Characterising differences between self-reported and wastewater-identified drug use at two consecutive years of an Australian music festival

BACKGROUND

In the context of drug prohibition, potential adulteration and variable purity pose additional health risks for people who use drugs, with these risks often compounded by the outdoor music festival environment. Ahead of the imminent implementation of drug checking services in Queensland, Australia, this study aims to characterise this problem using triangulated survey and wastewater data to understand self-reported and detected drug use among attendees of a multi-day Queensland-based music festival in 2021 and 2022.

METHODS

We administered an in-situ survey focusing on drug use at the festival to two convenience samples of 136 and 140 festival attendees in 2021 and 2022 respectively. We compared survey findings to wastewater collected concurrently from the festival's site-specific wastewater treatment plant, which was analysed using Liquid Chromatography Tandem Mass Spectrometry.

RESULTS

Most survey respondents (82 % in 2021, 92 % in 2022) reported using or intending to use an illicit drug at the festival. Some respondents reported potentially risky drug use practices such as using drugs found on the ground (2 % in 2021, 4 % in 2022). Substances detected in wastewater but not surveys include MDEA, mephedrone, methylone, 3-MMC, alpha-D2PV, etizolam, eutylone, and N,N-dimethylpentylone.

CONCLUSION

Many substances detected in wastewater but not self-reported in surveys likely represent substitutions or adulterants. These findings highlight the benefits of drug checking services to prevent harms from adulterants and provide education on safer drug use practices. These findings also provide useful information on socio-demographic characteristics and drug use patterns of potential users of Queensland's future drug checking service.

Root pressure-volume curve traits capture rootstock drought tolerance

BACKGROUND AND AIMS

Living root tissues significantly constrain plant water uptake under drought, but we lack functional traits to feasibly screen diverse plants for variation in the drought responses of these tissues. Water stress causes roots to lose volume and turgor, which are crucial to root structure, hydraulics and growth. Thus, we hypothesized that root pressure-volume (p-v) curve traits, which quantify the effects of water potential on bulk root turgor and volume, would capture differences in rootstock drought tolerance.

METHODS

We used a greenhouse experiment to evaluate relationships between root p-v curve traits and gas exchange, whole-plant hydraulic conductance and biomass under drought for eight grapevine rootstocks that varied widely in drought performance in field trials (101-14, 110R, 420A, 5C, 140-Ru, 1103P, Ramsey and Riparia Gloire), grafted to the same scion variety (Vitis vinifera 'Chardonnay').

KEY RESULTS

The traits varied significantly across rootstocks, and droughted vines significantly reduced root turgor loss point (πtlp), osmotic potential at full hydration (πo) and capacitance (C), indicating that roots became less susceptible to turgor loss and volumetric shrinkage. Rootstocks that retained a greater root volume (i.e. a lower C) also maintained more gas exchange under drought. The rootstocks that previous field trials have classified as drought tolerant exhibited significantly lower πtlp, πo and C values in well-watered conditions, but significantly higher πo and πtlp values under water stress, than the varieties classified as drought sensitive.

CONCLUSIONS

These findings suggest that acclimation in root p-v curve traits improves gas exchange in persistently dry conditions, potentially through impacts on root hydraulics or root to shoot chemical signalling. However, retaining turgor and volume in previously unstressed roots, as these roots deplete wet soil to moderately negative water potentials, could be more important to drought performance in the deep, highly heterogenous rooting zones which grapevines develop under field conditions.

Metastatic renal cell carcinoma to the brain: optimizing patient selection for gamma knife radiosurgery

INTRODUCTION

The effects of single-fraction gamma knife radiosurgery (sf-GKRS) on patients with renal cell carcinoma (RCC) brain metastases (BM) in the era of targeted agents (TA) and immune checkpoint inhibitors (ICI) are insufficiently studied.

METHODS AND MATERIALS

Clear cell metastatic RCC patients treated with sf-GKRS due to BM in 2005-2014 at three European centres were retrospectively analysed (n = 43). Median follow-up was 56 months. Ninety-five percent had prior nephrectomy, 53% synchronous metastasis and 86% extracranial disease at first sf-GKRS. Karnofsky performance status (KPS) ranged from 60 to 100%. Outcome measures were overall survival (OS), local control (LC) and adverse radiation effects (ARE).

RESULTS

One hundred and ninety-four targets were irradiated. The median number of targets at first sf-GKRS was two. The median prescription dose was 22.0 Gy. Thirty-seven percent had repeated sf-GKRS. Eighty-eight percent received TA. LC rates at 12 and 18 months were 97% and 90%. Median OS from the first sf-GKRS was 15.7 months. Low serum albumin (HR for death 5.3), corticosteroid use pre-sf-GKRS (HR for death 5.8) and KPS < 80 (HR for death 9.1) were independently associated with worse OS. No further prognostic information was gleaned from MSKCC risk group, synchronous metastasis, age, number of BM or extracranial metastases. Other prognostic scores for BM radiosurgery, including DS-GPA, renal-GPA, LLV-SIR and CITV-SIR, again, did not add further prognostic value. ARE were seldom symptomatic and were associated with tumour volume, 10-Gy volume and pre-treatment perifocal oedema. ARE were less common among patients treated with TA within 1 month of sf-GKRS.

