Outcomes of patients with non-lower gastrointestinal cancer diagnosed via the lower gastrointestinal two-week-wait service

INTRODUCTION

Patients referred via lower gastrointestinal two-week-wait (LGI-2WW) services deemed at 'low risk' of LGI cancer may have delayed or no investigation. However, 20% of patients diagnosed with cancer via the LGI-2WW have non-LGI cancer. This study investigates the outcomes in this under-reported group.

METHODS

A retrospective analysis of patients referred to a UK LGI-2WW service with a non-LGI cancer diagnosis (International Classification of Diseases 10th revision) between 1 January 2015 and 31 December 2018. The primary outcome was all-cause mortality. Statistical analysis was undertaken using Kaplan-Meier survival curves with generalised log-rank test and binomial logistic regression of pre-investigation information to predict death. A p-value of < 0.05 represented statistical significance.

RESULTS

In total, 140 patients were diagnosed with non-LGI cancer (of 10,155 patients referred via the LGI-2WW pathway). Median follow-up was 13 months (range 0-65 months). Thirty-five patients (35/140; 25%) did not meet LGI-2WW referral criteria. Median survival varied by cancer site (upper gastrointestinal: 43/140 patients, median survival 4 months; gynaecological: 25/140, 25 months; haematological: 22/140, < 50% died; urological: 21/140, 47 months; unknown primary: 12/140, 3 months; lung: 10/140, 17 months; breast: 3/140, 5 months; retroperitoneal: 2/140, 9 months; brain: 1/140, 4 months; adrenal: 1/140, 52 months). Binomial logistic regression was statistically significant (chi-squared goodness-of-fit test = 12.334; p = 0.03); but the presence of comorbidity was the only significant predictive factor of death (p = 0.03).

CONCLUSIONS

Patients with non-LGI cancers cannot be easily predicted and have a poor prognosis. Pathways to streamline investigations for LGI cancer should include computed tomography scans for patients at 'low risk' of LGI cancer to ensure that non-LGI cancers are diagnosed.

344 Interval Ultrasound Scanning in Idiopathic Pancreatitis - Are We Following Up Patients Appropriately?

Aim

Acute pancreatitis of unknown cause requires investigation to identify reversible causes of the disease before classifying it as truly idiopathic. This study reports on the follow-up of patients in a district general hospital (DGH) who were diagnosed with acute pancreatitis of unknown cause compared to the gold standard evaluation of the disease by interval abdominal ultrasound scan (US) or outpatient endoscopic US.

Method

Inclusion criteria was all patients discharged from the DGH with a diagnosis of acute pancreatitis and no cause described on the discharge summary from 1st January 2021 to 30th June 2021. The primary outcome was outpatient abdominal US follow-up. Secondary outcomes included an endoscopic US booked as an outpatient. Patients with gallstones identified on imaging or with another identified cause of the acute pancreatitis were excluded.

Results

50% (12 out of 24) patients did not receive follow-up US or any other imaging. Of the patients who did receive follow-up imaging 50% (6 out of 12) had a magnetic resonance imaging (MRI) abdomen or magnetic resonance cholangiopancreatography (MRCP) and the remainder 50% had an abdominal US. 12.5% of patients (3 out of 24) had an outpatient endoscopic US requested.

Conclusions

Management of patients with acute pancreatitis is costly at an estimated £303 per night. To reduce likelihood of future unnecessary admissions, patients require appropriate investigation to have any reversible causes identified and managed. In a system which has suffered bed shortages and significant financial restraints we need to ensure these patients are not lost to US follow-up.

P61 Impact of the COVID-19 pandemic on the presentation and management of acute appendicitis: a single-centre analysis

Introduction

The COVID-19 pandemic has influenced the delivery of healthcare. In accordance with the UK Joint Royal Colleges’ advice the management of acute appendicitis (AA) changed with greater consideration for non-operative management (NOM) or open appendicectomy where operative management (OM) s sought. Our aim is to share our experience of the presentation, management and outcomes for patients presenting to our Trust with AA to guide care for future viral pandemics.

Methods

This single-centre retrospective cohort study included patients diagnosed with AA in March to July 2019 compared with March to July 2020. Medical records were used to evaluate demographics, inflammatory markers, imaging, severity, management, histology, length of stay (LOS), complications and 90-day outcomes.

