The cluster-randomized Quality Initiative in Rectal Cancer trial: evaluating a quality-improvement strategy in surgery

Background

Following surgery for rectal cancer, two unfortunate outcomes for patients are permanent colostomy and local recurrence of cancer. We tested whether a quality-improvement strategy to change surgical practice would improve these outcomes.

Methods

Sixteen hospitals were cluster-randomized to the intervention (Quality Initiative in Rectal Cancer strategy) or control (normal practice) arm. Consecutive patients with primary rectal cancer were accrued from May 2002 to December 2004. Surgeons at hospitals in the intervention arm could voluntarily participate by attending workshops, using opinion leaders, inviting a study team surgeon to demonstrate optimal techniques of total mesorectal excision, completing postoperative questionnaires, and receiving audits and feedback. Main outcome measures were hospital rates of permanent colostomy and local recurrence of cancer.

Results

A total of 56 surgeons (n = 558 patients) participated in the intervention arm and 49 surgeons (n = 457 patients) in the control arm. The median follow-up of patients was 3.6 years. In the intervention arm, 70% of surgeons participated in workshops, 70% in intraoperative demonstrations and 71% in postoperative questionnaires. Surgeons who had an intraoperative demonstration provided care to 86% of the patients in the intervention arm. The rates of permanent colostomy were 39% in the intervention arm and 41% in the control arm (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.63–1.48). The rates of local recurrence were 7% in the intervention arm and 6% in the control arm (OR 1.06, 95% CI 0.68–1.64).

Interpretation

Despite good participation by surgeons, the resource-intense quality-improvement strategy did not reduce hospital rates of permanent colostomy or local recurrence compared with usual practice. (ClinicalTrials.gov trial register no. {"type":"clinical-trial","attrs":{"text":"NCT00182130","term_id":"NCT00182130"}}NCT00182130.)Following surgery for rectal cancer, two unfortunate outcomes for patients are permanent colostomy and local recurrence of the cancer. Local recurrence is especially feared, because it is usually inoperable and patients can suffer a slow, painful death.¹ The use of total mesorectal excision, which involves dissection of the lymph node-bearing portion of the rectum,² has resulted in improved outcomes, with local recurrence rates as low as 1%–5% and rates of permanent colostomy of 10%–15%.^3–6 Population-based rates of local recurrence are unavailable for any North American jurisdiction, although a Canadian hospital series found that rates varied from 10% to 45% based on the practice volume and training of surgeons.⁷ A surgical report on health regions in the province of Ontario (population 13 million) found that rates of permanent colostomy varied from 31% to 41%.⁸ This geographic variation in outcomes, together with rates of inferior outcomes as compared to outcomes specific to total mesorectal excision, suggest that gaps exist in the quality of rectal surgery provided to patients with rectal cancer.Quality-improvement strategies for encouraging physicians to change practice include continuing medical education, the use of opinion leaders, and audit and feedback.^9–11 As well, improvement may be enhanced by using a participatory and supportive approach that focuses on the system and not on individual practitioners.^12,13 The small number of studies that have evaluated changes in surgeons’ practices often have targeted process measures, such as preoperative ordering of antibiotics, rather than patient outcomes, such as recurrence of cancer.^14,15We tested whether use of a surgeon-directed quality-improvement strategy would improve hospital rates of permanent colostomy and local recurrence of cancer among patients undergoing surgery for rectal cancer. We used the Quality Initiative in Rectal Cancer (QIRC) strategy, which integrates quality-improvement interventions and principles to encourage surgeons to provide optimal total mesorectal excision to patients with rectal cancer.¹⁶     

Pollen as a chronometer and sediment tracer,Burrinjuck Reservoir,Australia

Pollen analysis is widely used to reconstruct vegetation and land use histories, but can also provide sedimentological information. At Burrinjuck Reservoir, in south-eastern Australia, annual grass pollen peaks are used to distinguish each year's sediment, even when there are no visible laminations. In conjunction with other dating methods, this allows the determination of year by year influxes of all sediment components. Pollen grains in the Burrinjuck sediments are shown to be predominantly waterborne so that they can be used to trace sediment to its source in particular vegetation stands. Pollen concentration and the proportion of damaged pollen might also distinguish sediment eroded from topsoils and that from subsoils. Pollen analysis can thus be used to locate specific erosion events in both time and space.     

