Compliance with enhanced recovery programmes in elective colorectal surgery

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are often criticized for being difficult to implement outside clinical trials. This audit evaluated compliance with an ERAS protocol and compared it with that during a trial.

METHODS

Compliance was audited by case-note review of 100 consecutive patients undergoing colorectal surgery. This was compared with the compliance in a group of 95 patients who participated in a clinical trial.

RESULTS

Fewer patients in the audit group than in the study group received preoperative oral carbohydrate loading (61.0 versus 96 per cent; P < 0.001), a transverse incision (25.0 versus 39 per cent; P = 0.037), early fluid and diet reintroduction (73.0 versus 99 per cent; P < 0.001), and non-opiate postoperative oral analgesia (70.0 versus 99 per cent; P < 0.001). Lower non-opiate oral analgesia use in the audit group was not associated with a commensurate increase in opiate use (P = 0.061). There was no difference between groups in length of hospital stay (median (interquartile range) 7 (5-8) versus 6 (5-7) days respectively), septic morbidity or 30-day mortality rates.

CONCLUSION

Observance to some aspects of the ERAS protocol was lower outside the clinical trial. However, this made little difference to patient outcome.

Prevalence of chronic viral hepatitis in people of south Asian ethnicity living in England: the prevalence cannot necessarily be predicted from the prevalence in the country of origin

The prevalence of hepatitis B and hepatitis C in immigrant communities is unknown. Immigrants from south Asia are common in England and elsewhere, and the burden of viral hepatitis in these communities is unknown. We aimed to determine the prevalence of viral hepatitis in immigrants from south Asia living in England, and we therefore undertook a community-based testing project in such people at five sites in England. A total of 4998 people attending community centres were screened for viral hepatitis using oral fluid testing. The overall prevalence of anti-hepatitis C virus (HCV) in people of south Asian origin was 1.6% but varied by country of birth being 0.4%, 0.2%, 0.6% and 2.7% in people of this ethnic group born in the UK, India, Bangladesh and Pakistan, respectively. The prevalence of hepatitis B surface antigen was 1.2%-0.2%, 0.1%, 1.5% and 1.8% in people of this ethnic group born in the UK, India, Bangladesh and Pakistan, respectively. Analysis of risk factors for HCV infection shows that people from the Pakistani Punjab and those who have immigrated recently are at increased risk of infection. Our study suggests that migrants from Pakistan are at highest risk of viral hepatitis, with those from India at low risk. As prevalence varies both by country and region of origin and over time, the prevalence in migrant communities living in western countries cannot be easily predicted from studies in the country of origin.

Type 2 diabetes in Canada: concentration of risk among most disadvantaged men but inverse social gradient across groups in women

AIMS

To assess sex-specific associations of educational and income levels with Type 2 diabetes mellitus.

METHODS

Logistic regression analyses (Canadian Community Health Survey, cross-sectional) adjusted for ethnicity, immigration, urban/rural, overweight/obesity, physical inactivity, smoking, chronic conditions and regular physician.

RESULTS

Compared to women with some post-secondary education, Type 2 diabetes was more likely in both high school graduates without post-secondary education [odds ratio (OR) 1.27, 95% confidence interval (CI) 1.07-1.51] and high school non-completers (OR 1.73, 95% CI 1.47-2.04); among men, definitive conclusions in high school graduates without post-secondary education could not be drawn (OR 0.93, 95% CI 0.78-1.12), but Type 2 diabetes was more likely in high school non-completers (OR 1.26, 95% CI 1.08-1.48). Compared to women with the highest income, Type 2 diabetes was three times more likely in the lowest income group (OR 2.90, 95% CI 2.25-3.73), 2.53 times more likely in the low middle income group (OR 2.53, 95% CI 1.98-3.24) and 55% more likely in the high middle income group (OR 1.55, 95% CI 1.20-2.01). Among men, Type 2 diabetes was approximately 40% more likely in both the lowest (OR 1.41, 95% CI 1.10-1.80) and low middle income groups (OR 1.39, 95% CI 1.12-1.71); definitive conclusions in the high middle income group could not be drawn (OR 1.05, 95% CI 0.87-1.28).