CONCLUSIONS

We identified albumin, corticosteroid use and KPS as independent prognostic factors for sf-GKRS of clear cell RCC BM. Studies focusing on the prognostic significance of albumin in sf-GKRS are rare. Further studies with a larger number of patients are warranted to confirm the above analytical outcome. Also, in keeping with previous studies, our data showed optimal rates of local tumour control and limited toxicity post radiosurgery, rendering GKRS the tool of choice in the management of RCC BM.

The role of radiosurgery in the acute management of fourth ventricle compression due to brain metastases

Background:

Approximately 20–30% of all intracranial metastases are located in the posterior fossa. The clinical evolution hinges on factors such as tumor growth dynamics, local topographic conditions, performance status, and prompt intervention. Fourth ventricle (V4) compression with secondary life-threatening obstructive hydrocephalus remains a major concern, often requiring acute surgical intervention. We have previously reported on the application of adaptive hypofractionated Gamma Knife Radiosurgery in the acute management of critically located metastases, a technique known to us as rapid rescue radiosurgery (3R). We report the results of 3R in the management of posterior fossa lesions and ensuing V4 decompression.

Case Descriptions:

Four patients with V4 compression due to posterior fossa metastases were treated with 3R by three separate gamma knife radiosurgical sessions (GKRS) over a period of seven days. Mean V4 volume was 1.02 cm³ at GKRS 1, 1.13 cm³ at GKRS 2, and 1.12 cm³ at GKRS 3. Mean tumor volume during the week of treatment was 10 cm³ at both GKRS 1 and 2 and 9 cm³ at GKRS 3. On average, we achieved a tumor volume reduction of 52% and a V4 size increase of 64% at the first follow-up (4 weeks after GKRS 3). Long-term follow-up showed continued local tumor control, stable V4 volume, and absence of hydrocephalus.

Conclusion:

For this series, 3R was effective in terms of rapid tumor ablation, V4 decompression, and limited radiation-induced toxicity. This surgical procedure may become an additional tool in the management of intractable posterior fossa metastasis with V4 compression.

Melt layer erosion during ELM-like heat loading on molybdenum as an alternative plasma-facing material

Transient events that occur during plasma instabilities in fusion reactors impart large heat fluxes onto the surrounding plasma-facing components (PFCs). Erosion and splashing of PFCs can contaminate the plasma and shorten material lifetime. Although tungsten is currently considered the most promising candidate material for future PFCs, concerns over the thermal shock performance during type-I ELMs (transient events expected in fusion devices) necessitate the study of other comparable materials. ELM-like heat loading was applied via a pulsed Nd:YAG millisecond laser on a pristine molybdenum (Mo) surface to measure surface melting and mass loss. One potential advantage of Mo is its higher specific heat of vaporization, which could lead to reduced particle emission. Imaging of the surface after loading revealed that complete surface melting began at 1.0 MJ m-2 (heat load parameter of 31.62 MJ m-2 s-1/2). Photon excitation also increased significantly above 1.0 MJ m-2, indicating possible phase change. At 1.4 MJ m-2 (44.27 MJ m-2 s-1/2), in situ mass loss measurements found an exponential increase in particle emission, indicating the presence of droplet formation and boiling. Direct comparisons of erosion during pulsed heat loading between PFC candidate materials will ensure that future fusion devices design components with optimal thermal strength.

Rectal mobilization: the place of Denonvilliers' fascia and inconsistencies in the literature

Confusion remains as to what is meant by Denonvilliers' fascia. This review searched the literature on pelvic surgical anatomy to determine whether there is agreement with Denonvilliers' original description and its implication in defining the correct anterior plane of dissection when mobilizing the rectum. The original French description of the fascia was translated into English and then compared both with French and with English studies identified by searching PubMed, Medline and Scopus from 1836 to June 2015. Special emphasis was given to the years between 1980 and 2015 in order to capture the literature pertinent to, and following on from, the description of total mesorectal excision for rectal cancer. The final literature search revealed 16 studies from the original 2150 citations. Much of the debate was concerned with the origin and development of the fascia, arising from either the 'fusion' or the 'condensation' of local primitive tissue into a mature 'multilayered' structure. Controversy regarding the correct plane of rectal mobilization occurs as a result of different interpretations by surgeons, anatomists and radiologists and bears little resemblance to Denonvilliers' original description. This may reflect wide anatomical variability in the adult pelvis or a form of dissection artefact. Further study is required to investigate this. Logically, for both men and women, the plane of rectal mobilization should be behind Denonvilliers' fascia and between it and the fascia propria of the rectum.

Guanidinoacetate methyltransferase deficiency: first steps to newborn screening for a treatable neurometabolic disease

BACKGROUND

GAMT deficiency is an autosomal recessive disorder of creatine biosynthesis resulting in severe neurological complications in untreated patients. Currently available treatment is only successful to stop disease progression, but is not sufficient to reverse neurological complications occurring prior to diagnosis. Normal neurodevelopmental outcome in a patient, treated in the newborn period, highlights the importance of early diagnosis.

METHODS

Targeted mutation analysis (c.59G>C and c.327G>A) in the GAMT gene by the QIAxcel system and GAA measurement by a novel two-tier method were performed in 3000 anonymized newborn blood dot spot cards.