Rapid microtubule-dependent induction of neurite-like extensions in NIH 3T3 fibroblasts by inhibition of ROCK and Cbl

A number of key cellular functions, such as morphological differentiation and cell motility, are closely associated with changes in cytoskeletal dynamics. Many of the principal signaling components involved in actin cytoskeletal dynamics have been identified, and these have been shown to be critically involved in cell motility. In contrast, signaling to microtubules remains relatively uncharacterized, and the importance of signaling pathways in modulation of microtubule dynamics has so far not been established clearly. We report here that the Rho-effector ROCK and the multiadaptor proto-oncoprotein Cbl can profoundly affect the microtubule cytoskeleton. Simultaneous inhibition of these two signaling molecules induces a dramatic rearrangement of the microtubule cytoskeleton into microtubule bundles. The formation of these microtubule bundles, which does not involve signaling by Rac, Cdc42, Crk, phosphatidylinositol 3-kinase, and Abl, is sufficient to induce distinct neurite-like extensions in NIH 3T3 fibroblasts, even in the absence of microfilaments. This novel microtubule-dependent function that promotes neurite-like extensions is not dependent on net changes in microtubule polymerization or stabilization, but rather involves selective elongation and reorganization of microtubules into long bundles.     

Description and SEM Observations of Meloidogyne sasseri n. sp. (Nematoda: Meloidogynidae), Parasitizing Beachgrasses

Meloidogyne sasseri n. sp. is described and illustrated from American beachgrass (Ammophila breviliffulata) originally collected from Henlopen State Park and Fenwick Island near the Maryland state line in Delaware, United States (6). Its relationship to M. graminis, M. spartinae, and M. californiensis is discussed. Primary distinctive characters of the female perineal pattern were a high to rounded arch with shoulders, widely spaced lateral lines interrupting transverse striations, a sunken vulva and anus, and coarse broken striae around the anal area. Second-stage juvenile body length was 554 μm (470-550), stylet length 14 μm (13-14.5), tail length 93 μm (83-115), tapering to a finely rounded terminus. Male stylet length 20 μm (19-21.5), spicule length 33 μm (30-36). Scanning electron microscope observations provided additional details of perineal patterns and face views of the female, male, and J2 head. Wheat, rice, oat, Ammophila sp., Panicum sp., bermudagrass, zoysiagrass and St. Augustinegrass were tested as hosts. Distribution of the species was the coasts of Delaware and Maryland. The common name "beachgrass root-knot" is proposed for M. sasseri n. sp.     

QTLs for cell-membrane stability mapped in rice (Oryza sativa L.) under drought stress

Cell-membrane stability (CMS) is considered to be one of the major selection indices of drought tolerance in cereals. In order to determine which genomic region is responsible for CMS, 104 rice (Oryza sativa L.) doubled haploid (DH) lines derived from a cross between CT9993–5-10–1-M and IR62266-42–6-2 were studied in the greenhouse in a slowly developed drought stress environment. Drought stress was induced on 50-day-old plants by withholding water. The intensity of stress was assessed daily by visual scoring of leaf wilting and by measuring leaf relative water content (RWC). The leaf samples were collected from both control (well-watered) and stressed plants (at 60–65% of RWC), and the standard test for CMS was carried out in the laboratory. There was no significant difference (P>0.05) in RWC between the two parental lines as well as among the 104 lines, indicating that all the plants were sampled at a uniform stress level. However, a significant difference (P<0.05) in CMS was observed between the two parental lines and among the population. No significant correlation was found between CMS and RWC, indicating that the variation in CMS was genotypic in nature. The continuous distribution of CMS and its broad-sense heritability (34%) indicates that CMS should be polygenic in nature. A linkage map of this population comprising of 145 RFLPs, 153 AFLPs and 17 microsatellite markers was used for QTL analysis. Composite interval mapping identified nine putative QTLs for CMS located on chromosomes 1, 3, 7, 8, 9, 11 and 12. The amount of phenotypic variation that was explained by individual QTLs ranged from 13.4% to 42.1%. Four significant (P<0.05) pairs of digenic interactions between the detected QTLs for CMS were observed. The identification of QTLs for this important trait will be useful in breeding for the improvement of drought tolerance in rice. This is the first report of mapping QTLs associated with CMS under a natural water stress condition in any crop plants. Received: 8 September 1999 / Accepted: 13 October 1999     

Unidirectional Movement of Cellulose Synthase Complexes in Arabidopsis Seed Coat Epidermal Cells Deposit Cellulose Involved in Mucilage Extrusion,Adherence, and Ray Formation