CONCLUSIONS

In women, Type 2 diabetes increased monotonically with lower educational and income levels; in men, Type 2 diabetes was concentrated in the least educated and least affluent. Our findings support the need for policies and practices that lower diabetes risk among the most disadvantaged women and men and moderately disadvantaged women.

Hydatid disease of the breast

Cystic hydatid disease is caused by the parasite Echinococcus granulosus. Humans are the accidental intermediate hosts of this organism. Hydatid disease is endemic in countries in which raising sheep and cattle constitutes an important means of livelihood. The most commonly affected organs are the liver and lungs. Involvement of the kidney, bone, brain and other organs is rare. Breast involvement in this disease is also very rare. A case of isolated hydatid cyst of the breast is presented, along with a review of the literature and a discussion on the pertinent clinical and radiological aspects of the disease.

Superconductivity in just four pairs of (BETS)2GaCl4 molecules

How small can a sample of superconducting material be and still display superconductivity? This question is relevant to our fundamental understanding of superconductivity, and also to applications in nanoscale electronics, because Joule heating of interconnecting wires is a major problem in nanoscale devices. It has been shown that ultrathin layers of metal can display superconductivity, but any limits on the size of superconducting systems remain a mystery. (BETS)2GaCl4, where BETS is bis(ethylenedithio)tetraselenafulvalene, is an organic superconductor, and in bulk it has a superconducting transition temperature Tc of approximately 8 K and a two-dimensional layered structure that is reminiscent of the high-Tc cuprate superconductors. Here, we use scanning tunnelling spectroscopy to show that a single layer of (BETS)2GaCl4 molecules on an Ag(111) surface displays a superconducting gap that increases exponentially with the length of the molecular chain. Moreover, we show that a superconducting gap can still be detected for just four pairs of (BETS)2GaCl4 molecules. Real-space spectroscopic images directly visualize the chains of BETS molecules as the origin of the superconductivity.

Functional assessment in the multimodality imaging of pancreatic neuro-endocrine tumours

Pancreatic neuroendocrine tumours comprise a heterogeneous group that are rare but could result in serious manifestations. Surgical excision provides the best approach to treatment but many patients may have small lesions that are difficult to detect, or present with wide spread disease by the time of diagnosis. In addition to clinical assessment and biochemical tests, imaging is a major factor in establishing the diagnosis. Cross-sectional imaging such as US, CT and MR, play a major role in the initial assessment. However, they may miss small lesions or metastatic spread. Functional Imaging became possible with the development of somatostatin receptor imaging using 111In-octreotide, which when combined with anatomical imaging could provide enhanced detection. A major improvement has been achieved by combining receptor and PET inaging through the use of 68Ga-DOTA complexes that have been shown to have a much better sensitivity than other imaging modalities and can provide the basis for radionuclide treatment with 90Y or 177Lu labelled with DOTA complexes.

Potential role of mesenchymal stem cells (MSCs) in the breast tumour microenvironment: stimulation of epithelial to mesenchymal transition (EMT)

Bone marrow-derived mesenchymal stem cells (MSCs) are known to specifically migrate to and engraft at tumour sites. Understanding interactions between cancer cells and MSCs has become fundamental to determining whether MSC-tumour interactions should be harnessed for delivery of therapeutic agents or considered a target for intervention. Breast Cancer Cell lines (MDA-MB-231, T47D & SK-Br3) were cultured alone or on a monolayer of MSCs, and retrieved using epithelial specific magnetic beads. Alterations in expression of 90 genes associated with breast tumourigenicity were analysed using low-density array. Expression of markers of epithelial-mesenchymal transition (EMT) and array results were validated using RQ-PCR. Co-cultured cells were analysed for changes in protein expression, growth pattern and morphology. Gene expression and proliferation assays were also performed on indirect co-cultures. Following direct co-culture with MSCs, breast cancer cells expressed elevated levels of oncogenes (NCOA4, FOS), proto-oncogenes (FYN, JUN), genes associated with invasion (MMP11), angiogenesis (VEGF) and anti-apoptosis (IGF1R, BCL2). However, universal downregulation of genes associated with proliferation was observed (Ki67, MYBL2), and reflected in reduced ATP production in response to MSC-secreted factors. Significant upregulation of EMT specific markers (N-cadherin, Vimentin, Twist and Snail) was also observed following co-culture with MSCs, with a reciprocal downregulation in E-cadherin protein expression. These changes were predominantly cell contact mediated and appeared to be MSC specific. Breast cancer cell morphology and growth pattern also altered in response to MSCs. MSCs may promote breast cancer metastasis through facilitation of EMT.