RESULTS

None of the targeted mutations were detected in any newborn. Two novel heterozygous variants (c.283_285dupGTC; p.Val95dup and c.278_283delinsCTCGATGCAC; p.Asp93AlafsX35) were identified by coincidence. Carrier frequency for these insertion/deletion types of GAMT mutations was 1/1475 in this small cohort of newborns. GAA levels were at or above the 99th percentile (3.12 μmol/l) in 4 newborns. Second-tier testing showed normal results for 4 newborns revealing 0.1% false positive rate. No GAMT mutations were identified in 4 of the newborns with elevated GAA levels in the first tier testing.

CONCLUSION

This is the first two-tier study to investigate carrier frequency of GAMT deficiency in the small cohort of newborn population to establish evidence base for the first steps toward newborn screening for this treatable neurometabolic disorder.

The use of parenteral nutrition for the management of PKU patient undergoing chemotherapy for lymphoma: a case report

The metabolic control of phenylalanine levels is a challenge during illness. We present the metabolic management of a 6 year old boy with classical PKU who was diagnosed with stage III intraabdominal Burkit's lymphoma and underwent surgical resection and chemotherapy. The metabolic control during chemotherapy was achieved by the use of parenteral custom made amino acid solution and pro-active adjustment of intake. From the 94 obtained plasma phenylalanine (Phe) levels, 18.4% were above our clinic's recommended upper limit (360 μmol/L, 6 mg/dL) while 52.7% of Phe levels were below the recommended lower limit (120 μmol/L, 2 mg/dL). Phe levels above recommended range were associated with low caloric/protein intake, while levels below recommended range reflected the difficulty in achieving the full prescribed Phe intake. We recommend early institution of custom made amino acid solution with maximum amino acid content and caloric intake to provide optimal phenylalanine control. Administration of phenylalanine via regular intravenous amino acid solution may assist in avoiding low Phe levels when prescribed intake is compromised due to vomiting and other disease related illnesses. Use of custom made, phenylalanine free amino acid solution proved beneficial in the management of blood phenylalanine levels in a PKU patient during chemotherapy for Burkitt lymphoma.

Anastomotic leakage after resection of colorectal cancer generates prodigious use of hospital resources

OBJECTIVE

The aim of this study was to determine the demand for hospital resources generated by anastomotic leakage, including surgical, medical, imaging, pathology, and other allied health consultations or services and length of postoperative hospital stay.

METHOD

Data were obtained from a comprehensive, prospective hospital registry of all resections for colorectal cancer from January 1995 to December 2004 and from retrospective review of patients' notes.

RESULTS

Forty-one patients with a leak spent 92 days in intensive care, required 129 days of total parenteral nutrition, 69 days of enteric feeding and 41 days on ventilation and had a median postoperative hospital stay of 28 days (range 11-104). These patients required 24 re-operations and 2273 separate medical consultations or allied services.

CONCLUSION

Anastomotic leakage generates a very considerable demand for hospital resources and diverts these resources from the hospital population at large.

Understanding the anatomy of lymphatic drainage and the use of blue-dye mapping to determine the extent of lymphadenectomy in rectal cancer surgery: unresolved issues

OBJECTIVE

This paper reviews the literature on the pathways of lymphatic drainage of the rectum and their significance in radical cancer surgery.

METHOD

This paper reviews some of the seminal works on the lymphatic drainage of the rectum and its surgical implications when operating on patients with rectal cancer. Publications were searched via Medline, sourced from reference lists and by cross referencing with the most widely cited papers.

RESULTS

The classical European description of the anatomy of the lymphatic drainage of the rectum is presented. Early lymphatic mapping techniques and the role of newer technologies in lymphatic mapping, including sentinel lymph node mapping are discussed. The differing philosophies between Western practice, of dissection in the plane of the fascia propria and the Japanese wider pelvic lymphadenectomy are discussed.

CONCLUSIONS

A clear understanding of the regional lymphatic drainage of the rectum and precise anatomical mobilisation of the rectum is the surgical cornerstone to excellent locoregional control of rectal cancer. The success of the differing Western and Japanese philosophies on the degree of pelvic lymphadenectomy suggests a possible role for 'selective wide pelvic lymphadectomy'. Mapping lateral lymphatic drainage pathways could augment the selection process for radiotherapy.

What factors influence survival in patients with unresected synchronous liver metastases after resection of colorectal cancer?

OBJECTIVE

The aim of this study was to determine whether the survival of patients with untreated synchronous liver metastases after resection of a colorectal cancer was associated with any features of the primary tumour.

METHODS

Information for 398 consecutive patients with unresected liver metastases in the period 1971-2001 was examined by multivariate survival analysis.

RESULTS

Of 19 clinical and pathological variables considered, survival was independently associated only with residual tumour in a line of resection (hazard ratio (HR) 1.95), venous invasion (HR 1.87), right colonic tumour (HR 1.68), lymph node metastasis (HR 1.54), and extra-hepatic metastasis (HR 1.16); 8.3% of patients had none of these adverse features. Their 2-year overall survival rate was 39.2%, compared with only 16.5% (P < 0.001) in those with one or more adverse features.

CONCLUSIONS

These findings may assist in selecting patients most likely to benefit from treatment of hepatic metastases and in counselling patients and their relatives.

