Correlation between adenoma detection rate and polyp detection rate at endoscopy in a non-screening population.

It is understood that colorectal adenomas progress to colonic adenocarcinoma. Adenoma detection rate (ADR) at endoscopy has been used as a key performance indicator at endoscopy and is inversely associated with diagnosis of interval colorectal cancer. As most endoscopy reporting systems do not routinely incorporate histological assessment, ADR reporting is a cumbersome task. Polyp Detection Rate (PDR) has therefore been adopted as a surrogate marker for ADR. A prospectively maintained database of colonoscopies performed between July 2015 and July 2017 was analysed. This was cross referenced with a histological database. Statistical analysis was performed using IBM SPSS, version 24. Inferential procedures employed included the Pearson's correlation coefficient (r) and Binomial logistic regression. Of 2964 procedures performed by 8 endoscopists, overall PDR was 27% and ADR was 19%. The PDR, ADR, adenoma to polyp detection rate quotient (APDRQ) and estimated ADR (PDR x APDRQ group average = 0.72) was calculated for each individual. There was a strong positive linear correlation between PDR and ADR,r(8) = 0.734, p = 0.038 and between PDR and estimated ADR, r(8) = 0.998, p < 0.001. Adenoma detection rate strongly correlated with estimated ADR, r(8) = 0.720, p = 0.044. With the exclusion of a moderate outlier, these correlations increased in both strength and significance. There was a stronger correlation between PDR and ADR,r(7) = 0.921, p = 0.003 and between ADR and estimated ADR, r(7) = 0.928, p = 0.003.

Clinical utility of abdominal and pelvic ultrasound in the evaluation of right iliac fossa pain in females.

BACKGROUND: Ultrasound (US) is often the imaging modality of choice in women with acute right iliac fossa (RIF) pain, identifying the appendix in up to 99% of patients. The literature, however, lacks clear guidelines on how ultrasonography should be performed to maximise sensitivity and specificity in such patients. Many centres perform untargeted abdomino-pelvic scans, including organs such as the liver and spleen, which unlikely contribute to the presenting complaint. AIMS: We aimed to evaluate the clinical utility of unfocussed abdominal and pelvic US in women of reproductive age with acute RIF pain. METHODS: This multicentre study describes 501 women between the ages of 12 and 50, over a 3-year period from three institutions, presenting acutely with RIF pain and investigated with US abdomen and pelvis. RESULTS: 5.9% of cases confirmed appendicitis sonographically. A normal appendix was visualised in 0.2%. Over 10% identified gynaecological pathology, 41% relating to the right ovary. 10.4% incidental extra-pelvic findings were unrelated to the acute clinical presentation. 0.8% of patients had extra-pelvic findings meriting further clinical assessment. CONCLUSION: The results herein reflect findings from high volume emergency surgical departments, demonstrating that unfocussed abdominal and pelvic ultrasounds are not an appropriate use of resources in reproductive women with RIF pain. Clinically relevant extra-pelvic US findings account for less than 1%, rarely contributing to the acute presentation. The appendix was only visualised in 6% of patients, suggesting that a focussed appendiceal and pelvic US would better assist diagnosis with a higher yield and increased sensitivity and specificity.

Health locus of control and attributions of cause and blame in adjustment to spinal cord injury.

STUDY DESIGN: The Symptom Checklist 90 Revised (SCL-90-R) was used to assign participants to either a good adjustment group or a poor adjustment group. Group differences were analyzed with chi (2), t-tests and correlations on factors shown in previous research to be related to coping with spinal cord injury (SCI). OBJECTIVES: This study examines health locus of control (HLC) and attributions of cause and blame in relation to SCI. The replication of study findings in multiple settings is a cornerstone of the evidence base for developing interventions. Previous studies do not show a consensus on the role of attributions of cause and blame in persons with SCI. Similarly, their relationship to adjustment after SCI is unclear. Another attribution, HLC, is similarly analyzed in relation to adjustment. SETTING: Republic of Ireland. METHODS: Thirty people with SCI participated. They rated scales measuring psychological adjustment, locus of control (LOC) for health and attributions of cause and blame for the injury. RESULTS: The well-adjusted group had a less external HLC. In addition, participants who were well adjusted endorsed the notion they could have avoided their accident significantly more than the poorly adjusted group. Similarly, they rated the belief that they could have caused the accident at a somewhat greater level. They did not, however, blame themselves any more or any less. CONCLUSION: Results are consistent with general LOC theory, and suggest an adaptive or protective internal LOC for accepting responsibility for the injury.

