Are we overtreating patients with malignant colorectal polyps? A 5-year review of the ACPGBI position statement.

INTRODUCTION: In 2013, The Association of Coloproctology of Great Britain and Ireland (ACPGBI) issued a position statement regarding management of malignant polyps. We reviewed the management of endoscopically resected malignant colorectal polyps in a district general hospital to evaluate whether patients were being overtreated as per these guidelines. METHODS: All patients who underwent a complete, non-piecemeal endoscopic removal of a malignant polyp between October 2013 and September 2018 were studied. Polyps were risk stratified for residual disease and followed up as per the ACPGBI. Patients were divided into two groups based on management after polypectomy. Primary outcome measured was the presence of residual tumour or involved lymph nodes in the resection specimen. Secondary outcomes included complications and recurrence. RESULTS: Thirty-three patients were included: 21 in the non-operative group (NOG) and 12 in the operative group (OG). The ACPGBI risk score in the NOG varied between 1 and over 4 compared with the OG who all scored over 4. Two patients in the OG (16%) demonstrated residual disease. Five patients suffered a postoperative complication. No recurrences were noted in the OG and one in the NOG. CONCLUSION: Our findings against a backdrop of the available literature suggest that the risk of residual disease after malignant polypectomy may not be as high as stated by the ACPGBI. As a result, there is a risk of overtreating patients and exposing them to the significant complications of surgery if careful consideration is not exercised.

Systematic review and meta-analysis of histopathological factors influencing the risk of lymph node metastasis in early colorectal cancer.

AIM: Lymph node (LN) metastases are present in up to 17% of early colorectal cancers (pT1). Identification of associated histopathological factors would enable counselling of patients regarding this risk. METHOD: Pubmed and Embase were employed utilizing the terms 'early colorectal cancer', 'lymph node metastasis', 'submucosal invasion', 'lymphovascular invasion', 'tumour budding' and 'histological differentiation'. Analysis was performed using REVIEW MANAGER 5.1. RESULTS: Twenty-three cohort studies including 4510 patients were analysed. There was a significantly higher risk of LN metastasis with a depth of submucosal invasion > 1 mm than with lesser degrees of penetration (OR 3.87, 95% CI 1.50-10.00, P = 0.005). Lymphovascular invasion was significantly associated with LN metastasis (OR 4.81, 95% CI 3.14-7.37, P < 0.00001). Poorly differentiated tumours had a higher risk of LN metastasis compared with well or moderately differentiated tumours (OR 5.60, 95% CI 2.90-10.82, P < 0.00001). Tumour budding was found to be significantly associated with LN metastasis (OR 7.74, 95% CI 4.47-13.39, P < 0.001). CONCLUSION: Meta-analysis of the current literature demonstrates that in early colorectal cancer a depth of submucosal invasion by the primary tumour of > 1 mm, lymphovascular invasion, poor differentiation and tumour budding are significantly associated with LN metastasis.

Avoiding extraction site herniation after laparoscopic right colectomy.

Transverse abdominal wall incisions are favoured as part of enhanced recovery programmes. We explored the use of rectus-preserving extraction site incisions in laparoscopic right colectomy. The approach involved minimal anterior abdominal wall disruption with preservation of the rectus abdominis muscle: the rectus abdominis muscle extraction site (RAMES). In 15 patients, a RAMES was used electively in right colectomy for malignancy. The median wound length was 6 cms. There was no clinical or radiological evidence of incisional herniation in the 15 patients at 12-month and in the 12 survivors at 24-month follow-up. An anatomical dissection at specimen extraction site reduces early incisional herniation rates and should be of benefit in the longer term.

Comparison of patients' needs and doctors' perceptions of information requirements related to a diagnosis of oesophageal or gastric cancer.