Three-dimensional optical trapping of partially silvered silica microparticles

We demonstrate three-dimensional trapping of micrometer-diameter silica particles, partially coated with silver, within conventional optical tweezers. Although metallic particles are usually repelled from the beam focus by the scattering force, we show that transparent spheres partially coated with silver can be trapped with efficiencies comparable with dielectric particles. The trapping characteristics of these particles are examined as a function of metallic coverage, and the application of these particles to surface-enhanced resonance Raman scattering is investigated.

Changes in serum concentrations of methylmalonic acid and vitamin B12in cobalt-supplemented ewes and their lambs on two cobalt-deficient properties

AIM

To determine concurrent changes in serum methylmalonic acid (MMA) and vitamin B12 concentrations of ewes and their lambs on cobalt-deficient properties, subsequent to cobalt supplementation.

METHODS

Three experiments were carried out on two farms. Groups of ewes (n=25-50) were either supplemented with cobalt bullets during late pregnancy, 23-47 days before the mean lambing date, or left unsupplemented. In two experiments, lambs from within each group were supplemented directly by vitamin B12 injection at 3-weekly intervals from birth, and in the third experiment by injection with micro-encapsulated vitamin B12 at tailing and 3 months later. Pasture samples were obtained for analysis of cobalt content at each sampling time. Blood samples were obtained and liveweight recorded from ewes and lambs at approximately monthly intervals. On one farm (two experiments), liver and milk samples were obtained from ewes and liver samples from lambs.

RESULTS

Serum vitamin B12 concentrations in unsupplemented ewes fell below 250 pmol/L during early lactation in all experiments and mean concentrations as low as 100 pmol/L were recorded. MMA concentration was maintained below 2 micromol/L in serum from supplemented ewes but increased to mean concentrations ranging from 7 to 14 micromol/L at the nadir of serum vitamin B12 concentration during peak lactation. A significant liveweight response to supplementation was recorded in ewes on one property, and the vitamin B12 concentration in the ewes' milk and in the livers of their lambs more than doubled. No liveweight-gain response to supplementation was observed in lambs on this property. Mean serum MMA concentrations in lambs ranged from <2 in supplemented, to 19.2 micromol/L in unsupplemented lambs, and the latter had concurrent serum vitamin B12 concentrations of >300 pmol/L. Pasture cobalt concentration was lowest at 0.04-0.09 microg/kg dry matter (DM) on the property on which responses in lambs occurred but considerably higher (>0.09 microg/kg DM) on the property on which responses in ewes occurred. On the second property, serum vitamin B12 concentrations in lambs at tailing were extremely low (100 pmol/L), irrespective of supplementation of dams with cobalt. Mean serum MMA concentration was increased to 20 and 42 micromol/L in lambs from supplemented and non-supplemented ewes, respectively. Weight-gain response to direct supplementation of lambs with vitamin B12 occurred during suckling in the latter, but not the former. Lambs from ewes supplemented with vitamin B12 showed a much bigger increase in serum vitamin B12 concentrations a month after supplementation than did lambs from unsupplemented ewes (+1,400 pmol/L vs + 650 pmol/L).

CONCLUSIONS

Serum MMA concentration gave a more precise indication of responsiveness to vitamin B12 or cobalt supplementation than serum vitamin B12 concentrations in ewes and lambs. Neither very low serum vitamin B12 nor elevated MMA concentrations were necessarily indicative of responsiveness to supplementation in suckling lambs, but the latter gave an early indication of impending responsiveness. Supplementation of the ewe with a cobalt bullet appeared to protect the growth performance of the lamb for 90 days and influence the subsequent serum vitamin B12 response in the lamb to vitamin B12 supplementation.

CLINICAL SIGNIFICANCE

Supplementing ewes with cobalt bullets in late pregnancy can improve the vitamin B12 status of their lambs, and modify their response to vitamin B12 supplementation.

Concurrent changes in serum vitamin B12and methylmalonic acid during cobalt or vitamin B12supplementation of lambs while suckling and after weaning on properties in the South Island of New Zealand considered to be cobalt-deficient

AIM

To compare serum analyses of vitamin B12 and methylmalonic acid (MMA) as indices of cobalt/vitamin B12 deficiency in lambs around weaning.

METHODS

Lambs on five properties, considered to be cobalt- deficient, were supplemented with either cobalt bullets, or short- or long-acting vitamin B12 preparations. Blood samples, and in some cases liver biopsies, and liveweights were obtained at monthly intervals. Serum samples were assayed for vitamin B12 and MMA and liver for vitamin B12 concentrations. Pasture cobalt concentrations were measured on three of the properties.

RESULTS

Pasture cobalt concentrations were generally maintained below 0.07 microg/g dry matter (DM) on the properties sampled. Growth responses to supplementation were observed on only 2/5 properties, despite serum vitamin B12 concentrations being within the currently used 'marginal' reference range (336-499 pmol/L) for at least 3 months on all properties and in the deficient reference range (0-335 pmol/L) for at least 2 months on all farms except one. Serum MMA concentrations in supplemented lambs were <2 micromol/L, except in those animals sampled 1 month after receiving treatment with a short-acting vitamin B12 injection. Serum MMA concentrations in unsupplemented animals on properties on which no growth response to supplementation occurred generally reached peak levels of between 4 and 7 micromol/L at the nadir of serum vitamin B12 concentration. When a growth response was observed, differences in weight gain between supplemented and unsupplemented lambs occurred as mean serum MMA concentrations increased from 9 to 14 micromol/L. On one property where supplementation commenced before weaning, normal growth rates were maintained despite serum vitamin B12 concentrations of 140 pmol/L and serum MMA concentrations in excess of 40 micromol/L serum.

