Local recurrence after rectal cancer resection is strongly related to the plane of surgical dissection and is further reduced by pre-operative short course radiotherapy. Preliminary results of the Medical Research Council (MRC) CR07 trial

3512

Background: The MRC CR07 trial compared routine short course pre-operative radiotherapy (PRE) with selective post-operative chemo-radiation if there was involvement of the circumferential resection margin (CRM) (POST) and included a prospective pathological assessment of the quality of resection of the surgical specimen. Methods: A total of 1350 patients were randomised from 52 centres between March 1998 and August 2005. Median follow-up is 3 years. Trial pathologists were trained in histopathological assessment and reporting of the involvement of the CRM and plane of surgery (PoS) according to pre-set criteria describing the plane of dissection (Grade 1-muscularis plane: 2-intramesorectal plane: 3-mesorectal plane). 1232 patients were prospectively assessed for CRM and 1119 for PoS. Results: The CRM was involved (tumour ≤1mm) in 139 (11%) of resected specimens, and for these patients the 3-year local recurrence (LR), disease-free survival (DFS) and overall survival rates were 18%, 50% and 57%. For the 1093 patients with CRM-ve the respective rates were 7%, 81% and 84%. LR and DFS rates were associated with PoS (log-rank test p=0.0019 and p=0.0506 respectively), and in addition there was clear evidence of a reduction in LR and improvement in DFS rates in favour of PRE for all grades of quality of surgical assessment as shown in the table . Conclusions: The results indicate a strong association between the quality of surgery and the rates of local recurrence and disease-free survival, as well as a clear benefit from the addition of PRE to all grades of surgical dissection. Thus for patients with rectal cancer short-course pre-operative radiotherapy and good quality surgery can almost completely eliminate local recurrence.

[Table: see text]

No significant financial relationships to disclose.

A case study of regional catchment water quality modelling to identify pollution control requirements

There are four ecologically important river catchments that contain candidate Special Areas of Conservation (cSACs) under the Habitats Directive in the Lake District National Park located in the North of England. These are the rivers Ehen, Kent, Derwent and Eden. For each cSAC, there are defined ecological criteria that include water quality targets to protect the designated species. Stretches of the riverine cSACs in each catchment are failing to meet these and other water quality targets. The Environment Agency commissioned a study of each catchment to provide the underpinning scientific knowledge to allow it to deliver its statutory obligations under the Habitats Directive. SIMCAT river water quality models were produced and used to predict the water quality impacts resulting from a number of water quality planning scenarios aimed at achieving full compliance with the Habitats Directive and other national and EEC water quality targets. The results indicated that further controls on effluent discharges will allow the majority of targets to be met but other sources of pollution will also need to be controlled. The outcome of the study also recognised that water quality improvements alone will not necessarily produce the required improvement to the ecological interest features in each cSAC.

Interclinician variation in diabetes foot assessment--a national lottery?

AIM

The aim was to evaluate variation among clinicians in the outcome of assessments of foot health status and risk status in patients with diabetes.

METHODS

Seventeen clinicians assessed three patients with diabetes using a standardized assessment form and risk classification system.

RESULTS

There was variation among clinicians in all aspects of the assessment; recording basic demographic information; taking a medical history; vascular and neurological assessments. Variation was also evident in the risk categories allocated to each of the three patients.

CONCLUSIONS

As a consequence of the variation among clinicians in the foot assessment the same patient would have received different care pathways to monitor and manage their foot health depending upon which clinician undertook their initial assessment. We therefore recommend that more attention is placed on training for objective clinical testing, at both pre- and postgraduate levels.

A customizable MR brain imaging atlas of structure and function for decision support

We present a MR brain atlas for structure and function (diffusion weighted images). The atlas is customizable for contrast and orientation to match the current patient images. In addition, the atlas also provides normative values of MR parameters (T1, T2 and ADC values). The atlas is designed on informatics principles to provide context sensitive decision support at the time of primary image interpretation. Additional support for diagnostic interpretation is provided by a list of expert created most relevant 'Image Finding Descriptors' that will serve as cues to the user. The architecture of the atlas module is integrated into the image workflow of a radiology department to provide support at the time of primary diagnosis.

Adsorption of Nonionic Mixtures at the Air–Water Interface: Effects of Temperature and Electrolyte

Specular neutron reflection has been used to investigate the effects of temperature and added electrolyte on the adsorption of nonionic surfactants and nonionic surfactant mixtures at the air-water interface. For the alkyl poly-oxyethylene oxide nonionic surfactants, C(n)EO(m), the adsorption at the air-water interface is independent of temperature for surfactants with shorter ethylene oxide groups, whereas there is an increasing tendency for increased adsorption with temperature for surfactants with longer ethylene oxide groups. The addition of "salting in" (sodium thiocyanate, NaSCN) and "salting out" (sodium chloride, NaCl, sodium sulphate, Na2SO4) electrolyte results in reduced and enhanced adsorption, respectively, for C12EO8, whereas both types of electrolyte result in enhanced adsorption for C12EO12. The addition of electrolyte does not substantially alter the temperature dependence of the adsorption of the pure monolayers. For the nonionic mixtures of C12EO3/C12EO8 increasing temperature results in a surface richer in the least surface-active component, C12EO8. For the same nonionic mixture, the addition of "salting in" and "salting out" electrolyte results in an reduced and increased adsorption, respectively. The addition of "salting in" electrolyte results in a surface more rich in C12EO3, whereas for the addition of both "salting in" and "salting out" electrolyte the surface composition is essentially unaltered.

