Poor predictive value of lower gastrointestinal alarm features in the diagnosis of colorectal cancer in 1981 patients in secondary care.

BACKGROUND: Clinicians are advised to refer patients with lower gastrointestinal (GI) alarm features for urgent colonoscopy to exclude colorectal cancer (CRC). However, the utility of alarm features is debated. AIM: To assess whether performance of alarm features is improved by using a symptom frequency threshold to trigger referral, or by combining them into composite variables, including minimum age thresholds, as recommended by the National Institute for Health and Care Excellence (NICE). METHODS: We collected data prospectively from 1981 consecutive adults with lower GI symptoms. Assessors were blinded to symptom status. The reference standard to define CRC was histopathological confirmation of adenocarcinoma in biopsy specimens from a malignant-looking colorectal lesion. Controls were patients without CRC. Sensitivity, specificity, positive predictive values (PPVs) and negative predictive values were calculated for individual alarm features, as well as combinations of these. RESULTS: In identifying 47 (2.4%) patients with CRC, individual alarm features had sensitivities ranging from 11.1% (family history of CRC) to 66.0% (loose stools), and specificities from 30.5% (loose stools) to 75.6% (family history of CRC). Using higher symptom frequency thresholds improved specificity, but to the detriment of sensitivity. NICE referral criteria also had higher specificities and lower sensitivity, with PPVs above 4.8%. More than 80% of those with CRC met at least one of the NICE referral criteria. CONCLUSIONS: Using higher symptom frequency thresholds for alarm features improved specificity, but sensitivity was low. NICE referral criteria had PPVs above 4.8%, but sensitivities ranged from 2.2% to 32.6%, meaning many cancers would be missed.

The prevalence and outcomes of frailty in older cancer patients: a systematic review.

BACKGROUND: Frailty is a state of vulnerability to poor resolution of homeostasis following a stressor event, such as chemotherapy or cancer surgery. Better knowledge of the epidemiology of frailty could help drive a global cancer care strategy for older people. The aim of this review was to establish the prevalence and outcomes of frailty and pre-frailty in older cancer patients. METHODS: Observational studies that reported data on the prevalence and/or outcomes of frailty in older cancer patients with any stage of solid or haematological malignancy were considered. We searched Medline, CINAHL, Cochrane Library, EMBASE, Web of Science, Allied and Complementary medicine, Psychinfo and ProQuest (1 January 1996 to 30 June 2013). The primary outcomes were prevalence of frailty, treatment-related side-effects, unplanned hospitalization and mortality. Risk of bias was assessed using the Newcastle-Ottawa checklist. RESULTS: Data from 20 studies evaluating 2916 participants are included. The median reported prevalence of frailty and pre-frailty was 42% (range 6%-86%) and 43% (range 13%-79%), respectively. A median of 32% (range 11%-78%) of patients were classified as fit. Frailty was independently associated with increased all-cause mortality [adjusted 5-year hazard ratio (HR) 1.87, 95% confidence interval (CI) 1.36-2.57]. There was evidence of increased risk of postoperative mortality for both frailty (adjusted 30-day HR 2.67, 95% CI 1.08-6.62) and pre-frailty (adjusted HR 2.33, 95% CI 1.20-4.52). Treatment complications were more frequent in those with frailty, including intolerance to cancer treatment (adjusted odds ratio 4.86, 95% CI 2.19-10.78) and postoperative complications (adjusted 30-day HR 3.19, 95% CI 1.68-6.04). CONCLUSIONS: More than half of older cancer patients have pre-frailty or frailty and these patients are at increased risk of chemotherapy intolerance, postoperative complications and mortality. The findings of this review support routine assessment of frailty in older cancer patients to guide treatment decisions, and the development of multidisciplinary geriatric oncology services.

The prognostic significance of tumour-stroma ratio in oestrogen receptor-positive breast cancer.

BACKGROUND: A high percentage of stroma predicts poor survival in triple-negative breast cancers but is diminished in studies of unselected cases. We determined the prognostic significance of tumour-stroma ratio (TSR) in oestrogen receptor (ER)-positive male and female breast carcinomas. METHODS: TSR was measured in haematoxylin and eosin-stained tissue sections (118 female and 62 male). Relationship of TSR (cutoff 49%) to overall survival (OS) and relapse-free survival (RFS) was analysed. RESULTS: Tumours with ≥49% stroma were associated with better survival in female (OS P=0.008, HR=0.2-0.7; RFS P=0.006, HR=0.1-0.6) and male breast cancer (OS P=0.005, HR=0.05-0.6; RFS P=0.01, HR=0.87-5.6), confirmed in multivariate analysis. CONCLUSIONS: High stromal content was related to better survival in ER-positive breast cancers across both genders, contrasting data in triple-negative breast cancer and highlighting the importance of considering ER status when interpreting the prognostic value of TSR.

