Evaluation of the introduction of a standardised protocol for the staging and follow-up of colorectal cancer on resection rates for liver metastases

INTRODUCTION

In 2004, an audit in our unit demonstrated wide variation in liver resection rates for colorectal cancer (CRC) metastases within the cancer network. Subsequently, a network-wide CT-based follow-up and referral policy was introduced for all patients. A second audit was performed to assess the impact of the guidelines on liver resection rates.

SUBJECTS AND METHODS

Analysis of prospective liver resection database between 1997 and 2004 and after the introduction of standardised guidelines between January 2005 and April 2008.

RESULTS

A total of 362 patients underwent liver resection for CRC metastases between 1997 and 2008, 237 prior to the introduction of the referral guidelines and 125 after. Liver resection rates according to referring hospital varied from 0.92 to 2.32 per 100,000 population before guidelines were introduced. After 2005, resection rates from the four district hospitals standardised (1.68-1.84 per 100,000 population), but the central unit rate (Sheffield) remained significantly higher (2.67 per 100,000 population). No significant difference in 1-year disease-free survival between patients from Sheffield and the out-lying hospitals was found (P = 0.553).

CONCLUSIONS

Introduction of a referral protocol standardised resection rates from the four district hospitals, but these remain lower compared to the specialist centre. The wide-spread adoption of a policy to discuss all patients with liver metastases at an advanced disease multidisciplinary team meeting, in the presence of hepatobiliary specialists, may further increase resection rates across the UK.

Capsular retraction: an uncommon imaging finding in hepatic inflammatory pseudotumour

Capsular retraction is an infrequent but characteristic feature of malignant liver lesions such as hepatic metastases and intrahepatic cholangiocarcinoma. Rarely, this finding may be observed in association with benign lesions, such as atypical haemangiomas. Capsular retraction has not previously been reported in association with hepatic inflammatory pseudotumour (IPT). Hepatic IPT is an uncommon benign hepatic lesion with a good clinical prognosis. In this report, we discuss the case of a 48-year-old woman with capsular retraction secondary to multifocal hepatic inflammatory IPTs.

Introduction of a day-case laparoscopic cholecystectomy service in the UK: a critical analysis of factors influencing same-day discharge and contact with primary care providers

INTRODUCTION

The objective of this study was to determine the safety and acceptability of the implementation of a day-case laparoscopic cholecystectomy (LC) service in a large UK teaching hospital, and analyse factors influencing contact with primary care providers. Wide-spread introduction of day-case LC in the UK is a major target of healthcare providers. However, few centres have reported their experience. In the US, out-patient surgery for LC has been reported, though many groups have utilised 24-h observation units to facilitate discharge. Concerns remain amongst surgeons regarding the feasibility and acceptability of the introduction of day-case LC in the UK.

PATIENTS AND METHODS

Comprehensive care and operative data were prospectively collected on the first 106 consecutive day-case procedures in our hospital. Postoperative recovery was monitored by telephone questionnaire on days 2, 5 and 14, including complications, satisfaction and general practitioner consultation.

RESULTS

A total of 106 patients were admitted for day-case LC, of whom 84% were discharged on the day of surgery. Patient satisfaction rate was 94% in both the successful day-case and the admitted patients. Mean operation time was 62 min, with an average total stay on the day-care unit of 426 min. Training-grade surgeons performed 31% of operations. Both the readmission rate after surgery and rate of conversion to open surgery were 2%. Advice from primary healthcare providers was sought by 33% of patients within the first 14 postoperative days.

CONCLUSIONS

Introduction of day-case LC in the UK is feasible and acceptable to patients. The potential burden to primary care providers needs further study.

Identification of Porphyromonas levii isolated from clinical cases of bovine interdigital necrobacillosis by 16S rRNA sequencing

Laboratories use pigmentation, antibiotic susceptibility, and biochemical tests to identify anaerobic organisms that play a role in bovine interdigital necrobacillosis (bovine foot rot). In this study, 16S rRNA gene sequencing was used to identify strains to the species level that were originally classified as Prevotella or Porphyromonas spp by conventional phenotype assessment methods. Of 264 qualified strains from ceftiofur clinical trials, 241 isolates were definitively identified by 16S rRNA sequencing as Porphyromonas levii. Similarly, of 275 qualified strains from tulathromycin clinical trials, 156 isolates were definitively identified by 16S rRNA sequencing as P. levii. The predominance of P. levii in this study supports the role of this organism as an associative agent of bovine foot rot and may have implications for routine laboratory diagnosis.

