognosis of metastatic Merkel cell carcinoma is poor. Currently the optimal management for metastatic disease is unclear and lacks a firm evidence base due to the small number of cases reported.

An in situ hybridization method using radiolabeled oligonucleotide probes was developed to study primary sites of hepatitis A virus replication in an experimental animal model of infection. Hepatitis A genomic sequences were demonstrated in hepatocytes of four marmosets with acute hepatitis A by use of antisense probes. In two of these animals, staining was also found when a sense probe was used, which is consistent with active replication in the hepatocytes. The specificity of the hybridization signal was confirmed by neutralization with “cold” (i.e., unlabeled) probes and by absence of hybridization with non-A hepatitis and reverse antisense probes. The hepatocyte appeared to be the only cell type showing staining. No hybridization was found in other organs, including the intestine (n = 4) and, in one animal, the kidney and spleen. (HEPATOLOGY 1992;16:642–648.)

Delta hepatitis (HDV) infection can only occur in the presence of hepatitis B (HBV) infection, as HDV requires a coat of HBV surface antigen (HBsAg) for assembly of complete virus. A number of studies have examined the variation of HBV markers in serum and liver during establishment of HDV infection, but none has systematically examined the relationship between the two viruses in individual hepatocytes. Liver biopsies from five patients with HDV/HBV infection were stained for HBsAg, HBV core antigen (HBcAg) and hepatitis D (delta) antigen (HDAg). Double immunostaining was performed with a combination of indirect immunoperoxidase and alkaline phosphatase/anti-alkaline phosphatase techniques. HDV and HBV antigens were expressed in all five liver biopsies. Co-localization of HBsAg was seen in up to 39% of HDAg positive cells, and HBcAg in up to 8% of HDAg positive cells. HBcAg was detectable in approximately 9% of HBsAg positive cells, and HBsAg in approximately 12% of HBcAg positive cells. HDV can replicate without HBV but ultimately requires HBV to produce complete virus and subsequently infect other cells. In this study the majority of HDV positive cells did not appear to contain HBV markers. This might suggest delta virus replication without assembly, or possibly sequential production/assembly of the virus.

Gallbladder cancer (GBC) shows a marked geographical variation in its incidence, with the highest figures being seen in India and Chile and relatively low levels in many Western countries. Risk factors for its development include the presence of gallstones, infection and the presence of an anomalous pancreatobiliary ductal junction. It can arise from either a pathway involving metaplasia or dysplasia or one in which there is a pre-existing adenoma. The former is the more common and, because it is often not associated with a macroscopically recognizable lesion, leads to the recommendation that all gallbladders need to be examined microscopically. Accurate staging of invasive cancers is essential to determine prognosis and treatment, and this requires extensive tumour sampling. A number of genetic alterations have been identified in the preinvasive and invasive stages of GBC and they support the morphological evidence of there being two pathways by which tumours develop. Some of these genetic changes are associated with particular risk factors. For example, cases with anomalous pancreatobiliary ductal junction show a higher frequency of K-ras mutations. Some changes are associated with differences in prognosis. For example, cancers without expression of p21 but with expression for p27 have a better prognosis, whereas those that express c-erb-B2 have a worse one. Work has also been done on identifying clinical, imaging and other factors that indicate that patients have a higher risk of having GBC. This is particularly important in high-incidence areas in which GBC is a significant public health problem.

Colonoscopy is the most widely prescribed colonic imaging method for the clinical surveillance of colorectal cancer for the detection of adenomatous polyps. However, some adenomas appear diminutive and flat, making them difficult to discriminate from non-neoplastic tissue even for the most experienced colonoscopists. We report here an optical system for performing excitation resolved visible and near-infrared autofluorescence imaging and hyperspectral imaging for the accurate distinction between neoplastic and non-neoplastic tissue. This is demonstrated on ex vivo colorectal tissues using our multimodal imaging system, which has potential applications for the in vivo endoscopic imaging and diagnosis of colorectal cancer tissue.