The urokinase plasminogen activator system in cancer: a putative therapeutic target?

The urokinase plasminogen activator (uPA) system is an endogenous proteolytic cascade which can be actively subverted by the neoplastic process to facilitate progression and metastasis. Abundant experimental and clinical evidence supports such a role and elevated levels of components of the uPA system are strong negative prognosis indicators in a wide variety of tumor types. Collectively this data makes the uPA system an attractive option for targeted intervention. This review examines the role of the uPA system in tumor invasion and metastasis and assess the various therapeutic modalities developed to selectively exploit this system.

Relationships among 3 Kochia species based on PCR-generated molecular sequences and molecular cytogenetics.

Forage kochia (Kochia prostrata ssp. virescens 'Immigrant' is native to the arid and semiarid regions of central Eurasia. It was introduced into the United States in 1966 as PI 314929 and released as a perennial forage shrub in 1984. Kochia americana is a perennial native to the United States, whereas Kochia scorparia is an introduced annual species that became a weed. To assess both the breeding potential and the possibility of genetic contamination, relationships among the 3 Kochia species were analyzed using random amplified polymorphic DNA (RAPD) markers, sequence tagged site (STS) marker sequences of the chloroplast NADH dehydrogenase gene (ndhF), genomic in situ hybridization (GISH), and multicolor fluorescence in situ hybridization (MC-FISH). Seventy decamer random primers yielded 458 polymorphic bands from 9 plants of K. americana, 20 plants of K. prostrata, and 7 plants of K. scoparia. Fifty-four and 55 species-specific RAPD markers were identified for K. americana and K. prostrata, whereas 80 RAPD markers were specific to K. scoparia. Based on the presence or absence of informative RAPD markers, the 3 species always grouped into 3 distinct clusters in a NTSYSpc2.01b-generated dendrogram. The same relationships were found among the 3 Kochia species based on ndhF DNA sequence divergence. Using a set of 7 STS markers that can identify each Kochia species, we did not find a single interspecific hybrid from artificial hybridizations among the 3 Kochia species. In GISH studies, chromosomes of 1 species fluoresced in green only when they were probed by genomic DNA of the same species. Cross-hybridization by genomic DNA of another species was not observed. In FISH studies using pTa71 (for 18S-5.8S-26S rDNAs) and pScT7 (for 5S rDNA) as probes, there were 1, 1 and 3 pTa71 sites and 2, 1, and 1 pScT7 sites in each haplome of K. prostrata, K. americana, and K. scoparia, respectively. It is concluded that these 3 Kochia species are so genomically distinct that gene introgression among them would be extremely rare.

TRPC3 mediates pyrimidine receptor-induced depolarization of cerebral arteries.

We tested the hypothesis that TRPC3, a member of the canonical transient receptor potential (TRP) family of channels, mediates agonist-induced depolarization of arterial smooth muscle cells (SMCs). In support of this hypothesis, we observed that suppression of arterial SMC TRPC3 expression with antisense oligodeoxynucleotides significantly decreased the depolarization and constriction of intact cerebral arteries in response to UTP. In contrast, depolarization and contraction of SMCs induced by increased intravascular pressure, i.e., myogenic responses, were not altered by TRPC3 suppression. Interestingly, UTP-evoked responses were not affected by suppression of a related TRP channel, TRPC6, which was previously found to be involved in myogenic depolarization and vasoconstriction. In patch-clamp experiments, UTP activated a whole cell current that was greatly reduced or absent in TRPC3 antisense-treated SMCs. These results indicate that TRPC3 mediates UTP-induced depolarization of arterial SMCs and that TRPC3 and TRPC6 may be differentially regulated by receptor activation and mechanical stimulation, respectively.