Inorganic pigments made from the recycling of coal mine drainage treatment sludge

Continuous industrial development increases energy consumption and, consequently, the consumption of fossil fuels. Coal mineral has been used in Brazil as a solid fuel for thermoelectric generators for several years. However, coal exploitation affects the environment intensely, mainly because Brazilian coal contains excess ash and pyrite (iron disulfide). According to the local coal industry syndicate, the average annual coal run per mine is 6 million ton/year; 3.5 million ton/year are rejected and disposed of in landfills. Besides pyrite, Brazilian coal contains Mn, Fe, Cu, Pb, Zn, Ge, Se, and Co. Additionally, the water used for coal beneficiation causes pyrite oxidation, forming an acid mine drainage (AMD). This drainage solubilizes the metals, transporting them into the environment, making treatment a requirement. This work deals with the use of sedimented residue from treated coal mine drainage sludge to obtain inorganic pigments that could be used in the ceramic industry. The residue was dried, ground and calcined ( approximately 1250 degrees C). The calcined pigment was then micronized (D(50) approximately 2mum). Chemical (XRF), thermal (DTA/TG), particle size (laser), and mineralogical (XRD) analyses were carried out on the residue. After calcination and micronization, mineralogical analyses (XRD) were used to determine the pigment structure at 1250 degrees C. Finally, the pigments were mixed with transparent glaze and fired in a laboratory roller kiln (1130 degrees C, 5min). The results were promising, showing that brown colors can be obtained with pigments made by residues.

Sensitivity of magnetic resonance imaging in the detection of colorectal liver metastases

INTRODUCTION

The aim of this study was to evaluate the sensitivity of magnetic resonance imaging (MRI) in the detection of colorectal liver metastases.

PATIENTS AND METHODS

Pre-operative MRI scanning of the liver was performed by a single radiologist and the size and number of definite liver metastases were recorded. Patients then underwent hepatectomy with routine intra-operative ultrasonography (IOUS) and resected specimens were sent for histopathology. Pathology findings were compared with those of MRI scans to determine the sensitivity of this imaging modality. Exclusions were patients undergoing hepatic resection more than 4 weeks after the MRI scan, those undergoing chemotherapy at the time of the scan, and those with conglomerate unilobar metastases.

RESULTS

Complete data were available for 84 patients. There was total agreement between MRI, IOUS and histology in 79 patients (101 metastases). MRI missed 5 metastases in 5 patients that were found on IOUS (or palpation of superficial lesions) and subsequently confirmed by histological examination. These measured 5 mm or less (4 patients) and 7 mm (one patient). The sensitivity of MRI in the detection of colorectal liver metastases was thus 94% for all lesions and 100% for lesions 1 cm or larger in diameter.

CONCLUSIONS

MRI of the liver is a non-invasive technique with an extremely high degree of sensitivity in the detection of colorectal liver metastases and should be considered as the 'gold standard' in the pre-operative imaging of these patients.

Genetic control of prion incubation period in mice

The prion gene complex (Prn) is located on mouse chromosome 2 between the beta-2-microglobulin (B2m) and agouti (A) genes. Within this complex are the prion protein gene (Prn-p), which encodes the only identified macromolecule (PrP) that purifies with infectious scrapie agent, and a scrapie incubation time gene (Prn-i). Using a variety of restriction endonucleases, six allelic forms of the Prn-p gene have been distinguished by their patterns of restriction fragment length polymorphisms. We had previously shown that the exceptionally long scrapie incubation period of I/LnJ mice inoculated with the Chandler isolate (over 200 days) was due to the effects of a scrapie incubation time gene tightly linked to Prn-p. So far, this long scrapie incubation time allele has been found only in those inbred mouse strains (I/LnJ, P/J and IM) that have the b allele of Prn-p. It is not known whether the incubation time gene and prion protein gene are two distinct loci or are one and the same. Putative recombinants between the incubation time phenotype and Prn-p genotype have been observed, but this could be due to effects of other genes segregating in the population. Regardless of whether or not the incubation time and PrP genes are identical, if any differences were found in the amino acid sequences of PrP encoded by the different Prn-p alleles there would be important implications for interpretation of results on 'strains' of scrapie agent. It would not be necessary to invoke nucleic acid as the informational macromolecule of the scrapie agent because differences in prion 'strains' recovered from mice with different Prn-p genotypes need not be the result of host selection but could be due to differences in host-encoded PrP.