BackgroundTreatment strategies in chronic hepatitis B (CHB) are evolving as more potent oral antivirals become available. However, drug resistance remains a major challenge and policy guidelines on management are limited by the evidence base. This study aims to review the implications of the National Institute for Health and Clinical Excellence (NICE) guidelines in a cohort of unselected CHB patients in the United Kingdom and to evolve a management algorithm for their treatment.MethodsIn total, 783 unselected hepatitis B surface antigen-positive patients, were assessed of whom 212 (27%) underwent liver biopsy. Age, alanine aminotransferase, hepatitis B virus DNA and necroinflammatory score were analysed to determine their value as predictors of fibrosis. Patients with biopsy evidence of fibrosis were offered treatment and followed longitudinally. Six-month on-treatment virologic response was evaluated to determine the validity of this strategy in predicting the early emergence of resistance.ResultsAge, gender and necroinflammatory score were predictors of fibrosis in CHB patients, whereas age >40 years was a predictor of cirrhosis in both hepatitis B e antigen (HBeAg)-positive ( PConclusionsAdvanced liver disease was present in patients falling outside current treatment guidelines, highlighting the importance of liver histology in identifying fibrosis and the need for antiviral therapy. While 6 month on-treatment virologic response as a trigger for instituting add-on therapy may be an improvement on the current recommendations, such a strategy should be integrated into any new treatment algorithm, likely to consist of entecavir and tenofovir.

The presence of hepatitis delta virus genomic RNA and hepatitis delta antigen was investigated in woodchuck liver and extrahepatic tissues by in situ hybridization using synthetic radiolabeled probes, Northern-blot analysis and immunohistochemical staining for hepatitis delta antigen. Hepatitis D virus RNA and hepatitis delta antigen were detected in the nuclei of infected hepatocytes but in none of the other tissues examined. Northern-blot analysis of total cell RNA confirmed these findings and revealed a series of hepatitis D virus transcripts, including full-length genomic RNA and dimers and trimers of hepatitis D virus RNA that may represent replicative intermediates. Use of single-stranded probes showed genome-size monomers and dimers to be both of genomic and antigenomic polarity, although dimers were found to be predominantly antigenomic. These findings document the strict hepatotropism of hepatitis D virus and support the rolling-circle model of genome replication for this unique, defective RNA virus.

Terahertz pulsed imaging (TPI) is a non-ionizing and non-destructive technique. Image contrast has been seen between normal and diseased tissues in ex vivo measurements. In this study, terahertz images of excised colon tissue show contrast between regions of tumor and normal tissue. Averaged waveforms from within tumor and normal regions are different. A number of parameters from the data have been identified that show statistically significant differences (p

Background and aims Patients with HIV and hepatitis C virus (HCV) coinfection are at increased risk of developing hepatic steatosis. The aims of this study were to assess the prevalence of steatosis in a cohort with HIV-HCV coinfection, and to determine an association, if any, between steatosis, antiretroviral therapy (ART), and advanced hepatic fibrosis. Patients and methods HIV-HCV coinfected patients were retrospectively identified from the HIV clinic. ART was classified as none, nucleoside reverse transcriptase inhibitors (NRTIs) only, highly active antiretroviral therapy (HAART) only, and sequential therapy (initial NRTIs followed by HAART). Fibrosis stage and necroinflammation grade were assessed by the modified HAI (Ishak) scoring method. Steatosis was graded as 0–3. Results Sixty patients were identified. The overall prevalence of hepatic steatosis was 58%. Those that received HAART only had a lower prevalence of steatosis (41%) compared to those on NRTIs only (70%) or sequential therapy (82%). Independent predictors of hepatic steatosis were absence of HAART only therapy, OR 2.9, p = 0.09, and presence of cirrhosis, OR 4.6, p = 0.044. Forty five percent of the patients had advanced fibrosis (fibrosis stage ≥ 3). NI grade (OR 1.9, p = 0.030), and steatosis grade (OR 3.6, p = 0.045), were independent predictors of advanced fibrosis. Conclusion Hepatic steatosis is associated with more advanced hepatic fibrosis in the HIV-HCV coinfected population. HAART only therapy (rather than NRTIs only or sequential therapy) appears to be associated with a lower prevalence of hepatic steatosis. This may be one of the mechanisms by which HAART could attenuate hepatic fibrosis in such a cohort.