Antiferrodistortive reconstruction of the PbTiO(3)(001) surface

We present in situ x-ray scattering measurements of the surface structures of PbTiO(3) (001) in equilibrium with PbO vapor. At 875 to 1025 K, a reconstruction having c(2x2) symmetry is present under most conditions, while a 1 x 6 reconstruction occurs under PbO-poor conditions. The atomic structure of the c(2x2) phase is found to consist of a single layer of an antiferrodistortive structure with oxygen cages counter-rotated by 10 degrees about the titanium ions.

The reasons for, and lessons learned from, the closure of the Canterbury GP After-Hours Service

This paper describes a trial of the Canterbury GP After-Hours Service (CGPAHS), a GP staffed after-hours service within the Canterbury Hospital Emergency Department. It was decided not to continue the service beyond the twelve-month trial phase because the opportunity cost to do this was greater than existing alternative services. The efficiency of the service might have been improved had greater numbers of patients been referred to it, either from the adjacent emergency department or the local community. Reasons why the trial was not able to realise these efficiencies are explored.

Comparative affinity of duloxetine and venlafaxine for serotonin and norepinephrine transporters in vitro and in vivo, human serotonin receptor subtypes, and other neuronal receptors

The blockade of serotonin (5-HT) and norepinephrine (NE) transporters in vitro and in vivo by the dual 5-HT/NE reuptake inhibitors duloxetine and venlafaxine was compared. Duloxetine inhibited binding to the human NE and 5-HT transporters with K(i) values of 7.5 and 0.8 nM, respectively, and with a K(i) ratio of 9. Venlafaxine inhibited binding to the human NE and 5-HT transporters with K(i) values of 2480 and 82 nM, respectively, and with a K(i) ratio of 30. Duloxetine inhibited ex vivo binding to rat 5-HT transporters and NE transporters with ED(50) values of 0.03 and 0.7 mg/kg, respectively, whereas venlafaxine had ED(50) values of 2 and 54 mg/kg, respectively. The depletion of rat brain 5-HT by p-chloramphetamine and depletion of rat hypothalamic NE by 6-hydroxydopamine was blocked by duloxetine with ED(50) values of 2.3 and 12 mg/kg, respectively. Venlafaxine had ED(50) values of 5.9 and 94 mg/kg for blocking p-chloramphetamine- and 6-hydroxydopamine-induced monoamine depletion, respectively. Thus, duloxetine more potently blocks 5-HT and NE transporters in vitro and in vivo than venlafaxine.

Preventing transmission of Sarcoptes scabiei var. suis from infested sows to nursing piglets by a prefarrowing treatment with doramectin injectable solution

Studies were conducted at swine facilities in Illinois and North Carolina to evaluate the effect of treatment with doramectin injectable solution on transmission prevention of Sarcoptes scabiei var. suis from sows to nursing piglets. Approximately 42 days prefarrowing, 58 mange-free sows were experimentally infested with 200 S. scabiei in each ear. Seven to fourteen days prior to farrowing, 22 sows were given doramectin injectable intramuscularly at a dose of 300 microg/kg of body weight. A total of 21 sows served as untreated controls. Skin scrapings for mite counts and lesion scoring were performed on sows before treatment on day 21, and on either day 35 or 42. Each sow was observed on days 0, 7, 14, 21, 28, and 35 or 42 for the incidence of scratching/rubbing. Skin scrapings, lesion scoring, and observation of scratching/rubbing were performed on the piglets after weaning and at the end of the nursery stage. Geometric mean mite counts of the untreated sows were 0.70 and 0.26 on days 21 and 35 or 42, respectively, and 0.00 for doramectin-treated sows over the same time periods (P<0.05). Lesions scores and the incidence of scratching/rubbing were both higher in the untreated sows as compared to the doramectin-treated sows during the same time periods (P<0.05). Geometric mean mite counts of piglets farrowed by untreated sows were 0.50 and 0.60 after weaning and at the end of the nursery stage, respectively, and 0.00 for piglets from doramectin-treated sows over the same time periods (P>0.05). Lesion scores and the incidence of scratching/rubbing were both higher in piglets from untreated sows as compared to those piglets from doramectin-treated sows (P<0.05). Treating S. scabiei-infested sows with doramectin injectable solution before farrowing eliminated mite infestation and prevented the transmission of S. scabiei to piglets.