The aim of this study was to assess the information needs of patients diagnosed with oesophageal and gastric cancer and to compare these with their perceived information needs in the opinion of junior doctors. One hundred patients and 100 doctors responded to a questionnaire regarding the information needs of cancer patients. Seventy-nine per cent of patients wanted as much information as possible about their diagnosis, but only 35% of doctors were willing to give all the available information (P < 0.0001). Seventy-seven per cent of patients wanted to receive their diagnosis from a consultant whereas only 5% of doctors believed that patients should receive their diagnoses from a consultant (P < 0.0001). Eighty-four per cent of doctors were willing to communicate a serious illness with a good prognosis, yet only 43% would communicate a diagnosis with a poor prognosis (P < 0.0001). All 100 doctors had received formal training in breaking bad news, but 20 considered this inadequate. Socio-economic deprivation was associated with poor access to supplementary Internet derived information (P < 0.001). The majority of patients with a diagnosis of oesophagogastric cancer want a great deal of information regarding their illness, which contrasts with doctors' perceptions. Adequate training in information disclosure may help address this issue.

Contrast enhanced ultrasound should be the initial radiological investigation to characterise focal liver lesions.

INTRODUCTION: Contrast enhanced ultrasound (CEUS) involves the administration of a microbubble contrast agent followed by a US scan to evaluate the liver lesion through all phases of enhancement. Although technical difficulty and operator dependence can be encountered, CEUS is thought to be superior to conventional US and CT. This study aims to determine how effective CEUS is at characterising focal liver lesions and to establish its role in the diagnostic algorithm. METHODS: All patients who underwent a liver CEUS performed by a single consultant radiologist were identified over a 5 year period. The CEUS report, CT, MRI and/or PET report, histopathology report and case notes were reviewed. RESULTS: 127 patients were included. CEUS correctly identified 71 of 77 malignant lesions and all of the benign liver lesions. The sensitivity of CEUS for detecting and correctly characterising a malignant FLL is therefore 92% with a specificity of 100%. CONCLUSION: Our study shows that CEUS has a high sensitivity and specificity for characterising focal liver lesions. CEUS has advantages over CT and MRI of a high degree of safety, good patient tolerance and often availability at the time of initial detection. We therefore suggest that CEUS should be used as the initial study in the characterisation of FLLs. The study should be followed, as appropriate, by CT and MRI or PET studies. Biopsy, with its risks of tumour seeding and false negative results should only be considered after review of the imaging studies and full MDT discussion.

Detection of Y-chromosome in gonadal tumours using fluorescence in situ hybridization: diagnostic value in intersex conditions including older patients with clinically unsuspected androgen insensitivity syndrome.

AIMS: To evaluate fluorescence in situ hybridization (FISH) for SRY, the testis-determining gene on the Y-chromosome, in gonadal specimens from patients with intersex disorders including two older individuals presenting with Sertoli cell adenomas and clinically unsuspected androgen insensitivity syndrome (AIS). METHODS AND RESULTS: FISH, using probes for SRY and the X-centromere, was performed on two Sertoli cell adenomas presenting as ovarian masses in phenotypic females aged 62 and 73 years with previously undiagnosed AIS. Gonadal biopsies and tumours from eight additional patients with known intersex disorders and XY phenotype were also studied. Signal for SRY was demonstrated in at least one specimen from all patients, and from 16/18 (89%) specimens overall. The specificity of FISH was determined by analysis of 10 sporadic ovarian tumours including six dysgerminomas and four Sertoli-Leydig cell tumours: all cases expressed a female XX chromosomal signal. CONCLUSIONS: The demonstration of SRY using FISH is useful in the assessment of gonadal specimens from patients with intersex disorders, particularly in older individuals where the diagnosis may be unsuspected clinically. However, it may be necessary to examine multiple specimens in some cases to confirm the presence of Y-chromosomal material.

Photostabilizing milled wood lignin with benzotriazoles and hindered nitroxide.

The inhibitory processes operating when a 2(-2'-hydroxyphenyl) benzotriazole-based ultraviolet absorber (UVA) and a hindered nitroxide free radical are applied to high-yield pulps were studied using milled wood lignin and filter paper as a model. Using quantitative 31P NMR it was determined that the UVA is almost completely photostable during irradiation, suggesting that its protective mechanism is based primarily on ultraviolet absorption. Furthermore, the nitroxide was found to protect the UVA from photodegradation. Analysis of irradiated lignin samples involved derivatization followed by reductive cleavage of beta-arylether groups. The phenolic-OH groups thus released were quantified using 31P NMR. The benzotriazole/nitroxide stabilizing system was found to cooperatively inhibit the cleavage of beta-arylether groups. Furthermore, this system was found to have a synergistic inhibitory effect on the formation of catechol structures. These results suggest that the synergism observed between benzotriazole-based UV screens and nitroxyl radicals on the inhibition of yellowing could be a result of their ability to slow the formation of catechol structures and beta-O-4 cleavage in addition to the possibility of a UVA-regeneration mechanism.