Background Staples are made of titanium, which elicits minimal tissue reaction. The authors have encountered foreign body reaction associated with stapled human gastrointestinal anastomoses, although the literature has no reports of this. The aim of this study was to identify the refractile foreign materials causing this reaction. Methods Histological sections were taken from 14 gastrointestinal specimens from patients with a history of a stapled anastomosis within the specimen excised. These were reviewed by light and polarization microscopy. Scanning electron microscopy and energy dispersive X-ray analysis were carried out on these sections, staples and stapler cartridges used for gastrointestinal surgery. Results Foreign bodies rich in fluorine were found in three patients, and those rich in carbon in 12. Other elements identified included oxygen, calcium, sodium, potassium, magnesium, aluminium and silicon. One specimen was found to contain titanium with no surrounding foreign body reaction. Stapler cartridges contained carbon, oxygen, fluorine, calcium, sodium, potassium, magnesium, aluminium, silicon and traces of titanium. Staples were composed of pure titanium with some fibrous material on the surface containing elements found in stapler cartridges. Conclusion The presence of foreign body reaction was confirmed in stapled human gastrointestinal anastomoses. The source of refractile materials eliciting this reaction was the stapler cartridges.

Background: there is strong evidence demonstrating that coagulation system activation contributes to wound healing and promotes organ fibrosis. Several epidemiological studies have now shown that prothrombotic status, including carriage of the factor (F)V Leiden mutation, is associated with rapid progression of hepatic fibrosis.Objectives: to assess the effect of a procoagulant state on progression of hepatic fibrosis in a controlled environment and to test whether anticoagulation could attenuate fibrogenesis.Methods: we investigated the effects of coagulation status on liver fibrosis development in a mouse model of chronic toxic liver injury. Prothrombotic FV Leiden mutant mice, C57BL/6 control animals and anticoagulated mice were studied after chronic exposure to carbon tetrachloride.Results: carriage of the FV Leiden mutation caused a significant increase in hepatic fibrosis. Anticoagulation with warfarin significantly reduced fibrosis progression in wild-type mice but was less effective against the profibrotic FV Leiden mutation. Changes in the fibrosis scores were mirrored by changes in liver hydroxyproline content and hepatic stellate cell activation detected by alpha-smooth muscle actin expression.Conclusions: these results demonstrate that coagulation status has a strong influence on hepatic fibrogenesis. It is likely that thrombin signaling through the proteinase-activated receptor 1 (PAR(1)) receptor expressed on hepatic stellate cells is responsible for this relationship. These results represent the first reported use of anticoagulation to slow hepatic fibrogenesis and suggest a potential novel anti-fibrotic therapeutic approach for the future.

To assess the role of immunization against hepatitis delta antigen in the prevention of hepatitis delta virus infection, woodchuck carriers of woodchuck hepatitis virus were immunized with a 64 amino acid portion of hepatitis delta antigen from its N-terminal region. The protein was expressed in Escherichia coli and contained a major immunogenic epitope. A significant anti-hepatitis delta response was observed that did not, however, protect the animals from hepatitis delta virus superinfection. Unexpectedly, the period of detectable viremia was longer in the immunized than in the control animals. We conclude that immunization with this recombinant hepatitis delta antigen does not afford protection against subsequent hepatitis delta virus exposure. (HEPATOLOGY 1990;12:1125–1128).