An observational study investigating the health provision for children with epilepsy within secondary schools in the East Midlands, UK.

BACKGROUND: Epilepsy is a common medical condition affecting many children in mainstream education. The practice of local secondary schools and the health service with regard to pupils with epilepsy was examined. The extent to which these children had activities at schools restricted and the schools' perception of the health service with regard to epilepsy was explored. METHOD: A structured interview was conducted with selected staff members from mainstream secondary schools in East Midlands region, UK. RESULTS: Fourteen out of 17 schools participated. Fifty-seven children were identified from a total pupil population of 14 534. Seven schools used the DOH/DfEE (The Department of Health/Department for Education and Employment) 'Supporting Pupils with Medical Needs' publication as a resource. No schools created individual health care plans for children with epilepsy. Six out of seven schools reported appropriate provision for children during swimming activities. The commonest restriction was related to computer use. Nine schools stated a need for more training for staff members with regard to seizure management. CONCLUSIONS: Schools rely heavily on obtaining medical information from non-medical sources. Individual health care plans for children with epilepsy are not commonly undertaken. Few children had any restriction or special provision placed upon them because of their epilepsy except in the area of computer use. Further action is needed to consider how the system for providing for such children can be improved so that each child's individual health needs can be satisfactorily met.

Assessment of faecal occult blood loss by qualitative and quantitative methods.

BACKGROUND: Various methods exist for the assessment of faecal occult blood loss in a patient with suspected gastrointestinal blood loss. METHODS: The present study examined the effectiveness and financial implications of a qualitative guaiac-based method (Haemoccult) of faecal occult blood detection and a quantitative measure of haeme-derived porphyrins (Hemoquant) in 184 patients who underwent assessment of faecal blood loss by both methods over a three year period during assessment of iron deficiency anaemia. MAIN FINDINGS: At least one Haemoccult test was positive in 72.2% of patients while Hemoquant was suggestive of significant blood loss (> 2mg haemoglobin/g faeces) in 29.9%. Patients underwent a total of 324 further endoscopic or radiological investigations of which 76.5% demonstrated no abnormality. A diagnosis was reached in 60 patients (32.6%). A significant potential source of gastrointestinal bleeding was found in 48 patients (26.1%). Hemoquant achieved a sensitivity of 62.5% and a specificity of 81.6% while with Haemoccult it was 85.4% and 32.4%, respectively. Hemoquant was normal in 18 patients with significant gastrointestinal conditions including peptic ulcers and colonic polyps. While Haemoccult only missed 7 lesions, two of these were colonic cancers. The quantitative nature of the Hemoquant test gave little clue as to diagnosis. CONCLUSION: Neither of the tests examined was ideal but Hemoquant had an overall better performance and further investigation of patients with evidence of blood loss from this test should be mandatory.

Percutaneous endoscopic external ring hernioplasty using Dundee inguinal canal retractor.

The percutaneous endoscopic external ring (PEER) hernioplasty is a novel technique that uses a minimal access approach to the inguinal canal by the anterior route and reproduces the conventional open tension-free mesh repair. The procedure consists of two stages: an open phase through a 2.5-cm incision over the external ring followed by an endoscopic repair of the defect. During the open stage, the spermatic cord is mobilized from the external ring, blunt finger dissection of the inguinal canal is used to create a space beneath the external oblique aponeurosis, and the hernial sac is dissected down to level of the preperitoneal fascia. The second endoscopic stage is performed after insertion of a telescope-mounted retractor through the external ring. The posterior wall of the inguinal canal is visualized and the hernial defect repaired by a tension-free mesh repair (Lichtenstein onlay mesh repair or mesh plug repair). The procedure provides an anatomic approach that is familiar to general surgeons. In a pilot study, the authors have established that the PEER hernioplasty is an easily learned, safe, and cost-effective operation that offers the benefits of minimal access surgery in terms of patient recovery and early return to work, and can be performed as a day case under local or regional anesthesia.

