Lymph node retrieval for colorectal cancer: Estimation of the minimum resection length to achieve at least 12 lymph nodes for the pathological analysis.

INTRODUCTION: Adequate lymph node retrieval is important in colorectal cancer staging for the selection of patients that necessitate adjuvant treatments. The minimum number of 12 lymph nodes is one of the premises and is dependent, among the other factors, from the length of bowel resected. We have reviewed our specimens to identify the high-risk operations for inadequate nodal sampling and estimate the minimum length of bowel needed to resect to achieve this purpose. MATERIALS AND METHODS: A retrospective review of colorectal specimens over 10 years of activity looking at data including location of the tumor, type of operation performed, length of bowel resected and number of lymph nodes retrieved. RESULTS: Abdominoperineal and Hartmann's resections produced significant lower adequate retrievals compared to other colorectal operations, corresponding to 45.4% and 59.1% of cases respectively. The measured average length of bowel was 30 cm and 25 cm respectively, increasing the length to 36 cm and 42 cm would increase the adequacy rate to 90%. CONCLUSIONS: Abdominoperineal and Hartmann's resections are, in our series, high-risk operations that frequently do not produce the minimum number of lymph nodes necessary. These operations may require additional maneuvers such as mobilization of the splenic flexure to achieve the minimum length of bowel to resect.

Routine versus selective histologic analysis of gallbladder specimens for the detection of incidental gallbladder cancers. A retrospective review over 9 years of activity with a special focus on patients' age.

BACKGROUND: Incidental gallbladder cancer (IGC) is an infrequent possibility in patients undergoing cholecystectomies. Routine histologic examination of all gallbladder specimens is the current approach to detect this disease. Our study presents the influence of age to perform a selective histologic analysis. METHODS: A retrospective review was conducted of all gallbladder specimens during the last 9 years in our hospital. The medical notes were retrieved for cases of IGC or dysplasia and perioperative data were collected. RESULTS: A total of 3,330 cholecystectomies were conducted over the study period, 3,041 for gallstone disease. Twelve patients were found with dysplasia and 13 patients with IGC, all of them occurred in gallbladders removed for gallstone diseases. There were 18 men with a median age of 65 years (range 18 to 85). Median age for cancer patients was 70 years (range 51 to 85) and 54 years for dysplasia (range 18 to 75). No patient below the age of 51 years (n = 1,464) experienced IGCs. CONCLUSION: Age should be considered as an additional factor for a selective approach to the histologic analysis of all gallbladder specimens following cholecystectomies.

Ten years experience of managing the primary tumours in patients with stage IV colorectal cancers.

INTRODUCTION: Approximately 20% of patients with colorectal cancer have metastases at the time of presentation. Such patients are often offered systemic chemotherapy but debate continues as to whether these patients benefit from resection of the primary tumour. We describe our ten years experience of managing the primary tumours in patients with stage IV colorectal cancer. The aim of this study was to describe the overall survival of patients undergoing surgery in these circumstances and to determine whether any prognostic indicators could be identified. PATIENTS & METHODS: 920 consecutive patients presenting with stage IV colorectal cancer disease were identified from the Leicester Colorectal Cancer database. Patients undergoing resection of the primary tumour (Resection Group) with the residual metastatic disease were compared to those patients who had not their primary tumour excised (Non-Resection Group). Various different variables in two groups were compared by using Mann-Whitney U test. Kaplan-Meier survival analysis and log-rank test were used to compare the overall survivals. Univariate analysis was performed for each group to elicit the significant prognostic factors whereas Cox regression model was used to identify the independent predictors of overall survival. RESULTS: The Kaplan-Meier survival analysis of two groups showed prolonged survival for Resection Group compared to the Non-Resection Group (median; 14.5 Vs 5.83 months, p = <0.005). The multivariate analysis of different survival predicting variables, revealed the resection of the primary tumour as an independent predictor of overall survival (p < 0.001). The univariate analysis of resection group identified age at presentation, tumour site, tumour stage (pT), lymph nodal stage (pN), complete histological resection, tumour fixity, ASA grade, mode of surgery, post-operative chemotherapy and sites of metastasis as significant factors (p < 0.05) for survival prediction. When these factors were used in Cox-Regression model, only the age at presentation (p = 0.001), tumour fixity (p = 0.012) and lymph nodal involvement (p = 0.042) were independent predictors for overall survival. Treatment with post-operative chemotherapy and a smaller volume of liver metastases were associated with prolonged survival (p < 0.05). CONCLUSIONS: Surgical resection of primary tumour for stage IV colorectal cancers is associated with prolonged survival for selected patients. Age at presentation, extent of liver involvement, tumour fixity and ASA grade can help to decide the patients who will benefit from surgery.