An increase in the ratio of phosphomonoester (PME) to phosphodiester (PDE) during 31P MR spectroscopy of the liver has been observed with increasing severity of hepatitis C-related liver disease. The purpose of this study was to investigate the utility of 31P MR spectroscopy as a biomarker of response to interferon and ribavirin treatment.Forty-seven patients with biopsy-proven hepatitis C undergoing viral eradication treatment with interferon and ribavirin underwent hepatic 31P MR spectroscopy at 1.5 T (voxel size, 70 x 70 x 70 mm; TR, 10,000; number of signals averaged, 48). All underwent baseline imaging before treatment and repeated imaging at 6-month intervals after the start of treatment.All patients underwent follow-up imaging 6 months after the start of treatment; 25 patients, 12 months; and 10 patients, 18 months after the start of treatment. According to the Ishak histologic scoring system, nine patients had mild hepatitis; 30 patients, moderate to severe hepatitis; and eight patients, cirrhosis. Thirty-two patients responded to antiviral treatment. Among these patients, 25 had a decrease in PME/PDE ratio on follow-up imaging. Among responders the mean baseline PME/PDE ratio decreased from 0.27 +/- 0.02 (standard error) to 0.16 +/- 0.01 after treatment (paired Student's t test, p0.001). Among the 15 virologic nonresponders, the ratios were similar in six patients; six other patients had an increase on follow-up imaging. In the latter nonresponder group, the mean baseline PME/PDE ratio was 0.21 +/- 0.03 compared with 0.31 +/- 0.08 after treatment (paired Student's t test, p =0.24).The in vivo hepatic PME/PDE ratio decreased in patients with hepatitis C who responded to antiviral treatment and remained similar or increased in patients without a virologic response. These results suggest that PME and PDE can be used as biomarkers in a noninvasive test of response to treatment.

Introduction REIMS permits real time analysis of tissue specific molecular information contained within an electrocautery smoke plume. 1 This study validated its diagnostic accuracy in colorectal cancer (CRC) and developed a novel endoscopic methodology. Method Patients undergoing elective surgery for CRC were recruited at St. Mary’s hospital London. 1. A standard electrosurgery handpiece using monopolar diatheramy on 30 W cutting mode (Valleylab TM ) was modified to allow aspiration of the electrosurgical aerosol to a Xevo G2-S iKnife QTof mass spectrometer (Waters Corporation). Ex-vivo analysis was performed and H&E staining and histological examination was carried out for validation. Multivariate analysis was performed using principal component analysis and linear discriminant analysis. Classification of each tissue type was performed using leave-one-patient-out cross-validation and receiver operating curves were generated. 2. Ex-vivo colorectal tissue was sampled using an endoscopic snare (Olympus Medical) modified to allow aspiration of the electrosurgical aerosol. Results 40 consecutive patients were recruited (22 male, median age 68 y, range 47–90). 23 tumour samples were analysed: 10 rectal adenocarcinomas and 13 colonic adenocarcinoma were analysed with TNM stages T2 (8), T3 (11) T4 (4), N0 (12), N1 (6) N2 (5), M0 (22), M1 (1). Distinction of malignant colorectal tissue was achieved with a classification accuracy of 94.4% and a sensitivity of 92.4%, Specificity 96.8% (ROC AUC 0.98). The diagnostic accuracy for dysplasia was 93.7% (Specificity 95.1%, sensitivity 85.7%, AUC 0.97). Distinction of tissue histology was possible based on membrane lipid ratios. Increases in glycerophospholipids (p = 0.0027), and triacylglycerols (p = 0.0004) were seen in healthy mucosa and increased prostaglandin D2 was found in malignant tissue (p = 0.0002). Endoscopic analysis was technically feasible and could identify colonic wall sub layers with a tissue classification accuracy of 88%. Discrimination of healthy colorectal tissue, adenomatous polyps and cancerous tissue (12 patients) was achieved with a tissue classification accuracy of 87.5%. Conclusion REIMS is able to diagnose dysplasia and malignant colorectal tissue with a high degree of accuracy in real time. This technology could improve the efficacy and safety of the endoscopic treatment of colon cancer. Disclosure of interest L. Muirhead: None Declared, J. Kinross Grant/ Research Support from: Imperial College BRC funding, Conflict with: Director of getwell media, R. Preece: None Declared, A. Speller: None Declared, O. Golf: None Declared, R. Goldin: None Declared, A. Darzi: None Declared, Z. Takats: None Declared. Reference Balog J, Sasi-Szabo L, Kinross J, et al . Intraoperative tissue identification using rapid evaporative ionization mass spectrometry. Sci Transl Med. 2013; 5 (194):194ra93