CELLULOSE SYNTHASE5 (CESA5) synthesizes cellulose necessary for seed mucilage adherence to seed coat epidermal cells of Arabidopsis (Arabidopsis thaliana). The involvement of additional CESA proteins in this process and details concerning the manner in which cellulose is deposited in the mucilage pocket are unknown. Here, we show that both CESA3 and CESA10 are highly expressed in this cell type at the time of mucilage synthesis and localize to the plasma membrane adjacent to the mucilage pocket. The isoxaben resistant1-1 and isoxaben resistant1-2 mutants affecting CESA3 show defects consistent with altered mucilage cellulose biosynthesis. CESA3 can interact with CESA5 in vitro, and green fluorescent protein-tagged CESA5, CESA3, and CESA10 proteins move in a linear, unidirectional fashion around the cytoplasmic column of the cell, parallel with the surface of the seed, in a pattern similar to that of cortical microtubules. Consistent with this movement, cytological evidence suggests that the mucilage is coiled around the columella and unwinds during mucilage extrusion to form a linear ray. Mutations in CESA5 and CESA3 affect the speed of mucilage extrusion and mucilage adherence. These findings imply that cellulose fibrils are synthesized in an ordered helical array around the columella, providing a distinct structure to the mucilage that is important for both mucilage extrusion and adherence.The epidermal cells of Arabidopsis (Arabidopsis thaliana) seed coats produce two distinct secondary cell walls: pectin-rich mucilage and cellulose-rich columellae (Western et al., 2000). When seeds are hydrated, mucilage expands rapidly, rupturing the outer tangential cell wall and forming a mucilage capsule that surrounds the seed. Seed coat mucilage is composed primarily of rhamnogalacturonan I (RG I) and also contains homogalacturonan (HG), hemicelluloses (such as xylans and glucomannans), and cellulose (for review, see Haughn and Western, 2012). Extruded mucilage consists of an outer, nonadherent fraction and an inner, adherent fraction (Western et al., 2000, 2001; Macquet et al., 2007a). The adherent and nonadherent mucilage layers differ in the amount of methylesterified HG (Rautengarten et al., 2008; Saez-Aguayo et al., 2013; Voiniciuc et al., 2013), galactans (Dean et al., 2007; Macquet et al., 2007b), arabinans (Arsovski et al., 2009), mannans (Yu et al., 2014), and cellulose (Harpaz-Saad et al., 2011; Mendu et al., 2011; Sullivan et al., 2011), all of which influence the physical properties of the layers.Adherent mucilage has a distinct structure, which can be examined using cell wall dyes and antibodies. When treated with cellulose-specific dyes, densely stained rays extend from the top of each columella to the outer edge of the adherent layer, many cell lengths above the seed surface (Mendu et al., 2011; Sullivan et al., 2011). Cytological evidence indicates that cellulose, pectins, and mannans are components of the ray (Haughn and Western, 2012; Griffiths et al., 2014; North et al., 2014; Yu et al., 2014), although the exact manner in which they are assembled is unknown.Cellulose is abundant in mucilage rays and mediates adherence. Loss-of-function mutations in CELLULOSE SYNTHASE5 (CESA5) result in reduced cellulose levels and increased detachment of mucilage from the seed (Harpaz-Saad et al., 2011; Mendu et al., 2011; Sullivan et al., 2011; Griffiths et al., 2014). How a reduction in cellulose results in a loss of adherence is still unknown, but it likely involves interaction with other mucilage components such as pectin and arabinogalactan proteins (Griffiths et al., 2014). Since cesa5 mutants still have some cellulose in the rays of the adherent mucilage halo (Mendu et al., 2011; Sullivan et al., 2011), additional cellulose synthases must be involved in mucilage cellulose biosynthesis.The Arabidopsis genome encodes 10 different CESAs (Delmer, 1999; Richmond and Somerville, 2000). Multiple lines of evidence suggest that three different CESAs are required to form one active cellulose synthase complex (CSC; for review, see Somerville, 2006). CSCs are membrane-bound protein complexes that synthesize cellulose microfibrils in the apoplast (for review, see Somerville, 2006; Endler and Persson, 2011; Lei et al., 2012). CESA1, CESA3, and CESA6 are considered the core components of the primary wall CSC (Desprez et al., 2007; Persson et al., 2007). CESA2, CESA5, and CESA9 are partially redundant to CESA6 in primary wall biosynthesis, and genetic evidence suggests that each of these CESA polypeptides can form a functional CSC with CESA3 and CESA1 (Desprez et al., 2007; Persson et al., 2007). CESA10 is expressed in young plants, stems, floral tissue, and the base of rosette leaves (Beeckman et al., 2002; Doblin et al., 2002), but its function in cellulose biosynthesis is unclear. Other cesa mutant lines have been examined for altered mucilage phenotypes (cesa1, radially swollen1 [Burn et al., 2002; Sullivan et al., 2011], cesa2, cesa6, and cesa9 [Mendu et al., 2011]; CESA3, je5 [Sullivan et al., 2011] and cesa10-1 [Sullivan et al., 2011]); to date, only CESA5 has been shown to be required for cellulose biosynthesis during mucilage deposition.Two mutant alleles of CESA3, isoxaben resistant1-1 (ixr1-1) and ixr1-2, were isolated in a screen for resistance to the herbicide isoxaben (Scheible et al., 2001). Isoxaben inhibits the incorporation of Glc into the emerging cellulose polymer and is considered a potent and specific inhibitor of cellulose biosynthesis (Heim et al., 1990). Homozygous ixr1-1 and ixr1-2 lines show increased resistance to the herbicide, and the mutations causing this resistance were mapped to the genomic locus of CESA3 (Heim et al., 1990; Scheible et al., 2001). The ixr1-1 and ixr1-2 mutations cause amino acid substitutions near the C terminus of the CESA3 protein. ixr1-1 causes a Gly-to-Asn substitution (G998A) located in a transmembrane domain, while ixr1-2 contains a Thr-to-Ile substitution (T942I) in an apoplastic region of the protein between two transmembrane domains (Scheible et al., 2001). Recently, the ixr1-2 allele was shown to affect the velocity of CSCs in the plasma membrane, which consequently modifies cellulose crystallinity in the cell wall (Harris et al., 2012). It is not exactly clear how the ixr1-1 mutation affects cellulose biosynthesis. The effects of either of these mutations on seed coat mucilage have not been investigated.Since mucilage is composed primarily of pectins with smaller amounts of cellulose, seed coat epidermal cells represent an excellent system to study cellulose biosynthesis and interactions between cellulose and other wall components in muro. In this study, we investigated how cellulose is synthesized and deposited in seed coat epidermal cells. We show that at least three different CESA proteins are highly expressed in the seed coat epidermis during mucilage biosynthesis. These CESAs are oriented and move in a linear fashion around the cytoplasmic column of each cell in an identical pattern to cortical microtubules. In addition, we provide evidence that the adherent mucilage has a helical structure that expands and unwinds during extrusion to form the mucilage ray. We propose that during seed coat epidermal cell development, the biosynthesis of cellulose predetermines the structure of rays in the adherent mucilage layer.     