Laparoscopic common bile duct exploration after failed endoscopic stone extraction.

BACKGROUND AND STUDY AIMS: Despite the documented success rate and safety of laparoscopic ductal stone extraction, the majority of patients are treated with preoperative endoscopic stone extraction followed by laparoscopic cholecystectomy. When this fails, conventional open cholecystectomy and common bile duct exploration are performed. We report here a series of patients who were treated laparoscopically after failed attempts at endoscopic stone extraction. PATIENTS AND METHODS: Nineteen patients (12 women and seven men, aged 41-96 years) were treated laparoscopically. Four had undergone previous cholecystectomy. ERCP had been attempted in all patients, was unsuccessful in three patients, and had been interpreted as normal in two. Endoscopic stone extraction had been attempted in 14 patients. The mean follow-up period was 23 months, range 1-54 months. RESULTS: Ductal calculi were confirmed in 18 patients with successful and complete laparoscopic ductal clearance in 15 (83%), two of whom underwent an additional laparoscopic choledochoduodenostomy due to a large stone load and a grossly dilated common bile duct. Conversion to open surgery was required in three cases (17%). Ductal clearance at a single operation was achieved in all 18 patients. There were no postoperative deaths, but two patients developed postoperative complications (11% morbidity), one requiring laparotomy. The median postoperative hospital stay was five days, range 4-41 days. Recurrence of calculi was encountered in one patient. CONCLUSIONS: Laparoscopic ductal stone clearance after failed endoscopic stone extraction is successful in the majority of patients, and should be attempted prior to recourse to open surgery, provided the necessary laparoscopic biliary expertise is available.

Relation of hormone and menopausal status to outcomes following excimer laser photorefractive keratectomy in women. Melbourne Excimer Laser Group.

PURPOSE: To examine the effect of hormone use, pregnancy and menopausal status on clinical outcomes following excimer laser surgery for myopia and myopic astigmatism. METHODS: Participants comprised all female patients of the Melbourne Excimer Laser Group (MELG). A standardised surgical protocol was followed by the 27 MELG members, using the VisX 20/20 excimer laser and included the prospective collection of the following information preoperatively and one, three, six and 12 months after the procedure: uncorrected and best corrected visual acuity with a LogMAR chart; best manifest refraction; and subjective assessment of corneal clarity. A survey that elicited information about oral contraceptive (OC) use, pregnancy history, surgical and natural menopause, and use of hormone replacement therapy (HRT) was mailed to all the women. RESULTS: A 77% response to the mailed survey was achieved. Two women were pregnant at the time of surgery, one became pregnant during the first month after surgery, and all three women were excluded from further analyses, although a review of two of the case histories revealed suboptimal clinical outcomes. Women taking OC were included in the control group after OC use was shown not to be associated with outcome. Women were grouped accordingly: control, n = 225, pre-menopausal on HRT, n = 7, post-menopausal not on HRT, n = 34; and post-menopausal on HRT, n = 21. The groups differed significantly with regard to age and preoperative spherical equivalent. After controlling for age and preoperative spherical equivalent, the mean number of uncorrected LogMAR letters read one year after surgery was significantly lower for the post-menopausal women on the HRT in comparison with the control group. Best corrected acuity and corneal clarity were not significantly different among the groups. DISCUSSION: These preliminary results suggest that the interaction of menopausal and HRT status could decrease the effectiveness of PRK and PARK, but require confirmation with a further study in a prospective manner using objective measures of corneal epithelial healing and serum hormone levels.

Importance of reflux symptoms in functional dyspepsia.