Elevated high-sensitivity C-reactive protein levels are associated with local inflammatory findings in patients with osteoarthritis

OBJECTIVE

C-reactive protein (CRP) has been associated with disease progression in patients with osteoarthritis (OA), but the reasons for this remain unclear. We hypothesized that higher CRP would be related to local inflammatory findings in the joints of patients with OA.

METHODS

Plasma and synovial membrane specimens from 54 OA patients undergoing total hip or knee arthroplasty or arthroscopy were obtained. Synovial fluid was obtained from 25 of these patients. Hematoxylin and eosin stained synovial membrane sections were scored for degree of inflammatory cell infiltration. Plasma high-sensitivity CRP (hsCRP) levels, and serum and synovial fluid interleukin (IL)-6 and IL-1beta levels were measured by enzyme-linked immunosorbent assay.

RESULTS

Fifty-seven percent of patients with idiopathic OA had inflammatory infiltrates within the synovial membrane. The mean hsCRP level in patients with inflammatory infiltrates was significantly higher than those without inflammation (4.7 +/- 5.0 mg/L vs 1.7 +/- 3.6 mg/L, P = 0.003). There were significant correlations between hsCRP levels and synovial fluid IL-6 (r = 0.64, P = 0.0006), degree of synovial inflammatory infiltration (r = 0.43, P = 0.002), and body mass index (r = 0.31, P = 0.02). Multivariate analysis indicated that only degree of inflammatory infiltrate was significantly associated with hsCRP level (P = 0.026).

CONCLUSION

These results suggest that systemic hsCRP levels reflect synovial inflammation in OA patients, perhaps by means of synovial IL-6 production. Future studies are needed to clarify how these infiltrates and their products may contribute to disease pathogenesis.

Reduced penetrance alleles for Huntington's disease: a multi-centre direct observational study

OBJECTIVE

To obtain penetrance data for Huntington's disease when DNA results are in the range of 36-39 CAG repeats and assess the consistency of reporting the upper allele from two reference centres.

METHOD

Data were collected anonymously on age of onset or age last known to be unaffected from a cohort of individuals with results in this range. DNA samples were re-analysed in two reference centres. Kaplan-Meier analysis was used to construct an age of onset curve and penetrance figures.

RESULTS

Clinical data and concordant DNA results from both reference centres were available for 176 samples; penetrance figures (and 95% confidence intervals) for this cohort, at age 65 and 75 years, were 63.9% (55.5% to 73.2%) and 74.2% (64.2% to 84.2%), respectively. Inclusion of 28 additional subjects for whom repeat DNA results were unavailable, obtained from only one reference centre, or discrepant by one repeat within this range, gave penetrance data (including 95% confidence intervals) at ages 65 and 75 years of 62.4% (54.4% to 70.4%) and 72.7.% (63.3% to 82.1%), respectively. 238 duplicate results were available from the reference centres; 10 (4.2%) differed by one CAG repeat in the reporting of the upper allele and in two (0.84%) of these cases the discrepancy was between 39 and 40 repeats.

CONCLUSION

When DNA results are in this range, a conservative approach is to say that there is at least a 40% chance the person will be asymptomatic at age 65 years and at least a 30% chance the person will be asymptomatic at age 75 years.

Should the precautionary principle guide our actions or our beliefs?

Two interpretations of the precautionary principle are considered. According to the normative (action-guiding) interpretation, the precautionary principle should be characterised in terms of what it urges doctors and other decision makers to do. According to the epistemic (belief-guiding) interpretation, the precautionary principle should be characterised in terms of what it urges us to believe. This paper recommends against the use of the precautionary principle as a decision rule in medical decision making, based on an impossibility theorem presented in Peterson (2005). However, the main point of the paper is an argument to the effect that decision theoretical problems associated with the precautionary principle can be overcome by paying greater attention to its epistemic dimension. Three epistemic principles inherent in a precautionary approach to medical risk analysis are characterised and defended.