Comparison of caregivers', residents', and community-dwelling spouses' opinions about expressing sexuality in an institutional setting.

Opinions regarding the appropriateness of elderly residents' sexual behaviors in a chronic care hospital and how to respond to inappropriate behaviors were surveyed. Study participation was open to all staff (N = 1,205), eligible residents (N = 182) and community-dwelling spouses (N = 103). Participation rates were 40% (residents), 42% (spouses), 34% (nursing staff), 50% (allied health staff), and 22% (support staff). Staff completed the questionnaire independently, while residents and spouses were offered self-completion or a structured interview. Almost all selected the interview. Residents and spouses were less tolerant than staff of residents' masturbating, engaging in sexual relationships, viewing sexual materials, and making sexual approaches to staff. Privacy was the primary determinant of appropriateness for behaviors for all groups. Staff and spouses were more likely to endorse counseling when behaviors were perceived as inappropriate than residents. Nurses endorsed counseling less frequently than allied health professionals and support staff. Nurses were more likely to have been approached sexually by a resident. Differences of opinion are interpreted in terms of cohort influences on values and contextual influences on behavior.

Interdisciplinary pilot project in a rehabilitation setting.

This project qualitatively evaluated the planning, implementation, and outcome of an interdisciplinary model of clinical education. Expectations of physiotherapy (PT), occupational therapy (OT), and speech-language pathology (SLP) students and clinicians were assessed to determine whether the model allowed for the acquisition of the interdisciplinary knowledge and skills needed for current practice. Students from OT (n = 5), PT (n = 3), and SLP (n = 1) undertook normally scheduled five-to-eight-week clinical placements, beginning on the same start date. All students were at intermediate or senior levels in their programs. Discipline-specific activities were supervised by clinical instructors from the disciplines. Interdisciplinary sessions during the first five weeks covered cross-disciplinary activities related to clinical reasoning, interviewing techniques, professionalism, and communication skills for team reporting. Themes related to the clinical experience were derived from student and supervisor responses to pre-and post-placement questionnaires, post-placement focus group interviews, and student journals. The response to the model was positive. The students felt they had gained insights into developing interdisciplinary skills, although they did feel that some discipline-specific needs were not met. The instructors were less enthusiastic but, given better planning and communication before the placement, welcomed the opportunity to try it again.

Aluminum Tolerance in Wheat (Triticum aestivum L.) (I. Uptake and Distribution of Aluminum in Root Apices).

We investigated the uptake and distribution of Al in root apices of near-isogenic wheat (Triticum aestivum L.) lines differing in Al tolerance at a single locus (Alt1: aluminum tolerance). Seedlings were grown in nutrient solution that contained 100 [mu]M Al, and the roots were subsequently stained with hematoxylin, a compound that binds Al in vitro to form a colored complex. Root apices of Al-sensitive genotypes stained after short exposures to Al (10 min and 1 h), whereas apices of Al-tolerant seedlings showed less intense staining after equivalent exposures. Differential staining preceded differences observed in either root elongation or total Al concentrations of root apices (terminal 2-3 mm of root). After 4 h of exposure to 100 [mu]M Al in nutrient solution, Al-sensitive genotypes accumulated more total Al in root apices than Al-tolerant genotypes, and the differences became more marked with time. Analysis of freeze-dried root apices by x-ray microanalysis showed that Al entered root apices of Al-sensitive plants and accumulated in the epidermal layer and in the cortical layer immediately below the epidermis. Long-term exposure of sensitive apices to Al (24 h) resulted in a distribution of Al coinciding with the absence of K. Quantitation of Al in the cortical layer showed that sensitive apices accumulated 5- to 10-fold more Al than tolerant apices exposed to Al solutions for equivalent times. These data are consistent with the hypothesis that Alt1 encodes a mechanism that excludes Al from root apices.

Midazolam enhances anterograde but not retrograde amnesia in pediatric patients.