The relation between symptom severity in gastro-oesophageal reflux disease (GORD) and quantitated oesophageal acid reflux is variable. Furthermore, when oesophageal acid exposure lies within the conventional normal range, the cause of the symptoms is unknown. This prospective study evaluated 24 hour ambulatory oesophageal pH profiles in relation to objective symptom scores in 100 dyspeptic patients who were free from ulcer and gall stones. Twenty patients had raised oesophageal acid exposure and reflux symptoms consistent with GORD, and 80 had oesophageal pH profiles within the conventional normal range. Forty four of the 80 had severe or moderate reflux symptoms and were classified as having reflux like functional dyspepsia (RFD); 36 had minimal or absent reflux symptoms, and were categorised as having non-reflux dyspepsia (NFD). While oesophageal pH profiles lay within the conventional normal range in both functional dyspepsia subgroups, patients with RFD had consistently greater acid exposure values as follows: mean (SEM) total oesophageal acid exposure time, RFD 16.2 (2.56) min v NFD 9.05 (2.0) min (p < 0.03); percentage of time with pH < 4, RFD 1.4 (0.2) v NFD 0.8 (0.2) (p < 0.03); DeMeester scores, RFD 12.8 (0.5) v NFD 11.4 (0.4) (p < 0.03). The RFD group had a pain/reflux event correlation of 23.8 (5.3)% v 8.1 (3.7)% for the NFD group (p < 0.01). This study shows that patients with RFD have oesophageal acid exposure that lies below the diagnostic threshold for GORD, but exceeds that of patients with NFD. The high pain/reflux event correlation in RFD, suggests that subthreshold oesophageal acid exposure may be associated with troublesome reflux symptoms.

Response of migrating motor complex to variation of fasting intraluminal content.

The characteristics of the phases of the migrating motor complex (MMC) were studied in the antrum, duodenum, and jejunum after alteration of intraluminal gas and acaloric fluid in 17 healthy volunteers. Aspiration of gas and fluid from the upper gastrointestinal tract reduced motor activity. In the antrum and duodenum, phase II contraction amplitude decreased, while in the duodenum and jejunum, the duration of phase II decreased and phase I increased. Phase III contraction frequency decreased in the duodenum only. Intragastric instillation of gas caused an increase of phase II duration and contraction amplitude in all regions. Similar effects were observed after intragastric instillation of fluid. Fasting periodic motor activity is responsive to volume changes of intraluminal gas and acaloric liquid content.

Mucosal function after ileal mucosal fenestration and colonic autotransplantation.

A method of small bowel mucosal augmentation called ileal mucosal fenestration and colonic autotransplantation (IMFCA) was devised and tested in pigs. In this technique, a vascularized mucosal graft was harvested from a 12-cm ileal loop, fenestrated by serial incision and then expanded to 20 cm. A 20-cm colonic loop was isolated and surgical mucosectomy was carried out. The fenestrated ileal mucosal graft was then autotransplanted into the prepared colon and the resulting composite structure was exteriorized as a Thiry-Vella loop. With this technique, ileal mucosal fenestrations healed by lateral epithelial in-growth, giving a new mucosal continuum within the recipient colon. At 60 days after surgery, the surface area of transplanted mucosa exceeded that within the original ileal loop by approximately 85 per cent. At this time, the transplanted mucosa had morphology and capacity for Na(+)-dependent glucose transport which were indistinguishable from those of control ileal mucosa.

Computerised method for acquisition and display of gastrointestinal motility data.

A computerised system is developed for the acquisition and display of gastrointestinal motility data which utilises a purpose developed software program called 'PC-motil', running on an IBM compatible microcomputer. 'PC-motil' displays data during collection, writes data to disk file and compresses all data at the end of a study on to a single monitor screen for convenient overview. Any area of interest, in single or multiple channels, may be selected and expanded for detailed examination. This system is tested by the recording of gastric and jejunal motility patterns of 11 healthy volunteers in fasting and fed states. All antral and jejunal migrating motor complexes (MMCs) in fasting studies, as well as all fed motility patterns were recognisable in both 'compressed' and 'expanded' form. The reproduction of motility patterns by the computer based system was indistinguishable from that of a conventional analogue chart recorder. This computerised system provides a convenient and cost-effective means of acquisition, storage and display of motility data in digital form.