CONCLUSIONS

The possibility that current serum vitamin B12 references ranges for diagnosis of cobalt deficiency are set too high and lead to over-diagnosis of responsiveness to cobalt/ vitamin B12 supplementation is discussed. The suggestion is made that serum MMA concentrations in excess of 9-14 micromol/L will provide a more reliable diagnostic test for cobalt deficiency. However, there was sufficient variation between properties in the relationships between cobalt concentrations of pasture and serum vitamin B12 or MMA concentrations to require more rigorous testing of the reliability of using serum MMA concentration for this purpose. The possibility that differences in rumen fermentation and therefore propionate and vitamin B12 production could be involved is discussed. The measurement of serum MMA and vitamin B12 appears to be of little value whilst the lamb is still suckling.

CLINICAL SIGNIFICANCE

Serum MMA concentration may offer advantages over serum vitamin B12 concentrations in the diagnosis of a cobalt/vitamin B12 responsiveness in weaned lambs.

Adverse histopathological findings as a guide to patient management after curative resection of node-positive colonic cancer

Background

The aim of this study was to identify patient and tumour characteristics that might assist in developing an improved approach to patient selection for chemotherapy after resection of clinicopathological stage C colonic cancer.

Methods

Clinical, pathological and follow-up data have been collected prospectively for all patients undergoing resection for colorectal cancer at Concord Hospital since 1971. From an initial 2980 patients, after exclusions 378 remained who had a potentially curative operation for colonic cancer with nodal metastases and did not receive adjuvant chemotherapy. Associations between several pathological features and survival were examined by proportional hazards regression.

Results

In a multivariate model, both overall and colonic cancer-specific survival rates were negatively associated with serosal surface involvement, apical node metastasis, high histological grade and venous invasion. The survival of patients with stage C disease who had none of these adverse features was not significantly different from that of patients with stage B lesions. However, survival diminished significantly when one or more of the adverse features were present.

Conclusion

Patients with a stage C tumour but with none of the identified adverse features experience relatively good survival and are unlikely to benefit from adjuvant chemotherapy. In this series such patients accounted for 40·5 per cent of patients with stage C disease.

Anastomotic leakage after curative anterior resection results in a higher prevalence of local recurrence

BACKGROUND

The aim of this study was to determine whether leakage from a colorectal anastomosis following potentially curative anterior resection for rectal cancer is an independent risk factor for local recurrence.

METHODS

The study included all patients who had a potentially curative anterior resection with anastomosis for adenocarcinoma of the rectum between 1971 and 1991 at Concord Hospital. The data were collected prospectively, with complete follow-up for at least 5 years. The Kaplan-Meier method was used to compare time to recurrence between strata of categorical variables. Proportional hazards regression was used in multivariate modelling.

RESULTS

There were 403 patients in the study. After adjustment for lymph node metastases, the distal resection margin of resection, non-total anatomical dissection of the rectum and the level of anastomosis, multivariate analysis identified a significant association between anastomotic leakage and local recurrence (hazard ratio 3.8, 95 per cent confidence interval 1.8 to 7.9).

CONCLUSION

Leakage following a colorectal anastomosis after potentially curative resection for adenocarcinoma of the rectum is an independent predictor of local recurrence.

Combined endoscopic laser and radiotherapy palliation of advanced rectal cancer

BACKGROUND

In the palliative treatment of patients with advanced, inoperable rectal cancer, combined endoscopic laser and radiotherapy have been claimed to be more effective than laser therapy alone. The number of laser treatments, laser energy used, relapse rate, treatment of relapse, morbidity and survival in consecutive patients who were treated either by laser therapy alone or laser plus radiotherapy was compared.

METHODS

Prospective data were analysed with regard to number of treatments, laser energy used, relapse rate, morbidity and survival for 56 consecutive patients.

RESULTS

The crude relapse rate was significantly higher in the laser only group than in the laser plus radiotherapy group (58 and 15%, respectively; P = 0.002). There was no difference between the groups in the median total number of laser treatments or the mean total laser energy used. In patients experiencing a relapse, there was no difference in the median number of relapses, the number of laser treatments post-relapse or the total energy used post-relapse. Survival did not differ between the groups and there were no treatment-related deaths.

CONCLUSIONS

These findings demonstrate a clear reduction in relapse after using combined laser and radiotherapy to palliate patients with advanced rectal cancer with no appreciable additional morbidity and have encouraged continuing use of this treatment.