Zoonotic transmission of Streptococcus equi subsp. zooepidemicus from a dog to a handler

This is, to the best of our knowledge, the first case report to describe the apparent transmission of Streptococcus equi subsp. zooepidemicus from an infected dog to a handler who subsequently developed severe systemic infection. Characterization of the haemolytic streptococci isolated from both the patient and the dog, by phenotypic and molecular analysis, confirmed the canine and human isolates were identical.

Endocrine tumors: the evolving role of positron emission tomography in diagnosis and management

Endocrine tumors comprise a range of benign and malignant conditions that produce a spectrum of clinical symptoms and signs depending on the specific hormones they produce. The symptoms and presentations of these tumors are often independent of their size and location. Because of their expression of cell membrane receptors or production of specific types of hormones or peptides, endocrine tumors can be identified with functional radionuclide imaging much more readily compared to standard cross-sectional imaging. In recent years, 18F-fluoro-deoxy- D-glucose positron emission tomography (18F-FDG-PET) has emerged as a useful tool for diagnosing and assessing many tumors. In this review we describe how PET, using 18F-FDG and other radiopharmaceuticals can be useful in the diagnosis and management of a wide range of endocrine tumors.

Increased Expression of Inflammatory Genes in Pregnancy-Associated Breast Cancers

Introduction: Epidemiological studies have shown that women of all ages experience a transient increase in the risk of developing breast cancer following pregnancy. Furthermore, breast cancers detected soon after a completed pregnancy (pregnancy-associated breast cancers, or PABCs) have a worse prognosis than those detected at more distant intervals (Schedin 2006). We previously found evidence for increased expression of inflammatory genes in the human breast following pregnancy. (Asztalos et al. 2008). In this study we analyzed the same gene set in human breast cancer tissue, to investigate the role of inflammation in pregnancy associated breast cancers.Patients and Methods: Women ≤ 45 years of age with breast cancer were eligible for the study, and were categorized as either nulliparous, recently pregnant or distantly pregnant. Thirteen nulliparous, 14 recently pregnant (&lt;2 years since pregnancy) and 15 distantly pregnant (5-10 years) patients were identified. Tumor regions were isolated from formalin-fixed paraffin embedded tissues using Laser Capture Microdissection, followed by RNA extraction and cDNA synthesis. Genes of interest were preamplified linearly, followed by real time PCR. We chose 59 genes involved in the processes of inflammation, ECM remodeling and angiogenesis. A small number of breast cancer prognostic genes were also included. Gene expression between groups was compared using either t-test, ANOVA or unsupervised hierarchical clustering.Results: When recent and distant PABCs were combined and compared to the nulliparous group, we observed a number of significantly differentially regulated genes, such as CXCL1, THBS1, ELN, IL11 and MMP3. Upregulation of CXCL1 in the post-pregnant samples is interesting since CXCL1 is an important inflammatory chemokine, with implications in cancer. THBS1, a natural inhibitor of neovascularization and tumorigenesis, was downregulated in the post-pregnancy group. In this early analysis, we did not observe a difference in gene expression between recent and distant pregnancies, possibly due to the limited number of samples. However, immunoglobulin A showed a trend towards upregulation in the recent pregnancy group, suggesting an enhanced state of immune activity in the cancers occurring in the recently pregnant breast. When concerted gene expression was compared by non-supervised hierarchical clustering, we found that PABCs (both recent and distant) had more frequent associations with inflammation associated gene-expression patterns than those of nulliparous patients.Conclusions: This is the first study to address the hypothesis suggesting the role of post-pregnancy events, such as inflammation, ECM remodeling and angiogenesis in the etiology and aggressiveness of PABCs by looking at a set of human breast cancers with known pregnancy history. We show that the cancers of patients detected post-pregnancy are more frequently associated with an inflammation-associated gene expression pattern, than those of nulliparous women. The exact role of inflammation in the aggressiveness of PABCs remains to be further elucidated.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5158.