Results

There were 149 and 125 patients in the 2019 and 2020 cohort, respectively. 14 patients (9.4%) had NOM in 2019 versus 31 patients (24.8%) in 2020 (p = 0.001). In the 2019 OM group 125 patients (92.6%) had laparoscopic appendicectomy versus 69 (73.4%) in 2020. 59 patients (39.6%) had a CT in 2019 versus 70 (56%) in 2020. The median LOS was 4 days (interquartile range (IQR) 3 to 6 days) in 2019 and 3 days (IQR 2 to 5 days) in 2020 (p = 0.03). Two patients in each year who received NOM had treatment failure (14.3% in 2019 and 6.5% in 2020). Three patients in 2019 who had OM had treatment failure (2.2%). Of 95 patients tested for COVID-19 all but one was negative.

Conclusion

During the COVID-19 pandemic there was no observed increase in severity of AA, patients had a shorter LOS and were more likely to have imaging. NOM proportionally increased with no observed change in outcomes.

Thrombocytopenia following autologous bone marrow transplantation: evidence for autoimmune aetiology and B cell clonal involvement

Thrombocytopenia outlasting anaemia and neutropenia is a well recognised sequel of autologous bone marrow transplantation (BMT) but the pathogenesis remains unclear. Autoimmune destruction of platelets has been suggested as a possible mechanism. We studied 5 patients who had undergone autologous BMT and were found to have persistent thrombocytopenia (< 150 x 10(9)/l) 6 months from transplantation with a normal haemoglobin level and granulocyte count. Apart from a mild reduction in the megakaryocyte numbers in one case, no other quantitative or qualitative defects of the megakaryocyte lineage were present to explain the peripheral thrombocytopenia. Two cases had positive anti-platelet autoantibodies. Immunoglobulin heavy chain gene rearrangement studies of peripheral blood and bone marrow mononuclear cells using the polymerase chain reaction showed evidence of clonal rearrangement in one of the two cases with positive anti-platelet autoantibodies. Our results support the previous reports that anti-platelet antibody-mediated destruction of platelets may play a role in the pathogenesis of post-autologous BMT thrombocytopenia. Furthermore, the demonstration of a clonal B cell expansion in one of the cases with anti-platelet antibodies suggests an aetiological link between clonal B cells, autoantibody production and thrombocytopenia.

Liver regeneration: a comparison of in situ hybridization for histone mRNA with bromodeoxyuridine labeling for the detection of S-phase cells

We developed an in situ hybridization technique for measurement of proliferative cell numbers through detection of histone mRNA in routinely fixed, paraffin-embedded tissue sections. Histone gene expression is coordinated with the cell cycle, and the increase in expression during S-phase permits unambiguous identification of cells undergoing DNA replication. Histone mRNAs were identified in routinely processed rat liver tissue by non-isotopic in situ hybridization with digoxigenin-labeled oligonucleotide probes. Specific hybrids were detected with alkaline phosphatase-labeled anti-digoxigenin antibody and visualized by BCIP-nitroblue tetrazolium indicator substrate. Unequivocal cytoplasmic labeling was observed in various cell types in the liver remnant during the first 72 hr after a two-thirds partial hepatectomy. The spatial and temporal patterns of histone labeling were almost identical to those obtained by staining with an antibody to bromodeoxyuridine. The identification of histone mRNA appears to be a reliable marker of the S-phase fraction, a technique with the further advantage that the tissue does not have to be first exposed to a nucleotide analogue. Hence, retrospective studies are possible. The probes can be applied to human and animal cells and tissues because the nucleotide sequences of histone genes are conserved.

In situ and slot hybridization analysis of RNA in colorectal tumours and normal colon shows distinct distributions of mitochondrial sequences

cDNA clones of mRNAs with an abnormal abundance in familial adenomatous polyposis were used to examine the levels and distribution of the mRNAs in tissues from 15 patients with colorectal cancer. Of 12 cloned sequences studied by slot hybridization, one was substantially reduced in tumours compared with normal tissue. Sequence analysis showed this to code for IgA. In situ hybridization was consistent with slot hybridization and immunohistochemistry. Two mitochondrially encoded sequences had distinct distributions detected by in situ hybridization but did not have detectable quantitative differences in whole tumour or mucosa extracts.