Evidence for hypomotility in non-ulcer dyspepsia: a prospective multifactorial study.

A prospective multifactorial study of symptoms and disturbance of gastrointestinal function has been undertaken in 50 patients with non-ulcer dyspepsia. Objective tests including solid meal gastric emptying studies, gastric acid secretion, E-HIDA scintiscan for enterogastric bile reflux, and hydrogen breath studies were carried out in all patients and validated against control data. Gastroscopy and biopsy were carried out in non-ulcer dyspepsia patients only. Non-ulcer dyspepsia patients were categorised on the basis of predominant symptoms as: dysmotility-like dyspepsia (n = 22); essential dyspepsia (n = 14), gastro-oesophageal reflux-like dyspepsia (n = 11); and ulcer-like dyspepsia (n = 3). In the total non-ulcer dyspepsia population, solid meal gastric emptying was delayed (T50 mean (SEM) = 102 (6) minutes (patients) v 64 (6) minutes (controls), (p less than 0.01) and high incidences of gastritis (n = 26) and Helicobacter pyloridis infection (n = 18) were found. An inverse correlation was observed between solid meal gastric emptying and fasting peak acid output (r = -0.4; p less than 0.01). Indeed gastric emptying was particularly prolonged in eight patients (T50 mean (SEM) = 139 (15) minutes) with hypochlorhydria. In the non-ulcer dyspepsia population oral to caecal transit time of a solid meal was delayed (mean SEM = 302 (14) minutes (patients) v 244 (12) minutes (controls) (p less than 0.01]. Seven patients had a dual peak of breath hydrogen suggestive of small bowel bacterial overgrowth. No association was observed between symptoms and any of the objective abnormalities. This multifactorial study has shown that hypomotility, including gastroparesis and delayed small bowel transit, is common in non-ulcer dyspepsia and may be related to other disorders of gastrointestinal function. No relation between symptoms and disorders of function, however, has been shown.

Study of belching ability in antireflux surgery patients and normal volunteers.

The ability to belch was evaluated by a novel test, after gaseous stomach distension to standard volume, in 16 patients after antireflux surgery and nine healthy volunteers. A structured assessment of dyspeptic symptoms was also carried out in both groups. Repeat studies in volunteers showed acceptable reproducibility for the new test of belching capacity (within-subject coefficient of variance 4.5 per cent). After antireflux surgery, patients had lower volume individual belches (median(range) 27.5(0-104) ml in patients versus 76(15-165) ml in volunteers; P less than 0.02) and belched less gas within 1 h of the stimulus than volunteers (median(range) 205(0-1363) ml in patients versus 456(45-818) ml in volunteers; P less than 0.05). Belching frequency was similar in both groups. The incidence and severity of symptoms were unrelated to belched gas volumes.

Biopsy problems in patients with musculoskeletal tumours.

The problems of biopsy procedures and the effect that these had on subsequent surgery were studied in fifty one consecutive patients with musculoskeletal tumours. Difficulties included inadequate tissue for histology in 4 patients, wound infection in 5, haematoma formation in 2, inappropriate biopsy site in 7 and incorrect placement of drain exit site in 4. Open biopsy gave a more reliable diagnosis than needle biopsy, but was associated with a higher incidence of complications. Staging techniques such as magnetic resonance imaging, computed tomography and bone scans were less accurate when performed after the biopsy. Longitudinal incisions, centred over representative tumour tissue with the drain site placed in line with the incision, facilitate the adequate and uncomplicated removal of the entire biopsy scar and tract at the time of the definitive surgical procedure. It is concluded that biopsy for suspected musculoskeletal tumours should not be delegated to junior residents and should be performed in centres that have experience in the management of such tumours.