Antifungal susceptibilities, varieties, and electrophoretic karyotypes of clinical isolates of Cryptococcus neoformans from Brazil, Chile, and Venezuela

One hundred clinical isolates of Cryptococcus neoformans from human immunodeficiency virus (HIV)-infected and non-HIV-infected patients from Brazil, Chile, and Venezuela were separated according to varieties and tested for antifungal susceptibility. A high susceptibility to antifungal agents was observed among all the isolates. The electrophoretic karyotyping of 51 strains revealed good discrimination among Cryptococcus neoformans var. neoformans strains.

Speech disorder in children with Down's syndrome

The speech of children with Down's syndrome (DS) is often unintelligible, unlike many other children who have an intellectual disability. However, the nature of their speech disorder is controversial. The speech error patterns of children with DS were compared to those of intellectually average children with phonological disorder whose errors were characterized by inconsistency. The groups were matched for percentages of consonants produced in error. The data revealed no differences between the groups in terms of the number of words which were produced inconsistently on repeated productions in a picture-naming task. However, further analyses revealed differences in the type of errors made by the groups in that the children with phonological disorder characterized by inconsistent errors made more changes to words on repeated production than the group with DS. The deficits underlying inconsistent pronunciation of words in the two groups of children under investigation would appear to differ. Intervention strategies should target the deficits identified.

Battle of the sexes: gender stereotype confirmation and reactance in negotiations

The authors examined how gender stereotypes affect negotiation performance. Men outperformed women when the negotiation was perceived as diagnostic of ability (Experiment 1) or the negotiation was linked to gender-specific traits (Experiment 2), suggesting the threat of negative stereotype confirmation hurt women's performance relative to men. The authors hypothesized that men and women confirm gender stereotypes when they are activated implicitly, but when stereotypes are explicitly activated, people exhibit stereotype reactance, or the tendency to behave in a manner inconsistent with a stereotype. Experiment 3 confirmed this hypothesis. In Experiment 4, the authors examined the cognitive processes involved in stereotype reactance and the conditions under which cooperative behaviors between men and women can be promoted at the bargaining table (by activating a shared identity that transcends gender).

A comparison of patients with different types of syndactyly

We performed a retrospective review of finger syndactyly releases at Shriners Hospital for Children, Houston Unit, between January 1983 and January 1993. This study was performed in an attempt to compare the long-term postoperative function in patients after release of syndactyly resulting from Poland's syndrome with that in patients with idiopathic forms of syndactyly. Only patients with one involved hand were included in this study. The contralateral hand was used as a control. Twenty-seven patients with only one hand involved underwent syndactyly release during this period. Of these, 13 patients who underwent a total of 30 syndactyly releases were available for evaluation. For each patient, the type of syndactyly was determined. Each patient was subjected to a detailed physical examination and participated in occupational-therapy modalities. We noted statistically significant differences in function between operated-on and control hands in the Poland's group, whereas operated-on hands affected with idiopathic forms of syndactyly did not demonstrate significantly different function compared with contralateral controls. These data suggest that functional deficits in hands affected by Poland's syndrome are attributable to more than the syndactyly alone. Hands affected by idiopathic forms of syndactyly are likely to have little postoperative functional deficit.

Analysis of a natural immune response against tumor antigens in a melanoma survivor: lessons applicable to clinical trial evaluations

The long-term survival of some patients with metastatic melanoma may be attributable in part to cellular immune responses to melanoma antigens. However, little is known about the level of CTL reactivity in vivo that is required for immunological control of tumor progression. In the present report, T-cell responses were evaluated with lymphocytes obtained from tumor-involved nodes and peripheral blood of a long-term melanoma survivor. Using an ELISPOT assay, naturally occurring functional T cells, which recognize the peptide ALLAVGATK (gp100(17-25)) plus two other HLA-A3 restricted peptides, were detected in a tumor-involved lymph node. The ALLAVGATK-reactive T cells were also evaluated by MHC-tetramers staining and were found to be CD8+ CD45RO+ L-selectin(-) CD11a+, suggesting that they are antigen experienced and have a memory phenotype. Unstimulated peripheral blood lymphocytes from the same patient demonstrated no detectable T-cell responses; however, a single stimulation with ALLAVGATK peptide in vitro resulted in a dramatic expansion of peptide-reactive CTLs. This patient, with evidence of tumor-reactive CTLs targeted to several tumor antigens in a tumor-involved lymph node and with evidence of a circulating memory T-cell response, has remained disease-free for 6 years, despite prior bulky nodal metastasis. In contrast, three HLA-A3+ patients with rapidly progressive metastatic melanoma had no detectable T-cell response in tumor-involved nodes or peripheral blood lymphocytes, even after peptide stimulation ex vivo. The presented data are consistent with a systemic polyvalent immune response against tumor in this long-term survivor. These data provide an estimate of the level of CTL response that may be associated with protection from tumor recurrence.