Development and validation of a self-completed HIV symptom index

Traditional, open-ended provider questions regarding patient symptoms are insensitive. Better methods are needed to measure symptoms for clinical management, patient-oriented research, and adverse drug-event reporting. Our objective was to develop and initially validate a brief, self-reported HIV symptom index tailored to patients exposed to multidrug antiretroviral therapies and protease inhibitors, and to compare the new index to existing symptom measures. The research design was a multistage design including quantitative review of existing literature, qualitative and quantitative analyses of pilot data, and quantitative analyses of a prospective sample. Statistical analyses include frequencies, chi-square tests for significance, linear and logistic regression. The subjects were from a multisite convenience sample (n = 73) within the AIDS Clinical Trials Group and a prospective sample from the Cleveland Veterans Affairs Medical Center (n = 115). Measures were patient-reported symptoms and health-related quality of life, physician-assessed disease severity, CD4 cell count, and HIV-1 RNA viral quantification. A 20-item, self-completed HIV symptom index was developed based upon prior reports of symptom frequency and bother and expert opinion. When compared with prior measures the index included more frequent and bothersome symptoms, yet was easier to use (self-report rather than provider interview). The index required less than 5 minutes to complete, achieved excellent completion rates, and was thought comprehensive and comprehensible in a convenience sample. It was further tested in a prospective sample of patients and demonstrated strong associations with physical and mental health summary scores and with disease severity. These associations were independent of CD4 cell count and HIV-1 RNA viral quantification. This 20-item HIV symptom index has demonstrated construct validity, and offers a simple and rational approach to measuring HIV symptoms for clinical management, patient-oriented research, and adverse drug reporting.

Patient- and provider-reported adherence: toward a clinically useful approach to measuring antiretroviral adherence

We seek to develop a clinically useful measure of antiretroviral medication adherence. Because there is no gold standard for adherence, we will assess the clinical validity of patient- and provider-reported adherence by the strength of their expected associations with current viral load, depressive symptoms, alcohol and illicit drug use, and homelessness. The Veterans Aging Cohort 3 Site Study (VACS 3) is a multisite study of 881 patients at Cleveland, Houston, and Manhattan Veterans Affairs health care systems. Data was collected on adherence using patient report and provider assessment; depressive symptoms using the Center for Epidemiological Studies Depression (CESD) and provider assessment; alcohol use using the Alcohol Use Disorders Identification Test (AUDIT) and provider assessment; and homelessness using patient report only. Viral load was collected from electronic laboratory data. Although agreement between providers and patients about the patient's adherence was not better than chance (61%; weighted kappa =.07), both patient and provider-reported adherence were related to viral load (P <.001), current alcohol use (P <.01), current drug use (P <.01), and depressive symptoms (P <.001). Patient-reported adherence was also associated with homelessness (P <.05). In multivariate regression models, provider assessment of adherence demonstrated independent associations with viral load (P <.001), current alcohol use (P <.001), current drug use (P <.001), and depressive symptoms (P <.001) after adjustment for the patient's report of adherence (also significantly associated). The consistent and largely independent association between patient and provider reported adherence and a range of variables previously shown to be associated with adherence suggests that patient- and provider-reported adherence independently measure actual adherence. Future work will explore how patient- and provider-reported adherence might best be combined, and whether the measure may be further enhanced with pharmacy refill data.

Eroding the barriers between public and private health care

A Concordat with the Private and Voluntary Health-care Provider Sector (Department of Health (DoH), 2000a) proposed a strategy to remove barriers between public and private health-care providers. The document set out a broad framework to enable the NHS to use a wider range of services more imaginatively to meet local health needs. It was recommended that decision-making be devolved to the local level to enable more tailored services to be available to the community. Primary care groups (PCGs) were therefore encouraged to commission services from the private sector. This was especially relevant to relieve pressure on hospital beds during the winter months (DoH, 2000b).

Heterologous expression and characterization of a rare Gaucher disease mutation (c.481C > T) from a Canadian aboriginal population using archival tissue samples

Gaucher disease is an inherited sphingolipidosis resulting from deleterious mutations in the glucocerebrosidase gene. Through direct sequence analysis of genomic DNA from whole blood, fibroblast cultures, and formalin-fixed archival tissue samples, we have identified a rare homozygous C > T transition at cDNA nucleotide 481 of the glucocerebrosidase gene that results in a proline to serine amino acid substitution (p.P122S) in an aboriginal family of Cree descent in northern Alberta, Canada. A 13-month-old boy (JB) presented with severe visceral Gaucher disease and was treated with enzyme replacement. Currently, at 11 years he is developmentally delayed, with oculomotor apraxia. A cousin (MS) had previously died at age 7 from complications of severe Gaucher disease, before enzyme replacement therapy was available. She was also developmentally delayed. Heterologous expression of this allele using a baculovirus expression system revealed 19.2% of normal enzyme activity on the artificial substrate 4-methylumbelliferyl beta-d-glucopyranoside (4MUGP). Genotype/phenotype correlation is complicated by incomplete clinical details, enzyme replacement therapy, and the difficulty in excluding other genetic and environmental causes of developmental delay. However the development of oculomotor apraxia in JB suggests a Type 3 Gaucher phenotype. The only previous report of this mutation was also from a member of the Cree Nation, who has had a rather similar clinical course. A protocol is described for the isolation of genomic DNA from formalin-fixed bone marrow aspirate archival specimens obtained from the deceased for subsequent PCR-based sequence analysis and mutation detection. This technique will be applicable to the screening of this and other populations for the frequency of known Gaucher mutations where traditional DNA sources are unavailable.

