Analysis of deaths occurring within the Nottingham trial of faecal occult blood screening for colorectal cancer.

OBJECTIVE: To report the causes of, and ages at, death of subjects in an English colorectal cancer screening trial. DESIGN AND SETTING: Analysis of 78 708 deaths occurring between 1981 and 2008, within the Nottingham randomised controlled trial of biennial faecal occult blood testing. MAIN OUTCOME MEASURES: Cause of death, age at death by sex and by cause. RESULTS: Significantly more subjects died from verified colorectal cancer in the trial's control group than in the intervention group (3.2% vs 2.9%). For no other major cause of death was the difference in proportion across the two groups statistically significant. Age at death was lower for cancer than for other principal causes, except for ischaemic heart disease among women. However, mean age at death was higher for colorectal cancer than for other cancers, except for prostate cancer among men. Increasing levels of material deprivation significantly lowered the expected ages at death, independently of cause. For both men and women, the mean age at death from all causes for screening participants was higher than that of controls and non-participants. Mean deprivation was lowest among participants. Of those participating in screening, and dying from colorectal cancer, subjects receiving negative test results lived significantly longer than those who received positive test results. However, if dying from other causes, they died at an earlier age. CONCLUSIONS: The age at death from colorectal cancer is higher than that of most other cancers. Those accepting a screening invitation live longer than non-participants. In part, this difference is explained by relative deprivation. Among screening participants, the receipt of a positive, as opposed to a negative, test result is associated with a later age at death.

Gallstone ileus: diagnostic pitfalls and therapeutic successes.

Gallstone ileus is a surgical emergency that occurs almost exclusively in the elderly. It is of increasing significance with current demographic changes. Clinical records and diagnostic imaging of 15 consecutive patients treated for gallstone ileus at one hospital over a 6-year period were reviewed. The median patient age was 80 years. Six plain-film diagnoses were made correctly. Contrast studies provided a diagnosis of intestinal obstruction in four patients. Abdominal X-ray findings were assessed incorrectly in two patients, with one false-positive and one false-negative result. The median preoperative hospital stay was 2 days. Three patients had Bouveret's syndrome, two of whom required a gastrostomy and enterolithotomy, and one of whom required a gastroenterostomy. The remaining 12 patients underwent enterolithotomies. Only one patient underwent a cholecystectomy. There was one postoperative death. No patient had biliary symptoms on follow-up. Gallstone ileus is a difficult clinical and radiologic diagnosis. Enterolithotomy alone is adequate treatment in the elderly, and subsequent cholecystectomy is not mandatory.

Periampullary diverticula and pancreaticobiliary disease.

BACKGROUND: Periampullary diverticula (PAD) are extraluminal outpouchings of the duodenum arising within a radius of 2-3 cm from the ampulla of Vater. They are frequently encountered in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and contribute to failure of ERCP. This review details the relationship of PAD to pancreaticobiliary disease and the influence of PAD on the management of patients. METHODS: The United States National Library of Medicine Medline database was searched for articles on and related to PAD published in English within the past 15 years. Major earlier works were also reviewed. RESULTS: The prevalence of PAD increases with age and could be as high as 27 per cent. PAD are associated with an incompetent sphincter of Oddi and colonization of bile duct with beta-glucuronidase-producing organisms. PAD are implicated in the pathogenesis of pigment common bile duct stones, but there is no conclusive evidence to associate them with cholecystolithiasis or pancreatitis. PAD are a major cause of failure of ERCP, but success rates of more than 90 per cent have been achieved in specialist centres. CONCLUSION: With an ageing population, there will be an increase in elderly patients with PAD and symptomatic pancreaticobiliary disease. Continuing improvements in radiological and endoscopic techniques should enable this vulnerable group to be treated effectively and safely.

An outbreak of meningococcal meningitis in Gauteng, Spring 1996.

OBJECTIVE: To describe a Neisseria meningitidis outbreak in Gauteng during the period 1 July to 31 December 1996. DESIGN: A descriptive study. SETTING: Patients with meningococcal meningitis in Gauteng who had been diagnosed by laboratory means, or notified during the period 1 July to 31 December 1996. MAIN OUTCOME MEASURES: Data including age, sex, date of admission to hospital, N. meningitidis serogroup and outcome were collected from Gauteng notification lists, South African Institute of Medical Research (SAIMR) records, a linelist compiled by the Gauteng Health Department, and hospital records. RESULTS: A total of 201 patients was studied; of this number 87 (43%) had been notified. Seventy per cent of cases were below 30 years of age and 78% were male. More than half (54%) of the cases were from the West Rand. The case fatality rate for 70 cases of known outcome was 14%. Serotyping of 85 isolates showed that a majority (76%) were serogroup A, with 57% being serogroup A clone I-1. Serogroup A clone III-1 accounted for 14% of the typed isolates. All isolates were sensitive to penicillin with minimum inhibitory concentrations of < 0.05 microgram/ml. CONCLUSION: In 1996 Gauteng experienced an epidemic of serogroup A meningococcal meningitis. The serotype that caused the majority of cases had been recorded in South Africa before, but serogroup A clone III-1, responsible for epidemics spreading across two continents, was recorded in South Africa for the first time. Notification of cases by health workers was inadequate in this epidemic.