BACKGROUND: Midazolam sedation has been shown to diminish recall of one to four cards shown prior to induction of general anesthesia in pediatric patients. This promising but limited finding prompted us to investigate the effect of midazolam sedation on retrograde and anterograde recall and recognition in children scheduled for elective surgery. METHODS: Forty patients aged 4-10 yr were randomized using a double-blind study design to receive either 0.2 mg/kg intranasal midazolam or 0.2 ml/5 kg placebo (distilled water) using a Devilbiss #286 atomizer. To assess postoperative memory of preoperative events, recall and recognition tasks were performed using a series of picture cards designed for this purpose. Retrograde amnesia was measured by postoperative recall and recognition of cards shown prior to midazolam/placebo administration, and anterograde amnesia was measured by postoperative recall and recognition of cards shown during the interval between midazolam/placebo administration and induction of general anesthesia. RESULTS: Compared to placebo, the midazolam group experienced a significant postoperative reduction in ability to both recall (P < .003) and recognize (P < .001) cards shown subsequent to midazolam/placebo administration (anterograde amnesia). In distinction, there was no difference between groups in postoperative ability to recall or recognize cards shown prior to midazolam/placebo administration (retrograde amnesia). CONCLUSIONS: These results support and extend the inference that midazolam diminishes anterograde recall. In addition, our findings indicate that midazolam diminishes anterograde recognition, thereby providing partial anterograde amnesia without affecting retrograde memory in pediatric patients.

A micromethod for agglutination and antiglobulin tests for antibody to Brucella abortus.

A micromethod has been developed for the standard agglutination and antihuman globulin tests for serum antibodies to Brucella abortus. The test uses a haematoxylin-stained antigen. The test is simple and quick to perform and, in a comparison at two centres involving 367 sera, the micromethod was found to be more sensitive than the classical test. It is highly suitable both for routine serological screening and for large-scale surveys of occupationally exposed industrial groups.

An epidemiological survey of human brucellosis in three Victorian abattoirs.

During the period 1977-1978, a serological and epidemiological investigation was conducted by the Victorian Departments of Health and Agriculture to determine the risk to abattoir workers of exposure to Brucella abortus from infected cattle. Nearly 1000 specimens of serum from workers at three abattoirs were tested for brucella antibodies at the Microbiological Diagnostic Unit. Serum agglutination and antihuman globulin tests were performed by a microtitre technique. Approximately 25% of these specimens gave positive results, with a wide variation in frequency in different abattoirs. Data relating to personal, employment and medical history were obtained by means of questionnaires. An attempt was made to identify risk factors by analysis of this information and the serological results. Within each abattoir, the presence of detectable antibodies was no more likely in people with symptoms than in asymptomatic people working in the same abattoir. However, the proportion of workers with symptoms was much higher in two abattoirs with a relatively high percentage of seropositive workers, than in a third, in which the percentage was comparatively low. There was evidence that the risk of exposure to B. abortus correlated with the percentage of cows in the total yearly "kill" for each abattoir.

An entomopoxvirus from Oncopera alboguttata (Lepidoptera: Hepialidae) in Australia.

A new entomopoxvirus has been isolated from field-collected larvae of Oncopera alboguttata at Ebor, New South Wales, Australia. The ovoid proteinaceous virus-containing bodies measured about 8 x 6 microns and contained up to about 17 centrally-embedded virus-free spindles and up to about 180 occluded virus particles. The virus particle had a beaded outer membrane and measured about 390 x 270 x 230 nm. The particle contained a single lateral body and a unilaterally concave core which in longitudinal section measured 320 x 80 nm. Dissolution of inclusion body and spindle protein to release virus particles occurred in carbonate/thioglycollate buffer at pH greater than 12.0. It is postulated that this virus has recently evolved from similar viruses in soil inhabiting coleopteran larvae.

Comparative ultrastructural studies of insect granulosis and nuclear polyhedrosis viruses.

Optical diffraction studies indicated that the periodic lattice structure in electron micrographs of the capsids of two granulosis and two nuclear polyhedrosis viruses were indistinguishable. The capsid is composed of stacked rings spaced 4-5 nm apart. Comparison of the intracellular forms of Bombyx mori nuclear polyhedrosis virus with negatively stained virus particles leads to encourage the more general use of the term 'capsid' instead of 'intimate membrane' and the term 'virus membrane' in place of 'developmental membrane'. These terms are consistent with those currently used for most animal and plant viruses.