A nucleic acid sequence-based amplification method to detect Salmonella enterica serotype enteritidis strain PT4 in liquid whole egg.

Nucleic acid sequence-based amplification (NASBA) was applied to the detection of Salmonella enterica cells in liquid whole egg. Samples (25 g) of liquid whole egg inoculated with Salmonella cells were enriched for 16 h in buffered peptone water, and the NASBA procedure was effective in detecting the presence of Salmonella in samples inoculated with 10 to 100 CFU prior to enrichment.

The relations between parental friendships and children's friendships: self-report and observational analysis.

The relations between the quality of mothers' and fathers' friendships and that of their children's friendships was examined. One hundred twenty-five fourth-grade children (9 year olds) completed the Friendship Quality Questionnaire. Observational measures of the target children playing with their self-selected friend were also collected. Mothers and fathers separately completed the Friendship Quality Questionnaire about their best friend. Results indicated that children's self-reports and observational measures of friendship quality were not highly correlated for girls, but were moderately associated for boys. The quality of mothers' and fathers' friendships was related to the quality of children's friendships, but the nature of the relations with children's friendships differed for girls and boys. The implications of these findings for the socialization of friendship patterns and the assessment of children's friendships were noted.

The effects of stance configuration and target distance on reaching. I. Movement preparation.

The aim of the present study was to investigate the relationship between the focal and postural components of a functional movement during the preparatory phase of a task. The contribution of the arms, trunk, and legs were varied by having subjects reach for two targets within and two beyond arm's length. In addition, the degree of postural stability was manipulated by varying the size of the base of support (BoS). Nine subjects reached and grasped a dowel placed at four locations while standing on a force plate with their feet in a parallel or step stance (right foot forward) under simple reaction-time (RT) conditions. Anticipatory postural adjustments (APAs) occurring prior to arm movement and RTs were analyzed. APAs varied depending on the demands of the task. For movements within arm's length, subjects selected different strategies to initiate the movement. However, for movements beyond arm's length, all subjects used the same strategy: the center of pressure (CoP) was shifted posteriorly, which resulted in the center of mass (CoM) moving towards the target. Target distance and BoS had no effect on the onset of APAs. In contrast, amplitude and duration of APAs increased linearly with target distance, and amplitude was always greater during the more posturally stable BoS configuration. Although wrist RT increased linearly with movement amplitude for both stance configurations, the rate of change was less under the more stable BoS. These results suggest that, during the performance of a functional task, dynamic changes that occur in the trunk and lower extremities prior to initiation of arm movement serve not only to stabilize the body, but are also used to initiate and assist whole-body reaching.

An RNA transcription-based amplification technique (NASBA) for the detection of viable Salmonella enterica.

Possession of mRNA is indicative of cell viability. RTPCR is not appropriate for mRNA detection as it cannot unambiguously detect mRNA in a DNA background. The alternative amplification technique, NASBA, avoids the disadvantages of RTPCR. We have devised a method for detection of viable Salmonella enterica. This involves NASBA amplification of mRNA transcribed from the dnaK gene. Amplification of mRNA extracted from viable and heat-killed cells from the same population produced consistent and highly significant (P > 0.01) differences between the respective signals. The signal obtained from viable cells was completely eradicated by RNase treatment, while PCR amplification of treated and untreated samples was unaffected, indicating that NASBA was unaffected by background DNA.

Analysis of first gastric compartment fluid collected via percutaneous paracentesis from healthy llamas.

OBJECTIVE: To evaluate the safety and efficacy of percutaneous paracentesis for fluid collection from the first gastric compartment of healthy llamas and to describe characteristics of that fluid. DESIGN: Prospective study. ANIMALS: 10 healthy adult llamas. PROCEDURE: Physical examinations were performed prior to sample collection and for 14 days afterwards. A CBC was performed prior to sample collection and 5 days later. A 16-gauge, 7.5-cm stainless steel needle, positioned approximately 20 cm caudal to the costochondral junction of the last rib, was pointed in a dorsocraniomedial direction and pushed through the abdominal wall into the lumen of the first gastric compartment. Fluid was aspirated and analyzed immediately for color, odor, consistency, pH, methylene blue reduction (MBR) time, protozoa, and bacteria. RESULTS: Fluid samples were obtained from 9 of 10 llamas. Mean volume was 4.1 ml, mean pH was 6.67, and mean MBR time was 173 seconds. Odor was slightly acidic, color was light brown-green to light yellow-green, and consistency was moderate. Small protozoa with variable iodine staining and gram-negative bacteria were commonly detected. With few exceptions, results of physical examinations and CBC remained within reference ranges. CLINICAL IMPLICATIONS: Fluid samples from the first gastric compartment can be successfully obtained by percutaneous paracentesis. Fluid characteristics were similar to those of fluid collected via orogastric tube in llamas and cattle.