Periampullary diverticula: consequences of failed ERCP.

Periampullary diverticula (PAD) are associated with biliary disease and contribute to failure of endoscopic retrograde cholangiopancreatography (ERCP), especially in elderly patients. The presence of PAD and causes of failure to cannulate the ampulla were noted in 1211 consecutive patients undergoing ERCP. Case notes of 100 consecutive patients with PAD were reviewed retrospectively. Overall prevalence of PAD was 9%. Prevalence was higher in patients > or = 75 years when compared with those < 75 years (19.2% vs 4.8%, P < 0.0001). Ampullary cannulation was successful in 62.4% of patients with PAD and 92.7% without PAD (P < 0.0001). Success rates were lower in patients with intradiverticular papillae than in those with juxtapapillary diverticula (38.1% vs 77.6%; P < 0.0001). Of 19 patients with PAD who did not have any imaging other than ultrasound, 16 were asymptomatic over a median follow-up of 20 months. Biliary surgery was performed on 35 patients, with no major complication. PAD are a major cause of failed ERCP. Failure rates are higher in patients with intradiverticular papillae than juxtapapillary diverticula. Though a large proportion of patients not imaged remain asymptomatic on follow-up, it is difficult to predict which patients may form this group. Surgery, when indicated, is safe and effective in elderly patients in whom ERCP has failed.

Pseudomyxoma extraperitonei: a lethal complication of mucinous adenocarcinoma of the appendix.

We report the unusual case of a 56-yr-old man who presented with an appendix abscess. This abscess failed to respond to standard treatment, and recurred despite operative intervention. A colocutaneous fistula developed, which initially discharged frank pus, then began discharging mucus via two cutaneous sinuses. No evidence of malignancy was detected from either repeat curettings or a diagnostic laparotomy. One and a half years after the initial presentation, histologic examination finally revealed mucinous adenocarcinoma of the appendix. We postulate that this malignancy in a retrocecal appendix resulted in a mucocele, which ruptured into the retroperitoneal space and drained via cutaneous sinuses, so-called pseudomyxoma extraperitonei. The patient declined further surgical intervention, and despite initial control by radiotherapy, the tumor spread locally to involve the entire right lower quadrant of the abdomen. The patient eventually died 39 months after the initial presentation.

Randomised controlled trial of faecal-occult-blood screening for colorectal cancer.

BACKGROUND: There is growing evidence that faecal-occult-blood (FOB) screening may reduce colorectal cancer (CRC) mortality, but this reduction in CRC mortality has not been shown in an unselected population-based randomised controlled trial. The aim of this study was to assess the effect of FOB screening on CRC mortality in such a setting. METHODS: Between February, 1981, and January, 1991, 152,850 people aged 45-74 years who lived in the Nottingham area of the UK were recruited to our study. Participants were randomly allocated FOB screening (76,466) or no screening (controls; 76,384). Controls were not told about the study and received no intervention. Screening-group participants were sent a Haemoccult FOB test kit with instructions from their family doctor. FOB tests were not rehydrated and dietary restrictions were imposed only for retesting borderline results. Individuals with negative FOB tests at the first screening, together with those who tested positive but in whom no neoplasia was found on colonoscopy, were invited to take part in further screening every 2 years. Screening was stopped in February, 1995, by which time screening-group participants had been offered FOB tests between three and six times. Screening-group participants who had a positive test were offered full colonoscopy. All participants were followed up until June, 1995. The primary outcome measure was CRC mortality. FINDINGS: Of the 152,850 individuals recruited to the study, 2599 could not be traced or had emigrated and were excluded from the analysis. Thus, there were 75,253 participants in the screening group and 74,998 controls. 44,838 (59.6%) screening-group participants completed at least one screening. 28,720 (38.2%) of these individuals completed all the FOB tests they were offered and 16,118 (21.4%) completed at least one screening but not all the tests they were offered. 30,415 (40.4%) did not complete any test. Of 893 cancers (20% stage A) diagnosed in screening-group participants (CRC incidence of 1.49 per 1000 person-years), 236 (26.4%) were detected by FOB screening, 249 (27.9%) presented after a negative FOB test or investigation, and 400 (44.8%) presented in non-responders. The incidence of cancer in the control group (856 cases, 11% stage A) was 1.44 per 1000 person-years. Median follow-up was 7.8 years (range 4.5-14.5). 360 people died from CRC in the screening group compared with 420 in the control group-a 15% reduction in cumulative CRC mortality in the screening group (odds ratio=0.85 [95%; CI 0.74-0.98], p = 0.026). INTERPRETATION: Our findings together with evidence from other trials suggest that consideration should be given to a national programme of FOB screening to reduce CRC mortality in the general population.