Objective Spectral-Spatial Analysis of Random Periareolar Fine Needle Aspiration of Women at High Risk for Contralateral Breast Cancer

Background: Random periareolar fine needle aspiration (RPFNA) cytology coupled with the Gail risk model has been used to predict the short-term risk of breast cancer in high risk women. The cytomorphologic features of atypical epithelial cells obtained by RPFNA can be subtle and result in inter-observer diagnostic variability and decreased sensitivity. Spectral-spatial analysis (SSA) is a method for objective image analysis that uses both color and spatial information to classify features into user-defined groups. We use SSA to classify cell clusters from RPFNA specimens into objective categories and compare that result to the cytopathology interpretation, which is the current standard.Design:Cell clusters on Papanicolau stained cytology Thin Prep slides from 7 benign and 7 malignant (14 total) breast RPFNA specimen were used to generate image stacks with the CRI Nuance platform. The specimens were processed and stained in three separate cytopathology laboratories. To build the algorithmic model, image stacks were analyzed using a neural network-based artificial intelligence system now distributed commercially as the Inform system. We manually painted green and red indicating feature (malignant) versus non-feature/background (benign) cells, respectively. A diagnostic algorithmic solution was created to stratify the new images as percent pixels correctly assigned as “malignant”. The solution was tested against cell clusters from 53 high-risk RPFNA specimen stratified by an expert pathologist (CZ) into the 5 categories of benign, epithelial hyperplasia, borderline, atypical and malignant. The specimens were collected from the contra lateral breast of patients with mastectomies for invasive carcinoma. Although 14 of the 67 cases were reused, no cellular clusters used in the training set were included in the validation set. The cytopathologist diagnosis was used as the gold standard and binarized to designate malignant cases as 1 and benign 0. These were compared to the green pixel (malignant) percentage in each case processed by INform.Results: The SSA algorithm classified all 7 malignant cases concordantly with the pathologist. The remaining 60 cases were classified as benign. The ROC curve generated from the cases had an AUC of 0.974 and an accuracy of 79.1%. The sensitivity was 100% and the specificity 76.7%.Conclusions: Spectral-spatial analysis can objectively classify benign and malignant cell clusters in excellent concordance to an expert pathologist. The epithelial hyperplasia, borderline, and atypical categories were all classified as benign by this solution representing a weakness in the solution. However, since these classes are not definitive with respect to biological behavior, the algorithm was binarized as above. In the future, algorithms will be based on biologically proven classes toward the goal of more definitive classification. A mature version of this technology could allow much broader usage of RPFNA since it would no longer be solely dependent on expert cytopathology interpretation.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6001.

Enhanced recovery programmes and colorectal surgery: does the laparoscope confer additional advantages?

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols aim to reduce postoperative lengths of stay (LOS). Laparoscopic surgery shares the same objective. Whether or not laparoscopic surgery conveys additional benefits over and above those achievable with ERAS alone is unclear.

METHOD

A review of the literature from January 1966 to June 2008 was performed. Randomized trial and case series investigating the role of laparoscopic surgery within ERAS protocols were included. These were assessed for LOS, readmissions, return of gut function, quality of life and cost of treatment.

RESULTS

Four publications from three randomized trials and another seven case series were identified. Two randomized trials revealed no difference in the LOS and readmission rates between ERAS when used alone and ERAS with the inclusion of laparoscopic surgery. However, a third trial revealed a significantly shorter LOS and a lower readmission rate in the ERAS and laparoscopic group.

CONCLUSION

The limited evidence presently available suggests that no further benefit is obtained by the inclusion of laparoscopic surgery in ERAS protocols. Further research is needed to derive more definitive conclusions.