MLH1 promoter methylation and gene silencing is the primary cause of microsatellite instability in sporadic endometrial cancers.

Defective DNA mismatch repair in human tumors leads to genome-wide instability of microsatellite repeats and a molecular phenotype referred to as microsatellite instability (MSI). MSI has been reported in a variety of cancers and is a consistent feature of tumors from patients with hereditary non-polyposis colorectal cancer. Approximately 20% of cancers of the uterine endometrium, the fifth most common cancer of women world-wide, exhibit MSI. Although the frequency of MSI is higher in endometrial cancers than in any other common malignancy, the genetic basis of MSI in these tumors has remained elusive. We investigated the role that methylation of the MLH1 DNA mismatch repair gene plays in the genesis of MSI in a large series of sporadic endometrial cancers. The MLH1 promoter was methylated in 41 of 53 (77%) MSI-positive cancers investigated. In MSI-negative tumors on the other hand, there was evidence for limited methylation in only one of 11 tumors studied. Immunohistochemical investigation of a subset of the tumors revealed that methylation of the MLH1 promoter in MSI-positive tumors was associated with loss of MLH1 expression. Immunohistochemistry proved that two MSI-positive tumors lacking MLH1 methylation failed to express the MSH2 mismatch repair gene. Both of these cancers came from women who had family and medical histories suggestive of inherited cancer susceptibility. These observations suggest that epigenetic changes in the MLH1 locus account for MSI in most cases of sporadic endometrial cancers and provide additional evidence that the MSH2 gene may contribute substantially to inherited forms of endometrial cancer.

A survey of percutaneous/mucocutaneous injury reporting in a public teaching hospital.

Our objective was to determine if healthcare workers were reporting all percutaneous and/or mucocutaneous injuries and to use such data to formulate appropriate interventions. The Infection Control Department distributed anonymous surveys of healthcare personnel between 1992 and 1995. The elicited information included the number of percutaneous and mucocutaneous injuries experienced and reported in the last five years and the reasons for not reporting every exposure when applicable. Five hundred and forty nine surveys were received, from physicians, dentists, registered nurses, licensed vocational nurses, nurses aides, and operating room technicians. Overall, of the 549 respondents, 45% (245) had no injuries, 30% (163) had been injured and had reported all injuries, and 26% (141) had not reported all injuries. Reasons for not reporting included sterile/clean needlestick (39%), little or no perception of risk to employee (26%), too busy (9%), and dissatisfaction with follow-up procedures (8%). Reasons stated for not reporting injuries indicate a need for continued education in the risk of acquiring blood-borne pathogens from such injuries. The results also illustrate the importance of targeting prevention efforts to specific groups, such as physicians, that would not be identified by routine reporting mechanisms.

Standardized management of patients and employees exposed to pertussis.

Waning pertussis immunity and spread of pertussis by asymptomatic adults contributes to increased pertussis exposures of vulnerable children. The Santa Clara Valley Medical Center had 49 pertussis exposures between July 1, 1989, and June 30, 1997, which originated in pediatric units or clinics and had an impact on the Employee Health Service (EHS) and Emergency Department (ED). We have developed a standardized protocol for management of employees and patients exposed to pertussis. The protocol includes a checklist for infection control staff; memoranda to exposed units conveying exposure information, instructions for employees to report to EHS or ED, and disease symptom information; written guidelines for physician management of patient exposures (prophylaxis and isolation) and EHS or ED management of employee exposures; and prophylaxis recommendations. We allow exposed employees to work while wearing a mask (worn until 5 days of prophylaxis are completed or for the entire potential contagious period if prophylaxis was refused). Employees who develop pertussis are restricted from work. Our protocol and standardized forms provide consistent management of pertussis exposures in both patients and employees.

Mapping an endometrial cancer tumor suppressor gene at 10q25 and development of a bacterial clone contig for the consensus deletion interval.