Fistulas are not always due to Crohn's disease: an unusual groin abscess.

A 38-yr-old white female with Crohn's disease was admitted for right hemicolectomy to treat an enterocutaneous fistula of 4 yr duration. At laparotomy, it was found that the fistula was related to an appendiceal diverticulum, rather than Crohn's disease, and simple appendicectomy was curative. The literature is reviewed.

Primary B-cell immunoblastic lymphoma of pancreas.

Extranodal lymphoma may present as an abdominal mass without evidence of disease elsewhere. Predominant pancreatic involvement with lymphoma is rare. Presenting as a pancreatic mass, it may be difficult to differentiate if from carcinoma. Ultrasound-guided fine needle biopsy and immunocytochemistry are helpful in establishing a histological diagnosis. It is important to differentiate lymphoma from carcinoma, because lymphoma is treated differently and has a better prognosis.

Randomised, controlled trial of faecal occult blood screening for colorectal cancer. Results for first 107,349 subjects.

To assess the effectiveness of screening by faecal occult blood tests, 107,349 people without symptoms of colorectal disease identified from general practitioner records have been randomly allocated to test and control groups. 53,464 test subjects were invited to carry out the screening test; 27,651 (53%) of the 52,258 who received the tests did so. Further investigation of the 618 (2.3%) with positive tests showed 63 cancers (52% stage A) and 367 adenomas (266 subjects). Rescreening of subjects with negative results every 2 years (9510 first rescreen, 3639 second) has shown a significant fall in the rate of positive results (1.7% of 7344; 0.3% of 2906). Cancers have also been diagnosed in 20 subjects presenting in the interval between a negative test and rescreening, and in 83 non-responders. The incidence of cancer in the control group (123 subjects; 10.6% stage A) was 0.72 per 1000 person-years. Cancers detected by screening were at a less advanced pathological stage, but it is too early to show any effect of screening on mortality from colorectal cancer.

Ureterosigmoidostomy complicated by polyp formation. Report of two cases.

Neoplasia associated with ureterosigmoidostomy is uncommon but important. Two patients, one of whom developed symptoms five years after the ureterosigmoidostomy had been taken down, are reported. The authors support the theory that these tumors may arise from the ureter. When ureterosigmoidostomies are dismantled, the site of implantation should be resected and the patients kept under long-term endoscopic review.

Cefotaxime plus metronidazole appears more effective than piperacillin in the prevention of postappendicectomy wound sepsis. Preliminary results of a comparative trial.

Metronidazole suppositories have previously been shown to be superior to povidone iodine intraoperative wound spray in reducing postappendicectomy wound sepsis. In subsequent studies metronidazole suppositories and cefotaxime injections reduced the sepsis rate to 9.3%, while the same combination produced a wound sepsis rate of 7.6% compared with 17.2% for cefotaxime alone. In an ongoing study, metronidazole and cefotaxime are now being compared with piperacillin in a single-blind trial. Adult patients undergoing emergency appendicectomy in Nottingham have been included in this study, which has ethical committee approval. When the decision to perform emergency appendicectomy was made, the patient was randomly allocated a numbered pack. This contained either 3 x 1g injections of cefotaxime and 6 x 1g metronidazole suppositories or 3 x 2g injections of piperacillin and 6 placebos. 40 minutes before operation the patient received the first suppository and the remainder every 8 hours. The patient received the first injection of antibiotic by intravenous or intramuscular injection and the remaining doses 8 and 16 hours later. A wound was regarded as infected if pus discharged either spontaneously or on incision. 175 patients have been studied to date. The treatment groups were well matched for age and sex. Seven of the 77 patients in the cefotaxime/metronidazole group (9.1%) compared with 12 of the 76 in the piperacillin group (15.8%) have developed wound infections. This study confirms that the combination of cefotaxime and metronidazole seems to be more effective than piperacillin alone in the reduction of postappendicectomy wound sepsis. Currently cefotaxime plus metronidazole is the therapy of choice.

Localized giant pseudopolyposis of the colon in ulcerative colitis. Report of a case.

Localized giant pseudopolyposis of the colon is a rare complication of both ulcerative colitis and Crohn's disease. It is not regarded as being premalignant, but it may masquerade clinically as a malignancy. This report presents a case and reviews others reported in the literature.