Recollections of Indian children after discharge from an intensive care unit.

OBJECTIVE: To analyze the recollections of children following discharge from the pediatric intensive care unit (PICU). DESIGN: Prospective interview-based study. SETTING: Multidisciplinary 111-bed general pediatric wards in a tertiary care hospital situated in Mumbai, India. PATIENTS: Fifty children aged between five and 12 yrs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Children's responses to a semistructured interview were documented between the first and fifth day after their transfer and interpreted by content analysis. Thirty-seven children (74%) had neutral recollections, nine (18%) had negative recollections, and eight (16%) had positive recollections of their PICU stay. Twenty-six children (52%) stated clean environment and 18 (36%) stated doctors as good features, whereas 25 (50%) stated injections as bad features of the PICU. Thirty-two children (64%) remembered feeling scared, 37 (74%) being in pain, seven (14%) being thirsty, eight (16%) being hungry, and nine (18%) having disturbed sleep. Thirteen children (26%) appreciated the nurses and 33 (66%) the doctors for a good deed done by them. Fourteen children (28%) wanted changes to make the PICU stay comfortable. CONCLUSIONS: More toys, proactive measures to prevent intravenous catheter phlebitis, sedation to provide amnesia and good sleep, and adequate analgesia for various painful procedures are necessary for children in the PICU. Doctors and nurses should introduce themselves to patients and ensure that children are comfortable in bed and do not witness procedures being done on other children or a dead body.

Achalasia--alacrima--ACTH insensitivity syndrome (Triple A syndrome).

Triple A syndrome is characterized by achalasia of the cardia, alacrima, adrenocorticotrophic hormone (ACTH) resistant adrenal insufficiency and progressive neurological abnormalities including autonomic nervous dysfunction. An 8-year-old girl presented to the pediatric intensive care unit with sudden loss of consciousness and was diagnosed subsequently to have this condition. The authors present this condition since it is easily treatable and can be fatal if undiagnosed.

Traumatic posterior cerebral artery occlusion in a 14-month-old child.

Following a head injury, a 14-month-old male presented with neck stiffness and 24 hours later developed bilateral lateral rectus palsies. An unenhanced cerebral computed tomographic scan performed on admission revealed evidence of subarachnoid hemorrhage, cerebral edema, and mild-to-moderate compensated supratentorial hydrocephalus. A second scan performed 96 hours after the head injury revealed a mural thrombus at the tip of the basilar artery without any evidence of infarction. A third scan performed 12 days later revealed that the thrombus had resolved. However, a left posterior cerebral artery territory infarct was visualized. We postulate that the thrombus had embolized to the left posterior cerebral artery and caused occlusion of its cortical branch and subsequent infarction. A magnetic resonance angiography performed 20 days later excluded any vascular abnormality. The bilateral lateral rectus palsies persisted at the 6-month follow-up. To our knowledge, a head injury leading to a posterior cerebral artery territory infarct has not been reported earlier in a young child.

Utility of clinically-directed selective screening to diagnose HIV infection in hospitalized children in Bombay, India.

The increasing prevalence of HIV infection in urban India together with limited financial resources necessitates judicious HIV testing. This prospective study was undertaken to determine the utility of selective screening for HIV infection based on five clinical risk factors reported in African children. The study was conducted at the Departments of Paediatrics and Microbiology, LTMG Hospital, Bombay, India between September 1998 and 2000. The children were enrolled after taking informed consent from their parents. The HIV seroprevalence rate was determined in children (aged 1 month to 12 years) consecutively admitted with severe malnutrition, serious pyogenic infections (pneumonia, pyogenic meningitis, septicaemia), disseminated tuberculosis, chronic diarrhoea and oral candidiasis, present either singly or in combination. Children above 18 months of age were diagnosed as being infected with HIV if they tested positive by two different HIV enzyme-linked immunosorbent assay (ELISA) tests. In children less than 18 months of age the diagnosis of HIV infection was made if they were ELISA positive and also fulfilled the WHO criteria for symptomatic HIV infection. Of a total 204 children (110 male, 94 female) screened, 24 (11.8 per cent) were diagnosed as HIV-infected. The HIV seropositive rate was highest in children having oral candidiasis (40.6 per cent), followed by chronic diarrhoea (18.2 per cent), disseminated tuberculosis (16.2 per cent), severe malnutrition (14.4 per cent), and serious pyogenic infections (11.2 per cent). Only the presence of oral candidiasis was a significant independent risk factor for predicting HIV infection (p < 0.0001). However, as the number of risk factors concomitantly present increased, the chances of the child being infected with HIV also increased significantly (p < 0.001). Our study shows that clinically-directed selective screening does have a practical role in diagnosing HIV infection in a resource-poor setting.