Frequent loss of chromosome 10q sequences in endometrial cancers suggests the involvement of a tumor suppressor gene. Previous loss-of-heterozygosity (LOH)studies have pointed to the 10q25-q26 region as the likely site of a tumor suppressor involved in endometrial tumorigenesis (S. L. Peiffer et al., 1995, Cancer Res. 55: 1922-1926; S. Nagase et al., 1996, Br. J. Cancer 74: 1979-1983; S. Nagase et al.,1997, Cancer Res. 57: 1630-1633). In an attempt to define further the localization of a tumor suppressor gene at 10q25, we screened a panel of 123 endometrioid adenocarcinomas for loss of heterozygosity of 10q25.3 sequences. Forty-three (35%) revealed LOH at one or more loci. The observed patterns of allelic loss define a minimum consensus region of deletion between D10S221 and D10S610. A sequence-ready bacterial clone contig and a long-range restriction map for a 1-Mb interval spanning the deletion region were developed as the first step in experiments directed toward the discovery the 10q25 tumor suppressor.

PTEN mutations in endometrial cancers with 10q LOH: additional evidence for the involvement of multiple tumor suppressors.

OBJECTIVE: The aim of this study was to assess the involvement of PTEN and other putative 10q tumor suppressors in endometrioid-type adenocarcinomas characterized by loss of 10q sequences. METHODS: PCR-based single-stranded conformational variant analysis and sequencing of individual PTEN exons in 34 tumor specimens and their corresponding normal DNA were used. RESULTS: Thirteen of the 34 tumors (38%) revealed a PTEN mutation: 2 frameshift, 3 nonsense, 3 missense, 3 splice site alterations, and 2 homozygous deletions. CONCLUSION: The observation that greater than 60% of endometrial cancers with 10q LOH lack PTEN mutations, in addition to previously reported LOH data, provides evidence for the existence of other tumor suppressors on 10q. Consideration of PTEN mutation status may prove important in deletion mapping studies to locate additional tumor suppressors on the long arm of chromosome 10.

Management of the obstetric patient with tuberculosis.

Tuberculosis in obstetric patients presents a challenging nursing problem to facilities caring for populations at high risk: the economically disadvantaged, minorities, the foreign-born, and patients with human immunodeficiency virus. Coordination of public health, outpatient, and inpatient services is essential for obtaining the desired outcome of a healthy family unit with a minimum of interruption of the attachment process. This article presents issues related to nursing care and medical management of tuberculosis in the perinatal period.

Comparison of the harmonic scissors and endostapler in laparoscopic supracervical hysterectomy.

We conducted a retrospective analysis of 29 consecutive patients undergoing laparoscopic supracervical hysterectomy to compare outcomes using the endostapler (15 women) versus harmonic scissors (14). Both instruments resulted in similar outcomes with regard to operating room time, blood loss, and hospital stay. The harmonic scissors have the advantage of decreasing patient cost compared with the stapler.

Safety product evaluation: six years of experience.

Safety products to prevent percutaneous injuries are rapidly being developed for health care. Decisions to purchase such products are often made by an institution's infection control committee. We evaluated 30 safety products. These products are most readily accepted when potential users perceive a need, believe they are at risk for injury, and have input into the selection process. Task forces of intended users are invaluable in determining which products to evaluate in high-risk areas. Some new devices may be unsafe if excessive manipulation or in-service education is required. New products may not be well accepted if the devices are a different size or configuration than usual or require changes in established practices or techniques. An adequate supply of new products must be available immediately when the evaluation begins or users will tend to select the older, more familiar product. Removing all similar devices except for the new product can facilitate acceptance. Frequency of use can also influence employees when trying a new product. For instance, nurses who only occasionally draw blood have different perceptions of a new blood-drawing device from those of the phlebotomy team. Key employees were designated as resource persons to complement the manufacturer's in-service education and to support transition to the new product. We recommend that decision making by infection control committees involve the individuals who will eventually directly use the new products, starting with the early phases of safety product evaluation.

Laparoscopic supracervical hysterectomy versus laparoscopic-assisted vaginal hysterectomy.

This retrospective study compared 41 patients, 21 undergoing laparoscopic-assisted hysterectomy (LAVH) and 20 undergoing laparoscopic supracervical hysterectomy (LSH). The groups were comparable in age, weight, and previous abdominal surgeries. Surgical indications were similar with the exception of uterine carcinoma, which was always treated by LAVH. Vaginal repairs were more common in the LAVH group. The mean operative times, estimated blood losses, uterine weights, and hospital stays were all comparable for both groups. A potential advantage of LSH is that it requires less operative dissection of the bladder, ureter, bowel, and uterine artery. The possible disadvantage of LSH is the 10% frequency of cyclic stump bleeding. Larger studies with prolonged follow-up will be necessary to evaluate risks and benefits of the procedures.