Endoscopic laser stricturotomy and balloon dilatation for benign colorectal strictures

BACKGROUND

A fibrous stricture may develop at the site of a colorectal anastomosis or as a complication following abdominal aortic surgery. A major resection may be necessary if the stricture cannot be released. The authors' experience with endoscopic stricturotomy using neodymium:yttrium-aluminium-garnet laser, together with balloon dilatation, as a conservative method of treating such strictures, is reported here.

METHODS

The case notes of all patients referred for laser treatment of benign distal large bowel strictures at Concord Hospital were reviewed.

RESULTS

Ten patients had endoscopic laser treatment combined with endoscopic balloon dilatation between October 1991 and July 1999. An anastomotic stricture had developed in eight patients and two patients had a fibrous stricture of the upper rectum after abdominal aortic aneurysm surgery. Nine of the 10 patients had their stricture treated successfully without complication or recurrence (median follow up 82 months; range: 14-104 months). The remaining patient re-presented with a large bowel obstruction at the site of his stricture 6 years following initial treatment.

CONCLUSION

A protocol combining laser stricturotomy with balloon dilatation appears to be a safe and effective treatment of such strictures.

Local recurrence after curative excision of the rectum for cancer without adjuvant therapy: role of total anatomical dissection

BACKGROUND

The wide variability of reported local recurrence rates after curative resection of rectal cancer without adjuvant therapy may be a consequence of many different factors. However, few studies have investigated the potential effects of such factors on local recurrence by multivariate analysis. The present study examined clinical and tumour characteristics, operation type and operative technique as potential predictors of local recurrence in patients treated by surgery alone.

METHODS

Prospective data were analysed by bivariate and multivariate methods including actuarial survival and proportional hazards regression.

RESULTS

Local recurrence (pelvic or pelvic and systemic) was diagnosed in 59 of 596 patients. The 5-year actuarial local recurrence rate was 11.1 (95 per cent confidence interval 8.7-14.3) per cent. Independent predictive factors for local recurrence were: positive nodes (hazard ratio (HR) 5.5, P < 0.01); distal margin of 1 cm or less (HR 3.8, P < 0.01); venous invasion (HR 2.0, P = 0.02) and total anatomical dissection of the rectum (HR 2.0, P = 0.01). There was no difference in local recurrence between patients who had the mesorectum divided and those in whom it was totally excised.

CONCLUSION

Nodal involvement is the most potent predictor of local recurrence. In patients in whom total anatomical dissection is performed, total mesorectal excision confers no additional protection against local recurrence.

Local recurrence after curative excision of the rectum for cancer without adjuvant therapy: role of total anatomical dissection

BACKGROUND

The wide variability of reported local recurrence rates after curative resection of rectal cancer without adjuvant therapy may be a consequence of many different factors. However, few studies have investigated the potential effects of such factors on local recurrence by multivariate analysis. The present study examined clinical and tumour characteristics, operation type and operative technique as potential predictors of local recurrence in patients treated by surgery alone.

METHODS

Prospective data were analysed by bivariate and multivariate methods including actuarial survival and proportional hazards regression.

RESULTS

Local recurrence (pelvic or pelvic and systemic) was diagnosed in 59 of 596 patients. The 5-year actuarial local recurrence rate was 11.1 (95 per cent confidence interval 8.7-14.3) per cent. Independent predictive factors for local recurrence were: positive nodes (hazard ratio (HR) 5.5, P < 0.01); distal margin of 1 cm or less (HR 3.8, P < 0.01); venous invasion (HR 2.0, P = 0.02) and total anatomical dissection of the rectum (HR 2.0, P = 0.01). There was no difference in local recurrence between patients who had the mesorectum divided and those in whom it was totally excised.

CONCLUSION

Nodal involvement is the most potent predictor of local recurrence. In patients in whom total anatomical dissection is performed, total mesorectal excision confers no additional protection against local recurrence.

[Management of colorectal cancer in Australian hospitals. Twenty four years' experience]

This study analyses time trends in clinical features tumour pathology and treatment outcomes of patients with colorectal cancer (CRC) treated by surgery alone during the period 1971 to 1994 in a large Australian tertiary referral centre. Throughout this period, both surgical technique and pathology reporting were standardized and a specialized unit of colon and rectal surgery was established in 1980. Improvement in overall survival during this 24 year period reflects changes in tumour stage with an increasing proportion of stage A tumours, declining proportions of stage D tumours, and some improvement in survival for stages B and C colon cancer only.

A novel complex allele and two new point mutations in type 2 (acute neuronopathic) Gaucher disease

Gaucher disease, the most prevalent inherited sphingolipidosis, is characterized by lipid laden histiocytes in the spleen, liver and bone marrow sinusoids of affected individuals. It results from deleterious mutations in the functional gene of glucocerebrosidase (acid beta-glucosidase, EC. 3.2.1.45) and is transmitted as an autosomal recessive trait. Three clinical forms of Gaucher disease have been described: Type 1 non-neuronopathic, type 2 acute neuronopathic, and type 3 subacute neuronopathic. In this report, we describe the identification and characterization of three novel mutations from two patients who died with type 2 Gaucher disease. Two heterozygous missense point mutations, one at cDNA nucleotide 238A (E41L) and the other at cDNA nucleotide 508T (R131C) were identified, both in the context of a cDNA nucleotide 1448C (L444P) mutation in the second allele. One of these L444P mutations was identified as a novel complex allele resulting from a crossover involving the glucocerebrosidase functional gene and pseudogene beginning between genomic nucleotides 5689 and 5723 and extending through the rest of the coding sequence. Based on the recent identification and sequence analysis of the metaxin gene and pseudogene contiguous with the glucocerebrosidase pseudogene and functional gene respectively, we have developed a PCR-based method for the analysis of the origin and extent of this recombination.