Roadside Revegetation in Glacier National Park, U.S.A.: Effects of Herbicide and Seeding Treatments

From 1992 to 1995 we experimentally evaluated the effectiveness of several revegetation treatments along a segment of Going-to-the-Sun Highway in Glacier National Park, U.S.A. This segment, reconstructed during the spring and summer of 1992, is bordered by fescue prairie vegetation and is known to be susceptible to invasion by several alien species, including Centaurea maculosa (spotted knapweed) and Phleum pratense (common timothy). We used a split plot study design to evaluate the effectiveness of herbicide and seeding treatments on assisting recovery of native flora and limiting the establishment of alien species. The herbicide treatment consisted of a yearly herbicide spray application of clopyralid (3,6-dichloropicolinic acid). Five seeding treatments were evaluated, three of which included an indigenous graminoid-forb seed mix. Percent canopy coverages of four species groups—alien graminoids, native graminoids, alien forbs, and native forbs—were determined in July 1995. In addition, community-level patterns in sprayed plots and unsprayed plots were compared with a reference site of native fescue prairie. Herbicide treatments decreased mean canopy coverage of alien forbs (treated = 4.2%, untreated = 23.4%) and increased mean canopy coverage of native graminoids slightly (treated = 6.3%, untreated = 4.0%). But herbicide treatments reduced mean coverage of native forbs (treated = 3.9%, untreated = 8.9%) and likely increased coverage of alien graminoids. Treatments that included a fall 1992 seed mix increased native graminoid coverages 2.8–4.6 times, although coverages were still lower than those attained by alien graminoids. Native and alien forb coverage appeared unaffected by seeding treatments. Species composition was less diverse in sprayed plots and more dominated by alien grasses than in unsprayed plots and the reference site. Areas for additional study are suggested, including seed bank assays to determine treatment effects on recruitment of alien versus native species and the use of native graminoids to create low-diversity communities with high canopy coverages to resist establishment of alien species.