Quality of life in patients undergoing treatment for chronic radiation-induced rectal bleeding

BACKGROUND

Laser and formalin therapy have recently been shown to be safe methods of haemostasis in patients with chronic radiation-induced rectal bleeding (CRRB). The effectiveness of this treatment in terms of improved quality of life remains to be determined. The aim of this study was to develop a questionnaire measure of self-perceived quality of life in patients with CRRB.

METHODS

A self-completed Rectal Bleeding Quality of Life Scale (RBQOLS) based on the social and emotional problems experienced by patients with CRRB was developed using standard psychometric methods. Before laser and formalin therapy, 34 consecutive patients completed the questionnaire which was repeated 1 month after treatment and again 5 months later. The validity of the scale was assessed in relation to patient response to treatment.

RESULTS

The RBQOLS had high reliability (alpha=0.89) and its concurrent validity was confirmed by a significant association with the pretreatment severity of CRRB assessed endoscopically. The mean RBQOLS score increased from 102 (95 per cent confidence interval 90-114) before treatment to 126 (111-141) after treatment (t=3.1, 33 d.f., P=0.004) and 136 (122-151) at follow-up attesting to its predictive validity.

CONCLUSION

The RBQOLS is a reliable and valid device for assessing quality of life of patients with this uncommon, previously intractable and potentially life threatening complication of radiotherapy.

Ancient schwannoma of the foot

Ancient neurilemoma (schwannoma) is an uncommon variant of neurilemoma. On the basis of histology, this slow-growing, benign neoplasm has often been confused with sarcoma, and this confusion has resulted in overzealous resection. The authors report a case of this lesion affecting the plantar aspect of the foot. A discussion of the clinical and histological findings that emphasizes diagnosis and treatment is included.

Guanine ribonucleotide depletion inhibits T cell activation. Mechanism of action of the immunosuppressive drug mizoribine

The immunosuppressive drug, mizoribine, has been used to prevent rejection of organ allografts in humans and in animal models. Based on studies in cell lines, mizoribine has been postulated to be an inhibitor of inosine monophosphate (IMP) dehydrogenase (EC1.2.1.14), a pivotal enzyme in the formation of guanine ribonucleotides from IMP. To further characterize the mechanism of action of this drug, we studied the effect of mizoribine on human peripheral blood T cells stimulated with alloantigen, anti-CD3 MAb, or pharmacologic mitogens. Mizoribine (1-50 micrograms/ml) was able to inhibit T cell proliferation by 10-100% in a dose-dependent fashion to all stimuli tested. Measurements of purine ribonucleotide pools by HPLC showed that mizoribine led to a decrease in intracellular GTP levels, and that repletion of GTP reversed its antiproliferative effects. We also examined sequential events occurring after T cell stimulation. Early events in T cell activation, as assessed by steady-state mRNA levels of c-myc, IL-2, c-myb, histone, and cdc2 kinase, as well as surface IL-2 receptor expression, were unaffected. However, cell cycle analysis revealed decreased numbers of cells in S, G2, and M phases, and showed that the G1/S block was reversed with GTP repletion. These data indicate that mizoribine has an effect on T cell proliferation by a mechanism distinct from that of cyclosporine or corticosteroids, and therefore may be useful in combination immunosuppressive regimens.

Metastatic cervical teratoma of infancy

The first case of a documented metastatic cervical teratoma of infancy is presented with a review of diagnostic considerations. Early biopsy of suspicious neonatal head and neck masses is recommended. Complete resection of the teratoma should be considered as soon as clinically possible.

Synovial sarcoma in the foot

Synovial sarcoma is a rare malignancy that occurs most frequently in the extremities. Its onset and associated symptoms are often insidious and therefore can be misleading. The authors review this primary malignancy and offer a case report to illustrate the importance of including such entities in the differential diagnosis and subsequent treatment of soft tissue masses found in the foot.

Diagnostic criteria and natural history of catheter-associated urinary tract infections after prostatectomy

Bacteriuria occurred postoperatively in 28 of 122 patients who had sterile urine before transurethral prostatectomy without antibiotic prophylaxis. Prospective monitoring of catheter bacteriuria indicated that a bacterial count of 10(3) colony-forming-units (cfu/ml progressed to significant infection except when the bacterium in the urine was Staphylococcus epidermidis. Bacteraemia developed in 4 bacteriuric patients, including 2 in whom the bacteria in the urine and blood were mixed. Catheter removal without antibiotic therapy resulted in spontaneous resolution of Staph epidermidis bacteriuria in 9 patients but infection persisted in 5 of 6 patients with other bacteria in the urine. This study indicates that a bacterial count of 10(3) cfu/ml in catheter urine is associated with pathological sequelae and that catheter removal does not result in resolution of bacteriuria caused by pathogenic bacteria.